14 20 371 https://staging.drfop.org/files/original/7b641cc2c5efff0b13ea00554ff0524c.pdf 7625f33cbc3d4cfb83ec80cc57916490 https://staging.drfop.org/files/original/2b460a57bd7e3cefefc865722303cf8f.jpg f61aec4f5e8a68c88c0f3a7934ceba87 https://staging.drfop.org/files/original/158699aa9b82e6f73a8a2b652cb7d6fd.jpg fbdb3216dca3e4ba5c6f63d3222e452b https://staging.drfop.org/files/original/a68325f5b73646b5b593a8acb1bbd837.jpg f36901c352aad3d7bb8795ed8f2a6646 https://staging.drfop.org/files/original/cc30670084ad14b7609684a6454ac848.jpg 56d45a2b3659d1499e21a5da9829a307 https://staging.drfop.org/files/original/233ef95f73081b8f7c73a4ef388b3eae.jpg deffb0023ad714487dbd06e45b858dc0 https://staging.drfop.org/files/original/4696142a132cee2456d1fdc6faeb4ca9.jpg 89c9bf5a3b883b4293bb308ede78dbd4 https://staging.drfop.org/files/original/5bffdfe2ad0da8b9f5cc1981f71cf7c3.jpg fddc2597a8f63495c8c21845fe13d0a5 https://staging.drfop.org/files/original/d4520c3e41c8750ce3b30ffd8da8e2e5.jpg 71f93afbfae1921384420fd2c1e67617 https://staging.drfop.org/files/original/4fe5adb111706602874b94494623dc2d.jpg b885f7d3eededf4598d34efa04ba7d66 https://staging.drfop.org/files/original/8efb8897726cd8dd75a4539c0b6b2463.jpg e7714a18bbc9e8eacf2f3a4f34b3a9eb https://staging.drfop.org/files/original/0c9233c7ec883b727ccba3e73ba7b4db.jpg f5bcc44ab3a4478f32af9bf11055980c https://staging.drfop.org/files/original/03d2e12c78b332580cb171eb3d225e8f.jpg 83b50125b9d6bb8baff6767c478c78dc DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_022.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 22 - 28 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/1957_02_022.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_02_022.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 Evolution of the Canadian-Type Hip-Disarticulation Prosthesis</h2> <h5>Colin A. McLaurin, BASc. <a style="text-decoration:none;">*</a><br /></h5> <p>Not many people are amputees. Still fewer people are prosthetists. Not many amputees are hip-disarticulation cases. Hence, not many prosthetists are interested in hip-disarticulation prostheses except when occasion demands. That just about sums up the history of hip-disarticulation prosthetics.</p> <p>A more intensive look at the picture reveals two more or less standard approaches to the problem, but usually there are as many variations as there are limbshops. The accompanying illustrations (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>, <b>Fig. 4</b>, <b>Fig. 5</b>, and <b>Fig. 6</b>) indicate the practice, if not the principle, of conventional fitting, together with some of the variants. A study of the principles of conventional fitting is even more revealing. The guiding one seems to be this: Take one standard above-kn ee leg and build on to it until it can be strapped to the amputee. The practice certainly bears this out. Even the term "tilting-table prosthesis" suggests working from the leg up to the stump, instead of beginning with the amputee, who properly should be the focal point in any attempt at rehabilitation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Saucer-type prosthesis for hip disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Tilting-table prosthesis for hip disarticulation, basic design. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Variations in tilting-table prostheses: strap-and-roller medial support. Left, anterior view; right, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Variations in tilting-table prostheses: latch-type medial support, cross-sectional view. Above, standing; below, sitting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Variations in tilting-table prostheses: hip joint below socket. Left, anterior view; right, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Variations in tilting-table prostheses: track-and-roller joint. Left, anterior view; right, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This back-handed approach to problems is not something unique among limbfitters. The plumber is more interested in joining pipes than he is in the water requirements of a household. The airplane pilot is more concerned with the trim of the aircraft than with the comfort of the passengers' seats. The prosthetist's main interest lies in making a leg he can fit on the customer, and in so doing he has shown a considerable amount of ingenuity. Perhaps had the variations not been local in nature, more progress could have been made. Many fitters have come surprisingly close to the Canadian-type prosthesis, and no doubt others actually envisioned the basic principles without achieving the mechanical design.</p> <p>Generally speaking, the hip-disarticulation case has been considered very unfortunate when compared with other above-knee cases. Perhaps some of this attitude is owing to the fact that a great many cases are not of traumatic origin and that therefore the life expectancy is short. In any event, the result is that the amputee is not encouraged to expect much from his prosthesis. The usual complaints are mechanical in nature-rattling in the joints and the need for frequent repair. Accordingly, most innovations in the prostheses have been directed toward solving these mechanical problems, and more by chance than by design functional advantages evolved.</p> <p>Conventional hip-disarticulation prostheses are usually classified into two main categories, the saucer type and the more common tilting-table type.</p> <h4>The Saucer-Type Prosthesis</h4> <p>The saucer type of prosthesis, shown in <b>Fig. 1</b>, is essentially a standard above-knee leg with a saucer-shaped socket on top of the thigh. Suspension is by means of a single-axis joint and pelvic band and may include fore and <!--Page 23--> aft straps that pass over the shoulder. This type is most suitable for short-femur amputations because adequate stability is difficult to achieve without the additional bone structure. In accord with common practice with above-knee legs, the hip joint is placed well forward, thus providing some measure of stability. A lock may or may not be used at the hip joint. If a lock is used, it is of the semiautomatic type. A lever is pressed to release the lock for sitting, and the lock engages automatically on full extension. The lock provides stability (at some loss of function), but it offers mechanical difficulties because all the loads are fun-neled through the relatively small joint.</p> <h4>The Tilting-Table Prosthesis </h4> <p>Although not so simple or as light as the saucer type, the tilting-table prosthesis is more generally used because of the additional support. <b>Fig. 2</b> shows a typical prosthesis. A socket, usually of leather, is made to fit the stump and attached by a belt around the pelvis and often with a strap over the shoulder. The socket is articulated on the thigh section with a metal joint lateral to the acetabulum. Again the joint may or may not have a semiautomatic lock. Without a lock, the wearer has little control over the limb, most of the stability during the stance phase being afforded by friction between the socket and the thigh section.</p> <p>Because it is extremely difficult to make a hip joint strong enough to bear the entire load, contact between the socket and the medial edge of the thigh section is essential in weight-bearing, and this expedient is of course equally important when a lock is used. <b>Fig. 3</b> and <b>Fig. 4</b> illustrate two methods <!--Page 24--> that have been tried. In <b>Fig. 3</b>, a strap is fastened to the socket and passed under rollers attached near the medial brim of the thigh. These rollers also take the downward thrust of the socket, and a metal track may be attached to the socket for the rollers to bear upon. <b>Fig. 4</b> illustrates a dead-center latch mechanism. When the hip joint is fully extended, the latch flips by dead center and secures the socket to the thigh. A hip lock is necessary with this arrangement.</p> <p><b>Fig. 5</b> illustrates a fairly common departure in design. The walking function is identical, but the hip joint has been lowered to a position beneath the socket where a full-width bearing may be made much lighter. Because of the position of the joint directly below the center of gravity, however, a lock must be used. Along with the usual inconveniences and mechanical difficulties, this type also has distinct disadvantages in sitting. The thigh section is much shorter than normal, and the bulk of the joint raises the socket about an inch above chair height.</p> <!--Page 25--> <p><b>Fig. 6</b> shows a rather interesting deviation. This design uses a track-and-roller mechanism in which the center of rotation is a few inches lower and anterior to the acetabulum. The actual model seen by the writer was heavy and crude in construction so that binding of the rollers on the tracks prevented free motion, but it is worth noting since in principle it is almost identical to the present Canadian type, and it seems to be designed with a view toward improving function.</p> <h4>The U.S. Navy Hydraulic Prosthesis</h4> <p>At the close of World War II, the U. S. Navy designed and fitted an hydraulic prosthesis with the primary purpose of improving function. <b>Fig. 7</b> illustrates the main features of the device. The very large ball-bearing hip joint was made strong enough to bear all the weight, thus obtaining a free joint. An extension controlled the motion about the knee joint. The cylinder in turn was controlled by a valve which was either automatically or manually actuated. Normal motion about the hip joint allowed the piston to move slowly, as in an automobile shock absorber, and the knee joint was thus permitted to flex and extend with some damping. But fast rotation about the hip joint (as in stumbling) caused the valve to close and thus stabilized the knee. The manual control also closed the valve and locked the knee in any position. There were two disadvantages of this device- cost and weight. In addition, the application of hydraulics to prosthetics usually introduces problems of noise, leakage, and occasional erratic behavior.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Navy hydraulic prosthesis for hip disarticulation, schematic. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Influence of Materials</h4> <p>A review of prosthetics practice in the hip-disarticulation case would be incomplete without reference to materials. The shank and thigh members are usually of wood covered with rawhide as in standard above-knee legs, but because of the saving in weight aluminum-alloy members are preferable when available. Steel is the almost exclusive medium for hip joints and locks, but in the Navy hydraulic prosthesis aluminum alloy was used to save weight. Sockets are usually made of two layers of leather, with Celastic core for stiffness. Aluminum alloy and monel (an alloy of copper and nickel) have been quite successful. They are usually lighter, more sanitary, and easier to attach to the joints. Plastic laminates are light, strong, sanitary, and easily molded to complex shapes, and it is not surprising to find them successfully used in hip-disarticulation sockets. It was the ease of <!--Page 26--> fabrication that made possible the plastic socket with the wrap-around pelvic band (page 33).</p> <p>Generally speaking, the materials and the mechanical designs were chosen with a view toward solving the mechanical problems, and it was with this thought in mind that design study was begun at Sunnybrook Hospital in Toronto. The highlights of this study are worth noting as an illustration of how an indirect approach to a problem can achieve results.</p> <h4>Evolution of the Canadian Design</h4> <p>The primary objective at Sunnybrook was to construct a hip-disarticulation prosthesis that would avoid the stress concentrations in conventional locks and to provide a simple method for releasing the locks. The first experimental prosthesis employed a four-link mechanism, as shown in <b>Fig. 8</b>. The links were about 4 in. wide to provide adequate lateral strength. The socket was plastic and the thigh section aluminum alloy. It was intended that a posterior strap be used to lock the leg in full extension, but initial trials indicated adequate stability without a lock owing to the fact that at or near full extension the effective hip center was well forward of the center of gravity and because the posterior brim of the thigh prevented hyperextension. In order to achieve simplicity in assembly and to increase mechanical rigidity, the forward link was lengthened and made strong enough to support all the main loads (<b>Fig. 9</b>). The rear link thus acted only as a guide and could be made light and adjustable.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: four-link mechanism. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: modified four-link mechanism. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>One difficulty remained-there was a chopping action between the top of the thigh and the socket such that serious pinching could result. Owing to the geometry of the linkage system, the gap between the thigh and the socket was present whenever the thigh was neither fully flexed nor fully extended.</p> <p>The next step in the evolution was to extend the front link to include the knee joint and to replace the rear link with a simple rubber stop to prevent hyperextension. This final configuration, shown in <b>Fig. 10</b>, permitted the use of a single broad joint without locks. At first it was felt that the position of the stop would be critical, and accordingly the first unit included a stop that could easily be adjusted by the amputee. It was soon found that this feature was not critical and that <!--Page 27--> initial adjustment by shimming or grinding was adequate. The most apparent difficulty was the tendency for too long and too slow a stride, and thus the elastic webbing was added to restrain hip flexion. Cosmetic appearance was improved by a floating thigh cover (<b>Fig. 11</b>) made of horsehide and attached to the socket only. A foam-rubber liner was glued to the horsehide to give it stiffness.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: final design. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Steps in the evolution of the Canadian-type hip-disarticulation prosthesis: floating thigh cover for cosmesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Apart from the mechanical simplicity of the new prosthesis, functional advantages soon became apparent. Little effort was required in the swing phase, and a full stride was easily obtained. Previously, with a locked hip joint, hip flexion was simulated either by pelvic rotation or by motion of the socket on the stump. The resultant gait was usually jerky and tiring, although some amputees had learned to walk surprisingly well. Since the amputee is actually "sitting" in the socket, complaints of discomfort were not common, but obtaining adequate security in the socket was a different matter.</p> <p>Too seldom have the bony prominences of the ilium been used for secure fitting. Usually a broad, leather pelvic belt, as in <b>Fig. 2</b>, was used for lateral support and a shoulder strap was added to prevent the socket from dropping down during the swing phase. The excessive weight of many prostheses necessitated the shoulder strap. The ischial seat is nearly always available for direct weight-bearing, and the areas for taking pressure elsewhere are large. If the socket is extended in the form of a band across the back of the pelvis and around to the opposite iliac crest, then three points of the innominate bones are firmly gripped, as shown in <b>Fig. 12</b>. Since these <!--Page 28--> three points are well spaced, excellent lateral stability is obtained. It is undesirable to have the socket extend above the iliac crests since doing so causes restriction and discomfort. Adequate vertical support can be obtained by ensuring a close fit in the area between the crests and the anterior-superior spine of each ilium.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Anterior view of socket-waistband showing three points where the skeletal structure is firmly gripped. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Conclusion</h4> <p>The Canadian-type prosthesis has been fitted to many amputees at various centers and over a period of several years. Stability with the free hip and knee joints is adequate if correct alignment is attained and if some gait training is provided. In a fall, the prosthesis is usually safer, since the joints collapse and prevent vaulting. One amputee has sustained several falls without injury to himself or the prosthesis. There are, however, several improvements possible in walking characteristics of the prosthesis. The elastic check-strap prevents excessive hip flexion, but some means should be provided for cadence control. Without restraining forces at the knee and hip, the leg tends to walk at its own pace as determined by its pendulum properties. Correctly applied friction or hydraulic devices could enhance the swing characteristics so that various speeds and strides could easily be attained. Furthermore, stability at the knee joint depends upon hyperextension. This means that knee flexion requires effort. A knee which would provide adequate stability at heel contact and yet flex easily when required would offer a big advantage. No doubt several years hence the present device will seem crude and clumsy; in the meantime it provides a light, strong, and relatively efficient prosthesis.</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>Colin A. McLaurin, BASc. </b></td></tr><tr><td class="clsTextSmall">Assistant Director, Prosthetics Research Center, Northwestern University, 401 E. Ohio St., Chicago; formerly Research Engineer, Prosthetic Services Centre, Canadian Department of Veterans Affairs, Sunnybrook Hospital, Toronto.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-011.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_02_022/aut57b-012.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 Evolution of the Canadian-Type Hip-Disarticulation Prosthesis Creator An entity primarily responsible for making the resource Colin A. McLaurin, BASc. * https://staging.drfop.org/files/original/d9df07ada71e9d7d83fffc2b3882605b.pdf dd5973e756028d4e9b05572ed933a126 https://staging.drfop.org/files/original/0f45aa6fc046dad209c2ecd2246d719d.jpg ef9ee0e2d6b75fb5a0f601219455c33c https://staging.drfop.org/files/original/d95df4afa4a2f4646ae80ab0c81b2c59.jpg eaf808db85894142fab323e6a395c193 https://staging.drfop.org/files/original/b6abea62fdee85f63c01f9f92f63427f.jpg 0cb011992156bd6cb8e3d2d0c7084ef2 https://staging.drfop.org/files/original/f0010ef48d7220a546c6825555e192d9.jpg 7d7fdedf615e168cb6806068e1c6ec9f https://staging.drfop.org/files/original/3b4551aa2727f7de686c9653c2e5a0a2.jpg 362acdaa1b00733aa29554d23964db97 https://staging.drfop.org/files/original/9d2755df918b9d45aa9be1ca6f563d0c.jpg 005f7f0338d752126218dd2d68eafbad https://staging.drfop.org/files/original/6c2c983e3d245d5c78f0820ce9ee4915.jpg 1d90a72444738f10f27abd1bac5c0faa https://staging.drfop.org/files/original/624b108ea7d5ee0507c22228b6f0d6a3.jpg 26f4ff3a54c4bccd797ca390cdf7ca5b https://staging.drfop.org/files/original/254ddecf8418d838cb6a8af9873a58de.jpg b4f775c186a69f8d2e53b158ac858068 https://staging.drfop.org/files/original/377df229bb696a03072dfd1c676bd050.jpg c0c4072b156f521d98c4f1354bbc325b https://staging.drfop.org/files/original/fd3e3ccdd2420ab18d0d0fffcbc9ab3c.jpg 0e72757a1dc47a5de48d7308461d5f6d https://staging.drfop.org/files/original/b5a660e0a92fcfe1dc39c8ff7fb409bf.jpg 2d614435d8ff3fe18ea8d22c8f3e3eb6 https://staging.drfop.org/files/original/bca83eadc2d6bdd1414a4a6220815d9b.jpg af655a4773be177a6f4c493d206128dd https://staging.drfop.org/files/original/a3377673f8480eff6b780ea492790238.jpg 31b69497a6c30f74af9e798ed25997b9 https://staging.drfop.org/files/original/14d1a5ad883e575f6f4ef41150d9abf1.jpg 3715824627641a0a6f1d6ee0636f59c2 https://staging.drfop.org/files/original/976df78ead28d770ef285a09c9bc0af9.jpg 423273a8db9972de7c0193e94f0f8bdc https://staging.drfop.org/files/original/cd85393dfea9ad19f0b6b560e893c1a6.jpg e2175b21b49484d983de253617cf5baf https://staging.drfop.org/files/original/59c142d232f6be2114140f4624655085.jpg 8e077cebc372f08ef05dd8002caf70d3 https://staging.drfop.org/files/original/efdc01af5dc1a7b942d551d17167eeca.jpg c00df2061434f0cde77ab3c22578b6b7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_01_041.pdf Year 1957 Volume 4 Issue 1 Page Number(s) 41 - 75 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_01_041.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_01_041.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 Experience with Prosthetic Problems of Above Knee Amputees</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br />Norman C. Johnson, M.D. <a style="text-decoration:none;">*</a><br />James Foort, M.A.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p>For almost a dozen years the University of California has been active in prosthetics research. On the recommendation of the then Committee on Prosthetic Devices (now the Prosthetics Research Board) of the National Research Council, there was established in 1945, with the cosponsorship of the School of Medicine in San Francisco and the College of Engineering in Berkeley, the Prosthetic Devices Research Project (now the Lower Extremity Amputee Research Project), a program designed primarily for the purpose of conducting studies in several areas of importance to leg amputees, especially fundamental studies of the processes of human locomotion. Supported on a continuing basis with funds supplied by the Veterans Administration, the work has from the beginning been under the supervision of Howard D. Eberhart, Professor of Civil Engineering, and Verne T. Inman, Professor of Orthopedic Surgery.</p> <p>In the course of fundamental research, the need for experimental devices required the activation of an engineering design group, and consequently a small staff of design engineers, draftsmen, and technicians has been active since 1948. This group, working with the fundamental study groups, research prosthe tists, and amputee subjects, has designed improved prosthetic devices, developed mechanical aids to fitting and alignment, and assisted in the application of well known principles of engineering mechanics to the problems of fitting and aligning lower extremity prostheses.</p> <p>As correlation of the results of the various fundamental study groups progressed, and as the engineering design group developed improved devices, it became increasingly apparent that, in order to make their results useful to the members of the medical profession and to prosthetists serving amputees, a program of amputee application was indicated. Accordingly, there was organized in the spring of 1953 a Clinical Study aimed at providing increased opportunity for application of research results to the solution of typical prosthetic problems of leg amputees. The work in fundamental research had studied the "man"; the Clinical Study was needed to consider the 'man machine combination." Its objectives were to evaluate current prosthetic practice and to develop improved procedures where needed, to establish basic principles of fit and alignment for all levels of lower extremity amputation, to evaluate medical and prosthetic factors in the rehabilitation of amputees, and to develop methods for evaluation of lower extremity amputees and their prostheses.</p> <p>An immediate outgrowth of the Clinical Study was an increasing awareness of the need for additional research directed toward the solution of the medical problems of the amputee. At the present time, the Medical Division of the Lower Extremity Amputee Research Project, located at the Medical Center in San Francisco, includes groups active in the fields of stump dermatology, amputation surgery, skeletal changes, energy, neuroanatomy, psychology, and the physiology of pain. The Clinical Study provides an opportunity for the solution of the prosthetic problems associated with the medical studies and also of the purely prosthetics research problems connected with better materials and improved techniques of fitting. To date, most of the experience has been had with above knee amputees, as here reported, although more than 100 patients, presenting all levels of lower extremity amputation, are currently under study.</p> <h3>Procedures</h3> <p>Each amputee processed through the Clinical Study has certain unique problems, and each must therefore be considered on an individual basis. Initially, it was thought that it would be possible to process amputees in certain rather loosely defined groupings such as ''short stump above knee," "long stump below knee," and so on. But this procedure has not been found practical since each amputee is referred to the study as his particular problem arises. Largely because of the attendant requirements of time, travel, and inconvenience, it is difficult to induce an amputee to become a research subject when he considers his prosthesis to be comfortable and well fitted. The cases reported here have almost without exception been referred to the Clinical Study as "problem cases" and have had chronic difficulties upon referral. The sample does not, therefore, necessarily indicate a typical cross section of the amputee population. The prosthetic problems of the group as a whole, however, constitute what we believe to be a rather common group of problems facing above knee amputees.</p> <p>Each amputee referred to the Clinical Study is given a preliminary examination for the purpose of obtaining information as to the nature of his problems, if any. The preliminary examination includes:</p> <ol> <li>An interview with an amputee specialist <i>(i.e., </i>a trainer). The amputee specialist obtains a brief prosthetic history, explains the research program to the amputee, and records personal data.</li><li>Medical examination by an orthopedic surgeon. The orthopedic surgeon obtains a brief medical history and endeavors to classify the major complaints of the amputee.</li><li>Prosthetic evaluation by staff prosthetists and other specialists. A group consisting of three or more people examines the amputee's stump, his prosthesis, and his performance in order to analyze the fit, alignment, and functional behavior of the amputee with his prosthesis.</li></ol> <p>The results of each of these examinations are recorded in the form of a written memorandum report. Upon completion of the reports, a group discussion is held for the purpose of making recommendations as to the further handling of the case. For example, it may appear on preliminary examination that a particular amputee has a severe skin infection of unknown origin. In such a case, the recommendation might be to refer the patient to the Skin Study Group at the Medical Center in San Francisco before considering any work directed toward improving fit and alignment.</p> <p>Certain cases considered to be of interest to the research staff as a whole are referred to the Amputee Conference held at the Medical Center, San Francisco, on a regularly scheduled weekly basis. Amputees may be referred to the Amputee Conference by medical study groups as well as by the Clinical Study Group. Attendance at the conference is limited to University of California staff members, and not more than three amputees are presented for discussion at any one session. The Amputee Conference provides an opportunity for presentation of the results of the preliminary examination and, thereafter, a general group discussion. At this time a general plan of treatment, including broad research objectives, is formulated.</p> <p>If an amputee is accepted by the Clinical Study as a case of research interest, a more complete medical examination is required. Cases referred to the Clinical Study from the medical study groups or the Amputee Conference have usually been examined at the Medical Center prior to referral. The complete medical examination includes routine clinical tests, plus x-rays of the stump and pelvis.</p> <p>Before any actual treatment is undertaken, a plan of approach is worked out by a team consisting of an orthopedic surgeon, a pros thetist, an engineer, and an amputee specialist. The team discusses research objectives in detail, writes a prescription for one or more phases of prosthetic treatment, and lays out an estimated schedule. A report is then written summarizing the discussion and recommendations, and the team meets periodically, as necessary, to review progress and to make further recommendations. Each phase of the treatment of the amputee is reported in a memorandum which becomes a written record of progress. Permanent records embrace medical records, including x rays; evaluation records, including evaluation forms and 16 mm. motion pictures (100 ft. per evaluation); black and white still photographs; 35 mm. color transparencies; and memorandum reports on plans and progress.</p> <h3>General Principles of Above Knee Prosthetics</h3> <p>As already noted, one of the major objectives of the Clinical Study was to provide the means for additional amputee trials of certain principles of fitting and alignment which had been evolved during several years of fundamental research, evaluation of current practices, and amputee trials but which had been developed with a limited number of amputee subjects. The technique of fitting the suction socket prosthesis to an above knee amputee has been reported by the University of California in a series of publications<a></a> which have been revised periodically as new knowledge and techniques became available. The latest article<a></a> stressed the interdependence of the shaping and fitting of the socket and the biomechanics of alignment of the prosthesis. A rational basis for planning and fitting the above knee prosthesis was presented. All of the patients reported upon in the present paper were fitted in accordance with these principles. It is therefore well to offer here a brief summary of the more important considerations.</p> <p>The prosthetist is undoubtedly <i>the </i>person on the prosthetics team with the heaviest responsibilities. His skill with his hands is largely responsible for the eventual rehabilitation of the amputee. But in carrying out his assignment of providing the amputee with a satisfactory prosthesis, he is faced with something of a dilemma in the establishment of an order of procedure. In order of importance, he must provide the amputee with, first, comfort; second, function; and third, appearance. It can be argued that he should approach the solution of these problems in reverse order if optimum results are to be achieved. Actually, there are two separate and distinct phases of equal importance in the fitting of a leg prosthesis the planning phase and the construction phase. It is during the planning phase that the objectives listed above should be considered in the reverse order. One of the principal reasons for failure to achieve optimum results in the fitting of a suction socket above knee leg is lack of appreciation of, and hence failure to formulate, a working plan before beginning the construction of the prosthesis.</p> <p>In order properly to plan the fitting and alignment of a prosthesis, the clinic team must have in mind a rational sequence which will eventually result in a satisfactory fitting for the amputee. The order of the sequence is necessarily dictated by the type of problem to be solved at a particular stage. Let us consider, for example, the case of a typical leg amputee. During the medical and prosthetic examination by members of the clinic team, a careful analysis is made of the patient's potential as a wearer of a prosthesis. This analysis includes classification as to stump type, stump length, activity level, habit patterns, and special medical factors. It dictates in general terms the type of alignment to be incorporated in the amputee's prosthesis (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 1. Variations in alignment to accommodate stumps of different functional lengths. With the short stump, the slow or hesitant walker, having limited use of the hip abductors and extensors, needs considerable alignment stability. The moderate walker, with stump of medium functional length, has average use of the hip abductors and extensors. Alignment for the long stump is for an active walker having good use of the hip abductors and extensors. These figures serve as a guide to typical features of alignment once the amputee has been classified After Radcliffe (6). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The alignment of the prosthesis will in large measure establish the gait pattern of the amputee, assuming of course that he has been trained to use his prosthesis in a manner consistent with its alignment. A leg amputee can walk efficiently with a symmetrical, narrow based gait only if his prosthesis has been planned and constructed to achieve such a gait pattern. The type of alignment also affects the manner of fitting the socket. An amputee walking with a narrow base may require a distribution of contact forces between stump and socket entirely different from that of an amputee walking with a wide base <i>(i.e., </i>abducted gait).</p> <p>The distribution of stump socket contact forces is determined by the functions the socket must perform, the major functions of a typical above knee suction socket being as follows:</p> <ol> <li>Suspension of the leg in the swing phase of walking. This requirement dictates that an airtight seal be maintained between stump and socket, especially in the proximal third of the stump.</li><li>Vertical support of body weight in the stance phase. The only efficient areas of an above knee stump for weight bearing are the ischial tuberosity and the gluteus maximus. Attempts to use for weight bearing in a suction socket the attachments of the adductor musculature in the perineal area have been unsuccessful Almost without exception this procedure leads either to painful pressure on the pubic ramus or to skin irritation where there exists a definite roll of adductor musculature over the medial brim of the socket.</li><li>Stabilization of the ischial tuberosity on the posterior brim (ischial seat) of the socket. Failure to provide stabilization of the tuberosity will allow the pelvis to slide forward and down into the socket, a circumstance which causes chafing and irritation of the skin under the ischial tuberosity and, in addition, is a major source of crotch discomfort.</li><li>Provision of effective stump reaction points for utilization of hip musculature on the side of the amputation. Any attempt to use the hip musculature either for control of the torso above the hip joints or for control of knee joint movements below the hip joint will require that the stump transmit a moment, or torque. For lateral stabilization of the torso, there is required a pair of mediolateral reaction forces equal in magnitude but opposite in direction one acting on the lateral side of the stump, concentrated in the lower third, and a second acting horizontally against the medial side of the stump in the upper third. During those times when the stump acts to maintain knee stability by active stump extension, the reaction points are against the posterodistal and the anteroproximal areas of the stump.</li></ol> <p>On the basis of these functional requirements, the quadrilateral shape of suction socket shown in (<b>Fig. 2</b>) has been developed. It not only conforms to the anatomical skeleton and musculature but also provides the four functions already listed suspension, support, ischial stabilization, and torque reaction points.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Quadrilateral shape of suction socket, as developed at the University of California, showing anatomical features of an above knee stump in weight bearing. Cross section 1/2in. below ischial level. After Radcliffe (6). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Thus far the objectives of appearance and function have been accounted for. It has been stated that appearance is determined by proper alignment and use of the prosthesis and that function is dictated by proper alignment accompanied by a rational design of socket to provide the necessary accommodation of stump socket forces. These concepts can be restated in the following two principles:</p> <ol> <li>Gait and alignment establish a definite pattern of stump socket forces.</li><li>The force pattern, in combination with anatomical proportions, dictates a rational design of socket of a generally quadrilateral shape.</li></ol> <p>The third objective is to provide a completely comfortable socket which will be consistent with the functional requirements and yet allow the amputee to use his prosthesis for long periods. Comfort is achieved by application of three additional principles:</p> <ol> <li>Relative motion or rubbing between stump and socket should be held to a minimum.</li><li>Stump socket contact forces can never be eliminated. Contact forces can be tolerated most comfortably if distributed over a large skin area.</li><li>Where a contact force must be transmitted in an area of the stump involving both soft and firm tissues, a uniform distribution of the contact pressure is accomplished by a proportionately greater distortion of the softer tissues.</li></ol> <p>Application of the three principles relating to comfort have resulted in four features of socket shape at the brim that are of particular importance:</p> <ol> <li>The anteroposterior dimension of the socket must be determined with considerable accuracy from skeletal measurements. Any error in this dimension will be reflected in improper placement of the ischial tuberosity on the posterior brim of the socket.</li><li>To ensure distribution of vertical support over the entire posterior brim <i>(i.e., </i>to achieve ischial gluteal weight bearing), a rather flat posterior contour with a flare in the gluteal area is required.</li><li>An anterior wall extending into the inguinal area (the high front), when used with the proper anatomical dimension, is extremely efficient in stabilization of the ischium on the ischial seat.</li><li>A definite protuberance into Scarpa's triangle (the adductor area extending downward into the socket), accompanied by a channel to fit the belly of the rectus femoris, is necessary to ensure a uniform pressure distribution and an airtight seal across the anterior brim of the socket.</li></ol> <p>The following cases have been selected as illustrative of typical problem cases and as being informative to others engaged in the rehabilitation of above knee amputees. Treatment was not completed in all cases because considerable improvement over the previous condition sometimes caused the individual to believe the optimum had been reached and to be reluctant to devote additional time. The cases are in general indicative of the kind of results that can be obtained under the team approach to the problem of amputee rehabilitation.</p> <h3>Some Above Knee Cases</h3> <h4>Case 1, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 1, a male, was 32 years of age, measured 5 ft. 8 1/2 in., and weighed 190 lb. His left leg had been amputated above the knee in October 1944 as the result of a wound. He was employed as a civil engineer. For two years after the amputation, he received intermittent physical therapy and exercise before being fitted with a conventional prosthesis with pelvic belt. The patient's second and third prostheses were similar. His fourth prosthesis, also a pelvic belt leg, was worn with fair results for 18 months. It was then converted to suction suspension in an unsuccessful attempt to increase comfort. The fifth prosthesis, also suspended by suction, was worn for a year with continuous stump trouble before the amputee was finally hospitalized.</p> <p>The patient was referred to the clinical study program in November 1953 following hospitalization for severe edema precipitated by his suction socket prosthesis. Treatment consisted of remaining off the prosthesis during and immediately following hospitalization.</p> <h5><i>Examination and Evaluation</i></h5> <p>The stump was 12 in. long, with limited tolerance to weight bearing on the end. Subcutaneous tissue was light and musculature soft, with some bunching of the hamstrings and slight atrophy at the distal end. X ray showed a healed but laterally displaced fracture of the distal 5 1/2 in. of the femur. The end of the femur was slightly rounded, was closed with new bone growth, and had a small medial spur. Approximately half an inch of muscle padding lay over the end of the femur. The ischial tuberosity was well padded, and the general health of the amputee was excellent.</p> <p>When the patient was admitted to the hospital, the end of his stump was severely edematous, open, and weeping. At the time of entrance to the study program, there was still some weeping and edema, and the end of the stump was discolored (<b>Fig. 3</b>). Follicular lesions were apparent in the area of the inguinal crease and of the crotch, and a small, healing abscess existed on the anteromedial portion of the stump 5 in. below the groin. Some rawness and irritation were still apparent in the crotch area. The distal area of the posterior aspect of the stump was tender, and there was a moderate adductor roll. Examination of the socket fit showed constriction of the stump, especially in the upper third. Weight was carried on a flesh roll at the brim of the socket (<b>Fig. 4</b> and <b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Case 1. Condition of the distal end of the stump on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Case 1. Prosthesis worn prior to referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Case 1. Shape of socket of prosthesis worn prior to referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Interest in the case centered around the edema, roll formation, and skin problems, including discomfort in the crotch. Ischial gluteal weight bearing, with increased area of support at the anterior wall, particularly in the upper third, was expected to eliminate crotch discomfort, skin lesions and irritation, roll formation, and constriction of the proximal portion of the stump. A snug fit of the socket in the upper third was required to reduce the adductor roll, and a close fit of the distal two thirds of the stump was required to reduce remaining edema and to maintain fit as the edema subsided.</p> <p>The amputee was provided with a suction socket prosthesis using a Navy above knee set up,<a></a> including the variable cadence knee, the functional ankle, and the sponge rubber toe. The socket was made of willow wood reinforced with rawhide and finished inside with cellulose acetate lacquer, and an automatic expulsion valve with standard spring was used. A flat, leather covered, sponge rubber pressure pad was placed in the bottom of the socket to provide back pressure on the edematous tissue at the end of the stump.</p> <p>No special provision was made for relief of the adductor roll. The anterior wall provided no protuberance over the femoral triangle, and there was no special relief for the displaced section of the femur. The perimeter of the socket was 2 1/4 in. less than that of the stump at the proximal end, 3/4 in. less at the mid stump level, and equal to that of the stump at the end. The distance from the channel for the tendon of the adductor longus to the ischial seat was 4 1/2 in., the corresponding anatomical dimension being 3 3/4 in. This difference between medial socket width and anatomical measurement was subsequently found to be a major source of difficulty. Current practice is to have the medial width of the socket compare very closely with the anatomical measurement.</p> <p>Prosthetic evaluation showed some instability of the knee in ramp descent owing to reduced range of plantar flexion. Although there was drop off at the end of the stance phase because of the soft dorsiflexion stop and the soft, sponge-rubber toe, the amputee's performance was excellent.</p> <p>During the final fitting, the end of the stump turned red, but a sponge rubber pad placed in the bottom of the socket improved stump color markedly within two hours. One week after delivery of the prosthesis, the edema was reduced; three weeks after, there was no edema; nine months after fitting, some edema was evident at the distal end of the stump.</p> <p>Evaluation indicated that the ischial tuberosity was sliding anteriorly off the ischial seat so that the stump was settling deeper into the socket, with increased constriction at the proximal end. Several factors were involved. The stump had shrunk, and the anteroposterior dimension of the socket, especially in the medial third, which had been too great initially, had been increased in an unsuccessful attempt to relieve discomfort in the inguinal crease and in the weight bearing area of the stump. The edema was confined to the areas of the stump which extruded into the valve recess and into the gap between the pad and the socket walls. The valve recess was lowered, the pad was refitted so that more weight was carried on the end of the stump, and the space between the pad and socket walls was eliminated. The edema cleared up.</p> <p>Roll formation over the anterior brim of the socket was eliminated through extension of the anterior wall of the socket above the level of the ischial seat. The adductor roll was completely contained within the socket. Tightness of fit in the upper third was a source of minor discomfort immediately, but this problem decreased with reduction of the roll, which was complete within six months (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Case 1. Present prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Follicular lesions in the area of the crotch and the inguinal crease quickly cleared up with reduced forces from the socket brim and elimination of roll formation over the brim. One year after treatment began, the discoloration at the end of the stump was markedly decreased. Irritation of the skin over the posterior brim was a persistent problem directly related to decreased effectiveness of ischial gluteal weight bearing and wedging of the posterior aspect of the stump against the inside edge of the posterior brim of the socket. Attempts to increase weight bearing on the distal end of the stump showed that the amputee preferred ischial gluteal weight bearing because of discomfort experienced on the stump end with prolonged support of body weight.</p> <p>Reduced support on the ischial tuberosity followed stump and socket changes and caused discomfort on the ramus. The medial brim of the socket was lowered to provide relief. This expedient was partially successful, but the stump sank deeper into the socket after wear, and ramus discomfort has recurred.</p> <h5><i>Summary</i></h5> <p>The problems of edema, roll formation, skin lesions, and discomfort in the crotch were studied. Edema was originally caused by a tight fit of the stump with constriction of the proximal end. Definite ischial gluteal weight bearing, with increased area of anterior support, was the primary factor in clearing up the edema. A pressure pad under the end of the stump helped to reduce the edema. Stump and socket changes which allowed the ischial tuberosity to slide into the socket, with wedging of the stump proximally, caused edema to recur. Improved fit of the pressure pad, with increased end bearing, cleared up the edema. The adductor roll was brought about by weight bearing in the crotch on the tight socket. Ischial gluteal support, adduction of the femur in the socket with relaxation of the adductors, and extension of the medial brim to the level of the ischial seat, without provision of a relief pocket, eliminated the adductor roll. Discomfort due to tightness of fit for adductor roll reduction decreased as the roll reduced. The high anterior wall eliminated roll formation over the anterior brim of the socket. Skin lesions and irritation were caused by high force concentrations on the stump. Ischial Gluteal weight bearing, with increased area of anterior support, eliminated irritation and follicular lesions in the area of the crotch and the inguinal crease. Ramus discomfort following stump and socket changes was a sign of reduced effectiveness of ischial gluteal weight bearing, which allowed the stump to sink deeper into the socket. Discomfort in the weight bearing area posteriorly was caused by wedging of the stump against the posterior brim of the socket as the tuberosity slid inside the socket.</p> <h4>Case 2, Mid Thigh</h4> <h5><i>History</i></h5> <p>Case 2, another male, was 57 years of age, measured 6 ft., and weighed 187 lb. He was employed as a district manager for an insurance company. Amputation was through the right femur following a railway accident at the age of 17. He was referred to the clinical study in November 1953 by a local limbshop because of a history of problems. These included skin infections and irritations, fatigue, and low back pains which had persisted since amputation. At the time, the amputee considered his prosthesis satisfactory. The first prosthesis, with shoulder harness suspension, was fitted in 1913 and worn until 1928. Prostheses with shoulder harness suspension were worn until 1943, when a change was made to pelvic belt suspension. The pelvic belt was uncomfortable and aggravated the back pains, and prior to referral the prosthesis was converted to suction suspension.</p> <h4><i>Examination and Evaluation</i></h4> <p>General health and physical condition were good. The stump was 10 in. long and cylindrical, with light subcutaneous tissue and average musculature except for moderately prominent hamstrings. There was a lateral distal bone spur, a mass of redundant tissue at the lateral posterior end of the stump, and sensitive scar tissue which was adherent to the femur. Perspiration level was high. Skin irritations were present in the area of the crotch and the inguinal crease, and hard skin nodules existed in the ischial gluteal area (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Case 2. Lateral view of patient standing. Note scar on distal portion of stump over lateral and posterior aspects. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The prosthesis did not provide ischial gluteal weight bearing, and the tuberosity of the ischium was sliding inside the socket during weight bearing. This set of circumstances resulted in painful pressure on the ramus and wedging of the proximal portion of the stump against the anterior and posterior brims of the socket, with a high concentration of forces at the brim level. The medial brim had been lowered a half inch below the level of the ischial seat in an unsuccessful attempt to relieve the discomfort at the ramus. Walking with a narrow base increased the ramus discomfort because the femur was not adducted in the socket for stabilization of the pelvis. There was roll formation over the low anterior brim. Knee stability at the end of the stance phase was excessive owing to a long forefoot and posterior placement of the knee joint, which further increased the force concentrations at the socket brim. Insufficient security at heel contact was due to stiff plantar flexion action. A pelvic hike on the side of the amputation in the swing phase was noticeable, probably because of experience with shoulder harness and pelvic belt suspension.</p> <h5><i>Treatment</i></h5> <p>Problems of interest included skin lesions, horny nodules, ramus discomfort, fatigue, and backaches. It was decided that relatively standard procedures, including ischial gluteal weight bearing with increased support from the anterior wall, would be effective in eliminating roll formation and in reducing pressure concentrations on the stump, especially in the crotch, in the inguinal crease, and in the ischial gluteal area. Further reduction of vertical forces in the region of the crotch could be achieved by adduction of the femur in the socket, thus eliminating pelvic drop in the stance phase.</p> <p>The amputee was provided with a suction socket prosthesis which included a single axis constant friction knee, a plantar dorsiflexion ankle, and a foot with single toe break. Segments of the prosthesis were willow wood reinforced with rawhide. The socket interior was finished with cellulose acetate lacquer, and use was made of an automatic expulsion valve with standard spring.</p> <p>Since the ischial tuberosity was not adapted to weight bearing, the gluteal channel was held shallow to increase gluteal support. In addition, this arrangement offered increased sitting comfort by allowing a thinner posterior wall. Definite hamstring relief was provided by channeling the posteromedial apex of the socket (<b>Fig. 8</b>). The medial brim was approximately 1/4 in. lower than the posterior brim to provide clearance for the ramus. The medial socket width was 4 3/4 in. as compared to an anatomical measurement of 3 3/4 in., a difference subsequently found to be a major source of difficulty. As already mentioned, current practice is to have the medial width of the socket compare very closely with the anatomical measurement. The anterior wall was extended 2 in. above the level of the ischial seat and was relieved slightly over the femoral triangle. But this idea, which was tried for fear that pressure in the femoral triangle would interfere with circulation, has since been abandoned in favor of a definite protuberance into this area. Such a shape gives considerable distributed anterior support.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Case 2. Socket shape of prosthesis worn at present. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket was placed well forward on the knee block to allow initial flexion of the femur in the socket for increased voluntary control, reduced energy requirements, and decreased lordosis of the lumbar portion of the spine. Prosthetic evaluation indicated that there was excessive stability at the end of the stance phase owing to a long forefoot and the posterior location of the knee axis, the long forefoot having been dictated by the large foot size. In the swing phase, there was some whip, which was not removed during alignment trials on the adjustable leg,<a></a> but the gait was markedly improved on the new prosthesis. There was no ramus discomfort, no irritation, and no roll formation in the crotch or inguinal crease. The ischial tuberosity was close to the inside edge of the socket, so that the medial wall had to be lowered to prevent ramus discomfort.</p> <p>After stump shrinkage, ramus discomfort recurred. The medial brim was lowered, but this measure provided only temporary relief as the stump settled deeper into the socket. Skin irritations from the anterior brim were reduced but persisted, since wedging occurred owing to inefficient ischial weight bearing. Force concentration at the anterior brim was reduced somewhat by extension of the brim 2 in. above the level of the ischial seat. Undercut of the anterior wall over the femoral triangle reduced the effective area of anterior support.</p> <p>Skin lesions in the crotch cleared up initially but recurred with failure of ischial weight bearing. Formation of horny nodules in the weight bearing areas was unchanged because poor ischial support allowed the tuberosity to move in and out of the socket over the inside edge of the posterior wall, thus creating abrasive and wedging action. Excessive perspiration was considered a factor both in the formation of horny nodules and in stump irritation because of the deteriorating effect it had on the inside finish of the socket.</p> <p>Although the anterior and posterior brims were rolled and adjusted periodically to reduce discomfort from skin irritations in the inguinal crease and from nodules in the weight bearing areas, this expedient provided only temporary relief, since the forces involved were either unchanged or increased. Reduced alignment stability, with increased flexion of the stump in the socket, did not relieve the backache. Activity level was not noticeably changed, and fatigue also remained unchanged.</p> <p>In the course of treatment, redundant tissue at the lateral distal portion of the stump was a problem in fitting because of the sensitivity of the adherent scar tissue. A large pocket was provided to give relief. Doing so reduced the effective length of the femur available for stabilization of the pelvis.</p> <h5><i>Summary</i></h5> <p>Failure of ischial gluteal weight bearing resulted in ramus discomfort and skin lesions. Lowering the medial brim provided only temporary relief, since the stump settled further into the socket. With recurrence of vertical pressure in the crotch, skin lesions were again a problem. The need for effective anterior stabilization to maintain the ischial tuberosity on the ischial seal was definitely indicated.</p> <p>The high anterior wall eliminated roll formation and reduced skin infections in the inguinal crease. Undercut of the anterior wall over the femoral triangle reduced the anterior support area and increased the force concentration al the brim. Modifications of the anterior wall and of the posterior brim reduced discomfort temporarily only, since the force pattern was unchanged.</p> <p>Placement of the prosthetic toe break at the shoe crease provided excessive knee stability at the end of the stance phase. This result suggested that the conventional location of the toe break was too far forward.</p> <h4>Case 3, Mid Thigh</h4> <h5><i>History</i></h5> <p>Case 3 was another male, age 51, height 6 ft., weight 180 lb. He lost his left leg above the knee at the age of 17 after an injury sustained in a baseball game. Since his original surgery, he had had no further revision. For the first five years after amputation, he used crutches without a prosthesis. He had since worn three prostheses during his 34 years as an amputee. The first leg had a shoulder harness suspension. The leg worn upon his acceptance as a research patient had been converted in 1952 from an aluminum socket, pelvic belt leg to a wooden suction socket prosthesis a year and nine months previously. He was employed as an expediter in a shipyard, and the nature of his employment was such as to involve considerable standing and moving about over short distances. His chief complaint was concerned with persistent edema of the stump since conversion to suction suspension, and this was the reason for his referral to the clinical study program by a local limbshop in November 1952. The patient complained of occasional phantom pain but had no persistent local pain.</p> <h5><i>Examination and Evaluation</i></h5> <p>The patient was in good general health, with normal reflexes and above average musculature. The stump was cylindrical, with 6 1/2 in. of femur below the perineum and 2 1/2 in. of soft tissue over the end of the femur (<b>Fig. 9</b>). Stump musculature was not abnormally prominent, and subcutaneous tissue was light. On contraction of the muscles, the redundant tissue pulled upward without bunching. A large scar, adherent to the distal end of the femur, extended 6 in. up the lateral side of the stump (<b>Fig. 10</b>). There was severe, nonpitting edema in the redundant tissue. The skin in the edematous area was without hair, distended, discolored, and scaly, with an orange peel texture. Small cysts and horny nodules were evident in this region as well as in the inguinal area and in the crotch. The patient said that these cysts frequently enlarged and broke down, producing a pinkish yellow discharge.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9 Case 3. X ray of stump, mediolateral view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Case 3. Lateral view of stump. Note large, adherent scar. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>X ray revealed the usual finding that there was lessened bone density on the amputated side and that the femur tapered and curved medially toward the distal end, which appeared to be closed. Comparison of socket and stump perimeters showed the socket smaller than the stump by 1 1/4 to 2 in. at corresponding levels. The distance from the tendon of the adductor longus to the ischial tuberosity was 3 1/2<i> </i>in., as compared to the corresponding socket measurement of 5 in.</p> <p>The suction socket the patient was wearing, although of the ischial bearing type, did not achieve ischial bearing. The anteroposterior dimension was too large, the mediolateral dimension too small (<b>Fig. 11</b>). The socket was too tight, especially in the distal half, and the proximal end of the stump was constricted because of a wedging action precipitated by failure to establish ischial gluteal bearing. Weight was borne on the medial brim of the socket, which was 3/8<i> </i>in. below the level of the ischial seat and generously flared. There was a small adductor roll, and the anterior brim of the socket was level with the posterior brim, with some roll formation in the area of the inguinal crease. The anterior wall was undercut, a feature that caused localized high pressure on the stump at the anterior brim. The patient was well adapted to the use of the prosthesis, although a number of undesirable characteristics of gait were apparent, including a 7 in. walking base, considerable sidesway, and exaggerated arm swing on the side of the amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11, Case 3. Socket shape of prosthesis worn on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>This patient's chief problem was the severe edema. It was felt that this disorder, as well as the skin lesions, could probably be controlled adequately by proper fit and alignment. The question of prime interest to the study group was whether or not suction suspension was the cause of the edema in this case.</p> <p>The amputee was provided with a suction socket prosthesis with conventional components, including a single axis constant friction knee, a plantar dorsiflexion ankle, and a foot with a single toe break. Segments were made of wood and reinforced with rawhide. An automatic expulsion valve with a strong spring was used to increase positive pressure in the socket during the stance phase.</p> <p>The socket perimeters were 1 1/2<i> in.</i> less than corresponding stump dimensions in the top third and equal to stump dimensions below that.</p> <p>The distance from the tendon of the adductor longus to the ischial tuberosity was 3 1/2 in., and the corresponding socket dimension was 4 in. The anterior wall was relieved to avoid pressure in the area contacting the femoral triangle (<b>Fig. 12</b>), and a flat sponge rubber pad covered with soft leather was placed in the bottom of the socket to provide back pressure on the edematous tissue.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Case 3 Socket shape, present prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the patient had worn the prosthesis for six weeks, the edema in the redundant tissue had decreased markedly. The improvement was maintained over a nine month period, although at no time was the condition completely eliminated. About the ninth month, there was a sudden increase in the amount of edema. Three factors seemed to be involved. There was increased activity. A weaker valve spring had been installed to reduce loss of suction. And there had been stump shrinkage, as indicated by the experience of ramus discomfort. The thickness of the control pad was increased, but doing so did not alter the condition. Next, a stronger valve spring was provided to increase the positive pressure in the stance phase, and there was then a marked and immediate improvement in the edematous condition of the stump. To provide increased ischial weight bearing by reducing the anteroposterior dimensions of the socket, liners were added in the area of the socket contacting the femoral triangle. Although ischial weight bearing was improved, as evidenced by the elimination of ramus discomfort, there was no change in the edema.</p> <p>The decision was then made to provide the amputee with a socket that would make total contact with the stump end, thus exerting greater back pressure on the edematous tissue. After a four day trial period, the patient found that accumulated perspiration irritated the stump acutely, and the socket had to be discarded. At present the amputee continues to wear the first prosthesis provided and still has moderate edema.</p> <p>Skin infections initially present in the crotch area were cleared with provision of ischial gluteal weight bearing, but with stump shrinkage the condition recurred because of decreased effectiveness of such weight bearing. Provision of liners over the area of the socket contacting the femoral triangle increased the effectiveness of ischial gluteal weight bearing and reduced the skin problems. Throughout treatment, there was irritation on the weight bearing area of the stump, especially around the ischial tuberosity. Provision of a section of nylon stocking, fastened to the outside of the socket and draped interiorly over the weight bearing area, improved comfort considerably by reducing shear between the skin and the socket. The skin irritations were due primarily to excessive anteroposterior socket dimensions, especially along the medial wall. This situation allowed the tuberosity to slip into the socket and the entire stump to settle deeper, with consequent wedging of the stump against the posterior brim and the anterior wall, thus creating a high force concentration on the ischial tuberosity. A pressure pad was found very helpful in controlling edema when other elements of the fit were satisfactory.</p> <p>Minor skin irritations resulted from deterioration of the inside finish of the socket, but refinishing the socket cleared them.</p> <h4><i>Summary</i></h4> <p>Although treatment was never completely successful in eliminating this patient's edema, function and comfort were markedly improved, and the course of his prosthetic treatment served to demonstrate several principles. Provision of ischial gluteal weight bearing eliminated ramus discomfort, reduced edema, and cleared skin infections anteriorly and medially where the stump contacted the socket brim. The posterior brim caused irritation of the stump when ischial bearing was indefinite, with the tuberosity near the inside edge of the socket, or when the radius of curvature over the inside edge was too small, or when the ischial area was not conditioned for weight bearing. Use of liners to decrease the anteroposterior dimension increased comfort. When there was stump shrinkage and decreased ischial support, edema increased, and a pressure pad alone was not successful in controlling it. Use of a stronger valve spring, to increase the positive pressure, decreased edema. In spite of the failure to control the edema completely, the patient was able to perform at a high level of activity.</p> <h4>Case 6, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 6, male, was 56 years old, stood 6 ft. <i>2 </i>in. tall, and weighed 142 lb. He lost his right leg above the knee as a result of a motor coach accident when he was 47. The patient's first prosthesis, fitted six months after amputation, used shoulder harness suspension. It was worn for two years. The next prosthesis provided pelvic belt suspension. It was being worn when he entered the Clinical Study in November 1953 (<b>Fig. 13</b>). Complaints included tightness of the socket, discomfort due to abrasion of the hip by the belt on the side of the amputation, and irritation in the distal lateral area of the stump. The prosthesis was in a state of general disrepair.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Case 6 Original prosthesis. Weight carried on adductor roll. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>General health was good, and activity level was high both at home and at work. The stump was conical, with light subcutaneous tissue and very light musculature, muscular atrophy having been brought about by stump inactivity in the walking cycle. Tissue over the end of the stump was very thin. The lateral distal portion of the stump was scarred, and the ischial tuberosity was small, sharp, and lightly padded. Scars in the crotch area indicated periodic folliculitis and boil formation, and there was local pain posterodistally.</p> <p>A number of points were of interest in this case. They included a heavy adductor roll due to abducted gait and the plug fit; inexperience with suction suspension and ischial gluteal weight bearing; gait faults, including the abducted gait and pelvic hike on the side of the amputation; and the history of boils and folliculitis in the crotch due to weight bearing in that area (<b>Fig. 14</b>, <b>Fig. 15</b>, and <b>Fig. 16</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 14. Case 6, Relaxed position of stump prior to treatment </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15, Case 6. Adductor roll prior to treatment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Case 6. Triangular shape of original socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The amputee was provided with a suction socket prosthesis which included a single axis knee with constant friction swing phase control, a plantar dorsiflexion ankle, and a foot with a single toe break. Segments were willow wood reinforced with rawhide (<b>Fig. 17</b> and <b>Fig. 18</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Case 6. New prosthesis, with ischial gluteal weight bearing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Case 6. Shape of socket of new prosthesis </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the gluteus maximus was atrophied, the extensor channel and gluteal flare were fitted closely. No relief was provided for the heavy adductor roll, which was drawn completely into the socket as a part of the process of reduction. The socket perimeters at the brim of the socket were 3 in. less than stump dimensions. Two inches below the level of the ischial seat, socket perimeters were approximately half an inch less than stump dimensions. At the lower levels, socket and stump perimeters were identical. The distance from the ischial seat to the channel for the tendon of the adductor longus was 3 3/4 in., the corresponding anatomical measurement being 3 in.</p> <p>Adduction of the femur in the socket relaxed the adductors and permitted inclusion of the roll in the socket with less difficulty (<b>Fig. 19</b>). Initially a safety belt was provided to increase the amputee's sense of security, since he had a fear of losing the leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 19. Case 6. Condition of subject one year after application of new prosthesis. Note reduced adductor roll. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For the first three months of treatment the prosthesis was worn three hours a day. During the next six months use of the prosthesis was increased to all day, the extended period of adaptation to use of the prosthesis being due to discomfort at the ischial tuberosity. After nine months there was marked increase in comfort, a circumstance which induced the amputee to discard the cane he had theretofore used regularly. A soft pad over the ischial seat reduced discomfort but was discontinued after two weeks in the expectation that adaptation would be accelerated.</p> <p>Tight fit of the proximal third of the stump for reduction of the adductor roll resulted in edema in the distal portion of the stump. But when the socket perimeters in the upper third were increased to reduce constriction, the edema cleared up. Two weeks later the adductor roll had shrunk, and there was loss of suction. A new socket was made and modified with liners at intervals for a period of a month as shrinkage continued. By this time, the perimeter of the stump at the perineum had been reduced 2 1/2 in., so that a new socket was required. The dimension of this socket from the ischial seat to the channel for the tendon of the adductor longus was reduced by half an inch, and a protuberance was provided over the area contacting the femoral triangle.</p> <p>Edema recurred after six months, and examination of fit showed considerable development of the hamstring muscles. Accordingly, the socket was opened at the posterior wall starting 2 in. below the ischial seat level; the edema cleared up.</p> <p>Further development of stump musculature resulted in edema at the end of the stump during the ninth month of treatment. Increased hamstring relief was provided, a stronger valve spring was installed, and a sponge rubber pad was placed in the bottom of the socket to increase back pressure on the end of the stump. Again the edema cleared up.</p> <p>Training was provided for a period of one hour a day for six weeks. Gait was excellent under observation, although there was some reversion to old habits when the amputee was not under supervision. Pelvic hike was particularly persistent. Those habits which were dependent on fit and alignment, including abducted gait, were gradually eliminated.</p> <h5><i>Summary</i></h5> <p>Problems studied included stump changes, particularly at the large adductor roll, adaptation to suction suspension, adaptation to ischial weight bearing, and gait faults. Boils and folliculitis did not recur during the process of treatment.</p> <p>Reduction of the large adductor roll formed in five years of weight bearing in the crotch with abducted gait required six months of treatment. During this period there was some edema owing to constriction of the proximal third of the stump. Edema was reduced by increasing the perimeters of the socket in this region. Edema resulted again owing to constriction following hamstring hypertrophy.</p> <p>Relief for this development, the use of a stiffer valve spring for increased positive pressure in the stance phase, and a sponge rubber pad in the bottom of the socket cleared up the edema.</p> <p>There was periodic loss of suction following stump shrinkage. The light subcutaneous tissue could be distorted very little. As a result, slight stump changes led to loss of suction.</p> <p>Initially some lateral instability and reduced control of the prosthesis, probably resulting from weakness of the gluteus medius, was experienced. With adaptation to suction suspension, there was increased stability and control as the gluteus medius became stronger. Adaptation was completed within the nine months required to stabilize the stump. The ischial tuberosity took more than nine months to condition for weight bearing, chiefly because of the lack of previous experience, the light padding over the tuberosity, and the especially sharp configuration of the bone.</p> <h4>Case 8, Mid Thigh</h4> <h5><i>History</i></h5> <p>Case 8, another male, was 42 years old, measured 6 ft., and weighed 175 lb. His right leg was amputated above the knee in December 1949 after a shotgun wound received in a hunting accident approximately a year previously. He had had only one prosthesis since amputation and was wearing it at the time he was accepted by the Clinical Study in January 1954. Although the prosthesis provided suction suspension, the components were conventional. The patient was dissatisfied with the prosthesis primarily on the basis of poor fit, but he felt that the alignment could be improved and that such improvement might give him more comfort and better function. He also complained of needlelike phantom pains in the ball or sole of the "foot," with persistent tingling.</p> <h5><i>Examination and Evaluation</i></h5> <p>General physical examination was normal. The stump was conical (<b>Fig. 20</b>), approximately 9 in. of femur remained below the perineum, and about an inch of tissue covered the end of the femur. Musculature of the stump was firm, but there was retracted muscle on the lateral side about 2 1/2<i> </i>in. from the tip of the femur. There was little subcutaneous fat. On the posterior aspect of the stump at the distal end was an inverted T shaped scar, and the distal end of the femur was sensitive to pressure. X ray showed a medioposterior spur arising from the end of the femur, curving upward, and tapering. There was edema and brown discoloration at the end of the stump (<b>Fig. 21</b>), and small follicular lesions were evident in the areas contacting the anterior and medial brims of the socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 20. Case 8 Stump molded by tight fit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Case 8. Socket shape of original prosthesis. Note edema and brown discoloration at the end of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The prosthesis had a wooden socket reinforced with rawhide, a single axis knee with constant friction for swing phase control, an ankle providing plantar dorsiflexion action, and a foot with a single toe break 5 in. anterior to the ankle axis. Weigh t was carried through a roll of flesh at the brim of thesocket (<b>Fig. 22</b>), and the amputee walked with a wide based gait owing to crotch discomfort and out set of the foot. Knee stability was excessive because of the long forefoot and the posterior position of the knee axis, which fell approximately 1 in. posterior to the tro chanter ankle reference line. The prosthesis was short, but this detail was not too apparent since the ischial tuberosity was 1 1/2 in. above the posterior brim of the socket. Because of insufficient knee friction and excessive kicker action, there was heavy impact at the end of the swing phase, and there was whip during the swing phase, probably owing to muscle activity within the socket and to the vigorous stump action required to break the prosthetic knee at the end of the stance phase. Rotation at heel contact was due to excessive stiffness of the plantar flexion bumper.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Case 8. Original prosthesis. Plug fit, with roll formation over the socket brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Problems of interest to the Clinical Study included the edema encountered with use of suction suspension, skin infections, the adductor roll, the time and circumstances involved in conditioning the amputee to ischial gluteal weight bearing, and gait training.</p> <h5><i>Treatment</i></h5> <p>Reduction of the edema required reduced constriction of the proximal third of the stump through provision of ischial gluteal weight bearing, extension of the anterior wall above the level of the ischial seat, and close fit of the distal two thirds of the stump. Reduction of pressure on the proximal end of the stump from the superior brim of the socket was required to clear up skin infections. At the same time, snug fit, with adduction of the femur in the socket to relax the adductors, was required for reduction of the adductor roll. Improved fit and alignment, with training, were planned to correct gait faults.</p> <p>The amputee was provided with a suction socket prosthesis which included a single axis knee with constant friction swing phase control, a plantar dorsiflexion ankle, and a foot with a single toe break. Segments were of wood, reinforced with plastic laminate. The extensor channel was held shallow and flared minimally at the brim to increase gluteal weight bearing, since the amputee was not accustomed to ischial weight bearing. Xo relief was provided for the adductor roll. The anterior wall of the socket was slightly relieved over the area contacting the femoral triangle (<b>Fig. 23</b>). The toe break was cut 5 in. anterior to the ankle axis so as to coincide with the normal break of the shoe. To increase knee stability in the initial phase of the fitting, the knee axis was placed 3/4 in. behind the trochanter ankle reference line. Socket perimeters were 1 1/4 in.<i> </i>under stump perimeters at the proximal end and equal to stump perimeters at the level of the distal two thirds. The distance between the ischial tuberosity and the adductor longus tendon was 3 3/4 in., the corresponding socket dimension being 4 1/2 in.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Case 8 Socket shape, new prosthesis </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Evaluation following delivery of the prosthesis indicated that knee stability was excessive owing to the long forefoot and the posterior position of the knee axis. Training was required to improve balance and cadence symmetry and to overcome the vaulting as well as to reduce the width of the walking base. The ischial tuberosity was on the seat, and there was no ramus contact with the medial brim of the socket. The adductor roll was contained in the socket. Roll formation over the anterior brim of the socket was eliminated (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24 Case 8. New prosthesis. Note elimination of roll formation over the brim of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Initially there was some edema at the distal end of the stump owing to constriction proximally. As the flesh roll reduced, constriction and edema decreased, and finally the edema cleared up. After an illness which caused the patient to lose considerable weight, the stump settled deeper into the socket as the ischial tuberosity slipped inside. This circumstance allowed the ramus to contact the medial brim and caused the anterior and posterior brims to constrict the stump. But because the somewhat conical shape of both stump and socket maintained the snug fit over the entire stump as the latter settled down into the socket, and because, consequently, the pressure differential between the proximal and distal portions of the stump was not increased sufficiently, edema did not recur. Nevertheless, ramus discomfort decreased activity on the prosthesis. The problem was eliminated with provision of a new socket.</p> <p>Follicular lesions cleared up with effective ischial gluteal weight bearing but recurred when ischial support was decreased following loss of weight. Provision of a new socket with ischial gluteal weight bearing again cleared up the skin condition. With the first socket, poor stabilization of the ischial tuberosity on the seat contributed to skin irritation and to the formation of horny nodules in the weight bearing area. Comfort was greatly improved by reduced anteroposterior dimensions, with improved anterior support by provision of a protuberance on the anterior wall over the area contacting the femoral triangle.</p> <p>Gait training improved walking habits but focused attention on deficiencies of fit by forcing the amputee to walk according to a preconceived pattern rather than one that provided maximum comfort. Sixteen months after training was complete, evaluation indicated that, because of discomfort from loss of fit, gait was somewhat worse than before training. Since in any case the amputee adapted his gait pattern to provide maximum comfort, training was of doubtful value as compared with good prosthetic treatment. With the first prosthesis, excessive knee stability detracted from naturalness of gait, and this condition also was a factor in causing the discomfort in the ischial gluteal area and at the end of the femur anteriorly, where the stump showed the results of the force required to break the knee. Subsequent fit and alignment corrected these problems and greatly improved comfort. The length of the forefoot was reduced to approximately 3 1/2 in. to decrease knee stability, and the knee axis was placed on the ankle trochanter reference line.</p> <h5><i>Summary</i></h5> <p>The patient's edema on the prosthesis worn at the time of referral was apparently caused by constriction of the stump in the socket, especially in the proximal third. A contributing factor was weight bearing on the adductor roll over the medial brim. Provision of ischial gluteal weight bearing, with wide distribution of the pressure on the anterior aspect of the stump, had a number of consequences. The edema disappeared with the reduction of the adductor and anterior rolls and recurred only when fit and ischial support were lost with loss of weight from illness. Skin irritations in the crotch, along the gluteal fold, and around the ischial tuberosity were cleared up by reduction of shearing forces when positive support was provided. Reduction of alignment stability by shortening the toe break length and by moving the knee axis forward cleared up the skin irritation on the anterodistal aspect of the stump by reducing the force required to break the knee at toe off. Training appeared to have far less effect on symmetry of gait than did fit and alignment. When the patient was able to walk symmetrically with comfort, he did so. When last seen, the amputee reported a general increase in comfort and a corresponding increase in his level of activity.</p> <h4>Case 9, Bilateral Above Knee, Upper Third of Thighs</h4> <h5><i>History</i></h5> <p>Case 9, male, 27 years of age, weight 100 lb., underwent amputation at the age of eight as a result of crushing injuries to both legs sustained in a truck accident. He had had six pairs of legs since his amputation, the first pair having been fitted four months after surgery, without preliminary conditioning iherapy or exercise. That pair, employing shoulder harness suspension, was worn for four years. Between that time and 1948, he had had three sets of legs, all employing pelvic belt suspension and using conventional components. In 1948 he was fitted at the University of California with suction suspension. The prostheses were worn for two years and then discarded because of disrepair. New suction sockets, provided in 1950, were worn for two years. These were uncomfortable owing to tightness of fit. In 1953 a local limbshop fitted the patient with the suction socket prostheses he was wearing when referred to the Clinical Study in September 1953. The complaints included skin irritation with folliculitis, boils, and abrasion on areas of the stump contacting the socket brim; crotch discomfort; and edema in the ends of the stumps. Although working at essentially a sedentary occupation, he did a great deal of walking around his office.</p> <h5><i>Examination and Evaluation</i></h5> <p>There were no significant physical findings except as pertaining to the amputations. This young man was well nourished, healthy, and of average intelligence. The stumps were almost identical. They were approximately 6 in. long, measured from the perineum, and cylindrical, with approximately 2 in. of tissue over the distal ends of the femurs (<b>Fig. 25</b>). Hygiene of the stumps and prostheses was poor, perspira ation level high. There were boils, folliculitis, and abrasions on the stumps and the crotch areas, with boils and folliculitis in the inguinal creases. Both stumps had heavy, nonpitting edema and petechiae at the distal ends. The stumps were held in 28 deg. of abduction, but ranges of motion and muscle power were normal and equal. X ray showed medial curvatures of both femurs distally. The medullary cavities appeared to be closed, and there were no sensitive areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Case 9. Stumps relaxed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The prostheses (<b>Fig. 26</b>, <b>Fig. 27</b>, and <b>Fig. 28</b>) had rectangular suction sockets on single axis knees with constant friction swing phase control, plantar dorsiflexion ankles, and wooden feet with single toe breaks. Segments of the prostheses were made of willow reinforced with rawhide. No auxiliary suspension or control straps were used. Although the sockets were intended to provide ischial gluteal weight bearing, the ischial tuberosities were down inside the sockets so that weight was carried on the medial brims, which had been lowered in an unsuccessful attempt to provide relief, with severe wedging of the stumps against the anterior and posterior brims. This situation was a cause of irritation and infection of the stumps in the areas contacting the medial and posterior brims of the sockets and promoted edema by restriction of circulation. Excessive alignment stability due to posterior placement of the knee axes increased forces on the posterior aspects of the stumps as the amputee attempted to break the knees to initiate swing phase.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Case 9. Socket shape of prostheses worn at time of referral, medial walls nearest patient's hands. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Case 9. Prostheses worn at time of referral, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 28. Case 9. Pros theses worn at time of referral. posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient walked with a wide based gait, at least partially because of the abducted position of his stumps. He customarily used a cane but was able to walk without it. Because the amount of friction in the swing phase control units was adjusted to provide minimum resistance to rotation, there was impact at the end of the swing phase. Rotation at heel contact was due to excessive stiffness of the heel bumper of the left prosthesis. Torso and pelvic list were due to shortness of the right prosthesis.</p> <h5><i>Treatment</i></h5> <p>The objectives of treatment in this instance were:</p> <ol> <li>Elimination of crotch discomfort and skin problems by providing definite ischial gluteal weight bearing ;</li><li>Elimination of irritation and follicular lesions in the inguinal areas by reducing force concentrations in these areas through use of high anterior walls and definite ischial gluteal weight bearing;</li><li>Reduced wedging of the stumps proximally through provision of definite ischial gluteal weight bearing and high anterior walls for increased area of support;</li><li>Close fit oi the slumps along their entire lengths, with decreased wedging of the stumps proximally, for reduction of the edema;</li><li>Reduction in energy consumption by providing increased voluntary control with flexion of the stumps in the sockets and reduced alignment stability; and</li><li>Study of the effect of narrow and wide base alignment on lateral stability, within the limits imposed by the abducted positions of the stumps.</li></ol> <p>In March 1954, the patient was provided with two suction socket prostheses (<b>Fig. 29</b>). A light webbing belt was furnished to aid suspension. Single axis constant friction knees, plantar dorsiflexion ankles, and wooden feet with rocker toe breaks and foam crepe shoe sole material in the toes were used. The prostheses were reinforced with rawhide, the inside surfaces of the sockets were finished with cellulose acetate lacquer, and automatic expulsion valves with standard springs were used. For knee stability, the reference line joining the ankle axis to the point of contact of the greater trochanter passed 1 in. ahead of the knee axis on both prostheses. The ankles were provided with stiff plantar flexion bumpers to increase anteroposterior stability.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Case 9. Present prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Within approximately a month from the time of fitting the initial prostheses, there was substantial improvement in comfort and skin problems in the crotch areas. The medial brims were not appreciably lower than the posterior brims. Skin problems in the inguinal creases were relieved by ischial gluteal weight bearing, by high anterior walls, and by provision of a protuberance over the region of the femoral triangle (<b>Fig. 30</b> and <b>Fig. 31</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Case 9. Socket shape, present prostheses. Ischial seats are at bottom center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Case 9. Present prostheses, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Provision of ischial gluteal weight bearing and increased anterior support resulted in reduced wedging of the stumps proximally, and a close fit of the stumps over their entire length produced a prompt and marked reduction in edema. Irritation in the weight bearing area was a persistent problem in the early stages of fitting. At one point, the amputee had the sockets modified in a commercial limbshop in an attempt to relieve this discomfort. But these changes increased the anteroposterior adjusted to dimensions of the sockets medially in the upper third. The tuberosities slipped into the sockets, and edema recurred. New sockets were fitted to re establish ischial support. Irritation and discomfort in the area of the tuberosities disappeared after approximately two months of conditioning. Ischial gluteal weight bearing raised the stumps in the sockets and decreased voluntary control, but after four months the patient became this change. It was found that he could walk with adequate control and stability when using stiff plantar flexion bumpers, with the ischial seats well behind the projected lines through the ankle and knee axes, and with initial flexion of the stumps for voluntary control (<b>Fig. 31</b>). Because of long established habits of abduction, it was necessary to provide wide base a lignment of the second pair of prostheses. At the time of the final evaluation, the stumps were in excellent condition.</p> <h5><i>Summary</i></h5> <p>The patient's problems of edema and skin irritation in the areas of the crotch, the inguinal creases, and the gluteal folds responded well to the standard principles of fitting. Irritation in the weight bearing area was a temporary problem which cleared up with tissue conditioning. A wide walking base was required in this case for lateral stability. The stiff plantar flexion bumpers provided anteroposterior stability both standing and walking. Placement of the sockets well forward on the knees provided adequate security.</p> <h4>Case 10, Very Short Above Knee</h4> <h5><i>History</i></h5> <p>Case 10, male, was 51 years of age, weighed 150 lb., and was 5 ft. 7 in. tall. Amputation was through the left femur in the upper third. The original amputation had been carried out in December 1952 as a result of arteriosclerosis, and the stump had been revised in August 1953.</p> <p>This patient was referred by a local limb shop that was in the process of fitting him with a pelvic belt prosthesis converted from a suction socket because of failure to maintain suction. He was pessimistic about the use of suction suspension and was unwilling to attempt it except for the benefit of the research group. Because of pressure in the groin, insecurity at the knee, toe scuffing in the swing phase, and stump withdrawal when sitting, he was dissatisfied with the leg being fitted by the local shop.</p> <h5><i>Examination and Evaluation</i></h5> <p>Physiologically, the patient appeared older than his age, but he was alert and cooperative. The abdomen was severely scarred from surgical incisions for appendectomy and double sympathectomy, and scars also extended from the distal end of the stump up the antero medial aspect to mid groin. The medial scars were deeply adhered to underlying tissue. Subcutaneous fat was moderate and musculature firm, with prominent adductors and gluteus maximus. There were no sensitive areas. Skin was normal. The femur extended 1 1/2 in. below the perineum and 7 in. below the great trochanter (<b>Fig. 32</b> and <b>Fig. 33</b>). A spur extended upward on the medial side, and the stump showed some abduction contracture.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Case 10. Lateral view of the stump in the hanging position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Case 10. Stump in 90 deg. of flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This patient was of interest primarily because of the very short stump. Also of interest was the patient's inexperience, which offered an opportunity to study problems of adaptation and stump changes. Experience in prosthetic treatment of cases with circulatory impairment was also desired.</p> <h5><i>Treatment</i></h5> <p>The patient was provided with a suction socket prosthesis. At first a single axis knee with constant friction swing phase control, a plantar dorsiflexion ankle, and a foot with single toe break were used. Segments were of wood, reinforced with plastic laminate. Later the knee was changed to a friction stabilized type. The final socket was made of plastic laminate, and a SACH foot (solid ankle, cushioned heel) was used instead of the conventional foot.</p> <p>Two sockets were fitted within the first two months. With the second socket, all requirements for the successful application of suction suspension had been met, but, because of obscuring factors related to the amputee's attitude, this condition was not altogether understood at the time. A remolding process had brought about elongation of the stump, a feature which made suction easier to maintain.</p> <p>Successful application of suction suspension depended upon undercutting the posterior, medial, and anterior walls of the socket below the ischial seat level, maintaining the lateral wall above the level of the ischial seat, and holding the fit close in the proximal part of the stump. Because of the undercut medial wall, bunching of the adductors did not break the suction. Suspension aids, valuable in providing increased sense of security in the initial phase of treatment, were unnecessary once the amputee was adapted to the use o'f his prosthesis. Because of the limited amount of femur available, and also because of the abducted position of the stump, no attempt was made to adduct the femur in the socket. Flexion of the stump in the socket was designed to meet the natural requirements of the stump and spine rather than to provide voluntary control of the knee, since stump power was limited and undercutting of the anterior and posterior walls of the socket reduced the effectiveness of the stump in controlling the knee (<b>Fig. 34</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Case 10. Rectangular socket provided for patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Initially the patient was provided with a conventional single axis knee with adequate knee stability. Fear of falling and buckling of the prosthetic knee due to weakness of the normal leg, inexperience, and other factors, however, led to use of a friction stabilized knee. But aligning the friction stabilized knee in accordance with the rules for the single axis conventional knee resulted in excess stability at the end of the stance phase. Accordingly, the knee was later aligned to provide decreased alignment stability with greater reliance on the friction mechanism.</p> <p>Although narrow based gait was not anticipated in the alignment of the limb, the amputee was able to walk with a 4 to 6 in. base. The prosthesis was made about 1 1/2 in. shorter than the normal limb (<b>Fig. 35</b>) because the amputee found that the shorter prosthesis permitted better control. Before prosthetic treatment started, the patient had back pains, and it was anticipated that the shorter leg might lead to recurrence. As a matter of fact, he had some recurrence of the back pains early in the fitting when a webbing belt was tried as a supplement to suction suspension. But this problem disappeared when use of the belt was discontinued.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Case 10. New prosthesis, posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Stump changes during the study were minimal. In the first two and a half months, stump shrinkage occurred, but the stump remained stable throughout the following two years of observation. After the patient had worn the first suction socket prosthesis a short time, the tissue of the stump started to extend, so that by the time the stump had stabilized there was an increase from 1 1/2 in. to 3 in. of tissue available below the perineum for effecting a suction seal. At no time was there more than a reddening of the stump in the weight bearing area, and, as the tissue became conditioned, the skin became dark and tough. There was no edema.</p> <h5><i>Summary</i></h5> <p>The problem in this case was to attempt application of suction suspension to a very short, heavy, above knee stump. Suction proved to be a practical means of suspension. All walls were concave, and relief was provided for bunching adductors to prevent the stump from being forced away from the socket in the medial apexes with consequent failure of the suction seal. For increased control and reduced effort, the amputee preferred the prosthesis approximately 1 1/2 in. shorter than the normal leg. There were no back pains. The stump shrank slightly during the first two months, and there was elongation of the stump, particularly on the medial side. Because of insufficient knowledge for adequate prosthetic treatment of the patient, and because of the poor adjustment of the patient to his amputation and physical condition, rehabilitation was a lengthy process. Once the patient was successfully treated, no changes in fit and alignment were required over a two year period.</p> <h4>Case 24, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 24, female, was 41 years of age, stood 5 ft. 2 in. tall, and weighed 126 lb. She had undergone amputation at the level of the lower third of the left femur. There had been a congenital lymphangioma involving the tissues of the left leg from the knee down. Infection developed in the soft tissues over the anterior portion of the tibia, and subsequently there was an osteomyelitis of the tibia. Later a mass, which was diagnosed as carcinoma, appeared in the ankle. Amputation was performed in May 1954.</p> <p>The amputee had had only one prosthesis since amputation. It consisted of conventional components and a molded leather socket laced anteriorly (<b>Fig. 36</b>). When she entered the study program in January 1955, complaints included skin irritation and infection, with discomfort in the crotch, discomfort and restriction from the corset used to suspend the prosthesis, right sided backache, and excessive wear of hosiery.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Case 24. Prosthesis worn on referral. Note lateral displacement of the socket on the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>Normally a very active person, the patient had a rather low activity level owing to limitations imposed by her prosthesis. General physical condition was good, except for very flabby abdominal musculature, but the patient experienced phantom sensations as though the "leg" were "falling asleep." Phantom pains in the form of cramps in the ''calf" and shooting pains on the medial side of the "ankle" also were present. They lasted only a few seconds and were less frequent since she had been fitted with a prosthesis.</p> <p>The stump was cylindrical and 9 in. long measured from the perineum, including approximately 2 in. of redundant tissue over the end of the femur. Subcutaneous tissue was heavy but firm. Musculature was of average strength, with no group particularly prominent. There was no significant edema or skin problem in the distal end of the stump, but follicular lesions existed in the crotch, and areas of irritation were present on the torso from pinching and bruising by the corset stays.</p> <p>The prosthesis provided weight bearing on a flesh roll around the brim of the socket, in the crotch, and against the side walls of the socket (<b>Fig. 37</b> and <b>Fig. 38</b>). A pressure pad in the bottom of the socket did not provide appreciable support, and the patient walked with a wide base and with torso and pelvic list owing to excessive length of the prosthesis, wide base alignment, and discomfort in the crotch. Stride length, cadence, and arm attitude were unsymmetrical because of excessive stability of the prosthetic knee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Case 24. Socket shape at the brim, prosthesis worn on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Case 24. Lateral view of the stump in the hanging position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This amputee presented several problems of interest to the study group. They included skin infections, the relationship between redundant tissue at the end of the stump and edema with suction suspension, factors involved in changeover from corset to suction suspension, factors involved in changeover to ischial gluteal weight bearing, stump changes, the cosmetic problems of a female amputee, and use of the SACH foot with high heeled shoes.</p> <h5><i>Treatment</i></h5> <p>In September 1955, the patient was provided with a suction socket prosthesis consisting of a single axis constant friction knee, a SACH foot made for a high heeled shoe, and wooden segments reinforced with plastic laminate. An automatic expulsion valve with standard spring was used, and the inside surface of the socket was finished with phenolic resin varnish. A polyvinyl chloride acetate cosmetic cover was provided for the shank. Since the amputee was unaccustomed to ischial weight bearing, and also in order to increase sitting comfort, the gluteal flare and the extensor channel were fitted closely to provide increased gluteal support. The lateral wall was closed in over the stump above the ischial seat level, and the anterolateral apex was closed to reduce conspicuousness of the brim of the socket under the clothing.</p> <p>This socket was worn on the adjustable leg<a></a> for approximately a month and was then installed in a finished prosthesis. After a week, the redundant tissue at the end of the stump was moderately edematous. The only known difference between the prosthesis with the adjustable leg and the finished prosthesis was that the latter had five coats of "Platon" varnish on the inside of the socket. There were three possibilities related to the finish of the socket interior. The stump worked down into the socket through weight bearing, with increased effect of muscle activity on negative pressure and reduced positive pressure in the stance phase owing to reduced excursion of the stump in the socket. There was adherence of the stump to the walls of the socket and, hence, reduced massaging action at the distal end. Vacuum seal was improved so that negative pressure was maintained, especially during sitting.</p> <p>The edema cleared up after provision of a pressure pad in the bottom of the socket and after atrophy of the stump, which reduced constriction proximally. In addition there was, as a result of aging and lubrication of the surface finish by body oils, decreased adherence of the stump to the socket. Addition of liners to compensate for shrinkage did not cause edema with this socket.</p> <p>A second prosthesis was supplied in December 1955, the socket of this limb being fitted snugly in anticipation of further shrinkage of the stump. Six weeks after delivery of the prosthesis, examination showed edema at the end of the stump. A pressure pad was provided, but there was no reduction in the edema during the next two months. Pad thickness was then increased. When the amputee was examined next, six weeks later, the pad had been discarded owing to ineffectiveness in controlling the edema. Edema was reduced, and the stump had atrophied further. This development had reduced constriction of the proximal portion of the stump without reducing the effectiveness of ischial support, thus indicating that edema was caused by constriction of the proximal area and that the pressure pad was ineffective in reducing it so long as constriction persisted proximally. Six weeks later there was no edema, and the socket was looser. Liners were installed over the anterior and posterior walls to decrease perimeters of the socket in the upper third by one inch. Edema did not recur. Socket perimeters proximally were reduced another inch two months later as a result of stump atrophy. There was no edema before or after addition of the liners, and at no time was there failure of ischial support.</p> <p>The patient adapted very well to the changeover from corset to suction suspension and appreciated the comfort and freedom that resulted. Control of the prosthesis was excellent. Adaptation to ischial gluteal weight bearing was immediate, and skin lesions and discomfort in the crotch cleared up quickly. The shallow gluteal flare and extensor channel, with relief for hamstring attachments at the ischial tuberosity, provided sitting comfort. As the stump atrophied, proper weight bearing was maintained effectively by the addition of liners to the anterior and posterior walls of the socket as necessary (<b>Fig. 39</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Case 24. Socket shape, new prosthesis. Note liners added for shrinkage adjustment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Stump atrophy due to heavy subcutaneous tissue was a problem, and the stump had not stabilized at the end of a year. It was found that initial fitting of the socket snugly, in anticipation of shrinkage, was satisfactory practice and did not produce a serious amount of edema. Such edema as was produced subsided as stump atrophy proceeded. As further shrinkage occurred, liners were added without complications.</p> <p>Closing the lateral wall over the stump above the ischial seat level and curving the anterolateral apex improved appearance of the prosthesis under clothing. The SACH foot provided a good cosmetic junction between the shank and the foot and permitted use of high heeled shoes. The polyvinyl acetate cosmetic covers used were sufficiently durable (<b>Fig. 40</b>) and were acceptable in appearance until they become discolored. Staining was objectionable within about six months.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 40. Case 24. Anterior view of new prosthesis with cosmetic covering. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the cosmetic effect of the SACH foot was appreciated by the amputee, there was objection to the decreased plantar flexion action and to the damage this caused to spike heeled shoes. As a result, the patient requested a foot with an articulated ankle. It was found that the decreased plantar flexion action was a problem down ramps only.</p> <h5><i>Summary</i></h5> <p>In spite of the excessive amount of redundant tissue at the distal end of the stump, it was possible to use successfully suction suspension embodying the principles and techniques previously outlined. Problems of edema, skin changes, and loss of suction that occurred during fitting and wearing of the prosthesis were successfully treated by controlling the fit and alignment. Proper fit and alignment were instrumental in promoting stump reduction to a more firm and functional state and in eliminating skin lesions and discomfort in the crotch due to the heavy subcutaneous tissue and steady stump reduction. With a properly fitted suction socket prosthesis, the patient was able to assume a more satisfactory level of activity without discomfort, and it was possible without difficulty to adapt this type of prosthesis to the requirements of cosmetic appearance. Foot and ankle function were suitable for use with high heeled shoes, but frequent examinations and modifications to socket fit were required to maintain comfort.</p> <h4>Case 28, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 28, male, age 62, height 5 ft. 11 in., weight 121 lb., underwent amputation in the lower third of the left femur in June 1955 following circulatory failure. When he entered the Clinical Study in August 1955, he was wearing a plaster socket on a peg leg with shoulder harness suspension. He disliked the peg leg because of its appearance and because of discomfort in the crotch. Activity level postoperatively was very much less than prior to amputation and was a matter of great concern to the amputee, who had just retired to a small farm.</p> <h5><i>Examination and Evaluation</i></h5> <p>The amputee's physiological age was in advance of his chronological age. The stump was 11 in. long and cylindrical, with light subcutaneous tissue, average musculature considering the age of the patient, and full range of motion at the hip (<b>Fig. 41</b>). The end of the femur was adequately covered and tolerated considerable pressure. At the end of the stump there was persistent, mild pain not related to use of the temporary prosthesis, and there were diminishing shooting phantom pains. X ray showed a spur on the lateral distal end of the femur. Postoperative edema was slight. The plaster socket on the pylon leg had been furnished to aid in reducing the stump. As shrinkage proceeded, the number of stump socks used had been increased to adjust for it. Considerable stump shrinkage had occurred, a circumstance which, despite the added stump socks, allowed the stump to drop into the socket. Severe crotch discomfort was present, since ischial weight bearing was not used. The amputee walked with a circumducting gait, stride length on the prosthesis was shorter than that on the normal side, there was rotation around the pylon in stance phase, gait was abducted, and one cane was used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Case 28. Stump in abduction, slack tissue on medial side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of interest to the research group were the effects of the temporary plaster socket and the peg leg, stump changes, the rate of rehabilitation of the amputee, and evaluation of suction suspension on an elderly amputee with circulatory deficiency.</p> <h5><i>Treatment</i></h5> <p>The patient was provided with a suction socket prosthesis which included a willow socket, a variable cadence friction controlled knee, a willow shank, and a SACH foot (<b>Fig. 42</b> and <b>Fig. 43</b>). Wooden segments were reinforced with plastic laminate, and the socket was finished inside with a phenolic varnish. The extensor channel was shallow, and there was minimal gluteal flare to ensure as much gluteal support as possible (<b>Fig. 44</b>). The anterior wall protruded over the area contacting the femoral triangle starting at the anterior brim and extending downward to a point one third the distance down into the socket. Evaluation of the finished prosthesis indicated that the forefoot was too long and that there was insufficient initial flexion of the stump in the socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Case 28. Lateral view of new prosthesis. Note amount of initial flexion of the stump, as indicated by the angle between the shank and thigh sections Note also extension of the gluteus maxi mus over the brim of the socket, indicating weight bearing on the tendinous hamstring attachments. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 43. Case 28. Posterior view of new prosthesis providing ischial gluteal weight bearing and narrow based alignment. Knee is friction stabilized. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Case 28. View of the crotch area of the stump and of the socket brim of the new prosthesis. Note the distance between the level of the ischial tuberosity and the very prominent tendon of the adductor longus. Note also the corresponding socket dimension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At first the amputee found it difficult to don the prosthesis, partly because of his age and partly because of the snugness of fit, which was intended to aid in stump reduction. The difficulty decreased as the patient became more accustomed to the limb and as snugness was reduced with stump shrinkage. Because of the patient's age and physical condition, it was necessary to maintain a comparatively low activity level during fitting and training, a matter which resulted in minimum discomfort or abrasion of the skin from impact between the stump and socket. The single axis knee offered sufficient stability under normal circumstances, but the amputee felt insecure at such activities as gardening. As a result, he was provided with a friction stabilized knee, and alignment stability was reduced. Initial indications were that the friction stabilized knee was an advantage, especially at heel contact. More supervision during fitting and training was required than is usually the case with younger amputees. Suction suspension offered good control, but had the patient been weaker this method of suspension might not have been practical because of the difficulty of putting the leg on.</p> <p>Gait evaluation showed two faults. One, circumduction of the prosthesis, was probably carried over from the peg leg. The other, which consisted of stepping from the prosthesis to the normal leg as soon as the resistance of the prosthetic forefoot was felt, may also have been related to the use of the pylon. Training reduced but did not eliminate these characteristics of nonsymmetrical gait.</p> <p>There was consistent stump shrinkage over the first six months of treatment. The initially snug fit of the socket was of limited significance since shrinkage was extensive. Addition of liners as the stump shrank was a successful means of maintaining fit, although it eventually affected alignment. Most extensive shrinkage occurred in the proximal third of the stump. Postoperative edema was not a significant factor, nor was stump hypertrophy. To avoid excessive enlargement of the socket during adjustments, it was necessary to apply a shrinker bandage before prosthetic treatment was started.</p> <p>There were no fitting problems related to the limited time lapse between amputation and prosthetic treatment. Adaptation was rapid, and the cane used with the plaster pylon was discarded before delivery of the permanent prosthesis. Use of the prosthesis as part of the reduction treatment introduced the difficulty of frequent examinations and adjustments but was less troublesome and more effective than applying the shrinker, especially at the proximal end of the stump, which the amputee found difficult to wrap properly.</p> <p>At no time were there skin or circulatory problems with suction suspension, but initially there was moderate discoloration at the distal end of the stump owing to the snugness of fit at the proximal end. Loss of suction, a matter related to the lightness of the subcutaneous tissue, was a frequent problem. Only a small amount of stump shrinkage produced loss of suction, since the amount of tissue distortion possible prior to shrinkage was limited, which is to say that stump fit had to be maintained close to optimal at all times.</p> <p>Some end bearing was provided on a pad of foam crepe shoe sole material in the bottom of the socket. When end bearing was increased periodically as the stump dropped deeper into the socket with stump shrinkage, the stump end became sensitive and even painful.</p> <h5><i>Summary</i></h5> <p>Problems studied with this amputee included those involving his age, his experience on the peg leg, stump changes, rate of rehabilitation, use of suction suspension where there had been circulatory impairment, and training. Prosthetics treatment was more time consuming, but stump discomfort was not a problem since activity level was low. At first the patient found the leg hard to put on, but this problem was overcome with practice. Fitting and training schedules were less strenuous than would be followed with a younger amputee. Use of the friction stabilized knee increased the amputee's confidence, and voluntary control was thus improved because it was possible to provide more flexion of the stump in the socket. Use of the temporary prosthesis with plaster socket and peg leg attachment introduced gait problems which could not be eliminated entirely, but the plaster socket was effective as a means of reducing postoperative edema. There was, for example, almost no postoperative edema when treatment was started. It was therefore not a problem. Suction suspension caused no circulatory difficulties.</p> <h3>Case 37, Very Short Above Knee</h3> <h5><i>History</i></h5> <p>Case 37, male, age 39, height 5 ft. 11 in., weight 180 lb., underwent amputation through the right femur, 1 1/2<i> in.</i> below the perineum, as a result of an injury sustained in World War II. At various times, but without success, attempts had been made to fit him with above knee prostheses, including suction (<b>Fig. 45</b>) and belt suspension. These circumstances led to a proposal by the referring agency to have the patient fitted as a hip disarticulation case using the Canadian type of prosthesis.<a></a> A plaster cast check socket had been fitted as a preliminary, with apparent success.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Case 37. Unsuccessful suction socket worn on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>The stump, though short, was powerful, and the end of the femur was covered by approximately 1 in. of muscle padding. Subcutaneous tissue was fairly heavy. The ischial tuberosity was broad and well padded, but there was pressure sensitive scar tissue on the lateral side of the stump and in the crotch (<b>Fig. 46</b>, <b>Fig. 47</b>, and <b>Fig. 48</b>). The distal end of the stump tolerated considerable pressure but, because of a trigger point on the anterodistal aspect, it was unsatisfactory for end bearing. Abduction and flexion contracture of the hip was typical of an above knee amputee with a short stump. Because of the habit of extending the knee when crutch walking, a practice which had reduced extensor control at the knee, the normal knee buckled occasionally under load in the flexed position. A triple arthrodesis of the normal ankle was an additional complication.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Case 37. Posterior view of stump. Note scar on posterolateral apex. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 47. Case 37. Anterior view of stump. Note scars in crotch and on lateral side of anterior aspect. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Case 37. Lateral view of stump in maximum flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The problem presented was how to fit an amputee who was on the borderline between the above knee case and the hip disarticulation. Were the patient fitted as a hip disarticulation, there would be loss of stump function, and, since the amputee lived in a hot summer climate, the socket would present a particularly acute heat problem. Joint placement with the hip disarticulation prosthesis would also be a problem, since, when the stump was flexed, it extended 2 in. ahead of the usual anterior contour for a hip disarticulation amputee.</p> <p>An above knee type of prosthesis offered the advantage of preserving stump function, particularly where suction suspension could be used effectively, since with the use of suction there is reduced excursion and piston action of the stump in the socket. At the same time, the shortness of the stump, with the reduced area for effecting a suction seal, and the large volume change in the stump between the relaxed and the tensed states, accompanied by prominent bunching of the adductors, could cause difficulty in achieving a reliable suction seal. Moreover, the possibility existed that the close fit required could cause discomfort to the sensitive scar tissue in the crotch.</p> <p>It was decided to treat this patient simultaneously as an above knee and as a hip disarticulation amputee, first to check the possibilities of using suction suspension on such a short stump and, second, to check the Canadian hip disarticulation prosthesis as a method of treating very short above knee stumps. The amputee was successfully fitted with a plaster hip disarticulation check socket and walked for two hours with a peg leg attached. The socket constructed from this check socket would have provided sufficient clearance for installation of the hip joint, but the hip disarticulation fitting was discontinued at this stage because of success achieved with suction suspension.</p> <p>Within five days of the beginning of treatment the subject walked successfully on the adjustable leg using suction suspension. The first socket failed from loss of suction through the posterolateral apex because the socket had been enlarged in this area in an attempt to compensate for the action of the gluteus maxi mus, which tended to force the stump away from the socket. The second socket, modified in view of lessons learned from the first, held suction and was comfortable (<b>Fig. 49</b>). It was provided in a finished prosthesis. A short above knee pelvic harness, as designed at the University of California (<b>Fig. 50</b>), was added to assist in swing phase control and to maintain the prosthesis on the stump in the sitting position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Case 37 Successful suction socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Auxiliary suspension for short stump above knee amputee (modified Silesian belt), as designed at the University of California. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Components incorporated into the finished prosthesis included a SACH foot, a wooden shank reinforced with plastic laminate, a friction stabilized knee, and a wooden socket providing definite ischial gluteal weight bearing. The tuberosity was located on the posterior edge of the seat, so that considerable weight was carried on the tendinous hamstring attachments, and the gluteal flare was fitted close to provide some gluteal support and to ensure a suction seal. The medial brim was held level with the posterior brim, while the anterior brim extended 2 1/2 in. above the ischial seat level. The socket protuberance into the area of the femoral triangle did not extend below the level of the ischial seat, and the lateral brim was held at the same level as the anterior brim. To aid in effecting a suction seal, the perimeter of the socket was enlarged below the brim level. The concavity of the anterior wall started 1 in. above the level of the ischial seat and extended downward, while the concavity of the lateral wall was above the ischial seat level. Concavity of the medial wall below the brim provided room for the prominent adductors, so that suction was not lost when the stump was tensed. At the brim, the socket perimeter was approximately 3 in. less than the stump perimeter. Alignment stability was reduced, inasmuch as a friction stabilized knee was provided.</p> <p>The short stump harness was successful in preventing loss of suction during sitting, the leg adhered firmly with tensing of stump musculature when the amputee walked, and there was no ramus discomfort. The scar in the crotch proved to be no problem in fitting and was not a source of discomfort. Except for a mild discomfort in sitting, which resulted in stretching of the skin, especially while sitting in soft seats, there was no discomfort from the posterior brim of the socket. Gait was satisfactory using one cane.</p> <p>Examination one month after treatment. was begun showed little change in the stump since the initial examination; it had simply elongated about 1/2 in. on the medial side. The ischial tuberosity tolerated weight bearing without difficulty, and the skin over that area was somewhat toughened. No edema, skin abrasion, or skin infection was evident. Six weeks after treatment started the amputee used the leg all day with one cane, but at a low activity level. Buckling of the normal knee was reduced as a problem when use of the knee increased with improved physical condition.</p> <p>Five months after treatment started the amputee wore the prosthesis from rising to retiring, and the stump was in excellent condition. Activity level was average, considering the level of amputation. One cane was used, although the patient was able to walk without it. There was some brownish discoloration in the weight bearing area. Stump shrinkage was not noticeable, and there was no further elongation of the stump. The tuberosity was firmly supported on the ischial seat, and there was no crotch discomfort, although there was slight skin irritation in the crotch due to roughness of the socket finish. The amputee considered the socket comfortable but wanted the leg lengthened. The rough area on the medial brim was covered with "Teflon" tape in an attempt to reduce friction. Elongation of the prosthesis by 5/8<i> </i>in. resulted in an improved gait appearance.</p> <h5><i>Summary</i></h5> <p>The problem in this case was to define prosthetic requirements correctly. Suction suspension with the above knee type of prosthesis, in conjunction with the short stump pelvic harness, was successful and, since it preserved usable function of the stump, seemed to offer for this amputee a method of treatment to be preferred over the hip disarticulation prosthesis. Difficulties encountered were minimal owing to the previous experience gained with Case 10 (page 64).</p> <p>Gait, more natural with the use of one cane, improved markedly over the five months of study. Weight bearing on the gluteus maxi mus, ischial tuberosity, and tendinous attachments of the hamstring musculature was satisfactory. Use of the high anterior wall, without a protuberance of the socket wall over the area in contact with the femoral triangle, except above the ischial seat level, was satisfactory. For retention of suction, it was necessary to make all walls of the socket concave, especially below the medial brim because of bunching of the adductors.</p> <h3>Conclusion</h3> <p>From working with a group of amputees such as has been reported here, or from work with any similar group, many lessons are to be learned. One of the most obvious is that considerable "tincture of time" is required to solve chronic problems. The hope is that, as a result of the considerable amount of time devoted by a relatively small group of research subjects at the University of California, prosthetics clinic teams will gain some insight into possible methods of solving the problems of many other amputees.</p> <p>The most common prosthetic problems of above knee amputees as a group are edema, formation of an adductor roll, discomfort in the perineum (ramus pressure), and skin lesions. It has been found possible to control edema by maintaining a relatively uniform contact pressure between stump and socket. The proximal third of the socket need be fitted only slightly tighter than the more distal areas while still maintaining an airtight seal. In the case of an edematous stump, it is important to recognize the necessity for skillful application of socket liners to maintain a functional socket fit as the edema is reduced. Such liners are usually applied along the anterior and lateral walls only.</p> <p>The adductor roll which typically occurs with plug fit requires considerable time before the change can be made to an efficient, well fitting suction socket. Almost without exception, such a condition requires a second socket to complete the fitting.</p> <p>Ramus pressure is a thing of the past. Use of the higher anterior brim and the proper anteroposterior dimension from Scarpa's triangle to the posterior brim will eliminate completely this most troublesome complaint of above knee amputees. No longer need the above knee amputee suffer in silence because he just naturally expects his leg to be uncomfortable in this area.</p> <p>Provision of an efficient supporting surface along the posterior brim of the socket and of a proper fitting of the lateral wall of the socket to provide femur stabilization will relieve common areas of skin irritation, such as at the anterior brim, at the ischial seat, at the medial brim, and at the lateral distal end of the stump. The most common sources of skin difficulties are poor stump hygiene or rubbing and abrasion. Abrasion can be minimized by a functional fitting of the socket.</p> <h3>Acknowledgments</h3> <p>The group that worked on the patients presented in this article comprises in fact the whole staff of the Lower Extremity Amputee Research Project. Even more than amputee treatment must be, this study has been the product of many minds and many labors. Particular mention should be made of the staff members who were especially concerned in the study of the patients here reported. Dr. Henry E. Loon, Coordinator of the Medical Division, served as medical consultant to the group through much of the work. Jack C. Bates, Prosthetic Specialist, served in the vital function of trainer, in addition to making all arrangements with patients. And Jim C. McKennon and William H. Hoskinson served as prosthetists and faced the task of interpreting the plans of the research group as fully as possible to the patients in the fitting room.</p> <p><b>References:</b></p> <ol> <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 Human limbs and their substitutes, McGraw Hill, New York, 1954.</li> <li>Foort, J., and C. W. Radcliffe, <i>The Canadian types hip disarticulation prosthesis</i>, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Prosthetics Research Board, National Research Council, March 1956.</li> <li>Radcliffe, C. W., <i>Use of the adjustable knee and alignment jig for the alignment of above knee prostheses</i>, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</li> <li>Radcliffe, Charles W., <i>Mechanical aids for alignment of lower extremity prostheses</i>, Artificial Limbs, May 1954.</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, 1954.</li> <li>Radcliffe, Charles W., <i>Functional considerations in the fitting of above knee prostheses</i>, Artificial Limbs, January 1955.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, <i>The suction socket above knee artificial leg</i>, revised edition, April 1948.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>The suction socket above knee artificial leg</i>, 3rd edition, April 1949.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, <i>Functional considerations in fitting and alignment of the suction socket prosthesis</i>, March 1952.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Functional considerations in the fitting and alignment of the suction socket above knee prosthesis</i>, 2nd edition, August 1953.</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 developments in lower extremity prostheses</i>, Chapter 17 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954. See especially pp. 497 and 547.</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">Foort, J., and C. W. Radcliffe, The Canadian types hip disarticulation prosthesis, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Prosthetics Research Board, National Research Council, March 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower extremity prostheses, 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>3.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower extremity prostheses, Artificial Limbs, May 1954.</td></tr><tr><td class="clsTextSmall"><b>5.</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, 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">Wagner, Edmond M., Contributions of the lower extremity prosthetics program, Artificial Limbs, May 1954.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis, New developments in lower extremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954. See especially pp. 497 and 547.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Radcliffe, Charles W., Functional considerations in the fitting of above knee prostheses, Artificial Limbs, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</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, 1954.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower extremity prostheses, Artificial Limbs, May 1954.</td></tr><tr><td class="clsTextSmall"><b>5.</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, 1954.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above knee artificial leg, revised edition, April 1948.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above knee artificial leg, 3rd edition, April 1949.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in the fitting and alignment of the suction socket above knee prosthesis, 2nd edition, August 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>James Foort, M.A.Sc. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Engineer, Lower Extremity Amputee Research Project, University of California, Berkeley; formerly with Prosthetic Services Centre, Canadian Department of Veterans Affairs, Sunnybrook Hospital, Toronto.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Norman C. Johnson, M.D. </b></td></tr><tr><td class="clsTextSmall">Orthopedic Consultant, Lower Extremity Amputee Research Project, University of California, Berkeley.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Engineering Design, University of California, Berkeley; member, Committee on Prosthetics Research and Development, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-39.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-42.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-43.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-44.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-45.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-46.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-47.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-48.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-49.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-50.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-51.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-52.jpg Figure 13 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-53.jpg Figure 14 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-54.jpg Figure 15 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-54b.jpg Figure 16 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-55.jpg Figure 17 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-56.jpg Figure 18 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-57.jpg Figure 19 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-58.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 Experience with Prosthetic Problems of Above Knee Amputees Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * Norman C. Johnson, M.D. * James Foort, M.A.Sc. * https://staging.drfop.org/files/original/76322a13e4393e786aa6cf728e59d575.pdf 39fce9c7a6f2005a4ab1a72a880e7a96 https://staging.drfop.org/files/original/6e81640a2432fc3ff431c866ed257b5c.jpg 8a184d6c2cd09aa48d4deaf1a96a38e6 https://staging.drfop.org/files/original/228636863105038050c9d1327b56b149.jpg 35aa8e8f4be17cb772ee210e3491fe14 https://staging.drfop.org/files/original/0af8fc502d0a1e956ea8f14b47d06604.jpg b909a129f28f2159f8e8bab0032ca6fb https://staging.drfop.org/files/original/fd19c2ac9eecfb1b3389a8f532f8e987.jpg 0ca302e2ee4871004f9413e5fe7590ca https://staging.drfop.org/files/original/540b3a9d46612360fc39147886c0b410.jpg 12dadbf7283c4ddccd4be09443d58a54 https://staging.drfop.org/files/original/53ce02b8b45bc077a8134a1eef613649.jpg c21f7b4c2c06da48794cd9b0e5701f7a https://staging.drfop.org/files/original/70e664f9f3fea8b660104097849c1575.jpg e7f5d7ce8648e996a99440c72aa5073b https://staging.drfop.org/files/original/10ac518f74cc982aa6c1487671310f26.jpg 43f03940f4c5e6f5d6af345c6f3cf534 https://staging.drfop.org/files/original/83efde55b3303296ae07e3355a5c7f07.jpg 4ecf3ea6aae70e48f884aa146992d924 https://staging.drfop.org/files/original/c81ea73ab2a49c1dd9aa85e2b3707800.jpg 31d0ff6607e8608783a11d5e22f5e813 https://staging.drfop.org/files/original/a7525b0e8bcf6995ccb0702172c1a8d1.jpg 7996d249ebcb7bd84bef604b6341e2fb https://staging.drfop.org/files/original/b479e667bfc97de15ecaee15bf7da57d.jpg c65f98e9c63b8a48493f0ae7bdad8ca3 https://staging.drfop.org/files/original/74d334c8eaea06c0fd36087ec6c15ee3.jpg 9f96c0135add7753cc6cd00eae64cb3b https://staging.drfop.org/files/original/5ad5ea26960beed46a890e753e0587b6.jpg 33b17a56e9879d4754892185ca02332d https://staging.drfop.org/files/original/e1c7350ac7ddb0982d6b99fd1e5e0e6c.jpg e32301edc95c253b8417babecef0e710 https://staging.drfop.org/files/original/29f1c3079e19139973951937d38dbc96.jpg 1b5c5363292cde70bf72f725ca443206 https://staging.drfop.org/files/original/2b643269f7fa8020dd0bb4fd44dfdf3e.jpg 89774b2094aa1a19bdc55dce84a80489 https://staging.drfop.org/files/original/9c808215701b321e9407b27c9bc39d47.jpg fc644c56a0bc85f0c8cbff07ba6870fa https://staging.drfop.org/files/original/5292a74440790c92d38b23c86b501fe7.jpg 2ea50f3af857e6a92f61a0e0e77220c7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_01_076.pdf Year 1957 Volume 4 Issue 1 Page Number(s) 76 - 104 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/1957_01_076.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_01_076.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 Management of the Nonfunctional Hand Reconstruction vs. Prosthesis</h2> <h5>Sterling Bunnell, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>In the course of routine practice, the orthopedic surgeon is frequently confronted with the task of dealing with hands that are damaged by trauma or disease or that are otherwise nonfunctional owing to any of a variety of causes. In all such cases, he is called upon to decide whether or not to undertake amputation of parts of the hand or amputation through the wrist, with the expectation of later applying a suitable prosthesis, or whether, with the prospect of long continued treatment and the possibility of ultimate failure, to attempt surgical construction of a functional hand from such anatomical elements as can be saved. The considerations involved are many and varied, and rarely do two cases resemble each other in more than a remote way. Each individual case must therefore be evaluated on the basis of its own merits.</p> <p>There has been in the past dozen years a great advancement in the development of hand prostheses, so that in the case of major hand problems one might be inclined to choose wrist disarticulation over attempts at surgical reconstruction. But during the same period surgical reconstruction also has advanced remarkably, so that in judging any individual case there should be a careful analysis as to which procedure is the better to follow. Doing so usually results in a sort of compromise—reconstruction, if reasonably possible, being chosen first, a prosthesis being applied when proven necessary, major amputation being considered only as a last resort. It is the purpose here to attempt to extract from many years of clinical experience with hand surgery certain general principles that may offer guidance in making the choice. Generally, the current rule of "save all length possible," now applicable at most other levels of amputation, is applicable in the case of damaged hands also.</p> <p>The fundamental difference between a reconstructed hand and any present day hand prosthesis lies in the absence of direct sensation in the latter. Although the wearer of a modern hook or artificial hand may receive indirect sensory impulses through shoulder harness or cineplastic muscle pin, the conventional arrangement constitutes only a crude and inefficient signal system which must be supplemented and directed by sight. A hand prosthesis is of little use in the dark. In contrast, there is the exquisite appreciation we receive from the normal hand by feeling. By light touch, coarse touch, response to heat or cold, and compass point discrimination, we appreciate texture, and by muscle, joint, and tendon sense we appreciate size and shape. By combining these sense impressions in our cerebral cortex in the opposite parietal lobe, we can identify from memory an object held in the hand. This is stereognosis, a phenomenon replaced by no artificial hand now available. To quote Kirk,<a></a> "No hand is so badly crippled that, if it is painless, has sensation, and strong prehension, it is [not] far better than any prosthesis." This being the case, it is generally desirable to preserve any and all hand structures that can reasonably be counted on to have adequate nerve and blood supply. Eventual application of a prosthesis may or may not be indicated, depending upon individual circumstances and the particular demands of occupation.</p> <p>Before considering any hand amputation, then, one should weigh well the possibility of surgical reconstruction, especially with the idea of restoring natural sensation and strong prehension. Whenever reasonably feasible, surgical reconstruction of a damaged hand or arm should be attempted first. Often the result will be such that a prosthesis will not be necessary. In any case, a reconstructed hand stump is apt to be much better adapted to application of a prosthesis. As a matter of fact, reconstruction and use of a prosthesis are so interrelated that they should be considered together in each individual case. Every useful part of a limb, and every bit of skin that has sensation, should be preserved, thus giving more useful material for reconstruction and, finally, for the fitting, if necessary, of a prosthesis.</p> <p>Reconstruction may often be done in one operation; in other cases multiple operations are required over a period of a month to a year. But considering that the goal is to provide a useful hand for the remainder of an individual's life, it seems worth while. Nevertheless, it should not be undertaken unless there is reasonable assurance that a good practical result can be obtained.</p> <h4>Methods of Surgical Reconstruction</h4> <p>Although the hand does the work, the arm places and innervates the hand. Accordingly, if any particular hand is to be truly useful, it is necessary to have good shoulder, elbow, and wrist function and also good pronation and supination half furnished by the shoulder and half below the elbow. Because they supply the hand, the nerves of the arm are particularly important. In the hand itself there should be a good quality of sensation as well as mobile units that can work against each other with at least a pinch grasp or hook action to simulate normal prehension.</p> <p>Hands coming in for repair usually evidence partial amputations, stiffening in the position of nonfunction, flexion contracture from scar formation, malalignment of bones, loss of motion from injury to tendons and nerves, loss of sensation from injury to nerves, ischemic contracture, or painful states from vasomotor causes or from tender neuromata. Usually the surgeon's problem is composite, dealing with cover, joints, bones, nerves, and tendons.</p> <p>For each of these conditions there is much that can be done surgically.<a></a> For partial amputation, clefts between digits may be deepened, and digits can be built out and made to appose each other. Tender stumps may be corrected. For stiffening in the position of nonfunction, the joints may gradually be drawn around to the position of function by spring or elastic splinting and can be mobilized surgically. Scar tissue of flexion contracture can be replaced by good pliable skin giving good cover and improving nutrition. Malalignment of bones may be corrected so that the mechanics of tendon action are correct. Substitute thumbs may be formed. Tendons and nerves may be repaired or transferred, or new ones may be furnished. Ischemic contracture can be relieved so that a hand thus affected can regain some function. Painful states may be corrected by sympathectomy, and tender neuromata may be removed.</p> <h4>Partial Amputation</h4> <p>Arm stumps resulting from amputation through the wrist or through the carpometacarpal joint, or those without the thumb and with amputation through the metacarpals or proximal phalanges, require a prosthesis (<b>Fig. 1</b>). Hands retaining a good thumb working against one or more fingers (as in <b>Fig. 2</b>), or even against a surgically constructed post (as in <b>Fig. 3</b>), do not. Sometimes the usefulness of a sound thumb may be much enhanced by surgical procedures conducted on other remaining hand parts (as for example in <b>Fig. 4</b>). Other partial hands (like those shown in <b>Fig. 5</b> and <b>Fig. 6</b> for example) when reconstructed usually are more functional than a prosthesis. Some with a partial hand amputation use remnants of the hand for fine work and a prosthesis for heavy work.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Levels of hand amputation requiring prosthesis. A, Wrist disarticulation, including removal of the distal prominences of radius and ulna; B, amputation through the carpometacarpal joint; C, transmetacarpal amputation; D, amputation through all proximal phalanges In B, some useful wrist motion may be retained. In C, hand remnant may be used as a wrist motor to power a prosthesis or simply to point one. In D, hand stump may be made to work against some prosthetic device, residual sensation offering a substantial advantage over A, B, or C. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Examples of partial hands requiring no prosthesis. When the thumb can work against one or more fingers, function usually is better than can be obtained with a hand substitute. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Partial hand (A) and result of reconstruction (B), no prosthesis needed. When, in the absence of all the fingers and much of the palm, a good thumb remains, it is possible, by means of pedicle and bone graft, to build up a post for the thumb to appose. Function thus obtained is likely to be better than that to be had from a hand substitute. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Case M. S. Fingers lost between a sprocket and chain. Excised the tender neuromata of the stumps. Undermined and drew skin down for better coverage. Excised metacarpal of ring finger, covering sides of new digit by plastic maneuvers, in order to give more mobility (2 in.) to the metacarpal of the little finger. Deepened thumb cleft by Z plasty (Fig. 21, page 86). The patient obtained a strong and useful grasp between the thumb, the phalangized index and long "fingers," and the little "finger." From Bunnell, Surgery of the Hand, 3rd ed , Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Case P. L. Hand caught between two rollers. Debrided and skin grafted. Later, pedicle flap applied, then interdigitation. Sensation gradually returned throughout. A useful hand was obtained. From Bunnell, Surgery of the Hand, 3rd ed , lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Case B. P. Partial amputation by power saw. Split grafted next day. Pedicle graft applied and thumb cleft deepened. Index metacarpal removed for wider cleft. Rotary osteotomy done on all metacarpals for better apposition. Pinning with Kirschner wires. A good "hand," with good prehension, was obtained. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia, 1956. by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In partial amputations it is best, if possible, to retain the metacarpal heads and hence the full width of the palm for firm grasp of tools, but the metacarpal head of an index or of a little finger that has been amputated through the metacarpophalangeal joint is best beveled off so that it will not snag on entering a pocket. The metacarpal of an index or little finger off through the shaft is best removed obliquely at its base (<b>Fig. 7</b>). The interosseous muscle is then transferred to the adjoining digit to give abduction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Typical example of loss of fourth and fifth rays through the shafts of the metacarpals. In such a case, it is best to delete the stub of the fifth metacarpal and round the stub of the fourth. A corresponding procedure is advisable in the event of loss of the second digit, or of the second and third digits, by transmetacarpal amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A hand amputated through all metacarpophalangeal joints or proximal phalanges may be improved by mobilizing the fifth metacarpal, cutting the transverse metacarpal ligament, and perhaps removing the metacarpal of the ring finger and covering the cleft by a plastic maneuver (<b>Fig. 4</b>). The ulnar side of the hand thus becomes a movable part. Motion may be increased as much as 2 in. If the second and fourth metacarpals are deleted, there will remain three digits, consisting of the metacarpals of the thumb and of the long and little fingers, and the thumb cleft will be wide and deep. Phalangizing the metacarpals gives considerable useful mobility so that one can dress oneself, use knife and fork, and so forth. The metacarpals of the thumb and little finger are cut across at the base and bent toward each other for better grasp (<b>Fig. 8</b>). A similar osteotomy may be performed on a hand having only two remaining digits, as for example thumb and little finger (<b>Fig. 9</b>), or even when only one complete digit remains, as in (<b>Fig. 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Reconstruction procedure for loss of all digits through the metacarpophalangeal joints. A, Second and fourth metacarpals are deleted, clefts are covered by plastic maneuver, first and fifth metacarpals are osteot omized. B, Functional three finger "hand" results </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Angulatory osteotomy of first and fifth metacarpals to aid apposition of thumb and little finger. Sometimes it is necessary to effect a tendon T transfer also. See Figure 31, page 91. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Angulatory osteotomy of first and fifth metacarpals to bring thumb and ulnar side of palm into easy apposition. Tendon T transfer may be needed here also (Fig. 31, page 91). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Frequently a finger or hand stump is so hypersensitive from poor terminal padding and sensitive neuromata that it prevents all of the remaining parts of the hand from functioning. Crushing injuries to fingers present the most difficulty because, in such cases, the fingers usually have been damaged well proximal to the site of amputation. In revising such stumps, the digits must often be shortened enough to give good, well padded cover, but it is possible to swing a visor flap from the dorsum over the end of the stump and then to skin graft the dorsum. Still another possibility of furnishing good tactile cover over the end involves use of a cross finger flap and then skin grafting the back of the donor finger. Nerves in hands and fingers have a special tendency to proliferate. If they terminate in scar tissue or close under the skin, the neuromata formed may be extremely sensitive and give, on slight tapping, the sensation of an electric shock. These are corrected by uncovering the nerve, dissecting it well back, and cutting it off in good tissue free from scar. Neither alcohol injection nor ligation is used.</p> <h4>Stiffening in The Position of Nonfunction</h4> <p>Following injury, infection, or paralysis, a hand frequently stiffens in the position of non function so that the digits can no longer touch each other and the hand is therefore useless. In the position of function (<b>Fig. 11</b>), the wrist is extended<i>35 </i> deg., the joints of the fingers are moderately flexed, and the thumb is in moderate apposition, as in holding a baseball. In the position of nonfunction (<b>Fig. 12</b>), the wrist is flexed, the metacarpophalangeal joints are hyperextended, the remaining finger joints are flexed, and the thumb is at the side of the hand or even back of it. Although such a hand is totally useless, in general it should not be amputated. For if the joints can be pushed around into the position of function, the available motion will be useful for picking up and holding objects, and the hand will be used more and more from then on.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The position of function. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. The position of nonfunction. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The first approach to hands stiffened in the position of nonfunction involves use of a system of elastic or spring splinting by which joints can gradually be drawn around into positions of function. Usually the joints are kept active and are not damaged, and the muscles and all tissues are activated, a matter which greatly improves their condition. If, however, the response to such treatment is unsatisfactory, surgical means are resorted to, starting with capsulectomies (<b>Fig. 13</b>) and, where there is damage to bone structure, resorting to arthroplasties.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Case E. T. Top, preoperative position of nonfunction from shark bite on upper arm, severing nerves and vessels. Bottom, correction to a position of function by fusion of the wrist, capsulectomies and opening of the cleft of the thumb, and transfer of the extensors of the wrist to the flexors of the fingers. A tendon transfer through a pulley constructed at the pisiform was used to give apposition to the thumb. No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed , Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Capsulectomies are usually performed on the meta carpophalangeal joints but sometimes also on the proximal interphalangeal joints. Usually the trouble is found to lie in the fact that the two collateral ligaments are too short and thick to permit the joint to flex. Excision of these structures makes flexion possible. Often it is necessary also to free the long extensor tendons (<b>Fig. 14</b>) and to clean out the volar pouch of the joint. In performing an arthroplasty, the metacarpal head is shortened and reshaped, and a hood of fascia is fastened over it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Case J. D. Left, old dislocation of metacarpals on carpus, upsetting muscle balance, thus resulting in the useless position of nonfunction. Right, dislocation reduced, restoring muscle balance in the position of function. A pedicle graft was applied to the dorsum of the hand and to the open thumb cleft. Freeing of the extensor tendons, together with capsulectomies, allowed the proximal finger joints to flex. No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Arthroplasty is not often done on the wrist joint; arthrodesis is used instead. In many cases, however, removal of a mass of scar tissue from the volar aspect of the wrist allows the wrist to extend. When pronation and supination are retained, arthrodesis of the wrist or of the proximal finger joints into the position of function gives very little disability (<b>Fig. 15</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 15 Case A B Hand useless from birth pals)". Several operations had been performed, including fusion of the wrist. The proximal finger joints were lax and bent backward out of use Patient could not abduct at the shoulder, and the forearm was in supination. The shoulder was arthrodesed lo enable placement of the hand, and by osteotomy the ulna was rotated into pronation. The proximal finger joints were arthrodesed into the position of function. Patient gained much use of the hand and became self supporting. From Bunnell, Surgery of the Hand, 3rd ed , Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Flexion Contractures and Furnishing New Cover</h4> <p>Most reconstruction commences with excision of a big plaque of scar tissue that is drawing the hand into flexion contracture and strangling the rest of the tissue (<b>Fig. 16</b> and <b>Fig. 17</b>). The skin is then undermined and allowed to retract, thus freeing the hand for better nutrition. New cover is then provided, sometimes by a free graft but usually by a pedicle graft from the abdomen (<b>Fig. 18</b>), thus giving good, pliable skin with a layer of soft fat beneath. Doing so releases the whole hand and makes it possible to reconstruct the deeper parts joints, bones, tendons, and nerves. Although the refinements of stereognosis never return to such skin, eventually sensation to light touch and pin prick develops.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Case J. M. From birth the cicatrix from a tear at the ulnar side of the wrist so distorted the growth of the hand that there was no function. The scar was excised, the ulna elongated, and a pedicle applied. Two years later osteotomies were done on all metacarpals, the thumb cleft was deepened, and a pulley operation was performed to improve apposition. Three years later the hand was reported to be quite useful. From Bunnell, Surgery of the Hand, 3rd ed Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Case D C. M. Hand severely burned in oil fire so that all digits pointed backward out of use. Fingers were webbed, and middle joints were exposed. There was no thumb cleft, the thumb being at the rear of the hand with the metacarpal arch reversed. In this position of nonfunction, the hand was entirely useless Excised all dorsal skin, including nails Sawed away exposed bone. Corrected webs. Established thumb cleft and positioned thumb. Positioned fingers by capsulectomies. Covered all with free skin graft. Patient returned to his job as locomotive engineer No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia. 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Case A. C. Hand badly crushed between rollers. Poor skin surface, position of nonfunction, entire hand and joints stiff, extensor tendons adherent, thumb at side, amputation contemplated. First operation: excised all skin from both dorsal and volar surfaces, covered with one large pedicle graft, and spread thumb from hand; brought joints around by elastic splints. Second operation: freed extensor tendons and placed fat beneath; did capsulectomies on proximal joints; used sublimis of long finger for apposition; freed flexor tendons, placing fat beneath; defatted pedicle. The hand made remarkable recovery in nourishment, function, and position. There was good grasping power and a complete change in the morale of the patient. No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed , Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Skeletal Malalignment</h4> <p>The bones of the hand constitute the framework along which the muscles and tendons function in their proper planes. The joints allow the digits to flex and extend in their proper positions for adequate grasp. After fracture, bones often unite at such odd angles that the whole mechanics are thrown out of true. If, after healing, there is an angle of the bones along the length of the limb, the tendons over the convexity will be tight, over the concavity loose. Such a circumstance upsets the whole nicely adjusted muscle balance so that the joints are pulled into deformity all the way from the site of angulation to the end of the limb. To make the hand function properly again, realignment is necessary. The bones are chiseled or sawed across, a wedge being removed when necessary to place them in proper contact and alignment. They are then pinned so by Kirschner wires, the latter being withdrawn in two months when union is solid and the framework of the hand is restored.</p> <p>When the thumb does not entirely contact the ring finger or the little finger, the metacarpal of either or both may be severed at the base and the digits angulated toward each other in such a way as to provide for easy contact. Similarly, in the absence of a thumb, two or more fingers may be angulated and rotated to give them the ability to work against each other.</p> <p>When a metacarpal, including the soft tissues about it (tendons, nerves, interosseous muscles, and skin), is badly damaged, it may be excised. If it is one of the central rays, the metacarpal of the adjoining ray, either index or little, as the case may be, is cut across at its base, jogged over to the base of the excised metacarpal, and pinned near and parallel to the next ray (<b>Fig. 19</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Reconstruction procedure recommended in event of serious damage to (A) the fourth digit or to (B) the third digit. In A, delete the much injured fourth ray and jog fifth ray over to its place. In B, delete the much injured third ray and jog second ray over to its place. The result in either case is a functional four digit hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a metacarpal head is missing, the lack of support causes the adjoining metacarpals to rotate so that the fingers cross on flexion. In such a case, the metacarpal can be excised and one of the adjacent ones jogged over. Or the proximal phalanx of the ray in question can be recessed, or set back, so that its head will take the place of the missing metacarpal head.</p> <p>Often it is advisable to arthrodese a joint to place it rigidly in the position of function. This procedure can be carried out on either of the two distal joints of the fingers but rarely on the proximal joints. It is done on the wrist and can be done on the elbow. In the latter case, the choice must be made between arthrodesis, a block operation, muscle transfers, or the wearing of a prosthesis to activate a flail elbow. When the arm cannot be abducted at the shoulder but when muscles around the scapula are good, arthrodesis of the shoulder will allow the arm to position the hand for useful function (<b>Fig. 20</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 20. Case L. M. W. As a result of polio, arm was flail at shoulder, and there were no flexors in the hand Arthrodesed shoulder and wrist simultaneously so that the patient could place the hand. Transferred extensor carpi radialis to flex fingers, palmaris longus to abduct thumb, the long extensor of the ring finger for apposition. Slit the proximal pulleys so that long flexors could flex the proximal joints. Patient gained much use of hand, was able to grasp a piece of paper or a tumbler, could place the hand well, and occupied a position in a bank. No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Thumb Problems</h4> <p>So essential to prehension is the thumb that every possible bit of an injured one should be saved. Amputation of the thumb through the metacarpophalangeal joint results in a partial digit almost loo short to be useful, but a new thumb cleft can easily be made by a Z plasty operation (<b>Fig. 21</b>), meanwhile scraping the adductor origin down from the third metacarpal. The thumb is thus made relatively longer. If the shaft of the index metacarpal projects into the web so as to interfere with grasping, it should be excised at its base to widen and deepen the cleft (<b>Fig. 22</b> and <b>Fig. 23</b>). Whenever possible, the tip of the third metacarpal should be preserved to provide a concave palm for the remnant of the thumb to work against (<b>Fig. 22</b>). Preservation of the broad tip of the third metacarpal is particularly desirable when a complete thumb remains (<b>Fig. 24</b>). The range of motion of a normal thumb extends from a position at the side and slightly back of the hand, with the nail at right angles to the palm, through a wide ellipse toward the volar aspect until it is opposite the fingers, the nail being then parallel to the palm. In the latter position, the thumb is available to participate with the fingers in grasping large objects. The motion is effected by the ten muscles long and short that control the thumb. In paralysis of the median nerve, in injury to the thenar muscles, in stiffness of the carpometacarpal joint of the thumb, or in flexion contracture on the dorsum of the web, normal range of motion of the thumb is lost. If the other parts of the hand are mobile, the ability to appose the thumb can readily be provided by a simple tendon transfer that draws the thumb toward the pisiform bone and pronates it. When this is not possible, the thumb may be held permanently in a useful position by a bone graft at the base of the first metacarpal.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Phalangization of thumb cleft by Z plasty. Left, hand with short and more or less useless thumb stump. Middle, location of Z shaped incision; flap A is carried to fixed point X, flap B to fixed point Y, so that dorsal flap just covers defect on volar side while volar flap just covers defect on dorsal side; resulting suture line is as shown in insert. Right, end result, showing deepened thumb cleft. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Case C, H. Amputation by meat grinder. Thumb cleft deepened by Z plasty. Index metacarpal removed to give good grasp. From Bunnell, Surgery of the Hand, 3rd ed.. Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Case H. G. Amputation, by power saw, of all digits through proximal phalanges, leaving a mitten hand but no thumb cleft By a plastic maneuver and removal of the index metacarpal, a thumb cleft 3/4 in. deep was constructed. It opened 3/4 in and closed against the hand. Patient could write and hold objects Limited facility can be combined with the use of a prosthesis. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Operative procedure for loss of the second and third digits. Excision of the second metacarpal, but with retention of the third, furnishes easy apposition for the sound thumb. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a thumb is closely bound to the rest of the hand by scar, it can be spread away by excising the scar tissue and cutting across the cleft from a point opposite the hinge of the first two metacarpals on the dorsal side to the corresponding point on the volar side. The thumb is spread to the side and front of the hand, and the large denudation of skin is covered either by a large diamond shaped free skin graft or, better, by a pedicle graft from the abdomen. In three weeks, pedicle grafts are detached from the abdomen and laid smoothly on the hand.</p> <p>Although the thumb stump remaining after amputation through the metacarpophalangeal joint usually is not very serviceable, it may be built out by pedicle and bone graft. If a thumb is amputated proximal to the metacarpophalangeal joint, it should in any case be built out longer. If the thenar muscles and the stub of the metacarpal remain intact, the thumb will be quite movable. A short thumb is a good thumb. Various motions, such as apposition, extension, and flexion, may be furnished it by tendon grafts.</p> <p>In the case of total loss of the thumb, a new one can be supplied in various ways. The simplest approach is to raise a tube pedicle from the abdomen, attach the pedicle to the hand, and place in it a bone graft from the iliac crest (<b>Fig. 25</b> and <b>Fig. 26</b>). Although this expedient gives sensation, it does not provide much stereognosis. Nevertheless, a reconstructed thumb is apt to be very serviceable and considerably better than a prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Surgical construction of a new "thumb." A, Poorly functioning partial hand retaining digits four and five only. B, Serviceable partial hand made by constructing new "thumb" with pedicle and bone graft. Function is apt to be better than if a prosthesis were applied. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Case C. B. Injury from hand grenade. Pedicle graft covered the thumb, and arthrodesis was done on the trapezium by a graft from the ilium Abduction was furnished index finger by a proprius tendon graft A very useful hand resulted. No prosthesis needed. From Bunnell, Surgery of the Hand, 3rd ed., Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The graft should be grounded on some other bone rather than connected by a joint. It may be placed on the carpus to make a pad in the base of the palm, or it may be placed on the trapezium or on the stub of the metacarpal.</p> <p>The requirements of a new thumb are three in number—motion, sensation, and proper placement. The best new thumbs are made by pollicization of a finger, preferably the index linger but sometimes the long finger. Often, as part of the injury, the index finger is already somewhat shortened. In such a case, the finger, or a portion of suitable length, is transferred together with a bridge of skin and with its nerves, blood vessels, and tendons intact (<b>Fig. 27</b> and <b>Fig. 28</b>). It may even be transferred on a neurovascular pedicle circumscribing the skin all around (<b>Fig. 29</b>). When this procedure is possible, it makes for easy and exact placement. The tendons are brought over with the new "thumb" and joined up so as to give motion. The fingers should work directly against the new "thumb" and also, by their side motion, should pass to the side of it and close against the palm. Stereognosis and vascularization are provided by the neurovascular pedicle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 27. Pollicization of index finger. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Case H. W. W. First (1929) physiological reconstruction of thumb by pollicizing remains of the index finger. Metacarpal lashed to trapezium, nerves and vessels carried over, and all tendons and muscles connected up. "Thumb" had strong motion and normal sensation and was well positioned. Patient worked well as a carpenter for 20 years. Superior to prosthesis From Surgery, Gynecology, and Obstetrics, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Pollicization of index finger by neurovascular pedicle. Skin is circumscribed, and the index finger is pinned on to the stub of the metacarpal of the thumb in proper position. Tendons furnish motion, vessels nutrition, and nerves sensation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Should a newly constructed thumb not have sensation in its tactile area, a flap of skin may be exchanged for the nontactile skin by a Z plasty. Or tactile skin can be furnished by using a neurovascular pedicle passed beneath the skin at the base of the thumb. A living thumb, with motion, sensation, and proper positioning, is, of course, far superior to any prosthetic thumb.</p> <h4>Tendon Repair</h4> <p>Tendons are frequently lacerated, thus losing their function of transmitting muscle power to provide motion in joints. They can, however, readily be repaired (<b>Fig. 30</b>), the most difficult cases being the flexor tendons in the digits and in the distal part of the palm, where the resulting juncture tends to adhere to the surrounding parts. Frequently a tendon graft must be used to bridge the tendon over areas where adhesions are likely to form. Adherent tendons may be freed, and slippery material, such as paratenon and fascia, may be grafted between them and the bones so as to allow the tendons to glide again. Defects in tendons are readily bridged by free tendon grafts from spare tendons in other parts.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Case F. E. Charge from a shotgun entered palm and emerged dorsally, shattering the carpus and the lower radius and severing many tendons, extensors of the wrist, thumb, and fingers, and the median nerve. Debrided, filetted the index finger, and skin grafted. Considerable infection followed. First operation: excised scar and placed a pedicle. Second operation: furnished tendon grafts plus paratenon to extend thumb and fingers; freed the flexor tendon of the thumb; did a pulley operation for apposition; sutured median nerve to its four branches. The wrist became fused. But sensation, motion, and apposition returned, so that there resulted a very useful hand requiring no prosthesis. From Bunnell, Surgery of the Hand, 3rd ed. Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The upper limb interdigitates at the ends of the metacarpals, and the tendons normally have individual motion. If either an extensor or a flexor tendon is sutured over a finger stump, it will hold back all of the tendons pulled from the same muscle. But when all of the tendons are cut at the end of carpal or metacarpal stump, they should all be sutured together over the end to provide for movement of the stump.</p> <p>Isolated digits may be made to provide prehension if they are furnished with new flexor and extensor tendons. To make the fingers appose each other, the tendons can be placed diagonally across the hand, or a tendon T transfer, which consists of one cross bar tendon from digit to digit and a longitudinal one looped about the first, can be made (<b>Fig. 31</b>). When the muscle concerned is contracted, the "T" assumes the shape of a "Y," and the two digits are drawn toward each other. This procedure is particularly useful in median and ulnar paralysis, where it will provide adduction of the thumb and little finger while curving the metacarpal arch of the palm. When some digits have been amputated, great strength can be given to the remaining fingers by transferring in the forearm the tendons of the amputated ones to those of the remaining ones.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Lobster hand formed by tendon T transfer. A, Arrangement of tendons to form the "T." B, Contraction of the longitudinal tendon converts the "T" to a "Y" and thus effects apposition of thumb and little finger. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Especially in paralysis are tendon transfers useful. Good, strong muscle and tendon are transferred to the tendons of the paralyzed muscles. This operation may be performed, without fusing the wrist, to give very good return of function so that splints are discarded. In the case of any two nerves paralyzed high in the arm, the wrist can first be arthrodesed in the position of function, an expedient which results in very little disability. Thereupon the five tendons previously wrist movers become available as digit movers, and the resulting motion is more natural than that obtained using a prosthesis. The patient soon learns to adapt so that the motion becomes natural. A rule is to decide what movements are needed and then to consider the number of muscles available for transfer. For paralysis within the hand—that is, from the median and ulnar nerves—many transfers are available to restore muscle balance, thus correcting the position of the claw hand by substituting for the paralyzed intrinsic muscles.</p> <p>Another principle is tenodesis, a procedure in which the tendons that move the digits are fastened to the forearm bones. Then, when the wrist is flexed, the extensor tendons tighten and extend the digits; when it is extended, the flexor tendons tighten and cause the digits to flex so that thumb and fingers appose each other. These automatic movements are useful when only one or two strong muscles are available. When no muscles are available, the hand can be converted to a useful hook by tenodesis of the flexor tendons to the forearm bones.</p> <h4>Nerves</h4> <p>Movement and sensation in the hand, which are its two most important functions and which are of equal value, depend entirely upon the nerves. The three large nerves that course down the arm (the ulnar nerve, the median nerve, and the radial nerve) control the hand, and any injury to them is as damaging to the hand as is an injury to the hand itself. When a nerve is severed, it should be rejoined at once. Otherwise fibrous degeneration in both the lower portion of the nerve and in the muscles supplied by it will be so progressive that, after two years, muscle action will not return and, after five years, neither will sensation. A gap of several inches can be overcome and the nerve sutured directly. Even the little nerves in the hand itself can be repaired.</p> <p>After nerve suture, there is about 80 percent of functional recovery. Nerves can be sutured directly, transferred, or even free grafted. All of these procedures are successful, but nerve grafts must be used from the same person; if grafted from another person, they will melt away. From loss of nerve supply, the hand if neglected goes into the position of nonfunction, stiffens, and atrophies. Splinting should be by spring or elastic splints sufficient just to substitute for the paralyzed muscles and to hold the hand in the position of function so it can work. When the nerves are irreparable, as for example when too great an interval has elapsed since the time of injury, muscle function in the hand can be provided by tendon transfers. Paralysis in the hand and forearm from ischemic contracture can be overcome to a considerable degree, although never completely cured. In vasomotor disorders, surgery seldom need be weighed against prostheses.</p> <h4>Prostheses for Partial Hands</h4> <p>The literature on prostheses for the partial hand is meager, and therefore when a hand is damaged there is a distinct preference on the part of prosthetists to have a wrist disarticulation or a long below elbow amputation. In the event they are confronted with a partial hand amputation, many limbfitters prefer to enclose the wrist immobile (as in <b>Fig. 32</b>) rather than to construct a partial hand prosthesis. Even those who furnish cosmetic glove prostheses (as in <b>Fig. 33</b>) prefer to enclose the whole hand in the glove and to substitute, for the missing parts, foam filler reinforced with pliable wire. Although a long below elbow amputation offers the advantage that many more or less standard terminal devices may be applied (a split hook, a mechanical hand, perhaps some special tools), a partial hand, whatever can be saved, can often be fitted with considerably more success. If the thumb alone is spared, a casing over the palm and wrist can support a pad or other suitable device against which the remaining digit can work (<b>Fig. 34</b>). If only the palm, perhaps with a few remnants of phalanges, remains, a casing over the forearm can support a similar pad against which the palm can be pressed by wrist flexion (<b>Fig. 35</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. One form of prosthesis for partial hand amputation thumb free, wrist encased, split hook activated by shoulder harness as in the case of the wrist disarticulation. The disadvantages are numerous. The long cuff virtually eliminates any possibility of wrist motion. Except in the thumb remnant, residual tactile sense is obviated, and the device as a whole is much too long </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Cosmetic hand for partial amputation glovelike and zippered at the wrist. Fingers are filled out by foam filler and stiffened by armature flexible enough to hold any shape. Courtesy Prosthetic Services of San Francisco. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Simple prosthesis for loss of all digits except the thumb. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Simple prosthesis for major losses of most of the digits. Wrist serves as motor, hand working against prosthesis. Residual tactile sensation is utilized. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>By the combined talents of engineers, physicists, prosthetists, orthopedists, and others, there have been in the last ten years many advances in hand and arm prostheses. Accordingly, there has been developed the policy of saving as much of any limb as is likely to be functional and, particularly, as much of the hand as possible. Any portion of skin with sensation should be preserved because of the possibility of placing it in a functional part. Digits with sensation can do light work and, if necessary, a prosthesis can be applied to do heavy work (as in <b>Fig. 36</b>, <b>Fig. 37A</b>, and <b>Fig. 37B</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Partial hand capable of prehension. Top and middle, digital motion for light work. Bottom, wrist motor for heavy work. From Bunnell, Surgery of the Hand, 3rd ed,, Lippincott, Philadelphia, 1956, by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 37A. Case E. E. Top to bottom: Right hand pulled into hay chopper. Debridement and abdominal pedicle. Later a two digit hand was made with a tendon T operation for prehension and a spread of 1 1/2 in. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 37B. Case E. E. Top and middle: A prosthesis which enabled the hand to work against a hook. This was discarded because it was too unstable. Right, bottom: A prosthesis made by Robin Aids Manufacturing Company, Vallejo, Calif., that was very satisfactory. It preserved residual wrist motion and could be removed when fine digital motions were required. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For the wrist disarticulation, below elbow, above elbow, and shoulder disarticulation prostheses, many new devices have been developed. They include the alternator elbow lock for the above elbow case,<a></a> the outside locking elbow hinge for elbow disarticulation,<a></a> the polycentric elbow joint for below elbow cases,<a></a> the variable ratio step up hinge for the very short below elbow case,<a></a> the flexible cable units to allow pronation and supination for the very long below elbow and wrist disarticulation cases,<a></a> and the elbow coupled shoulder joint for shoulder disarticulation amputees.<a></a> For the arm amputee, these devices help to carry the terminal device (hook or artificial hand) to a place of usefulness. The <i>Manual of Upper</i> <i>Extremity Prosthetics </i><a></a> gives a full account of these and other devices that comprise a full armamentarium for upper extremity amputees. But the case of the partial hand amputation is not included.</p> <h4>Prostheses For One Digit Hands</h4> <p>For most practical purposes, loss of one or more distal phalanges does not require application of a prosthesis. Nevertheless, there are exceptions. An accomplished violinist, losing the distal phalanx of even one string finger, for example, is incapable of managing the strings properly. This could mean an occupational change for such a person. A good prosthetic replacement may enable him to continue his occupation. The same occasionally occurs with an organist, a pianist, a typist, or other person in any occupation where finger dexterity means the difference between success and failure. A suitable prosthesis for such a case can be made using thin stainless steel for the socket and extension framework and then dipping the device in flexible vinyl plastic to form the tip cushion and finger build up. The socket portion may be split along one side to allow it to expand and contract, thus ensuring snugness of fit.</p> <p>For amputation of all of the fingers at the metacarpophalangeal joint, or approximately half an inch distal thereto such that the volar crease of the metacarpophalangeal joint remains, a 1/8 in. rod framework of stainless steel can simulate the socket while leaving a maximum amount of exposed palm for traction and sensation (<b>Fig. 38</b>). The distal portion of the framework is bent to simulate the finger tips, the little finger side being curved to form a hook for pulling or lifting and the index side shaped to appose the thumb as would the first two fingers in three jaw chuck prehension.<a></a> This arrangement provides for prehension between the simulated index finger and the remaining thumb. A similar appliance can be made for an amputation proximal to the metacarpophalangeal joint, but in such a case the remainder of the hand must be fitted with a plastic, metal, or leather socket for attachment to the formed rod (<b>Fig. 39</b>). The notable disadvantage is the coverage of surfaces otherwise capable of sensation. In both instances, the rod framework is dipped in flexible vinyl plastic to provide a surface with adequate traction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Prosthesis for loss of all the fingers at, or slightly distal to, the metacarpophalangeal joint line. Metal ring, covered with vinyl plastic, is so shaped as to furnish one large hook, representing the index finger, and one small one, representing the little finger. Thumb works against ring throughout the range of the carpometacarpal articulation. Courtesy Robin Aids Manufacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Prosthesis for transmetacarpal amputation. Socket may be of leather, molded plastic, or hammered stainless steel. Metal ring, covered with vinyl plastic, is shaped to simulate fingers, as in Figure 38. Courtesy Robin Aids Manufacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 40</b> shows a single stainless rod curved in hook fashion and mounted to a stainless steel plate, which in turn is attached to a molded hand and wrist socket. The hook is so positioned as to give apposition to the thumb, and the thumb is exposed to utilize its capability for sensation. This single hook, being small and smooth, allows easy entry into pockets and other tight places.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 40. Simple prosthesis for loss of most of the palm but with retention of the thumb. Wrist and hand stump are encased in a socket to which is attached a single stainless steel hook. The hook may be used by itself or as a member for apposing the thumb. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the thumb is the most important single digit of the hand, it would seem a sound principle not to involve it as a motor for powering other mechanisms. A collar around the thumb would appear to diminish tactile surface, and any mechanical linkage would seem to lessen mobility and dexterity. In general, wrist flexion extension provides a far more desirable motor with less hindrance to function. But these principles have only general applicability and are not specific. For certain special needs, a thumb powered mechanism may be desirable. In any individual case, the selection of equipment must be left to the mutual judgment of the patient, the doctor, and the prosthetist. (<b>Fig. 41</b> and <b>Fig. 42</b>) illustrate the principles involved but show the distinct differences to be found in individual cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 41. Prosthesis for amputation of all fingers at the metacarpophalangeal joint line with retention of the thumb. Socket about wrist and hand stump supports split hook, which is powered by the thumb. Courtesy Navy Piosthelics Research Laboratory, U.S. Naval Hospital, Oakland, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 42. Prosthesis for loss of all digits but the thumb. Hinged at and powered by the wrist, this device provides for prehension by virtue of a thrust rod. Courtesy Robin Aids Manufacturing Company, Vallejo, Calif, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the arrangement shown in (<b>Fig. 43</b>), the hand, wrist, and forearm socket give versatility for the accomplishment of either light tasks or heavy duty work. For light tasks, the thumb stump is free to appose the remainder of the hand or to contact a small metal post or spoon attached to the hook. The forearm socket allows freedom of wrist motion but provides hook stability for heavy duty work. Since the thumb stump is also free to appose the hook activating lever, no shoulder harness is required.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Amputation of the fingers at the metacarpophalangeal joint line and of the thumb at the inter phalangeal joint; thumb phalangized for deeper cleft. Top to bottom: holding with thumb unassisted; use of hook (powered in this case by shoulder harness) as device to appose palm; holding with thumb, hook available for auxiliary function if needed; holding with hook, thumb as stabilizer. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For a hand retaining only the thumb, without fingers or even without their metacarpals, a special prosthesis designed by the United States Navy gives reciprocal motion and active prehension powered by the thumb (<b>Fig. 44</b>). To a simple hand cuff and wrist strap is attached a metal plate, which, on the radial side, supports a lever for the thumb to appose and, on the ulnar side, bears a metal finger pivoted on an axis near the base. Apposition of thumb and metal finger is effected by a linkage between the two lever systems.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Prosthesis for transmetacarpal amputation with retention of the thumb. Power supplied by the thumb activates metal finger, which is otherwise held in extension by a spring at its base. Courtesy Navy Prosthetics Research Laboratory, U.S. Naval Hospital, Oakland, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Prosthetic Thumbs</h4> <p><b>Fig. 45</b> and <b>Fig. 46</b> illustrate fixed prostheses for partial or complete loss of the thumb. Two features are essential. First, the prosthetic thumb must furnish proper apposition to the fingers, and its lip should be of such material as to provide adequate traction. Second, the thumb must provide a shaft and a crotch so as to make it possible to hold objects too large for the fingers themselves to encircle. A two position thumb, such as the thumb from an APRL hand,<a></a> can be used on a prosthesis for disarticulation of the thumb at the carpometacarpal joint. The result is that a larger selection of objects can be held in the hand.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Prostheses for partial or complete loss of the thumb. Fingers work in apposition to fixed member. Above, prosthesis for amputation of thumb at metacarpophalangeal joint, thumb web deepened surgically to provide cylindrical stump proximal to site of amputation. Below, variation suitable for amputation of thumb at carpometacarpal joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. One form of fixed prosthesis for total loss of the thumb. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 47</b> depicts the application of a mobile artificial thumb, powered by the wrist, to a partial hand possessing only the little finger. Attached to a hand cuff, which in turn is hinged to a forearm cuff, the thumb pivots about an axis near its base. Linkage between thumb and wrist hinge is such that wrist flexion causes the thumb to approach the little finger. In the example shown, the small finger has been rotated surgically toward the radial side of the arm to give better placement for apposition.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Prosthesis for loss of all digits except the little finger. Laminated plastic socket, hinged to leather or plastic forearm cuff, supports plastic covered metal thumb, which is so linked to forearm piece as to be driven by wrist motion. Little finger has been rotated surgically to provide better apposition with respect to prosthetic thumb. Courtesy Robin Aids Manufacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Prostheses For Loss of All Digits</h4> <p>In the case of a hand too crippled or too paralyzed to be of much use in the direct operation of a prosthesis, a split hook may be attached to a forearm cuff and positioned in the palm. This arrangement (<b>Fig. 48</b>) allows the palm to work against the hook for some types of prehension and still provides for the hook to be operated by shoulder harness in the usual way. The stainless steel hand plate shown in <b>Fig. 49</b> provides a simple, light, and cool means of mounting a split hook to a hand stump that is too short to grasp objects without a prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Prosthesis for virtual loss of all digits. Palm can work against hook, or hook can be operated in conventional way by virtue of cable attached to shoulder harness. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Method of attaching a split hook to a short hand stump. Mobility of the wrist is maitained </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Still another way of accommodating for loss of all digits is to enclose the base of the hand in a leather cuff linked to a forearm cuff, a split hook being attached to the hand cuff (<b>Fig. 50</b>). The cuff and forearm members are connected by a rod working levers in such a way that, when the wrist is flexed, the split hook opens; extension of the wrist closes the hook.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Prosthesis for loss of all digits. Wrist supplies power and excursion for operation of split hook. No shoulder harness needed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>New Devices for Paralyzed Arms</h4> <p>For the paralyzed arm, many new devices have come forth in the past five years. They all have the same essential purpose that of carrying the useful, or partially useful, hand to a place where it can operate to advantage. But in these cases there is an additional hurdle to be jumped. Whereas an arm prosthesis can be built to almost any desired weight, in the case of a paralyzed arm the weight of that arm must be overcome before motion can be reacquired. Equipment such as the shoulder suspension hoop, the locking lever arm brace, the alternator elbow lock arm brace, suspension slings, and single, double, or triple rocker feeders or arm balancers can do this job <i>.</i><a></a> </p> <p>Once a paralyzed arm can be positioned in a place of usefulness, hand function must be restored, either by surgical or by prosthetic means. Some of the terminal devices intended for arm amputees can be utilized for patients with paralyzed or badly disabled hands. A good example of the management of the paralyzed hand is to be found in the application of the "Handy Hook" <a></a>. It constitutes a simple but effective means of positioning a split hook in the palm of the hand and fastening it there to a metal or plastic palmar plate, which is held in place by straps around the dorsum of the hand (<b>Fig. 51</b>). In the event the wrist also is flail, a simple brace on the forearm constitutes a suitable modification (<b>Fig. 52</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. The "Handy Hook" as applied to a flail hand. Positioned in the palm by means of a plate passing over the dorsum, it is powered by shoulder harness. Hand sensation is preserved. Courtesy Robin Aids Manufacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. The "Handy Hook" as applied to a flail hand when the wrist also is flail. Courtesy Robin Aids Manufacturing, Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For a hand that is lacking in one or more features of normal motor power but which retains valuable sensation, there is still another assistive device, the "Handy Hand"<a></a>. <b>Fig. 53</b> and <b>Fig. 54</b> show two variations out of numerous possibilities, each designed to accommodate specific motor losses (flexion or extension of fingers, flexion or extension of wrist, and so on). In <b>Fig. 53</b>, finger opening may be brought about voluntarily (or, if necessary, by rubber bands), closure being effected by shoulder harness. In <b>Fig. 54</b>, active wrist extension effects finger closure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 53. The "Handy Hand" as applied to a flail hand when the wrist also is flail Extension of the fingers may be effected voluntarily or, if necessary, by rubber bands. Flexion of the fingers is brought about by means of shoulder harness Courtesy Robin Aids Manfacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 54. The "Handy Hand" as applied when extensors of wrist and fingers are active, finger flexors inactive. Extension of the wrist , Courtesy Robin Aids Manufacturing Company, Vallejo, Calif. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Conclusion</h4> <p>So vast and so laden with potentialities is the subject of surgical reconstruction of the hand, and so also is that of partial hand prostheses, that a single article such as this can constitute only a very brief introduction to either. But even a brief review of some of the recent advances, both in reconstructive surgery and in prostheses for partial hands, may offer valuable guidance in selecting the best procedure for any given case. In the absence of a well developed literature, the whole field of work with partial hands is long apt to remain highly empirical and largely dependent upon the experience, judgment, and skill of individual surgeon and prosthetist. Since, unlike the more conventional amputation stump, the partial hand is invariably a special problem, the approach to its solution, whether surgical or prosthetic or both, also invariably calls for special departures. The most that can be said is that from long practice and much trial and error it is possible to extract certain principles generally applicable to the more common types of hand losses.</p> <p>In any event, it is apparent that the surgeon who would undertake reconstructive hand surgery ought first to be intimately familiar with the best that can be done with prostheses for partial hands. Similarly, the specialist in partial hand prostheses needs to be acquainted with what can be accomplished through surgery. Both, separately and together, must consider each case individually not only from the standpoint of the patient's life and work but also with a view toward his ability to afford the financial outlay incident to surgery and recuperation. Fortunately, insurance has in recent years played a large part in eliminating the economic considerations otherwise involved.</p> <p>The strongest argument that can be advanced for reconstructive hand surgery is that it preserves the highly desirable facility of tactile sensation. Among the disadvantages are the fact that the result does not always present the best cosmetic effect and the additional one that the reconstructed hand may not be able to perform heavy work as well as could a full prosthesis. The particular requirements of the individual therefore exercise a strong influence upon the choice between the partial hand and the wrist disarticulation. As has been seen, the most practical result is often best obtained through some combination of surgery and prosthetics, the two complementing each other in such a way as to provide a wide range of functional regain.</p> <p>Of course there will always be hands with too much wrong with them to justify attempts at reconstruction. Where such appears to be the case, amputation at the lowest possible level, followed by application of a good, functional prosthesis, obviously offers the best solution. But in the face of a rapidly growing technique in hand surgery including special manipulations with muscles, tendons, nerves, and vessels it would appear wise always to choose the most conservative course possible. That would mean reconstruction whenever the anticipated result is likely to serve satisfactorily the needs of the individual concerned. The possibilities outlined here are representative of what might reasonably be expected under a given set of circumstances.</p> <h4>Acknowledgment</h4> <p>For much valuable information on partial hand prostheses that have proved successful, the author is indebted to George B. Robinson, of the Robin Aids Manufacturing Company, Vallejo, Calif. The drawings accompanying this article are the work of George Rybczynski, free lance artist of Washington, D. C.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., and Eugene F. Murphy, Prosthetics research and the amputation surgeon, Artificial Limbs, September 1954</li> <li>Bunnell, Sterling, Surgery of the hand, 3rd ed., Lippincott, Philadelphia, 1956.</li> <li>Fletcher, Maurice J., The upper extremity prosthetics armamentarium, Artificial Limbs, January 1954</li> <li>Fletcher, Maurice J , and Fred Leonard, The principles of artificial hand design, Artificial Limbs, May 1955.</li> <li>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, 1954.</li> <li>Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Co., Inc., Hagerstown, Md., 1944.</li> <li>Navy Prosthetic Research Laboratory, U.S. Naval Hospital, Oakland, Calif., Cineplaslic above elbow prosthesis (congenital bilateral arm amputation), Interim Progress Report [on] Research Project NM 007 084.26, 1 November 1954.</li> <li>Pursley, Robert J., Harness patterns for upperextremity prostheses, Artificial Limbs, September 1955.</li> <li>Robin Aids Manufacturing Co, Vallejo, Calif.,Functional arm bracing and artificial arms, 1956.</li> <li>Schottstaedt, Edwin R., and George B. Robinson, Functional bracing of the arm, J. Bone and; Joint Surg., 38A(3):477;38A(4):841 (1956).</li> <li>University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 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>9.</b> </td><td class="clsTextSmall">Robin Aids Manufacturing Co, Vallejo, Calif.,Functional arm bracing and artificial arms, 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">Robin Aids Manufacturing Co, Vallejo, Calif.,Functional arm bracing and artificial arms, 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>10.</b> </td><td class="clsTextSmall">Schottstaedt, Edwin R., and George B. Robinson, Functional bracing of the arm, J. Bone and; Joint Surg., 38A(3):477;38A(4):841 (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>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper extremity prosthetics armamentarium, Artificial Limbs, January 1954</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J , and Fred Leonard, The principles of artificial hand design, Artificial Limbs, May 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>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J , and Fred Leonard, The principles of artificial hand design, Artificial Limbs, May 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>11.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 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>7.</b> </td><td class="clsTextSmall">Navy Prosthetic Research Laboratory, U.S. Naval Hospital, Oakland, Calif., Cineplaslic above elbow prosthesis (congenital bilateral arm amputation), Interim Progress Report [on] Research Project NM 007 084.26, 1 November 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">Pursley, Robert J., Harness patterns for upperextremity prostheses, Artificial Limbs, September 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">Alldredge, Rufus H., and Eugene F. Murphy, Prosthetics research and the amputation surgeon, Artificial Limbs, September 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>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy, Prosthetics research and the amputation surgeon, Artificial Limbs, September 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">Alldredge, Rufus H., and Eugene F. Murphy, Prosthetics research and the amputation surgeon, Artificial Limbs, September 1954</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper extremity prosthetics armamentarium, Artificial Limbs, January 1954</td></tr><tr><td class="clsTextSmall"><b>5.</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, 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>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper extremity prosthetics armamentarium, Artificial Limbs, January 1954</td></tr><tr><td class="clsTextSmall"><b>5.</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, 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>2.</b> </td><td class="clsTextSmall">Bunnell, Sterling, Surgery of the hand, 3rd ed., Lippincott, Philadelphia, 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>6.</b> </td><td class="clsTextSmall">Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Co., Inc., Hagerstown, Md., 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Sterling Bunnell, M.D. </b></td></tr><tr><td class="clsTextSmall">516 Sutter Street, San Francisco 2, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-90.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-91.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-91b.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-92.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-93.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-94.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-95.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-96.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-98aa.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-98b.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-100.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-101.jpg Figure 13 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-102.jpg Figure 14 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-103.jpg Figure 15 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-104.jpg Figure 16 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-105.jpg Figure 17 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-106.jpg Figure 18 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-107.jpg Figure 19 http://www.oandplibrary.org/al/images/1957_01_076/1957-Spring-107b.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 Management of the Nonfunctional Hand Reconstruction vs. Prosthesis Creator An entity primarily responsible for making the resource Sterling Bunnell, M.D. * https://staging.drfop.org/files/original/e71416996352556efb023812c4eedec5.pdf 25ebf46eaf69e9b152e2c190d46f2a77 https://staging.drfop.org/files/original/b6c5c1116f50d1110f991f8a6c0e582b.jpg 53141fda199ab171208acf35d095a73d https://staging.drfop.org/files/original/42e04c9ddf407f09592f368dc9ff1c12.jpg 651ea138a11022d6edf8e33366739adf https://staging.drfop.org/files/original/bcdce6329da04a8a8f4710fbe3957aec.jpg 227b1bc4f43139dc742e5cfc3434f264 https://staging.drfop.org/files/original/061a0c8f6051439279c49121003e4252.jpg e92f1b105cd71be2e26422d8ed541101 https://staging.drfop.org/files/original/220a179b1734ff365426e6b757fbf1a4.jpg 106d747231911de3f7ab6a749818955f https://staging.drfop.org/files/original/a030df8afdd8d496ea38ff35eb10a376.jpg 099981a8288aa53e4f8ab7a1afcf3ec3 https://staging.drfop.org/files/original/06b6efdef352c9a36c19e593016d0058.jpg 5cf35916d68ebab5f2fa7015770d5ec5 https://staging.drfop.org/files/original/e33abac33eb28c4425dc5ba7d3d9829f.jpg bbf0ffd1753ca99e90634ba88f777e5b https://staging.drfop.org/files/original/741aaf7774c9fb485c220490dfa15d66.jpg 104b74ab4ce49065ab443a4973decc68 https://staging.drfop.org/files/original/c7f5624a84623a65da53be9b14b7ad50.jpg 0d835a39d62f5c64705c7b7f85ff2696 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_004.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 4 - 56 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_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_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>Studies of the Upper Extremity Amputee. I. Design and Scope.</h2> <h5>Edward Peizer, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Man's increasing dominion over his natural environment has been ascribed to three specific characteristics a highly developed brain, binocular vision, and an apposable thumb. Although not particularly specialized from a biological viewpoint, these three attributes have enabled him to adapt to a varied physical environment and, perhaps more important, to alter the physical environment to suit his needs. Loss of any one of them deprives him of fundamental human capacities and seriously inhibits his ability to compete, to interact, and to manipulate the objective world around him. Impaired brain function is usually irreversible, and in the case of vision loss heroic measures are often required to obtain even a modicum of functional restitution. But the situation is somewhat different today with respect to the loss of an upper extremity. New concepts and developments in the field of limb prosthetics have increased the potentialities of arm amputees. Not all the problems are solved. Far from it. But systematic and concerted efforts in medicine and engineering are being applied toward reducing the limitations attendant upon the loss of an arm. It is perhaps ironic that historically these constructive efforts have been stimulated by the destructive forces of war.</p> <h3>Historical Development</h3> <p>In the aftermath of World War II, a grateful nation spared no effort to alleviate the condition of those who had been wounded or maimed in its defense. Among its many other services, the Veterans Administration undertook the task of providing prosthetic and rehabilitation services to all veteran amputees. In pursuit of this goal, it soon became clear that existing artificial limbs fell far short of meeting the needs and expectations of their users. Perhaps because of the greater dependence of the leg amputee upon adequate service, and because of the consequent emphasis on attention to his problems, the major needs were found among upper extremity amputees. Arm prostheses were found to be heavy, uncosmetic and unsanitary, and possessed of very limited function (<b>Fig. 1</b>) and (<b>Fig. 2</b>). Too often they were relegated to the closet. Generally accepted standards of prosthetic quality were lacking. Better materials, improved design, new prosthetic components, and improved fitting and fabrication techniques were clearly required.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical below-elbow prosthesis, vintage World War II. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Typical above-elbow prosthesis, vintage World War II. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Not generally recognized was the need for highly individualized training to develop proficiency in the use of an artificial arm so that vocational and other skills could be acquired. Without a common ground of experience, the physician rarely took part in the prescription and fitting of prostheses. Thus, even the most skilled prosthetist, faced with the task of providing his patient with a well fitting, comfortable, and highly functional prosthesis, sometimes found himself in the unfamiliar role of psychologist, therapist, and/or vocational counselor. In short, sound, complete, systematic rehabilitation programs for amputees were lacking. Officials of the Army, the Navy, and the Veterans Administration wasted little time in hand wringing. Authority was soon forthcoming, and funds were made available for a broad attack on these problems. The resources of science, applied during the war years to destruction and demoralization, were now directed toward the restoration of human loss and the enrichment of human life. The first step was the establishment, in 1945, of the Committee on Prosthetic Devices of the National Academy of Sciences National Research Council, which later became the Advisory Committee on Artificial Limbs and which is today the Prosthetics Research Board. This led to the inception of the Artificial Limb Program and to the establishment of research projects for the scientific study of the problems involved. At the University of California at Los Angeles fundamental studies were undertaken of the biomechanical principle involved in normal prehension and of the problems of using artificial arms. At the same time, the industrial laboratories of Northrop Aircraft, as well as the Army Prosthetics Research Laboratory, were creating new materials, new devices, and new fabrication techniques, while New York University was assigned the task of evaluating these developments. The scientific facilities of both industry and government were thus employed to reduce the problem through efforts in basic and applied research.</p> <p>The earliest results indicated that solving the problems and fulfilling the needs of the upper extremity amputee was a task vastly greater than that of improving the mechanical aspects of fitting and fabricating prostheses. The finest artificial limb is of little value without training in its use. Further, the loss of a limb was seen to create important disturbances in the personality as a result of functional loss and distortion of the self concept. The amputee entertains doubts as to how he will appear to and be accepted by his family and friends. He wonders, often with misgivings, about his economic potential. He has what appear to him to be insuperable problems, and he needs help in restoring his self confidence as well as his lost function. In order to meet these amputee needs, a complete and rational system of rehabilitation programming was required, and since 1945 considerable progress has been made in developing such an approach to this problem.</p> <p>After several years of organized effort, a great deal of research information became the basis for an all around approach to the treatment of upper extremity amputees. Through the development of models, the testing of hypotheses, and the experimental treatment of a number of arm amputees of all types, it became possible to indicate with some confidence how certain types of patients should be fitted, how their arms should be constructed, and how they should be trained to use them. As an added result, it is becoming a commonplace that all the amputee's needs cannot be served by a single individual, regardless of his professional status or training. With recognition of individual needs and the variety of amputee problems, it became clear that successful rehabilitation of these patients demanded the highly qualified and specialized services of a number of disciplines. Prosthetists, therapists, and physicians each have vital contributions in this enterprise, as may also nurses, social workers, vocational counselors, and psychologists. The modern concept then became the "team approach," the team consisting minimally of the doctor, the prosthetist, and the trainer and including such other specialists as each case required.</p> <p>In order to evaluate these findings, a series of studies, which came to be known as the "NYU Field Studies," was conceived in 1951 at the Prosthetic Devices Study at New York University.</p> <h3>Goals of the Upper Extremity Field Studies</h3> <p>The NYU Field Studies of upper extremity prosthetics developed as the logical consequence of two main preconditions the laboratory research program and the prosthetics education program. As for the first, out of the laboratories had come a whole series of new devices which, on the basis of preliminary testing on relatively small groups, gave promise of being significantly improved components. Before some of them could be considered "proved" items of a prosthetic armamentarium, more definitive testing on broader, more representative samples under varying conditions seemed essential. But more than gadget testing was involved. New fabrication techniques employing plastics had also been developed, and although arms made according to these procedures seemed superior to older types, it remained to be seen if the procedures could be mastered by limbmakers all over the country and economically and conveniently applied to the production of all types of artificial arms.</p> <p>The second factor to be considered in planning the studies was the matter of broad and speedy dissemination of the new knowledge and skills. It was clear that the new procedures could not be evaluated in clinics whose personnel were not completely familiar with their use. Moreover, considerable urgency prevailed about making new developments and improvements available to all amputees as soon as possible. To fulfill this requirement, a prosthetics education program was organized to train clinic team personnel. But it was generally observed that additional assistance was required in significant numbers of clinics before they could begin to process patients effectively.</p> <p>For all of these reasons, the NYU Field Studies were designed in 1953 with three main objectives in view:</p> <ol> <li><i>To evaluate the utility and acceptability of specific prosthetic materials, components, and treatment procedures</i>. In order to appraise the usefulness of prostheses provided amputees by the program, and in order to gauge the reactions of the patients to the new arms, a comprehensive evaluation procedure was to be developed. The comfort and appearance of a prosthesis and the confidence it inspires in its user are as important in prosthetic service as are structural and mechanical adequacy. Each of these areas was explored.</li><li>To provide direction for future research in relation to practical field needs. Field study operations should provide access to large representative samples of upper extremity amputees. Clinical contact with these patients would furnish a means for determining existing prosthetic problems and, even more important, for evaluating the importance of these problems to amputees themselves. With this information available to the developmental laboratories through a feedback arrangement, their efforts could be directed toward the problems of most immediacy and importance.</li><li>To extend the educational process by rendering administrative and technical assistance to newly organized prosthetics clinics. Shortly after graduation from the prosthetics courses at the University of California at Los Angeles, potential clinic teams were to be visited by NYU representatives, the purpose being to encourage and aid in the establishment of a clinic procedure along the lines taught in the courses. The expeditious organization of a clinic served two functions amputees would have early access to modern treatment, and a clinic treating patients according to these procedures was a potential participant in the field studies and a source of research data.</li></ol> <p>Before these concepts could be tested in the crucible of clinic practice throughout the nation, several preliminary steps were necessary. First, meaningful and reliable methods had to be found for evaluating the effect of prosthetic treatment procedures. Second, a number of clinics had to be organized to participate in the studies if valid inferences about the general utility of the experimental procedures were to be drawn. Third, training in the new prosthetic techniques and procedures had to be given to those who dealt directly with amputees. Actually, all three of these steps were undertaken at approximately the same time.</p> <h4>Inauguration of the Upper Extremity Field Studies</h4> <p>The staff of the Prosthetic Devices Study of New York University had been engaged in developing on a generally theoretical basis a philosophy and methodology for evaluating the status of arm amputees. The problem was approached directly, attempts being made to determine the most important outcomes in prosthetic restoration and to measure the extent to which the newer management procedures provided them. Accordingly, procedures and instruments were devised for determining the extent of residual function and the degree of adjustment to physical disability (<b>Fig. 3</b>). The status of the patient after treatment could thus be compared with his pretreatment condition as a basis for evaluation. But before these instruments could be applied on a broad scale it was necessary to test their reliability and administrative feasibility as well as to refine the procedures for their application. For this purpose, a preliminary "pilot" study was planned, and Chicago was selected as the test site.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Calibrated grid for measuring the arm movements required to perform certain common activities. Use of top and side mirrors provides information in three dimensions simultaneously. Clocks record time data. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Chicago "Pilot" Study</h4> <p>The pilot study carried out in 1952 called for a small number of surgeons, therapists, and prosthetists from the Chicago area to attend a special four week course of instruction in upper extremity prosthetics at the University of California at Los Angeles in order to familiarize the participants with the devices, fabrication techniques, and clinical procedures to be evaluated.<a></a> Upon their return to Chicago, they were joined by representatives of NYU's Prosthetic Devices Study, and the pilot study was launched.</p> <p>This field trial of research instruments and procedures involved the screening of a number of amputees in the Chicago area and the selection of a group for treatment in the Veterans Administration clinic. To enable the clinic properly to prescribe the new prosthesis, each of the selected subjects was given a comprehensive evaluation prior to other treatment. In addition, research evaluations were conducted by NYU representatives to provide baseline data against which the effects of the rehabilitation procedures could be evaluated. The new arm for each participant was then prescribed in accordance with the prescription procedure taught in the UCLA course and was to be fabricated precisely as prescribed and according to the mechanical and cosmetic standards formulated. When the arm was complete, it was brought to the clinic for a checkout which consisted of a detailed examination by the clinic staff to assure themselves of the adequacy of the product. If revisions were required, they were made before the patient was given the arm; if none were needed, the clinic prescribed appropriate training treatments to be administered by the therapist.</p> <p>After training was completed, the amputee was again seen by the clinic team; if the arm were still satisfactory and maximum results had been achieved through training, the patient was to wear the arm routinely in daily living. At the end of a two month period of daily wear, the subjects were re evaluated in a manner similar to the pretreatment evaluation.</p> <p>As a result of the Chicago study, valuable experience was gained in the processing of patients. Research techniques were refined, clinic procedures were crystallized, methods for administering questionnaires and for taking measurements were standardized, and instruments were revised and augmented. With the end of the pilot phase, expansion of the upper extremity field studies to national proportions began, an expansion made possible by the participation in the program of a number of widely distributed private clinics as well as Veterans Administration clinics.</p> <h4>Organization Of Participating Clinic</h4> <p>The unprecedented nature of the projected field studies made the selection of a number of clinics a formidable task. It was first necessary to locate interested and qualified clinic personnel. Then it was necessary to orient them as to the nature of the program as well as to the need for special training. Steps for integrating the clinics into the field program required explanation, and specific operating procedures had to be worked out with individual groups. This task was undertaken by the Director of the Prosthetic Devices Study, Dr. Sidney Fishman.</p> <p>After completion of the pilot study in Chicago early in 1953, and continuously for two years thereafter, Dr. Fishman and Dr. Miles H. Anderson, the Director of the Prosthetics Education Project at UCLA, visited many large population centers throughout the country in order to meet with medical and paramedical personnel interested in the treatment of arm amputees. On the basis of expressions of interest, and of an appraisal of the available facilities and potential case loads, a number of clinical facilities were invited to participate. During these discussions, research procedures were described, expected outcomes were explained, and the roles of the clini members and of the NYU research workers were defined. Arrangements were made for members of each clinic staff to attend the courses in upper extremity prosthetics at UCLA (see below).</p> <p>It was quickly realized that financial problems would be encountered both by private clinics and by participating limbshops. In the former, the newer training procedures called for increased services of therapists and doctors. In the latter, the employment of newer fabrication and fitting techniques required an initial investment on the part of the prosthe tists in components, equipment, and materials. In addition, the checkout of an arm by the clinic team often resulted in revisions adding to initial fabrication costs. For these reasons, certain fiscal arrangements were indicated. Monies were made available to clinic teams to pay the training fees for amputee cases participating in the work. In order to spur the fabrication of the new type arms and to permit participation in the program by the prosthe tists, arrangements were made to purchase five experimental limbs from each shop participating in the studies. As a result of these efforts, 75 clinics representing 30 states and the District of Columbia (<b>Fig. 4</b>) participated in the field program. Each treatment center was directed and staffed by graduates of special upper extremity prosthetics training courses. Of the total number of clinics involved, 28 were Veterans Administration installations and 47 were other public and private institutions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Location of the participating clinics See facing page. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Prosthetics Education Program</h4> <p>The new knowledge and techniques, organized into courses of instruction and revised after the pilot school, were offered in a series of 12 schools (<b>Fig. 5</b>) conducted at UCLA, the chief purpose being to familiarize doctors, therapists, and prosthetists with the new developments and to encourage the team approach to the prosthetic rehabilitation of the upper extremity amputee. It thus became possible to teach to those with primary interest new concepts for the management of upper extremity cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Students and instructors of one of the 13 courses in upper-extremity prosthetics offered at the University of California at Los Angeles. This particular course was held in the autumn of 1954. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In effecting the transfer of information and skill to the primary amputee treatment grou consisting of the doctor, the therapist, and the prosthetist, academic tradition was broken. It seemed plain that if the "team approach" were to be taught, the members of the team should go to school together. Accordingly, in a unique educational enterprise, orthopedic surgeons, specialists in physical medicine, physical and occupational therapists, and prosthetics craftsmen became classmates. The six week course offered at UCLA began with a three week session of instruction for prosthetists only. During this portion of the course, prosthetists were exposed to a highly concentrated educational dose of prosthetic design and construction principles, plastics technology, anatomy, and kinesiology. Then they tested their knowledge by fitting patients under the direct supervision of their instructors.</p> <p>In the fourth week, the prosthetists were joined by the therapists. This group began with a concentrated portion of mechanics, biomechanics, and the characteristics of a wide variety of both newly developed and the older prosthetic components. Under the supervision of the instructors, they also received experience in training the patients previously fitted by the prosthetist students.</p> <p>At the beginning of the sixth week, the prosthetists and therapists were joined by the physicians and surgeons, who were given several days in which to review and digest the course materials. Practice clinic teams, consisting of the doctor as clinic chief and of at least one therapist and one prosthetist, were then organized. The entire class then proceeded to operate as clinic teams until graduation, whereupon each of the individuals returned home, a potential participant in the soon to follow upper extremity field studies. The new knowledge and skills were broadly disseminated by these educational efforts, but their utility and effectiveness on patients could not be clearly seen until large numbers of varying types of patients had been treated and evaluated.</p> <p>The Prosthetic Devices Study, charged with the responsibility for following up the program concepts, designed studies to evaluate the modern treatment methods. The central questions to be answered were deceptively simple: Are upper extremity amputees better served by means of the program procedures? In what specific areas can improvement, detriment, or indifference be found?</p> <h4>Areas of Research</h4> <p>In relatively unexplored fields, the formulation of meaningful research questions is often laborious, unsure, and time consuming. Merely selecting the most scientifically promising problems from the many questions which arise is in itself an important research task. Many possible approaches to the field must be evaluated, and those selected for study must give promise of becoming part of and contributing to the solution of larger problem areas. The research plan developed at the Prosthetic Devices Study to achieve the objectives of the field study program evolved in this way. It provided for three major interrelated study areas to be exploited concurrently.</p> <p>The first of these, a census of amputees, called for interviewing large numbers of upper extremity amputees in order to begin the organization of a broader body of knowledge concerning them and to provide a large population from which to select a sample for more detailed study. This was the "Survey Phase." Secondly, a segment of this population was selected for clinic treatment by means of the rehabilitation procedures under study. These efforts of the field operations, referred to as the "Clinical Studies," were designed to provide information about the feasibility of clinic procedures and prosthetic fabrication methods. The third study area provided for the pre and post treatment evaluation of a portion of the sample selected for clinic treatment. This approach, called "Evaluation Studies," was intended to elicit more detailed information about a smaller number of amputees than was possible in the survey and to provide a basis for evaluation of the methods and materials employed in the treatment procedure.</p> <p>In its final form, the research plan provided for trips by NYU field representatives to attend the monthly meetings of each participating clinic. Consequently, a given member of the staff would be in the field approximately two weeks out of each month, and a routine field trip often took him to five or six cities, where he would visit perhaps six or eight clinics and observe 20 to 30 amputees under treatment. With 75 participating clinics to serve, a field staff of 10 representatives directed by two field supervisors was organized. Since clinic meeting dates and times were quite firmly fixed, and since the time required to be spent with each subject varied from fifteen minutes to four hours, depending upon the stage of treatment, the trips required considerable planning. To minimize loss of time, schedules were arranged by correspondence, and confirmed when possible, before each trip. Despite the difficulty of control, the attrition rate when the studies ended was low. Some what less than 10 percent of those initially selected failed to complete the full treatment course and follow up studies.</p> <p>The NYU representative served two main functions: he established liaison among the treatment centers in the field and between them and New York University, which resulted in interchange of information and coordination of effort, and he was responsible for the collection of the research information. These data were gathered in the field by means of interviews, questionnaires, tests, and measurements.</p> <h4>Survey Studies</h4> <p>Each arm amputee referred to a participating clinic was considered a prospective research subject, and each was given a screening interview, the purpose being to obtain pertinent information concerning the patient, his prosthesis, and his needs and aspirations. Initially, clinics screened only those amputees who were immediately in need of treatment. The information thus gleaned contributed to the survey to be made of the status of upper extremity amputees in the United States and was also useful in the selection of subjects for more detailed study. On the basis of the screening data, two classes of subjects were selected. One group was to be treated only in the clinic by the prescribed procedures. The other, in addition to the clinic treatment, was to undergo a detailed pretreat ment evaluation and a similar post treatment procedure.</p> <p>At the screening interview, the purposes and general procedures of the program were explained to the prospective participant, and information of an administrative and medical nature was collected. The common vital statistics dealing with age, height, weight, and marital and occupational status were recorded. In addition, the date, cause, and site of amputation were obtained, and the length, range of motion, shape, and condition of the stump were described. Detailed descriptions were compiled of prostheses worn by candidates, and their quality and the subjects' ability to use them were evaluated. The data contributed by each amputee were recorded on forms developed for this purpose (Appendices IA and IB).</p> <p>The selection of amputees to be processed at the first and subsequent prescription meetings was made at the Prosthetic Devices Study on the bases of available information and the sampling requirements of the study. Factors taken into account in the selection of the subjects included type of amputation, general health and physical condition of stump, and motivation of patient (his interest and willingness to participate). The entire census included 1630 male upper extremity amputees, of whom 826 were below elbow cases, 668 had amputations above the elbow, 89 had disarticulations at the shoulder, and 47 were bilateral amputees of all types. The findings arising from these survey studies are described in the article by Berger.</p> <h4>Clinical Studies</h4> <p>The idea of the clinic team was the key concept of the newly developed management procedures. The clinic was viewed as a means and a method for focusing the special skills of all the necessary medical and ancillary specialists on the specific problems of providing the amputee with the best possible replacement for the lost member. The primary service group consisted of physicians and surgeons, therapists, and prosthetists. Other specialists, such as administrative personnel, vocational rehabilitation counselors, social service workers, or psychologists, were added according to the special needs of individual cases. The fundamental nature of the clinic was emphasized by the requirement that each of the basic members be present before an "official" meeting of the clinic could be opened. It was at these clinic meetings that the treatment concepts to be evaluated were applied. There were six basic steps in the clinic procedure prescription, preprosthetic treatment, fabrication of the prosthesis, initial checkout, training, and final checkout. Of these, three prescription, initial checkout, and final checkout required meetings of the full clinic team.</p> <h5><i>Prescription</i></h5> <p>Prescription, during these studies, called for the selection of specific components from an armamentarium of tentatively approved devices for assembly into an individual prescribed prosthesis. Most of these components were designed for specific types of cases or uses and were to be prescribed in accordance with their design purposes. The final prescription was to be the concensus of the clinic members as to the most applicable components in each case. In practice, however, the medical, surgical, and physical therapy needs of each patient were considered, as were also personal and vocational indications for specific components and materials. Required was a written prescription specifying every component to be used, and all deviations from standard applications were avoided unless expressly written into the prescription. To standardize the type and quality of the information collected at these meetings, the prescription form in Appendix IIA was developed. This procedure not only was the first treatment step but it also permitted the collection of research data describing the specific devices fitted to the subjects. On the basis of subsequent acceptability and utility to the amputees, inferences could be drawn as to the worth of these components.</p> <h5><i>Preprosthetic Treatment</i></h5> <p>As part of the prescription process, the patient was examined for conditions which might produce difficulty in wearing or using an artificial arm. Particular efforts were made to institute treatment prior to fitting a limb and thereby to avoid the influence of these factors upon the acceptance and use of the prosthesis. Medical and surgical problems involving disease, infection, inflammation, redundancies, bone overgrowth, neuromata, and plastic alterations were referred to the physician for treatment. Muscular weakness and limitations in joint mobility considered amenable to treatment were referred to the therapist.</p> <h5><i>Fabrication of the Prosthesis</i></h5> <p>When the prescription was completed, instructions were given to one of the attending prosthetists to fabricate the arm. With strict adherence to the details of the prescription, the limbmaker produced the arm by use of the techniques of fitting taught by the program. He was encouraged to inspect the completed arm by means of a checklist embodying the structural, functional, and cosmetic standard that his product would have to meet at the next clinic meeting.</p> <h5><i>Initial Checkout</i></h5> <p>When the arm had been fabricated, it was brought to the clinic prior to being worn by the subject. At this clinic meeting, called "initial checkout," the standards developed in the program were applied. The initial checkout included an objective and subjective appraisal to see that the device fulfilled the prescription requirements and that it met established standards of fit, comfort, function, and appearance (<b>Fig. 6</b>). The information thus obtained described the ranges of motion available with the arm, the forces required to operate it, and stability, fit, comfort, and weight. In addition, some 30 items dealing with details of fabrication, appearance, color, specific components, and general quality were checked. These standards were considered to represent minimal levels of prosthetic adequacy. All the appropriate measurements and checks were recorded on a form similar to that shown in Appendix IIB.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. A typical clinic meeting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These data were used to control the quality of the arms in order to permit valid generalizations about their worth. In addition, when compared with the outcomes of the treatment procedure, these data provided the basis for evaluation of the standards themselves.</p> <p>The checkout was performed at a regular meeting of all members of the clinic. If the arm failed checkout, it was referred to the prosthetist for appropriate revisions (<b>Fig. 7</b>). Consequently, it was sometimes necessary for the subject to appear at the clinic more than the minimum of three times. If the prosthesis met all the requirements, the amputee was permitted to wear the arm regularly and was scheduled for training by the therapist, the next step in the clinic procedure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Checkout. Final harness adjustments are made on a new arm prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Training</i></h5> <p>The training given to each subject by the therapist was organized in two parts controls training and use training.</p> <p><i>Controls Training.</i> In the preliminary step, the objective was to familiarize the amputee with the mechanics of his appliance and to develop his ability to control its movements.</p> <p>First he was taught to operate the arm freely so as to learn by kinesthetic reaction the motions and forces required to control it. Then various objects with abstract forms and of varying consistencies were introduced t develop prehension skill. When, in the opinion of both therapist and amputee, these control motions were adequately developed, the next training phase began.</p> <p><i>Use Training.</i> Once the basic operating techniques were learned, they were applied to performing the practical activities of daily living, including self help, home tasks, and vocational and social activities (<b>Fig. 8</b>). The training objectives were now to give the amputee confidence in his ability to use the arm by exploring a variety of activities and to achieve proficiency in performing them. In this connection, it was necessary to recognize that the prosthesis cannot replace the lost member and that at best it becomes an auxiliary of the remaining arm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Use training. The therapist explains how to approach, grasp, and manipulate a variety of common objects. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>By application of this fairly standardized sequence of activities, it was possible to collect research information relating to achievement levels and to the number of hours of training required to achieve satisfactory performance. When the amputee seemed capable of satisfactory performance with his prosthesis, the therapist arranged for him to reappear at the clinic for a final checkout.</p> <h5><i>Final Checkout</i></h5> <p>The final checkout concluded the process of providing the amputee with an arm. In a fashion similar to the pretraining initial checkout, it was conducted at a regular meeting of the clinic, all members present. The purpose at this time was threefold to recheck the mechanical and functional adequacy of the arm after use in training, to assure the clinic that satisfactory proficiency levels had been attained, and to be sure that nothing further in the way of service could be offered the patient if the first two conditions were met.</p> <p>The objective and subjective appraisal was again accomplished by means of the standardized checkout procedure (Appendix IIB). The arm was carefully inspected for signs of wear, and evidence was presented that the amputee was adequately trained. If the condition of the arm and proficiency of the subject in its use were deemed satisfactory, he was discharged with instructions to use the arm in accordance with his daily needs.</p> <h5><i>Recapitulation</i></h5> <p>Altogether, the group treated in the clinics included 378 below elbow, 321 above elbow, 46 shoulder disarticulation, and 24 bilateral amputees. Of the total of 769, 410 received no further treatment, while 359 were extensively studied prior to and after completion of the treatment procedures.</p> <p>The complete procedures employed in these studies are rather too complex for convenient presentation here in more than outline form. The full description and explanation of the most recent modification of these procedures is the subject of short term courses of instruction currently being offered at the University of California at Los Angeles and at New York University. The manuals used in these courses<a></a> contain detailed descriptions of the procedures and may be referred to for further information.</p> <p>The results of these clinic studies are presented in the article by Springer.</p> <h4>Evaluation Studies</h4> <p>The prosthesis for an upper extremity amputee is a necessarily limited means of providing those motions lost through amputation prehension, pronation supination, wrist flexion extension, and, in the case of the above elbow amputee, the additional function of flexion extension of the forearm. The chief goals of the evaluation procedures were to determine the extent to which a prosthesis provided functional as well as cosmetic replacement. A corollary purpose was to discover additional parameters of prosthetic utility and acceptability by increasing our knowledge of why an amputee accepts and uses more readily and efficiently one prosthesis in preference to another.</p> <p>The extent to which prosthetic restoration is successful is dependent upon what each subject brings to the appliance in terms of physical and mental characteristics and on what the appliance brings to him in terms of functional capabilities and qualities of comfort and cos mesis. Evaluation procedures were, therefore, aimed at the analysis and understanding of both the human and the mechanical variables that are involved in the successful use of an arm prosthesis. Although the potential significance of the pre injury personality was recognized, it was not investigated because of the difficulty of obtaining such information in a field study of this nature.</p> <p>Some of the significant evaluation factors lent themselves to objective measurement; others, of a more personal and subjective nature, could be obtained only from the amputee himself. For this reason, the evaluation procedures and instruments were designed to collect both objective measurements and more subjective data dealing with the reactions and responses of the amputee.</p> <p>In this connection, the measurement rationale underlying the collection of data should be understood. Quantitative data are convenient for systematic analysis. But quantification can be meaningful only within well developed and clearly defined evaluation areas. The appraisal, for example, of certain functional characteristics of an arm lends itself readily to objective or quantitative measurement, since the problem area is defined by the extent to which the prosthesis replaces certain lost motions. The problem here is clear; the ranges of motion and the forces applied can actually be measured. In much the same way, an evaluation of performance may be made by scoring such objective aspects as speed, errors, and even some types of quality. On the other hand, in dealing with those effects of treatment procedures relating to feelings, attitudes, emotions, comfort, and fit, the parameters to be measured are not at all clear. For this reason, in such obscurely defined areas qualitative data deriving from interviews and from both structured and unstructured responses of the subject tend to be more valuable in outlining and clarifying the areas of study. Once this is done, the particular factors may become amenable to quantitative measurement.</p> <p>Actually, only three possible sources of data were available objective measurements describing events, the expert opinions and judg ments of qualified observers, and the reactions of the subjects. Each of these sources was exploited. Specific mechanical and biomechani cal factors were measured by objective methods. Prosthetic quality and proficiency in performance with an arm were appraised by trained observers whose reliability was periodically checked and re established. Finally, the amputee himself provided information relating to his reactions to the arm, its quality, and its usefulness to him. Within two broa categories, the human and the mechanical, the following were studied:</p> <h5><i>Biomechanical Data</i></h5> <ol> <li>The strength and ranges of motion of the arm and shoulder girdle and the general physical condition of the amputee.</li><li>The ranges of motion permitted by the prosthesis, its efficiency, and the forces required to operate it.</li></ol> <h5><i>Performance Pattern</i></h5> <ol> <li>Proficiency in accomplishing the basic activities of prehension, transportation, and release in various planes and at different levels.</li><li>Quality of performance of practical daily life activities.</li><li>The range of activities in which prostheses are used and the extent of their importance.</li></ol> <h5><i>Amputee Reactions</i></h5> <ol> <li>Importance and extent of use of prostheses in daily living.</li><li>Reactions to treatment procedures.</li><li>Appraisal of prostheses and components.</li></ol> <h5><i>Psychological Reactions</i></h5> <ol> <li>Personal meanings of amputation and prosthetic restitution.</li><li>Social consequences of loss of limb and of prosthetic replacement.</li></ol> <h5><i>Biomechanical Data</i></h5> <p>It is reasonable to assume that an upper extremity prosthesis which affords the amputee a greater range of motion and which requires a minimal amount of energy or force for operation will be a more desirable appliance. While much more information is necessary before final judgment can be made, comparative data on these factors formed one of the bases for the evaluation of arm prostheses. This kind of data was obtained through direct measurement using such instruments as rulers, spring scales, and goniometers. They were used to measure pinch force between hook or hand fingers; efficiency of force transmission through the cable system; ranges of pronation, supination, and forearm flexion; socket displacement under axial load; and weight of the prosthesis. In the case of the above elbow amputee, additional information was collected on force input required to flex the forearm, angular deflection of the humerus needed to produce given ranges of forearm flexion, and ranges of motion at the shoulder. These measures were recorded on th instrument shown in Appendix IIIA. The outcome of these evaluations will be presented in an article in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <h5><i>Performance Patterns</i></h5> <p>The performance of the subjects in standardized, specially designed activities was observed and analyzed. This procedure was employed to provide information concerning the effectiveness and appearance of the performance patterns. Two approaches to the evaluation of performance were taken. Both abstract and practical function were evaluated. In the former, the ability accurately to grasp, transport, and release objects of varying sizes, shapes, weights, and consistencies was graded (<b>Fig. 9</b>). In the evaluation of practical function, amputees were graded on their performance of meaningful daily life activities (<b>Fig. 10</b>). Proficiency scores and time and motion data were recorded on the forms appearing in Appendix IIIB, while activities were tabulated as shown in Appendix IIIC.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Evaluation of abstract function. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Evaluation of practical function. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Amputee Reactions</i></h5> <p><em>Analysis of Importance and Extent of Use of Prosthesis in Daily Living.</em> In an attempt to appraise the importance of the prosthesis to the amputee, and to determine some of the specific ways in which prostheses were used, the interview technique was utilized. The subjects were asked if they used their prostheses in specific activity areas, including work, home tasks, social life, dressing, and eating. If thei response was positive in any area, they were asked to specify the particular use they made of the arm. They also were asked to rate the importance they placed on their prostheses in each of the activity areas.</p> <p>The extent to which a subject used his prosthesis to accomplish the tasks of daily life seemed to be a significant factor in appraising the degree of functional restoration afforded by the prosthesis. For this reason information was gathered about the frequency with which the prosthesis was used in ordinary two handed activities. In order to make this more meaningful, additional information was collected concerning the frequency with which each activity was encountered in the course of the daily life of the particular amputee. Additional information about common activities which were not done and the reasons therefor also was gathered.</p> <p>The following key questions were used:</p> <ol> <li>How often does the occasion arise for the amputee to perform each of a number of typical two handed activities?</li><li>How often does the amputee use his prosthesis in performing each activity?</li><li>If the need for an activity arises more often than the prosthesis is used in accomplishing the task, why does the amputee not use his prosthesis?</li><li>What is the relative importance of each of a number of activities?</li></ol> <p>These evaluations were made by means of the instrument shown in Appendix IIIC. The results of this study will appear in an article in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <p><em>Reactions to Amputation and Prosthetic Experience.</em> The subjective reaction of an amputee to his prosthesis was deemed an important factor in its evaluation. Apart from his feelings about the characteristics of the prosthesis, his experiences in securing it and wearing it are also contributing factors in his acceptance or rejection of the arm, and information in this regard may be important to an understanding of his status. This type of information was obtained through the use of interviews and questionnaires. By these means, data were gathered relating to:</p> <ol> <li>Time lapse between amputation and first prosthesis.</li><li>Preprosthetic physical therapy.</li><li>Procedures in prosthetic prescription.</li><li>Services of prosthetist.</li><li>Procedures in initial checkout of prosthesis.</li><li>Training in the use of the prosthesis.</li></ol> <p>The article by Springer describes the findings of this study.</p> <p><em>Amputees' Appraisal of Prosthesis and Components.</em> An evaluation of the prescribed components was an essential aspect of the studies. An armamentarium had been developed, and components had been prescribed on the basis of their design features. In order to appraise the relative value of these components, the amputees were asked to comment on specific characteristics of all the components of their prostheses and to describe the suitability or inconvenience of any device with which they were familiar. The following information was elicited:</p> <ol> <li>The extent of his acquaintance with prosthetic components.</li><li>His appraisal of certain specific characteristics of each device with which he was familiar.</li><li>His expression of the suitability of prosthetic components for activities.</li><li>A comparison of currently and previously worn prostheses.</li></ol> <p>These opinions and experiences were recorded as shown in Appendix HID. The results and significance of this study will appear in an article in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <h5><i>Psychological Reactions</i></h5> <p>It is frequently observed that some amputees fail to wear or use a prosthesis which seems to be well fitted and functional. Others, with properly prescribed and well fitted arms, and even those with inadequate prostheses, accept and use them extensively. These reactions were attributed to the varying, highly personal meanings of amputation and prosthetic restoration. For this reason, a psychological analysis by means of interviews and questionnaires was undertaken to explore the significance of these factors.</p> <p>The instruments used included a 57 item multiple choice questionnaire (Appendix HIE) developed by the Prosthetic Devices Study. Completed by the subject in the presence of an NYU representative, it was designed to provide information about the feelings and behavior of amputees relative to amputation and prosthetic restoration. The following reactions were elicited: feelings of functional adequacy, acceptance of loss, sensitivity about disability, ability to cope with social situations, feelings of independence, and attitudes toward prostheses.</p> <p>Another questionnaire (Appendix IIIF) contained nine open end questions. This provided an opportunity for the subject to express his feelings about the effects of his condition and treatment upon his personality and social activities. It supplemented the more highly structured 57 item questionnaire (Appendix IIIE).</p> <p>The third instrument (Appendix IIIG) was a novel (experimental) application of a projective device. It consisted of nine cartoons depicting common social situations in which the fact of amputation might lead to awkwardness or embarrassment. It permitted the amputee to select one of a number of possible responses to each potentially embarrassing situation. By his reaction, the patient was expected to express his feelings of independence, the degree to which he faced reality, hi acceptance of the amputation, and his sense of security. Each response represented a gradation of possible reactions to each situation.</p> <p>A fourth questionnaire (Appendix IIIH) was employed specifically to elicit information from subjects who had never previously worn prostheses. It consisted of 15 multiple choice questions relating to the amputee's knowledge of prosthetic components and his expectations regarding the functional, cosmetic, and comfort qualities of artificial arms. A series of open end questions was included to determine opinions of prosthetic usefulness and difficulties of prosthetic wear.</p> <p>Upon execution of these procedures, the evaluation of an amputee was complete, but the entire process was performed twice. The first appraisal, conducted by the NYU representative prior to the prescription meeting, provided a detailed description of the pre treatment condition of the patient with respect to his physical condition, functional capacity, experience as an amputee, quality and usefulness of his prosthesis, and his emotional reaction to disability. Approximately three months after a satisfactory final checkout, or six to nine months after fitting, the previously evaluated subjects were again processed for a post treatment evaluation, the procedures followed being essentially the same as in the pretreatment evaluation. The instruments used are given in Appendices IIIE, IIIF, IIIG, and IIIH.</p> <p>These data are analyzed and discussed in an article to appear in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <h3>Summary</h3> <p>Some of the problems involved in prosthetic service to amputees just after World War II, and the steps taken by governmental and private organizations toward their solution, have been described in this section. The development of the Artificial Limb Program has been traced briefly from its inception throug the initial studies in which problems were isolated and new methods and materials to solve them were developed. The dissemination of new knowledge through the organization of a prosthetics education program has been discussed, and the design and scope of the studies undertaken to evaluate the new developments have been described. "Survey Studies" were carried out to increase the available knowledge about amputees in this country. "Clinical Studies" were pursued to evaluate the effect of the newly developed treatment methods. And "Evaluation Studies" of the changes in amputees' conditions brought about by these treatments were planned and executed.</p> <p>The evaluation instruments and techniques have been described briefly in this section in the interest of presenting a clear overview of the whole process. A total of 359 amputees were studied by means of these procedures. This group contained 168 below elbow, 158 above elbow, 23 shoulder disarticulation, and 10 bilateral amputees.</p> <p>The upper extremity field studies represented a pioneering effort to apply special skills to special problems in a broad, only partially understood field. A multiplicity of interests, unique requirements, and a paucity of previous research combined to broaden the scope of the studies. The methods and instruments employed are considered a first step toward the establishment of more precise and valid methods for evaluating the condition of those with physical impairment. But despite the broadness of the field and the research requirements, service to the amputee was always a paramount consideration.</p> <p><b>References:</b></p> <ol> <li> Universeity of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prsthetics</i>, 2nd ed., W. R. Santschi and Marian Winston, eds., in press 1958. A preprint was used. </li> <li>New York University, Prosthetics Education Project, Post-Graduate Medical School, Prosthetic clinic procedures, 1956. Chapter I.</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>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall"> Universeity of California (Los Angeles), Department of Engineering, Manual of upper extremity prsthetics, 2nd ed., W. R. Santschi and Marian Winston, eds., in press 1958. A preprint was used. </td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">New York University, Prosthetics Education Project, Post-Graduate Medical School, Prosthetic clinic procedures, 1956. Chapter I.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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"> Universeity of California (Los Angeles), Department of Engineering, Manual of upper extremity prsthetics, 2nd ed., W. R. Santschi and Marian Winston, eds., in press 1958. A preprint was used. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 Peizer, Ph.D. </b></td></tr><tr><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., W. R. Santschi and Marian P. Winston, eds., in press 1958. A preprint was used.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-10.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 Studies of the Upper Extremity Amputee. I. Design and Scope. Creator An entity primarily responsible for making the resource Edward Peizer, Ph.D. * https://staging.drfop.org/files/original/49c94e40d4d54801334c52a842ace4ed.pdf dfd86192aa56e645f99a7c566fa941e8 https://staging.drfop.org/files/original/cce24bee2b5fe0991388af212606ef74.jpg ef1c0dca41b0ab7c44300e6d6091dd63 https://staging.drfop.org/files/original/199ca305134e9005ef91d638f8f25894.jpg 4d0d5f177626a693aa2a260770eb3efe https://staging.drfop.org/files/original/3b360735bbb0fa0e3625db6dd8935a67.jpg 8bdbbe6dafaf8a396b30924bdd787d52 https://staging.drfop.org/files/original/dc137a63c334eca56c849eda853b7319.jpg 7b8647f7d925ec33f9fa8a9a30a7d76f https://staging.drfop.org/files/original/58a988e3c29cc1d77b5365f3b12fe7d6.jpg 11bfd9c94220dbf30ca3160cb92e64f0 https://staging.drfop.org/files/original/4104cbcff18b94957f89ad19c3538698.jpg 8f1672e6e9c7dcacb675b2c54346f4cf https://staging.drfop.org/files/original/f86a93f16d5cf433387b83c39de6baa1.jpg 1ba6d10dde2dbe083655de3498ff8947 https://staging.drfop.org/files/original/fe9962a5d48a6f8a2f401747a9d789e2.jpg 18e845753cbf9ac4c03f05dccf0a62a0 https://staging.drfop.org/files/original/a69de05bc1f9b589ef237d17add3a5ea.jpg 5423422d8380b01fc0c804ba17696ffa https://staging.drfop.org/files/original/bd3186304f87a62dee0927d9e017c4a7.jpg 323ef747f37e5e92fd66564ce31dd76b https://staging.drfop.org/files/original/221f45275c014c8446f733e660935c09.jpg 9104d70c79a83ac6f37205e2e6128e18 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_029.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 29 - 38 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/1957_02_029.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_02_029.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Biomechanics of the Canadian-Type Hip-Disarticulation Prosthesis</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>Establishment of a rational procedure for the proper fitting of a leg prosthesis to an amputee at <i>any </i>level of amputation requires careful consideration of many factors. The process of evolution of a new and satisfactory method of fitting of prostheses has generally been a lengthy one involving trials on amputees by a number of experimenters over a period of many years. Recently, both in the United States and in foreign countries this process has been accelerated through the efforts of research teams, which through a combination of the skills of personnel from the fields of medicine, prosthetics, and engineering have attempted to solve problems in a more logical, scientific manner. The Canadian-type hip-disarticulation prosthesis is an excellent example of an improved device that has resulted from the efforts of organized research in limb prosthetics.</p> <p>In a technical discussion of the principles of fitting of <i>any </i>prosthesis, it is often convenient first to describe the biomechanics involved, the term "biomechanics" referring both to the residual functional anatomy and to the mechanical implications of wearing a prosthesis applied to the stump. The biomechanical analysis establishes the pattern of force trans- mission between the prosthesis and the stump. Once the force pattern is known, physiological and anatomical factors must be considered in determining whether or not the proposed areas of force transmission are pressure-sensitive or unsatisfactory for other reasons. If there are no physiological contraindications, it then becomes the responsibility of the pros-thetist to fit and align the prosthesis in a functional and comfortable manner as dictated by the biomechanical and physiological requirements. Comfort is generally achieved by a distribution of any individual contact force over an area of the socket large enough to reduce the pressure on the stump to a tolerable magnitude.</p> <p>The biomechanical analysis of the Canadian-type hip-disarticulation prosthesis can be divided conveniently into two parts: first, an evaluation of the stump-socket forces required to support the torso in the stance phase and, second, a review of the dynamic behavior of the combined amputee and his prosthesis in level walking.</p> <h4>Principles of Mechanics</h4> <p><b>Force</b></p> <p>A "force" is the physical action of one body upon a second body which tends to change its position in space (<b>Fig. 1</b>). In interpreting the diagrams to follow, it will be necessary to consider the concept of force as a vector quantity. Force vectors, for example that shown in <b>Fig. 2</b>, must be specified by magnitude (indicated by length of a particular force arrow), sense or direction (indicated by the <!--Page 30--> arrow head), and the line of action (indicated by location of the shaft of the arrow).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "Force" defined. A "force" is the physical action of one body upon a second body. It may be either a push (compression) or a pull (tension). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The "force vector." The one shown here represents a 100-lb. force applied by a "second body." The force acts to the right, through point <i>A, </i>along a line inclined 10 deg. from the horizontal line <i>AB. </i>The scale factor for this force vector is 100 lb. per inch of length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>PRESSURE</b></p> <p>"Pressure" is a measure of the distribution of force over an area. Since pressure is defined as force per unit area, it is calculated by dividing the force by the area over which it acts. This would give an "average" pressure. Pressure is seldom uniform, and its variation is often indicated by a series of pressure vectors such as shown by the smaller arrows in <b>Fig. 3</b>. Where both force and pressure vectors are shown on the same diagram, the force vector indicates the "resultant," that is, the sum of the effects of the distributed pressures in a particular region.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. "Pressure" defined. "Pressure" is force supported per unit area. A broad area of support results in lower values of average pressure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>EQUILIBRIUM</b></p> <p>In force analyses, use is made of two fundamental principles of analytical mechanics: the concept of "force equilibrium" and the concept of "moment equilibrium."</p> <p><i>Force Equilibrium</i></p> <p>The principle of force equilibrium, first stated by Newton, can be interpreted in the following form: In order for a body to remain at rest (fixed, relative to a point in space) the vector sum of all forces acting upon it must be zero (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. "Force equilibrium" defined. In force equilibrium, the vector sum of all forces is equal to zero. The force diagram must form a closed polygon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <!--Page 31--> <p><i>Moment Equilibrium</i></p> <p>A "moment" is the product of a force acting through some perpendicular distance from a reference point or "moment center." A moment tends to cause a physical body to rotate. In the simple lever shown in <b>Fig. 5</b>, the force <i>F </i>exerts a moment <i>F </i>X <i>a </i>about the point <i>O. </i>In order for the body to have no tendency to rotate, the sum of all moments acting upon it must be zero, such as when a force <i>P </i>on one end of the lever, acting through distance <i>b, </i>balances a similar force <i>F </i>on the opposite end, acting through distance <i>a, </i>as in <b>Fig. 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. "Moment equilibrium" defined. For moment equilibrium, the moments acting about a center of rotation must be in balance. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>FREE-BODY DIAGRAMS</b></p> <p>Another useful concept is the "free-body diagram" used extensively in engineering mechanics. When a system or structure involves more than one distinct physical body, the parts are often shown separately, as in <b>Fig. 6</b>, and the effect of each mating part is accounted for by a vector representing the force exerted by it on the part being considered as a free body.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Free-body diagrams of the individual, isolated bodies, with the action of the second body represented by a force vector. Note that "action" on one body results in a "reaction" on the second. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Functional Description of the Canadian-Type Hip-Disarticulation Prosthesis</h4> <p>The functional features of the original design of the Canadian-type hip-disarticula-tion prosthesis are shown in <b>Fig. 7</b>, which is reproduced from the Canadian report of March 1954. Although there has since been minor modification of the methods for fitting and <!--Page 32--> alignment of the device, its functional features remain unchanged (<b>Fig. 8</b>). They include:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Original design of the Canadian-type hip-disarticulation prosthesis. From McLaurin <i>(1).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The Canadian-type hip-disarticulation prosthesis as modified at the University of California (Berkeley). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p><i>A continuous, laminated-plastic socket-waistband. </i>The socket-waistband is fitted so as to provide three reaction points (points of suspension), as shown in <b>Fig. 7</b>. The weight-bearing area of the socket is constructed of rigid plastic laminate, while the waistband is made flexible to permit easy donning of the prosthesis.</p> <p><i>Alignment stability. </i>A unique arrangement of joint locations results in improved security against buckling of the knee in any normal walking situation, the hip joint being located below and forward of the normal axis of the hip (<b>Fig. 7</b>). With the hip joint so located, the effective length of the leg is the same in both standing and sitting. A reference line extended through the hip and knee joints passes a minimum of 1 in. behind the heel, so that as long as the prosthesis bears weight the load transmitted between the foot and the hip joint always passes ahead of the knee joint, thus ensuring knee security. When required, flexion of the knee is initiated by contact of the elastic hip bumper (attached to the bottom of the socket) with a stop on the upper posterior portion of the thigh. As long as the hip bumper is not in contact, the knee joint is always completely stable.</p> <p><i>Full-width hip joint. </i>The full-width hip joint allows a much stronger connection between socket and thigh. The hip joint is similar to a prosthetic knee joint and is highly effective in resisting lateral bending at the connection between socket and thigh piece.</p> <p><i>Hip-joint motion. </i>In level walking, the hip joint allows approximately IS deg. of relative motion between socket and thigh. The amount of motion is limited by the hip-flexion control strap (shown as "elastic band" in <b>Fig. 7</b>). This arrangement allows the leg to assume a natural inclination at heel contact without backward tilting of the pelvis.</p> </blockquote> <!--Page 33--> <h4>Functional Sequence in Use of the Prosthesis</h4> <p>The manner in which the amputee walks on the prosthesis can be described by dividing the stance phase of walking into three parts: heel contact, mid-stance (roll-over), and push-off.</p> <p><i>Heel Contact</i></p> <p>As the leg swings forward preparatory to heel contact, the hip-flexion control strap limits the free hip-joint motion to approximately 15 deg. This hip-joint motion, in combination with a slight pelvic motion, allows the leg to assume a natural backward inclination as the heel makes contact. The amputee moves forward over the prosthesis, and the heel is planted on the floor without hesitation.<a style="text-decoration:none;">*</a> The weight-bearing prosthesis is extremely stable owing to the alignment of the hip, knee, and ankle joints, and the objective is to attain knee security by having an appreciable amount of force transmitted through the prosthesis at the instant of heel contact. Where additional security is desired, the amputee leans forward slightly at the time of heel contact. Doing so results in an increased tension in the hip-flexion control strap, which helps to hold the knee in full extension.</p> <p><i>Mid-Stance (Roll-Over)</i></p> <p>As the amputee rolls over the extended prosthesis during the mid-portion of the stance phase, knee security is increased as the weight-bearing line moves forward toward the ball of the foot. Hip-joint motion causes the hip-flexion control strap to relax, and the amputee rides forward with the socket balanced on the free hip joint. Pelvic stability is maintained by the momentum of the torso.</p> <p><i>Push-Off (Start of Knee Flexion)</i></p> <p>At the end of the stance phase, the prosthesis must be propelled forward into the swing phase. The amputee using a tilting-table prosthesis does this by a lifting and internal rotation of the pelvis on the side of the amputation. A normal individual achieves knee flexion at the time of push-off by combined hip and ankle action. The amputee using the Canadian-type hip - disarticulation prosthesis initiates flexion by a method somewhat similar to that used by an above-knee amputee wearing a suction socket. As the prosthesis inclines forward with the weight borne through the ball of the foot, the angle of hip flexion is reduced until contact is made between the elastic bumper system at the rear of the hip joint. As the socket continues to progress forward in a straight line (without pelvic rotation), continued forward inclination of the thigh causes an increase in the compression in the bumper system. The moment thus developed about the hip joint eventually disturbs the knee stability and causes the knee to flex forward into the swing phase. By proper adjustment of the stiffness and point of contact of the hip-bumper system, a very natural knee flexion at the time of push-off can be achieved. The amputee should never lift the pelvis and swing the leg forward by internal pelvic rotation. Rather, the recommended action is exactly the opposite. The amputee "sits hard" on the prosthesis in order to start the knee flexing. Where more rapid knee flexion is desired, a slight backward rotation <!--Page 34--> of the socket to increase the compression of the hip bumper will propel the prosthesis forward forcibly. If weight is transferred to the natural leg simultaneously, there should be no feeling of insecurity at this time.</p> <h4>Action of the Socket in Lateral Support of the Torso</h4> <p><i>Foot Position</i></p> <p><b>Fig. 9</b>, a series of free-body diagrams, shows, as viewed from the front, the rather simple force system which is acting when an amputee is walking on a Canadian-type hip-disarticulation prosthesis, the situation depicted being the period of mid-stance on the prosthesis when mediolateral dynamic effects are negligible. <b>Fig. 9</b>A shows the system of externally applied forces acting on the prosthesis alone. <b>Fig. 9</b>B shows the forces acting on the combination of the amputee and the prosthesis.<a style="text-decoration:none;">*</a> <b> Fig. 9</b>C shows the external force system acting on the amputee considered as an isolated free body.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Mediolateral force diagram of the Canadian-type hip-disarticulation prosthesis. <i>A, </i>Forces acting on the prosthesis (exerted by floor and stump); <i>B, </i>forces acting on combination of amputee and prosthesis (exerted by floor and gravity); <i>C, </i>forces acting on amputee (exerted by prosthesis and gravity). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 9</b>B involves the simplest force system and is therefore discussed first. Two forces are involved-the supporting floor reaction and the downward force of the body weight. The vertical component of the floor reaction is equal in magnitude to the downward force and hence just balances the body weight. The body can therefore be assumed to be in force equilibrium in the vertical direction. But the floor reaction, being inclined generally inward, has an inward component along the floor, which means that the entire body is being accelerated toward the sound side. This acceleration would result in a change in direction of motion of the torso, that is, in a movement toward the amputee's normal side. Such mediolateral oscillating motion of the body as a whole is characteristic of normal subjects as well as of amputees. To maintain mediolateral motion within normal limits in the amputee, the inclination of the floor reaction to the plane of progression must be minimized, and the hip-disarticulation prosthesis is therefore aligned to give a narrow walking base. Experience has shown that the walking base should be less than 4 in. from heel center to heel center.</p> <p><i>Stump-Socket Forces as Viewed from the Front</i></p> <p>The consideration of forces acting on the stump, which result in part from the requirement of a narrow walking base, is more complicated. As can be seen in <b>Fig. 9</b>C, four forces act on the combined stump and torso of the hip-disarticulation amputee-the downward force of the body weight acting through the center of gravity, the distributed vertical support pressures acting upward on the ischial-gluteal region, and distributed socket pressure between stump and socket-waistband acting on both normal and amputated sides. A single force vector is used when necessary to approximate the effects of the actual pressure distribution.</p> <p><b>Fig. 9</b>A shows the forces acting on the prosthesis considered as an isolated free body. It is to be noted that the body weight, that is, the effect of the downward pull of gravity, does not act on the socket <i>per se. </i>The effect of the body weight is made apparent by the opposite reaction (acting downward) of the vertically upward ischial-gluteal support seen acting on the stump-torso in <b>Fig. 9</b>C. If the body weight and ischial-gluteal support forces were the only two forces acting on the torso, the body would have a tendency to rotate about the point of support and to drop toward the unsupported normal side. This tendency is counteracted by the moment of the couple formed by the two mediolateral forces <i>H </i>and <i>S. </i>For moment equilibrium, taking the summation of moments about point 2 equal to zero, <i>W </i>X <i>b = H </i>X <i>a. </i>Or,<br /> <b>H=(b/a)W</b><br /> Thus the magnitude of the reaction against the normal hip, or the tension in the waistband, or both, can be reduced by increasing the distance <i>a. </i>Moving the concentration of lateral forces on the stump to a lower level by alteration of fit is practical only within certain limits. Too low a position would result in shear forces along the bottom of the stump and in considerable relative motion between stump and socket. It is also apparent that, owing to the limitations on increasing dimension <i>a, </i>the lateral forces <i>H </i>and S are of the same order of magnitude as the vertical forces <i>W </i>and <i>I</i>, since dimensions <i>a </i>and <i>b </i>would be approximately equal.</p> <p><i>Stump-Socket Forces as Viewed from the Side</i></p> <p><b>Fig. 10</b> shows the pattern of forces acting on the amputee and/or his prosthesis as viewed from the side during level walking. <b>Fig. 10</b>A indicates the force system acting on the prosthesis isolated as a free body at heel contact. <b>Fig. 10</b>B shows the forces exerted by the socket on the stump-torso, plus the action of the body weight, during the three major divisions of the stance phase in level walking-heel contact, mid-stance, and push-off. <b>Fig. 10</b>C is a free-body diagram of the isolated prosthesis at push-off. Again the use of free-body diagrams allows a clear distinction between forces acting on the amputee and forces acting on the prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Anteroposterior force diagram of the Canadian-type hip-disarticulation prosthesis. <i>A, </i>Forces acting on prosthesis at heel contact; <i>B, </i>forces acting on stump at heel contact, mid-stance, and push-off; C, forces acting on prosthesis at push-off. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At the time of heel contact on the prosthesis, the normal leg is completing push-off. The force acting on the normal foot is then transmitted through the normal leg to the pelvis. This thrust of the normal leg is shown in <b>Fig. 10</b>B acting on the normal side of the pelvis. Shown in addition to the force from the normal leg are the force of body weight and the distal, posterodistal, and anteroproxi-mal stump-socket forces. The floor-reaction force is not transmitted directly to the stump but results in the system of stump-socket forces shown acting on the socket in <b>Fig. 10</b>A and <b>Fig. 10</b>C. For example, the isolated prosthesis must be in equilibrium under the action of stump contact forces plus the floor reaction. The same system of stump contact forces <i>react </i>to appear as forces applied in the opposite sense in the diagrams of <b>Fig. 10</b>B. Because of the offset lever arm between body weight and the line of vertical support through the ischium, as shown in <b>Fig. 10</b>B, a counter- acting stabilizing force is required in the anteroproximal region. The thrust of the normal leg tends to increase the unbalanced moment about the distal point of support and hence to increase the need for anteroproximal counterpressure in the inguinal region.</p> <p>In the mid-stance phase, the normal leg is off the floor, and the four forces shown in the middle diagram of <b>Fig. 10</b>B are acting. The anteroproximal pressure on the stump is reduced as compared to that existing in the heel-contact phase. This circumstance indicates that errors in fitting would be more noticeable at the time of heel contact than in the succeeding mid-stance phase. If the dynamic effects of acceleration are ignored, two forces are acting on the combined amputee and <!--Page 37--> prosthesis during the mid-stance phase- the body weight and the upward floor-reaction force on the sole of the foot. This situation prevails until the normal foot again contacts the floor ahead of the prosthesis.</p> <p>At about the same time that the normal foot strikes the floor, the hip-bumper system in the prosthesis makes contact and tends to flex the knee forward. During this push-off phase, there is again a thrust on the pelvis from the normal leg, this time from the front, as shown in <b>Fig. 10</b>B. The thrust of the normal leg counteracts the offset body weight and further reduces the need for anteroproxi-mal support from the socket. This feature gives the amputee a greater degree of perceptive control of the prosthetic knee, since the stump-socket forces are reduced and the effects of the hip-bumper force acting on the bottom of the socket are therefore more readily distinguishable. With a properly adjusted hip-bumper system, the amputee is able to exercise a more than adequate control and timing of knee flexion even though some of the body weight is still being carried by the prosthesis at this time.</p> <p>Owing to the ever-changing nature of the stump-socket force system as viewed from the side, it is necessary to fit the distal portion of the socket snugly in the posterior region in order to prevent relative motion between stump and socket in the more highly stressed areas of vertical support under the ischial tuberosity.</p> <h4>Surgical Implications</h4> <p><b>Fig. 11</b>A and <b>Fig. 11</b>B show front and side views of a typical hip-disarticulation stump. Cross-hatching on the surface of the stump indicates those areas where biomechanical analysis shows a functional need for supporting or stabilizing contact pressure between stump and socket. Clearly indicated are those areas where surgical incisions should be avoided, in particular the ischial-gluteal, inguinal, and lateral-distal areas. The incision and resultant scar should be located along the anterodistal portion of the stump, as shown in <b>Fig. 11</b>A. This area is not required to tolerate localized pressure and is generally relieved during the fitting process in order to avoid pressure-sensitive areas over bony prominences in the pubic region.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical dynamic pressure distribution on the hip-disarticulation stump when wearing the Canadian-type hip-disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Implications for Fitting</h4> <p>Biomechanical force analysis shows certain regions over the stump where particular attention must be paid to socket fit. They include the ischial-gluteal, inguinal, and waistband contact areas.</p> <p>In the ischial-gluteal area, functional pressures must be developed on a bony prominence and a neighboring area of atrophied gluteal musculature. This requirement calls for careful location and fitting of the bony prominence of the tuberosity. In order to develop pressure on the soft tissues, considerable modification of the cast is required. This displaces the soft tissues upward in the socket, and the necessary functional contact pressure is achieved. The pressure in the gluteal area is an absolute necessity in order to stabilize the distal end of the stump on the bottom of the socket. Otherwise chafing due to shearing motions between stump and socket will result.</p> <p>The inguinal region must provide a major contribution to the anteroposterior stabilization of the torso. An inaccurate fit in this region will result in concentration of pressure at a lower level in the generally sensitive pubic areas. The soft tissues of the inguinal and abdominal areas must be displaced inward if the proper functional stump-socket pressure is <!--Page 38--> to be achieved. This is most easily accomplished by wrapping the cast in this region while the patient is supine.</p> <p>The mediolateral force which must be transmitted by the waistband extending around the normal hip approaches the body weight in magnitude. The waistband must be fitted very carefully to avoid local concentration of pressure on bony prominences.</p> <h4>Training Implications</h4> <p>Training a hip-disarticulation amputee to walk on a properly fitted, aligned, and adjusted Canadian-type prosthesis is not a difficult or time-consuming process. If the therapist is thoroughly acquainted with the functional principles of the prosthesis and with the methods of fitting and adjustment, a well-coordinated amputee should walk unaided, without a cane, after less than 10 hours of training. Proper adjustment of the hip bumper, hip-flexion control strap, and ankle-foot characteristics is absolutely essential for efficient use of the prosthesis. For this reason, therapist and prosthetist should work together during the initial training sessions.</p> <p>Particular points which should be stressed by the therapist in working with the amputee are:</p> <ol> <li>Develop confidence in the stability of the knee at heel contact. Emphasize the necessity for a confident placing of the prosthetic heel and simultaneous weight-bearing. Show that the knee stability will increase in direct proportion to the amount of force transmitted by the prosthesis.</li><li>Show the action of the three-point mediolateral support of the torso. Do not allow the amputee to bend his trunk over the prosthesis. If painful pressure develops over a bony prominence, have the prosthetist provide relief or padding.</li><li>Place considerable emphasis on the timing and use of the pelvis to propel the prosthetic knee forward. Remember that the amputee "sits" to flex the knee while the prosthesis continues to bear a portion of the body weight. The amputee should not lift the prosthesis off the floor and then propel it forward by internal rotation of the pelvis.</li></ol> <h4>Summary</h4> <p>A biomechanical analysis is presented for the forces involved when an amputee stands and walks with a Canadian-type hip-disarticulation prosthesis. The results of the analysis are applied to the specialized topics of stump surgery, socket fitting, and training of the amputee.</p> <p><b>References:</b></p> <ol> <li>McLaurin, C. A., <i>Hip disarticulation prosthesis, </i>Report No. 15, Prosthetic Services Centre, Department of Veterans Affairs, Toronto. Canada, 19 March 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>Footnote</b></td></tr><tr><td class="clsTextSmall">In Fig. 9B contact forces between stump and socket are internal forces which cancel out when the combined system of amputee and prosthesis is considered.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The foot should not swing up and then snap back into contact with the floor.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Engineering Design, University of California, Berkeley; member, Committee on Prosthetics Research and Development, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-011.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 Biomechanics of the Canadian-Type Hip-Disarticulation Prosthesis Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * https://staging.drfop.org/files/original/897efa93c8f0f30a250eccc724813589.pdf e53c2e6eef7da7fdb79521021433f7d8 https://staging.drfop.org/files/original/c6c0a9c17de4d27109310814707b7ea9.jpg a92870c95ef82139b0b52a743706a5d4 https://staging.drfop.org/files/original/29c0d4894d9c12cab8e7e6de799c2eed.jpg 5aae8022f80eabcc317cdfc744911e6b https://staging.drfop.org/files/original/6ef64458260bc2d1bde1e86f529b05fd.jpg 059fabe5ce19ca7120b4dca37de6a827 https://staging.drfop.org/files/original/3ffdcbb4b21055eba4533c885af8d30e.jpg bf323b08ef78be03b4cdd81505b1117f https://staging.drfop.org/files/original/570c0db690f8d4929a4e24a544499f04.jpg a75a3433b11e417be3aaf5931af55647 https://staging.drfop.org/files/original/25ba53d34e86878d89a422613a423219.jpg 49d279d5f622a33f7bab7e9a13941475 https://staging.drfop.org/files/original/86c9a5fc2e2c6424943c5d82967bca6b.jpg df44bcb9079a48fad702bd6ce8cbd7c2 https://staging.drfop.org/files/original/7f22825f726c7c3cd036fdc490fc0311.jpg 49b270cdb8ab4bf273e44b7ff0d6adcd https://staging.drfop.org/files/original/d7e9a11114bd8cf398078615dc266ef0.jpg effa0ef8f6e071995f4db91e16956da6 https://staging.drfop.org/files/original/c791f2953272b15882d258981a1009c6.jpg 63e16f08b2372dab80ba402c7ec179da https://staging.drfop.org/files/original/b4e99d6ae2d85be6de0ebef5d20927f6.jpg 2764e06e43929f9813a2330db858522a https://staging.drfop.org/files/original/c90405176cc45ad9822c08f2c83403fc.jpg fb0324acf3b3efcca91cc33616b2ac93 https://staging.drfop.org/files/original/78a8fc8bb5859084900fc76a87459fec.jpg 39d5fd4f9942eeadc11787a402d0ee30 https://staging.drfop.org/files/original/3b8caa354bfe35ea776768597c689ace.jpg 3f44ac3f0d0fede052be1900dd619aa4 https://staging.drfop.org/files/original/234a59503cb92f7f867861e34588d1de.jpg be8cf73cabbf52ac504564063d5273ab https://staging.drfop.org/files/original/2c09290f6e88d7d02270ca5e0c495f52.jpg 0e05933eba5072a94777c38b2af8a9ba https://staging.drfop.org/files/original/9ebc06a2cd39befeb223452a2fce202d.jpg b4d10db15d99610189bd994126d8059a https://staging.drfop.org/files/original/e68efc6c51e5847738a124ba8c0650bd.jpg 3ca5390d466efbb2cefeaa72e57341c0 https://staging.drfop.org/files/original/72a98fe700fcf3286ffce2026dbfe490.jpg 926e883f350b7cc4cc2ca3e4da92e8d4 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_039.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 39 - 51 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/1957_02_039.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_02_039.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>Construction and Fitting of the Canadian-Type Hip-Disarticulation Prosthesis</h2> <h5>James Foort, MASc. <a style="text-decoration:none;">*</a><br /></h5> <p>True hip disarticulation connotes removal of the femur at the acetabulum. But loosely within the hip-disarticulation category a residual length of femur, too short to control a prosthesis effectively, may be left. A much more drastic operation, the hemipelvectomy, removes all of the ischium, all of the pubis, and most or all of the ilium on the side of the amputation. In this discussion, a classical and idealized hip-disarticulation amputee is considered in outlining a method for making the Canadian-type hip-disarticulation prosthesis. Certain adaptations have been found suitable for the short-stump above-knee amputee and for the hemipelvectomy.</p> <p>Consider the remaining functions of the hip-disarticulation amputee. The gluteal muscles have been pulled anterior and fastened at the suture line to form a rugged pad which supports the body's weight. Support forces are transmitted through this gluteal musculature and the ischial tuberosity to the stable pelvic base. Movement of the pelvis relative to the normal leg permits the amputee to position the artificial foot at the beginning of the stance phase of walking and aids in flexing the knee at the end of the stance phase and in sitting down. Pelvic movement relative to the rest of the body enables him to secure balance on and to control the prosthesis. The tuberosity on the side of the amputation, the iliac crests, and the sacrum provide excellent keying points for securing the body in the socket. To minimize movement between the body and the socket for the most efficient transmission of forces, the socket must snugly enclose those areas providing support, suspension, and stabilization and must give relief for any sensitive areas or bony prominences.</p> <p>The socketmaking technique, as worked out by the Prosthetics Research Group at the University of California, Berkeley, is described in detail in the report by Foort and Radcliffe<a></a>. The socket is made by taking a female impression of the pelvis with plaster bandage, forming it into a check socket and making the necessary modifications, making a male model from the check socket, and using the model as a mold for the plastic-laminate socket to which the rest of the prosthesis is attached.</p> <h4>Taking the Cast</h4> <p>To provide relief pockets for the anterior-superior spines, the posterior-superior spines, the spinous processes of the vertebral column, and any other sensitive areas, patches of 1/4-in. skived felt are attached to the body with adhesive tape (<b>Fig. 1</b>). To protect the body from plaster, a covering of cotton stockinet is pulled up over the lower part of the torso and extended well beyond the area where the socket is to be shaped (<b>Fig. 2</b>). In order to define accurately the areas which may require modification, the iliac crests and those areas which have been covered with felt are marked on the stockinet covering with indelible pencil. A mark around the waist, marks on the front and back mid-lines, and a mark extending from mid-line to mid-line around the normal leg at the level of the inguinal crease will define the approximate trim lines of the plaster cast (<b>Fig. 3</b>). Metal strips may be placed over the mid-line marks to facilitate subsequent cutting of the wrap cast.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Application of skived felt patches over pressure-sensitive areas of the stump and torso. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Stockinet pulled over lower part of the torso well above the waist, tied at waist and around proximal end of sound thigh. Waist, mid-line, and bony prominences marked with indelible pencil. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Waist, mid-line, and bony prominences marked in the rear. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>One way to get a good, snug fit for the socket is to take the wrapping of the upper part of the pelvis with the subject lying on his back on a cast table (<b>Fig. 4</b>, <i>A). </i>This position causes the viscera to move upward and backward and flattens the abdomen, thus reducing the distance from the anterior to the posterior wall of the cast and more sharply defining the iliac crests (<b>Fig. 4</b>, <i>B </i>and <i>C). </i>The cast of the lower pelvis is taken as a second step (<b>Fig. 4</b>, <i>D). </i>Snug fit is achieved by having the amputee bear weight on the stump as the cast hardens (<b>Fig. 4</b>, <i>E). </i>Three or four layers of plaster bandage are wrapped firmly around the upper part of the pelvis <i>{i.e., </i>from about 2 in. above the iliac crests to just above the pubic symphysis) and then, with tension, diagonally over the iliac crest on the amputated side and under the crest on the normal side (<b>Fig. 4</b>, <i>A </i>and <i>B). </i>After the wrap is complete, a block of firm sponge rubber 2 in. thick is placed under the patient's lumbosacral region to force the back portion of the cast against the body (<b>Fig. 4</b>C). By molding over the iliac crests with the hands while the cast is setting, and by pressing in firmly while the cast hardens, the operator obtains good suspension hooks.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Taking the cast. <i>A, </i>Wrapping the waistband area of the pelvis, patient supine on cast table, cast table set apart to facilitate wrapping; <i>B, </i>diagonal wrapping for distortion of the cast over the iliac crest on the side of the amputation; C, rubber pad under patient's lumbosacral region to give firm fit in that area, cast table closed; <i>D, </i>wrapping the stump area, a separate operation, patient standing; <i>E, </i>patient "sitting" on rubber pad to give weight-bearing impression. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the upper portion of the cast has set, the amputee stands, and the stump area is wrapped with plaster bandage. To unite the two portions completely, the bandage is applied back and forth over the stump with several turns around the upper section of the cast (<b>Fig. 4</b>, <i>D). </i>While the cast is setting, the amputee bears full weight on the sponge-rubber pad now placed under the stump area (<b>Fig. 4</b>, <i>E). </i>Weight-bearing at this time keys the body within the socket between the weight-bearing platform and the suspension hook over the iliac crest on the side of the amputation. Up-and-down motion of the body within the socket is thus minimized. There may be some gapping of the cast in the gluteal area and lateral to the pubic area, but such gapping will be closed with plaster when the cast is modified.</p> <p>When the cast has set, it is removed from the torso by cutting at the approximate midlines, front and back (<b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Cutting and removing the cast. <i>A, </i>Cast marked on mid-line, front view; <i>B, </i>cast cut along anterior and posterior mid-lines, rear view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Check Prosthesis</h4> <p>The cast is rejoined, reinforced, split again, hinged posteriorly, provided with a buckled closure anteriorly, and attached to a pylon base (<b>Fig. 6</b>). To rejoin the two sections, they are aligned in their original position, and plaster bandage is wrapped around the outside. Plastic laminate, consisting of polyester resin, stockinet, and glass cloth, is applied over the plaster cast to strengthen it. Two layers of glass cloth about 4 in. wide are laid over the outside on the posterior mid-line. One layer of 8- to 10-in. stockinet is then pulled over the cast and tied at the opening for the normal leg. Polyester resin is painted over the fabric and allowed to cure, after which excess material is trimmed away.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The check prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast is now sawed along the posterior mid-line, and a hinge is fastened over the cut. When the hinge is secured, the cast is sawed along the front mid-line, and a buckle-and-strap arrangement is attached. A block of wood about 4x4x4 in., scooped out to fit the bottom of the cast roughly, is attached to the cast with "gunk," a mixture of resin and sawdust, to serve as the base for the pylon.</p> <p>The pylon must now be attached to the wood block in the proper alignment and the socket tried on the amputee for any necessary modifications. With the plaster socket on the amputee, marks are made on the side and front of the block to indicate the inclination of the peg. It should be so set that it will make the same angle with the floor at the beginning and end of the stance phase of walking and so that it will clear the normal leg in the swing phase. Typically, this will mean that the distal end of the pylon will be set somewhat forward as viewed from the side and somewhat lateral as viewed from the front. A hole is drilled in the middle of the block at the required angles, and a length of crutch-tipped dowelling is inserted.</p> <p>To test for discomfort, excursion, and restriction of body motion, the amputee now performs on the check prosthesis. He is asked to bend his body and normal leg in every direction, and the cast is cut down until there is complete freedom of motion. Taking care to leave the ischial seat intact, the medial side is cut away to relieve rubbing against the normal leg and the genitalia. The edges of the cast are then smoothed and flared with plaster, and gapping in the areas of the gluteus and pubis is similarly closed.</p> <p>If there is ramus contact, the amputee usually will complain of it. This detail can be checked by locating the ramus with a finger and having the amputee put full weight on the socket while dropping his pelvis on the normal side. If there is contact, the ischial seat and other weight-bearing areas should be built up with 1/8-in. layers of plaster until the ramus is sufficiently cleared. Fore-and-aft excursion can be detected by placing a finger alongside the tuberosity while the amputee steps back and forth on the prosthesis. Any fore-aft excursion will be reduced if the prosthetist slips a hand between the torso and either the anterior or the posterior wall of the socket. If the amputee then feels more secure, the anterior and posterior walls should be built up appropriately with plaster so laid that the forces are evenly distributed.</p> <p>If the body has not been sufficiently stabilized in the socket in the up-and-down direction, the prominences will move along and out of the relief pockets established for them, and chaffing and painful pressures will occur. As a final check on excursion, therefore, the amputee should be walked in the check socket. Two hours of walking is usually enough to prove any discomfort. Further refinements may then be necessary:</p> <ol> <li>If the musculature in the area of the iliac crest on the side of the amputation has atrophied, the extent of the hook in this region may need to be increased. An increase is indicated if a hand placed inside the socket under the hook makes the socket seem more secure on the amputee.</li><li>If, without causing discomfort, security is increased by inserting 1/8-in. pads between the stump and the weight-bearing area of the socket, the weight-bearing area should be built up accordingly.</li><li>If the body seems stabilized in the up-and-down direction but there is still pressure on the prominences, either the areas around the relief pockets must be built up with plaster, 1/8-in. at a time, or material must be sanded out of the pockets.</li></ol> <h4>The Male Model</h4> <p>A hollow model is now made in the check socket. After the inside of the cast has been coated with petroleum jelly, a section of 8-in. stockinet is pulled over the check socket and tied closed around the pylon base. Sufficient thin plaster is then poured into the cast through the waist opening to coat lightly both the check socket and the stockinet closing the end (<b>Fig. 7</b>). When the first layer of plaster has set, successive layers of somewhat thicker plaster are added until the model is approximately 1 in. to l 1/2 in. thick. When the shell has hardened, a quart more of plaster is poured in, the stockinet is pulled across the opening, and the cast is inverted and placed on a table so that the plaster seals the end. The completed male model is removed from the check socket and dried.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Making the male model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Plastic Socket</h4> <p>To prepare the model as a mold for construction of the plastic socket, a hole is cut in the top (the waist), and a mandrel of 1-in. pipe about 2 ft. long is inserted and fastened with "gunk." The edges of the mold are trimmed so that the flares are not more than 1/4 in., and the whole is smoothed with fine sandpaper. To the surfaces which will become the open ends of the completed socket wooden blocks approximately 1/2 to 1 in. are attached with "gunk" (<b>Fig. 8</b>). They will later be used to secure the layers of fabric to the mold. A 1/4-in. pad of dense sponge rubber is placed over what will be the weight-bearing area of the socket. This pad will later be transferred to the corresponding area of the completed socket. A truncated cone of polyvinyl alcohol film is then pulled over the cast and tied to the mandrel at one end and to the leg-opening surface at the other (<b>Fig. 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Wooden blocks bonded to the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Truncated cone of polyvinyl alcohol film drawn over the model and fastened top and bottom. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <!--Page 44--> <p>To reinforce the polyester resin, da-cron tricot (a very strong fabric with one-way stretch) and glass cloth are used in construction of the socket. The dacron waistband will be limber enough to allow the socket to open, while areas of force concentration, reinforced with the glass cloth, will be strong and rigid.</p> <p>Six layers of dacron tricot are used, each layer being stapled into place individually. The six layers of dacron are cut with enough material to wrap around the cast horizontally and with an overlap great enough to span the distance between the crests. These are fitted and seamed to pocket the stump area (<b>Fig. 10</b>). Beginning at the vertical line of the normal iliac crest, the end of the material is stapled to the wooden blocks at either end of the model. As it is brought across the abdominal area, then around the back, continuing to its starting point, the dacron is stapled to the blocks (<b>Fig. 11</b>), the excess length of material being allowed to hang free. Alternating with the dacron, four layers of glass cloth are laid up over the stump area, extending upward to the crest (<b>Fig. 12</b>), and the lay-up is finished off with the final two layers of dacron tricot (<b>Fig. 13</b>). When all the fabric has been applied in this way, the loose sections of dacron are brought across the front and stapled into position over a sheet of polyvinyl alcohol film (<b>Fig. 14</b> and <b>Fig. 15</b>). The film separator prevents the overlap from bonding to the underlying section.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Dacron tricot tailored to fit the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Securing the fabric to the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Glass cloth applied over the stump area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Final lay-up of dacron fabric. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Application of PVA funnel and film separator under overlap of waistband. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Film separator and overlapping fabric stapled into position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In order to get resin to the fabric under the film separator, it is helpful to place a polyvinyl alcohol funnel, approximately 2 to 3 in. wide and 2 ft. long, under the film separator before it is stapled into position (<b>Fig. 14</b>). The mouth of the funnel will be at the mandrel. After the film separator and the overlapping material have been stapled to the wooden blocks in final position, two similar funnels are placed over the front and back surfaces of the lay-up with the mouths at the mandrel (<b>Fig. 16</b>). A final truncated cone of polyvinyl alcohol film is pulled over the entire mold and tied in the area of the wooden blocks at the stump end (<b>Fig. 17</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. PVA funnels applied to front and back of lay-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Truncated PVA cone placed over entire lay-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The required quantity of resin is weighed, mixed with catalyst, promoter, and pigments, and introduced into the fabric through the funnels, after which the funnels are removed (<b>Fig. 18</b>). The polyvinyl alcohol bag is tied closed at the mandrel, and the resin is squeezed through the fabric. When the fabric is completely saturated, excess resin and air bubbles are worked out toward both ends by "roping" (<b>Fig. 19</b>). Sponge-rubber pads are then bound over the undercut areas with Ace bandage in order to guarantee close adherence of the lay-up to the mold (<b>Fig. 20</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Resin introduced through the funnels, funnels ready to be removed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Saturation of the fabric and removal of air bubbles by "roping." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Sponge-rubber pads applied to undercut areas to guarantee adherence to mold. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is released from the mold by cutting around the waist and around the opening for the normal leg approximately 1/2 in. from the final trim lines (<b>Fig. 21</b>). Care should be taken not to cut the hands on the sharp edges of the overlapping sections (<b>Fig. 22</b>). After the socket has been removed from the mold, the edges are trimmed on a sanding drum.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Cutting the socket free of the mold. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Removing the socket from the mold. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <!--Page 46--> <h4>The Trial Leg</h4> <p>The fixtures are attached to the socket, the socket is attached to a thigh section through the hip-joint assembly, and the thigh section is attached to the adjustable leg and the foot (<b>Fig. 23</b>, <b>Fig. 24</b>, <b>Fig. 25</b>, and <b>Fig. 26</b>). Attachments for the socket are the weight-bearing pad (<b>Fig. 23</b>), the belt-and-buckle arrangement, and the wooden base for the hip joint (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Finished socket with weight-bearing pad installed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Socket with wood block attached. Dotted lines indicate the saw lines. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Hip-joint assembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Trial prosthesis set up on the UC adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Wooden Base</h4> <p>A block of wood 4 x 4 x 4 in. for the base, hollowed out to fit the front-bottom corner of the socket, is bonded in place with "gunk." When the resin has cured, the front-bottom corner of the block is cut off as close to the socket as possible to provide a surface to which to attach the hip - joint bearing. When the socket is in its normal position, this attachment surface will face downward and forward at a 45-deg. angle to the floor, so that when the hip-joint bearing is attached its axis will be approximately perpendicular to the line of progression and parallel to the floor (<b>Fig. 25</b>).</p> <h4>Hip-Joint Assembly</h4> <p>The hip-joint assembly (<b>Fig. 25</b>) consists of a special bearing, a shaft, and two metal side-straps. The bearing, which is lined with a bronze bushing, is machined out of a block of aluminum and includes four tabs with screw holes for attachment to the base of the socket. The shaft and sidestraps of the hip-joint assembly are from a 3 1/2-in. standard prosthetic-knee assembly.</p> <h4>Thigh Section</h4> <p>The thigh section is made from a 6- x 6-in. block of wood 12 in. long, with a core drilled from the middle at the edge of one end through the center of the block at the other. This hole facilitates pulling out wood from the interior of the thigh section later. A line is marked off 2 in. from the cored edge at one end, and, starting at this line, a diagonal cut is made to the opposite corner at the other end. The 6- x 6-in. face becomes the knee end, the 2- x 6-in. surface the hip end, and the vertical surface (6 x 12 in.) the front face of the thigh.</p> <p>The sidestraps of the assembled hip joint are traced on the front face of the block equidistant from the sides, and the block is cut along these lines to extend somewhat beyond the side-straps and to flare out toward the end. The straps are then attached to the cut sides flush with the front of the block at the bolt end and so that the axis of the bolt will be approximately 3/4 in. above the top surface of the thigh block. The portion of the block which extends behind the axis of the hip joint is sawed as necessary to provide the platform for the hip-stop bumper (<b>Fig. 24</b>). To position the hip joint on the base, the amputee dons the socket and sits down.</p> <p>Viewed from the front, the prosthetic thigh should be approximately parallel to the normal thigh and as close to the mid-line as possible, and the hip joint should be parallel to the floor and high enough on the base so that the back edge of the hip-stop platform is flush with the chair. The position of the bearing is traced on the block, and the free end of the thigh section is marked 2 in. back from the normal knee axis.</p> <h4>Trial-Leg Assembly</h4> <p>The socket is removed from the patient, the thigh section is cut where it was marked, and the components of the trial leg are assembled. The adjustable leg is attached to the knee end of the thigh piece, and the socket is attached to the thigh with screws through the hip-joint bearing. To prepare the trial leg for alignment checks, a temporary hip-stop bumper, a temporary hip-flexion control <!--Page 48--> strap, and a kick strap are attached to the leg, and the knee joint is located in a stable position (<b>Fig. 26</b>).</p> <h4>Temporary Bumper</h4> <p>A bumper of foam-crepe shoe-sole material is tacked temporarily to the hip-stop platform in such a manner that when the socket is against the bumper the vertebral spine will be in its natural position.</p> <h4>Hip-Flexion Control Strap</h4> <p>One end of the hip-flexion control strap is attached laterally to the socket 2 in. behind the hip joint; the other is attached to the shank 3 in. below and 1/2 to 1 in. ahead of the knee joint.<a style="text-decoration:none;">*</a> The distance between these attachments is adjusted to provide the correct stride length.</p> <h4>Kick Strap</h4> <p>The temporary kick strap is attached to the front of the shank at the same level as the hip-flexion control strap, passes over the knee in front, and attaches to the front of the socket 3 in. above the hip joint. The length of the strap is adjusted to provide the correct balance between heel rise and knee extension. Knee stability will be satisfactory if, when the knee is in full extension, the knee joint falls behind the line projected from the hip joint to the back of the heel.</p> <h4>Adjustments</h4> <p>The prosthesis is now ready for sitting, standing, and walking adjustments. When the amputee is sitting, the prosthetic shank should be vertical, the knee axis approximately level with the normal knee center and the toe-out equivalent to that on the normal side. In the standing position, with a 2- to 3-in. standing base, the length of the leg should be such that the hips are level. The thickness of the hip bumper is adjusted to eliminate humping or arching of the spine. The patient now walks on the trial leg, and checks are made of knee stability, width of walking base, stride length, toe clearance, whip in the swing phase, and swing-phase control.</p> <h4>Knee Stability</h4> <p>Although the knee has been stabilized on the bench, a number of factors may affect it in action. If the knee buckles, it may be that the hip bumper is contacting too soon and that its thickness needs to be reduced. A knee axis too far forward also will cause buckling.</p> <h4>Walking Base</h4> <p>With the toe-out of the prosthesis consistent with the natural toe-out, the medial distance between the heels is the walking base. If this base is found to be over 2 to 3 in., it should be made narrower by moving the foot in. If the feet are not clearing each other sufficiently, the base should be increased to 2 to 3 in.</p> <!--Page 49--> <h4>Stride Length</h4> <p>The distance between toe-off and heel strike should be approximately the same for the two legs. Stride length is adjusted by shortening or lengthening the hip-flexion control strap.</p> <p>The thickness of the hip-stop bumper affects stride length. If the thickness of the bumper is increased, the angle at which the leg inclines forward at the end of the stance phase is reduced, and the stride is shortened. But bumper thickness should never be changed to improve control and stride length at the expense of comfort.</p> <h4>Toe Clearance</h4> <p>A number of factors are involved in toe clearance-the length of the leg, the inclination of the foot, the amount of knee flexion in the swing phase, and suspension. Leg length is first adjusted, but the limb should not be shortened more than an inch. If scuffing persists, it is due to other factors. If the knee is not bending sufficiently, the toe will drag, and kick-strap tension should be reduced. If drop-off is causing the toe to scuff, a hand placed between the socket and the crest of the ilium on the side of the amputation should eliminate it. In this case, either the suspension hook over the crest should be enlarged or the weight-bearing area should be built up with pads and the length of the leg reduced equiva-lently. Correction of scuffing may make the clearance too great, in which case leg length must be readjusted.</p> <h4>Whip</h4> <p>Whip in the Canadian-type hip-disarticula-tion prosthesis typically takes a form comparable to circumduction in the above-knee prosthesis. Circumduction can be reduced by rotating the knee bolt externally. The degree to which the knee axis can be rotated is limited by the extent the foot will move medially in the sitting position. It may thus be necessary to effect at least some external rotation at the hip joint by cutting a wedge (with the apex medially) from the hip-joint base.</p> <h4>Swing-Phase Control</h4> <p>With alignment established, refinements can be made in swing-phase control. Heel rise at the beginning of the swing phase should be limited through adjustment of the kick strap rather than of the knee-friction units. The compound-pendulum system of the prosthesis does not allow the hip-disarticulation amputee to walk as fast as he would like, and it has been found that tensing the kick strap increases his speed more effectively than does increasing knee friction. This may mean that there will be some impact at the end of the swing phase, but it usually is quite tolerable because the hip joint flexes as soon as the knee comes against the extension stop, and the energy which would otherwise lead to impact is thus absorbed. Stride length may require periodic adjustment as changes are made in swing-phase control.</p> <h4>Finishing the Prosthesis</h4> <p>The leg is now ready to be used either as a training leg, or, after sufficient attention has been given to fit and alignment, to be duplicated.<a></a> The only difference between duplicating the Canadian-type hip-disarticulation prosthesis and a standard above-knee prosthesis is that in the case of the former the thigh section rather than the socket is clamped in the jig.</p> <!--Page 50--> <p>The thigh section, shank, and foot are shaped and reinforced according to standard techniques<a></a>. Weight of the thigh section is reduced by pulling wood from the inside. The hip joint is faired to the wooden base on the socket with "gunk" and tied to the base with three layers of resin-impregnated glass cloth extending about an inch beyond the wooden block. This reinforcement is smoothed and finished with a light coat of lacquer. For ventilation, the socket is perforated with 1/8-in. holes at 1-in. intervals, and padded areas are covered with nylon-coated leather or leather substitutes. The permanent kick strap and hip-flexion control strap are installed, their connections to the limb being such as to allow the straps to rotate about the points of attachment. The hip-flexion control strap (<b>Fig. 27</b>) is made of 1-in. vinyon or dacron webbing sewed on either end of a 4-in. section of heavy elastic webbing. For attachment to the prosthesis, a piece of leather large enough to include a 1/4-in. metal grommet (such as is used in below-knee corsets) is sewed at each end of the hip-flexion control strap, and a clamping arrangement is installed on the webbing to permit length adjustment. The conventional kick strap is used, with the exception that it is attached proximally to the socket instead of to the thigh. Final adjustments are made to socket edges and to the permanent swing-phase controls.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Hip-flexion control strap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The last step in the construction and fitting of the Canadian-type hip-disarticulation prosthesis is to provide a cosmetic fairing for the thigh section. A truncated cone of sponge rubber is made to fit over the thigh section so that it extends from just above the knee to the socket. The rubber cone is in turn covered with leather or a leather substitute extending beyond the rubber fairing at both ends, so that the covering can be attached to the thigh at the bottom and to the front and side of the socket with snap fasteners (<b>Fig. 28</b>). In order to make the fairing neat in both the sitting and the standing positions, a triangle with a 3-in. side and with the apex on the hip-joint axis may be cut from the lateral side of the covering and a piece of light elastic webbing substituted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Cosmetic fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The procedures outlined for checking the prosthesis during construction and fitting can be applied equally well to the evaluation of hip-disarticulation prostheses.</p> <h4>Acknowledgment</h4> <p> The line drawings which accompany this article were prepared by Frank N. Todd, illustrator with the Biomechanics Laboratory at <!--Page 51--> the University of California at Berkeley. The halftones are by George Rybczynski, free-lance artist of Washington, D. C.</p> <p><b>References:</b></p> <ol> <li>Foort, J., <i>Fiberglas laminate reinforcement of wooden prostheses, </i>Prosthetic Devices Research Project, University of California (Berkeley), [Report tohe] Advisory Committee on Artificial Limbs, National Research Council, February 1956.</li> <li>Foort, J., and C. W. Radcliffe, <i>The Canadian typehip disarticulation prosthesis, </i>Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Prosthetics Research Board, National Research Council, March 1956.</li> <li>Radcliffe, Charles W., <i>Mechanical aids for alignmentof lower-extremity prostheses, </i>Artificial Limbs, May 1954. p. 23.</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>1.</b> </td><td class="clsTextSmall">Foort, J., Fiberglas laminate reinforcement of wooden prostheses, Prosthetic Devices Research Project, University of California (Berkeley), [Report tohe] Advisory Committee on Artificial Limbs, National Research Council, February 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>3.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignmentof lower-extremity prostheses, Artificial Limbs, May 1954. p. 23.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">If the amputee is well adjusted to using a prosthesis and does not need the added stability offered by attaching the hip-flexion control strap below the knee, the distal end of the strap may be attached to the thigh section.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Foort, J., and C. W. Radcliffe, The Canadian typehip disarticulation prosthesis, Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Prosthetics Research Board, National Research Council, March 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>James Foort, MASc. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Engineer, University of California Prosthetics Laboratory, U. S. Naval Hospital, Oakland, Calif.; formerly Research Engineer, Prosthetic Services Centre, Canadian Department of Veterans Affairs, Sunnybrook Hospital, Toronto.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-011.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-012.jpg Figure 13 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-013.jpg Figure 14 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-014.jpg Figure 15 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-015.jpg Figure 16 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-016.jpg Figure 17 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-017.jpg Figure 18 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-018.jpg Figure 19 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-019.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. 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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/3ed6e858fb0862d7d2be1b23db392979.pdf 341e77544bf40d3db543a912bb5f0a44 https://staging.drfop.org/files/original/5bc396e4cedef13cf16a253eff163040.jpg ec592855cdba2557e088f78921c41388 https://staging.drfop.org/files/original/fdb6f406a2d352fb47a3cee9e8f38369.jpg 231b76d1408171ad64fae7742ecb2080 https://staging.drfop.org/files/original/7c0842c290468ef1fba4f4843d047f6e.jpg f826d6e153080c737808def1263cdd8b https://staging.drfop.org/files/original/e8a75b8ff67cee7bfa961096b4546fc2.jpg 1b87a973e8f3e3194184030a5e733712 https://staging.drfop.org/files/original/e9b74a814d560aa381bdccc572202d18.jpg 7e4403cff18523ddfb3120463a4be570 https://staging.drfop.org/files/original/ef75d0139e58c59e14d6dd35acdb17a2.jpg 70501d19f818f8d17d3b4ab798b5c8e3 https://staging.drfop.org/files/original/db9be3d7b4042ee252c02a83e44410f6.jpg 811f62d0d758421359d9516a636cc7f9 https://staging.drfop.org/files/original/9d40c9562a0fa9212368f1e2168e0414.jpg 2a71a8f8ae7d5478f89c2d59c2fd982b https://staging.drfop.org/files/original/79520afc4856b97de75b65ceca55ed6d.jpg c56d209e3cc0b131ddf0552ec40728ef https://staging.drfop.org/files/original/11938c318c7cf07237c990a66332d5e6.jpg e3023baa4d85b0b47a1f48737de7838c https://staging.drfop.org/files/original/b7f3d4881f3418405d87e322dad4c534.jpg 2d3c7a9b149b79c2b05043f12da68c06 https://staging.drfop.org/files/original/7f2f89a25a05551ade1e71a258885300.jpg 1c7361b6419e0d308961d5e58f72b6a2 https://staging.drfop.org/files/original/d8559825156298574f27b394d24be4e6.jpg 9c4e998131de15aafcc55e58721cf377 https://staging.drfop.org/files/original/251a6125624f21d3c3f26d9da96c3938.jpg 13d793d6f5c11a23a6232ac42f78aec2 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_073.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 73 - 87 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_073.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_01_073.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 III. The Treatment Process</h2> <h5>Warren P. Springer, M.A. <br /></h5> <p>The amputees who took part in the NYU Upper-Extremity Field Studies obtained their new prostheses through a treatment process characterized by seven clear-cut steps. These were preprescription examination, prescription, preprosthetic therapy (if indicated), fabrication of the prosthesis, initial checkout, training, and final checkout.</p> <p>The preprescription examination was conducted at the beginning of the treatment process in order to obtain information that would be useful in formulating the prescription and planning the entire treatment program for the patient.</p> <p>As for prescription, the research and educational program strongly encouraged the clinic-team approach, wherein the physician, as clinic chief, involved the prosthetist, the therapist, the patient, and frequently other individuals, such as the social worker or the vocational counselor, in the prescription process. The resulting prescription not only covered the strictly medicosurgical aspects of management but also specified the type of prosthesis and components that were to be used and the training the patient was to receive.</p> <p>The preprosthetic phase of treatment, when indicated, was directed toward providing the patient with the necessary strength and range of motion to operate his prosthesis and toward conditioning his stump for wearing it.</p> <p>In the fabrication process, the prosthetist, working with the patient, carried out the construction and fitting of the prosthesis in accordance with the specifications of the prescription.</p> <p>Initial checkout, which was done on a team basis, consisted of a systematic inspection and evaluation of the prosthesis to ensure that accepted standards of construction and function were achieved. This step was accomplished before the amputee received training and before he was permitted to wear his prosthesis for any extended period.</p> <p>Training consisted essentially of two parts—controls training and use training. The purpose of controls training was to develop the ability to open and close the terminal device, control prehension force, operate the wrist unit, interchange terminal devices, and, in the above-elbow cases, flex the prosthetic elbow and operate the elbow lock. Use training was designed to develop the ability to utilize the prosthesis in practical tasks related to daily-living activities and to occupational requirements.</p> <p>Final checkout was performed after the completion of training or after an initial period of wear. It paralleled initial checkout in that many biomechanical evaluation procedures were repeated to determine if wear had given rise to any difficulties or deficiencies. But in addition to the evaluation of the prosthesis itself final checkout also included an evaluation of training and of the amputee's ability to use the prosthesis at a practical level.</p> <p>This paper is primarily an account of the experiences and opinions pertaining to the treatment process as obtained from interviews with 359 adult, male amputees both at the beginning and at the end of their participation in the studies. The information concerning checkout and training is supplemented by clinical data from records of an additional 410 amputees who participated in clinical aspects of the study.</p> <p>The general characteristics of the research group of 359 amputees closely parallel those of the 1630 amputees in the survey group (Section II). Between the two groups there were no significant differences with respect to age, height, weight, marital status, cause of amputation, or strength and range of motion on the side of the amputation, although there were slight differences in educational level, in experience with arm prostheses, and in the relative frequency of below- and above-elbow types.</p> <p>In interpreting the data in this section, certain considerations should be kept in mind. First of all, a considerable portion of the information is based on the amputees' recollections of past events. The differences that may exist between the recollection of events and the events as they actually happened constitute a possible source of error. A second consideration has to do with the amputees' interpretations of the questions asked during the interviews, especially at the beginning of the study. Terms such as "clinic," "prescription," "checkout," "physical therapy," and "training" may have had widely varying meanings for different subjects. For example, a subject might have said that the prosthesis he was wearing at the beginning of the study had been subjected to a checkout when in reality it had been given only a cursory inspection instead of the systematic examination and evaluation that constituted a "checkout" in our meaning of the term.</p> <p>A third factor has to do with the number of amputees who were able to give meaningful responses to these questions. In some instances and for various reasons usable responses were not obtained from the entire group. In some cases questions were not answered. In most instances, however, classifiable responses were obtained from at least 80 percent of the group, and it seems reasonable that these responses are representative of the attitudes of the entire group.</p> <p>On the positive side, there is good reason to assign a considerable degree of importance to the opinions and reactions expressed by the subjects, since, in the last analysis, the amputee is the final judge of his prosthesis. The extent to which he accepts and approves of the process through which he obtains his prosthesis may have considerable bearing on the extent to which he accepts and uses the device.</p> <h3>Prescription</h3> <p>Prior to their participation in the research studies, only 17 percent of the amputees had ever received an arm that was prescribed by a clinic team (physician, limbfitter, and therapist). In the great majority of cases, decisions as to the type of limb and components had been made either on an individual basis by the limbfitter or the amputee or jointly by both limbfitter and amputee. Fifty-six percent of the amputees approved of this procedure, the most frequent reason (21 percent) given for approval being that they were consulted concerning their choice.</p> <p>In the group (44 percent) that did not approve of the preprogram procedure through which they had received a limb, 14 percent reacted negatively to the fact that they were not consulted. It was somewhat surprising to find that an additional 18 percent expressed the opinion that the amputee should not be consulted. Of the total group, 12 percent felt that the doctor should prescribe the prosthesis. Apparently a significant number of amputees prefer to trust the judgment of others in the matter of prosthetic replacement. Others (and the number probably increases with their prosthetic experience) prefer to become personally involved in the selection of components best suited to their needs.</p> <p>Since all of the prescriptions for the new prostheses and related treatments were arrived at on a clinic-team basis, the amputees were asked the following question to obtain their reactions to the team method of prescription: Do you think that prescription of a new arm by a clinic consisting of a doctor, limbfitter, and therapist is a good procedure? Ninety-four percent of the amputees answered in the affirmative. Compared to the mixed reactions concerning the preprogram procedures, the figure of 94 percent clearly indicates that the amputees preferred the new procedure. By far the most frequent reason given for this response was that the combined experience which could be obtained through the clinic procedure was useful. Typical comments were:</p> <blockquote><p>". . . more heads are better than one."</p> </blockquote> <blockquote><p>". . . experience of several people is helpful."</p> </blockquote> <blockquote><p>". . . no aspect is overlooked."</p> </blockquote> <p>Other reasons that were mentioned relatively frequently can be classified under these headings:</p> <blockquote><p>". . . prevents errors."</p> </blockquote> <blockquote><p>". . . team members act as a check on each other."</p> </blockquote> <blockquote><p>". . . amputee becomes involved in the prescription."</p> </blockquote> <p>Among the 6 percent who did not approve of the procedure, the most common reason offered was that:</p> <blockquote><p>"An old wearer knows what he needs."</p> </blockquote> <p>To obtain information on the parts the various clinic members played in prescription, the amputees were asked: Who was most influential in deciding the kind of arm you should havef The replies are summarized in the accompanying chart.</p> <h4>Terminal Devices</h4> <p>The next two charts show the relative frequency with which the various types of terminal devices were prescribed in the research study. For purposes of comparison, data on the hands and hooks that were being worn at the beginning of the study are included under the heading "Old Prosthesis."</p> <p>In interpreting the prescription data on hands and hooks, consideration should be given to the fact that it was a policy of the research program to encourage the prescription of APRL hands and hooks in order to obtain additional data for evaluation of these devices. This accounts for part, but by no means all, of the changes in terminal components of the old and the new prostheses. Other factors involved in the changes were related to an increasing tendency on the part of clinic groups to prescribe aluminum hooks and hooks with rubber or neoprene facings and to a natural interest in the possibilities of voluntary-closing terminal devices with their wide range of grasp forces. In the case of the APRL hand, the wide range of grasp forces was combined with improved appearance. This natural curiosity and interest in new devices is reflected in the increased use of the Sierra two-load hook also.</p> <h4>Wrist Units</h4> <p>The new prostheses showed a marked increase in the prescription of positive-locking wrist units with the "quick-change" disconnect. The chief reasons for this increase related to:</p> <ol> <li>Specific vocational or avocational indications for a positive lock to control rotation.</li><li>Prescription of both hand and hook for approximately four out of five subjects. A substantial majority of these cases required a wrist unit with a "quick-change" feature to facilitate interchange of hand and hook. (<b>Fig. 1</b>)</li></ol> <h4>Wrist-Flexion Units</h4> <p>There were only two wrist-flexion units on the old prostheses. Both cases were bilateral amputees. Twenty-two wrist-flexion units were prescribed in the research group. Ten were for bilateral amputees; six were for above-elbow, four for shoulder-disarticulation, and two for below-elbow amputees. (<b>Fig. 2</b>, <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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Below-elbow Hinges</h4> <p>A marked increase in the number of flexible hinges prescribed reflects the increased awareness of the value of utilizing residual rotation of the forearm stump whenever possible so that the need for pre-positioning the terminal device with the sound hand can be reduced or eliminated entirely. An additional advantage of flexible hinges is that they are less likely to damage the sleeves of the wearer's clothes.</p> <h4>Below-elbow Cuffs</h4> <p>Prescription for below-elbow cuffs showed a marked change toward smaller cuffs and elimination of straps. This change is a result of increased recognition of the desirability of providing a cuff large enough to give adequate stability and suspension but which would also have minimum bulk, would restrict motion as little as possible, and would give greater comfort.</p> <h4>Elbow Units</h4> <p>A guiding principle in the prescription of prosthetic elbow units for above-elbow and shoulder-disarticulation prostheses was that locking should be accomplished independently by controls attached to the harness, without recourse to operation of controls by the sound hand. The extent to which this principle was applied can be seen from the data, which show that all elbow units prescribed were harness-operated. This is a highly significant change from the data relating to the old prosthesis, which show that only 46 percent of the old elbow units were harness-operated.</p> <h4>Sockets</h4> <p>Practically all of the prescriptions for the new prostheses specified plastic laminate as the material to be used in fabricating the socket. The data on the socket material used in the old prostheses show that 37 percent were made of plastic, 28 percent were made of leather with a steel frame, and the remainder were made of fiber and metal, wood, or leather. Approximately four out of five of the new prostheses had double-wall sockets, as compared to less than one out of five of the old prostheses. Twelve percent of the old and 14 percent of the new below-elbow sockets were of the split-socket, step-up type in both the old and the new prostheses. (<b>Fig. 4</b>, <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 /> <h4>Harnesses</h4> <p>The data on harnesses show a highly significant increase in the number of figure-eight harnesses prescribed for below-elbow and above-elbow cases with the new prostheses as compared with the old. The reasons for this increase are related to the favorable attitude of the program toward this simple type of harnessing, except for cases wherein heavy lifting was expected. Practically all of the shoulder-disarticulation amputees had chest-strap harnesses on both the old and the new prostheses.</p> <p>Vinyon tape was specified in 96 percent of the prescriptions for new prostheses, and cotton webbing or nylon or dacron tape were prescribed in the remaining 4 percent. (<b>Fig. 6</b>, <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>In the old prostheses, 83 percent of the harnesses were made of cotton webbing, 8 percent were of leather, and the remaining 9 percent were made of vinyon or nylon tape. The marked shift to the use of vinyon tape was due primarily to the presumably superior characteristics attributed to vinyon with respect to dimensional stability, washability, fraying, and resistance to bacteria and fungi.</p> <h4>Control Systems</h4> <p>All of the prescriptions for new prostheses called for the use of the Bowden cable in the control system. In the old prostheses, 58 percent utilized Bowden cable; the remainder utilized nylon cord, leather, or steel cable without a housing. The change to Bowden cable was effected to take advantage of its higher efficiency in transmitting forces.</p> <h3>Preprosthetic Therapy</h3> <p>Four out of ten subjects said they had received treatment by some form of exercise or other physical therapy prior to their entrance into the study. The same proportion of the group indicated that their stumps had been bandaged to bring about shrinkage.</p> <p>In response to the question, Do you think these [preprosthetic] treatments were helpful?, 79 percent replied in the affirmative and offered the following reasons (in order of decreasing frequency): increased strength, increased range of motion, helped stump shrinkage, reduced pain, improved function, reduced flabbiness.</p> <p>During the course of the research studies, preprosthetic exercise or other physical therapy was prescribed for 13 percent of the amputees treated. That only a relatively small proportion of the subjects received preprosthetic treatment is accounted for by the fact that most of the amputations occurred quite some time before the amputees participated in the program. In most cases, treatment consisted primarily of exercise to increase strength and range of motion of the stump. Other physical-therapy measures, such as diathermy, massage, and hydrotherapy, accounted for a relatively small proportion of treatments. Almost all of the subjects indicated that treatment was received daily. (<b>Fig. 8</b>, <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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Seven percent of the amputees had their stumps bandaged to cause shrinkage. About two thirds of this small group indicated that bandaging had been continued over a period of 4 to 12 weeks; the remainder of the group said that bandaging had been continued for more than 12 weeks.</p> <p>Of those who did receive preprosthetic treatment, 88 percent considered the treatments helpful. The reason given most frequently was that the treatments increased strength and range of motion. About one out of five subjects mentioned stump shrinkage as the chief beneficial effect.</p> <h3>Initial Checkout</h3> <p>With reference to arms worn prior to entrance into the program, the subjects were asked: Was your arm checked for fit, comfort, and function before it was delivered to youf Four out of five indicated that their prostheses had been subjected to some form of initial checkout or evaluation, even though this was not done on a formal basis. One third of this group said that the limbfitter had made the check. Thirteen percent designated the physician as having made the check, and 9 percent said the check was made at the hospital. The others did not provide specific information as to who performed the checkout or evaluation.</p> <p>A basic principle guiding operations in the Field Studies was that the amputee would not be permitted to wear his new prosthesis or proceed to training until initial checkout had been passed successfully. If deficiencies were encountered that would interfere with wear or training, recommendations for correction were made, and the amputee was scheduled to appear again so that initial checkout could be completed.</p> <p>Several factors serve to explain why a relatively large proportion of amputees had to appear before the clinic two or more times in order to pass initial checkout. One is that the checkout procedure proved to be highly effective in directing attention to the necessary corrections and adjustments in individual components and to the prosthesis as a whole. A second related to the relatively high and rigid standards established by the checkout procedure. A period of time was generally required before the prosthetic experience necessary to meet these standards was gained. The relatively greater frequency with which above-elbow and shoul-der-disarticulation amputees failed to pass initial checkout on the first appearance, as compared to below-elbow amputees, was for the most part due to difficulties in harnessing. In addition, the relatively small number of shoulder disarticulations seen meant that it took correspondingly longer to obtain substantial experience in their fitting and harnessing. (<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>While a majority of prostheses passed initial checkout on the first presentation, this does not mean that no deficiencies were found at initial checkout in these cases. More often than not, a number of minor deficiencies were found, which resulted in a "provisional pass" rather than a "pass." When a provisional pass was given, recommendations were made for correction of the minor deficiencies found. When the amputee reported for his first training period, a check was made to see that the recommended changes had been effected.</p> <p>Among the below-elbow subjects, the most frequent deficiencies found at initial checkout were in connection with sockets. With above-elbow amputees, the deficiencies found most frequently were in connection with harnessing. The fewest deficiencies were encountered with wrist units. The charts show the order in which the various components ranked according to the number of deficiencies found.</p> <p>The amputees taking part in the study were asked: Do you think it was worth while that the new arm was checked for fit, comfort, and function before it was delivered to you? Ninety-four percent of the replies were yes. The most common reasons given for these replies were:</p> <blockquote><p>". . . to correct and prevent problems."</p> </blockquote> <blockquote><p>". . . provides a check on fit."</p> </blockquote> <blockquote><p>". . . provides a check on comfort."</p> </blockquote> <blockquote><p>". . . provides a check on prescription."</p> </blockquote> <p>Some of the comments of those few who did not think it was a good procedure were:</p> <blockquote><p>". . . made no necessary changes to arm."</p> </blockquote> <p>". . . am intelligent enough to decide for myself if it is comfortable."</p> <blockquote><p>". . . could be checked out at limbshop."</p> </blockquote> <blockquote><p>". . . had to wear it first to see if anything was wrong."</p> </blockquote> <h3>Training</h3> <p>The data pertaining to previous training showed that 42 percent of the amputees had received prosthetic training sometime prior to the beginning of the study. Eighty-nine percent of this group expressed the opinion that this training was helpful. Three fourths of the amputees who received no previous training said they thought training would have been helpful, while the remaining fourth thought it would have been of no use.</p> <p>Data obtained from the clinical studies showed that 81 percent of the subjects received training, that 14 percent received no training, and that owing to incomplete records the training status was indefinite for the remaining 5 percent. Among the amputees who received no training, the most common reasons offered were: the amputee had worn a prosthesis before and previous training was considered adequate; the amputee passed the prosthetic-use test without training; the amputee declined training. (<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>In response to a query concerning the value of prosthetic training, four out of five amputees replied in the affirmative. Among the most frequent reasons given for the affirmative answer were:</p> <blockquote><p>". . . training gives an idea of what can be done with the prosthesis."</p> </blockquote> <blockquote><p>". . . learned mechanical operation of components."</p> </blockquote> <blockquote><p>". . . expedited use of arm."</p> </blockquote> <p>Of the group who did not believe that training was valuable, there were proportionately twice as many below-elbow as above-elbow amputees. They offered such comments as:</p> <blockquote><p>". . . using an arm is easy."</p> </blockquote> <blockquote><p>". . . training was not well organized."</p> </blockquote> <blockquote><p>". . . I would rather learn my own way."</p> </blockquote> <blockquote><p>". . . amputee was left on his own too much."</p> </blockquote> <blockquote><p>". . . training helped very little."</p> </blockquote> <blockquote><p>". . . training was not long enough "</p> </blockquote> <p>In response to the question, Do you believe the training you were given in the use of your new prosthesis could be improved?, 41 percent answered in the affirmative. About one fourth of those who answered in the affirmative expressed the opinion that there should be more training in activities of daily living. An equal number thought that more time was needed. Among the group that expressed the opinion that more time was needed there were more than three times as many above-elbow amputees as there were below-elbow amputees.</p> <p>Other suggestions for improvement of training were:</p> <blockquote><p>". . . there should be more enforced training."</p> </blockquote> <blockquote><p>". . . provide a training manual which would allow the amputee to practice at home."</p> </blockquote> <blockquote><p>". . . adapt training to occupational needs."</p> </blockquote> <blockquote><p>". . . there is not enough supervision of training."</p> </blockquote> <p>The total training time for an individual amputee ranged from half an hour to 99 hours, but more than nine out of every ten amputees received less than 20 hours of training. Except for bilateral amputees, more than eight out of every ten amputees received 10 hours or less of training. The average number of hours of training for each amputee type is based on the great majority of amputees (94 percent) who required less than 20 hours of training. Of the small remaining group of amputees (6 percent), one half received from 21 to 30 hours of training; the other half received from 30 to 99 hours. It must, however, be emphasized again that the larger part of this group had had previous prosthetic experience. (<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>The average length of individual training sessions for the amputees in the clinical studies was one hour and forty minutes. There was no significant difference in the figures for below-elbow, above-elbow, shoulder-disarticulation, and bilateral amputees. For almost 50 percent of the amputees, the length of the individual sessions was one hour.</p> <p>In reply to the question, Did any difficulties arise in connection with the operation or comfort of your new prosthesis during training or the initial period of use?, 54 percent of the amputees replied in the affirmative. Among the below-elbow subjects, the socket was the most frequent source of difficulties relating to fit and comfort, while among the above-elbow group the harness constituted the major source of trouble. With respect to function, operation of terminal devices and the control system were the most troublesome. The control system was the most common source of difficulty with respect to maintenance.</p> <h3>Final Checkout</h3> <p>Prior to participation in the Field Studies, less than 30 percent of the amputees had had their prostheses rechecked for fit, comfort, and function after the period of initial wear or training. In accordance with the procedures</p> <p>described in Section I, all prostheses in the Field Studies were subjected to final checkout after the completion of training or the initial period of wear. At this time not only was the prosthesis given a systematic and thorough inspection and evaluation but, in addition, an appraisal was made of the patient's ability to use the prosthesis, and a careful examination was made to see if there were any medical or surgical problems that might interfere with successful wear and use. Clinics considered that an amputee had "passed" final checkout only when there were no further surgical, medical, or prosthetic problems of any kind that required attention.</p> <p>Sixty percent of the prostheses passed final checkout on first presentation, 26 percent passed on second presentation, and 14 percent required more than two appearances to pass final checkout. This compares with 69 percent, 24 percent, and 7 percent, respectively, for initial checkout.</p> <p>The decrease in the number of prostheses that passed final checkout on first presentation, as compared with initial checkout, was due chiefly to the results of wear of the prosthesis, the emphasis on the amputee's ability to use the prosthesis, the apparent need for additional training, and the need for modifications which had been overlooked at the initial checkout or on which judgment had been withheld until the effect of wear could be determined. The actual number of deficiencies found at final checkout was, however, smaller by far than the number at initial checkout. Among the below-elbow amputees, the total number of deficiencies recorded at final checkout was only 339 as compared with 801 at initial checkout. The corresponding figures for above-elbow amputees were 358 at final checkout and 970 at initial checkout. These figures show clearly that the prostheses were far better at final checkout than they were at initial checkout, even though it took a little longer to get through the checkout procedure. (<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 /> <p>As was the case at initial checkout, the difficulties found most frequently at final checkout were related to socket fit for the below-elbow amputee and to harnessing for the above-elbow amputee. The fewest difficulties were encountered in relation to wrist units. The order in which various components ranked according to the number of deficiencies found is to be seen in the combined data for initial and final checkout.</p> <p>The effects of wear and use were to be seen in the continued difficulties with fit and comfort of the below-elbow socket at final checkout and also in the relative increase in deficiencies encountered with terminal devices. The more common deficiencies in the latter case were related to malfunctions of hand or hook, staining of or damage to the cosmetic glove, and excessive backlash with voluntary-closing devices.</p> <p>At both checkouts, deficiencies of the elbow unit rank fairly high on the list. Analysis indicates, however, that most of these difficulties were not with the internal mechanism but rather with other factors such as adjustment of the harness and control attachments that activate the elbow lock.</p> <p>In response to the question, Do you think it was worth while that your arm was rechecked for fit, comfort, and function after training and initial period of wear?, 90 percent of the replies were in the affirmative. The most frequent reason for this reply was that the recheck permitted problems to be corrected. Typical comments were:</p> <blockquote><p>". . . gives an opportunity to correct problems after wear."</p> </blockquote> <blockquote><p>". . . experts can see difficulties better."</p> </blockquote> <blockquote><p>". . . it is important to find out if arm still functions properly."</p> </blockquote> <blockquote><p>". . . it provides a general check."</p> </blockquote> <h3>Summary</h3> <p>The amputees' experience in the field-studies program differed quite markedly from their previous prosthetic experience with respect to prescription and final checkout. Prior to their participation in the study, less than one out of five had ever had a prosthesis that was prescribed by a clinic team, and less than one third had had their previous prostheses subjected to a final comprehensive checkout. (<b>Fig. 14</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 differences with respect to preprosthetic treatment, initial checkout, and training were less marked. Relatively fewer amputees received preprosthetic treatment in connection with the new prostheses than was the case in connection with the prostheses that were being worn at the beginning of the study. This, of course, can be accounted for by the lessened need for these services with increased prosthetic wear.</p> <p>Although a substantial majority of the amputees said that their previous prostheses had been subjected to some form of initial checkout or evaluation, these had not been done on any formal or systematic basis and had in general not involved the application of standards of acceptance.</p> <p>Forty-two percent of the amputees who had worn a prosthesis prior to the beginning of the study had received training in its use, although the nature or extent of this training is not clear from the data. More than eight out of ten subjects received training with the prostheses obtained in the research program.</p> <p>Amputee opinion pertaining to the treatment process, as indicated by the data gathered, was for the most part strongly in favor of the new procedures. Ninety-four percent of the amputees approved of the team method of prescription. Eighty-eight percent of those who received preprosthetic treatment said the treatments were helpful. Ninety-four percent were of the opinion that initial checkout was worth while.</p> <p>Four out of five amputees were of the opinion that the training they received in the use of their prostheses was valuable. But 41 percent of the group thought that training could be improved. The most frequent suggestions for improvement were to increase the amount of training time and the amount of training in meaningful activities of daily living.</p> <p>The final checkout to which all of the prostheses in the research studies were subjected was particularly comprehensive and designed to uncover any medicosurgical, prosthetic, training, or other factors that might interfere with successful wear and use. Nine out of ten amputees were of the opinion that this procedure was worth while.</p> <p>All in all, the treatment process inaugurated as part of the studies was considered valuable and achieved a high degree of amputee acceptance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <br /> Figure 1 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-46.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-47.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-48.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-49.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-50.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-51.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-52.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-53.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-54.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-55.jpg Figure 11 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-56.jpg Figure 12 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-57.jpg Figure 13 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-58.jpg Figure 14 http://www.oandplibrary.org/al/images/1958_01_073/tmp4F8-45.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 III. The Treatment Process Creator An entity primarily responsible for making the resource Warren P. Springer, M.A.  https://staging.drfop.org/files/original/6480fc01f37b5e97a22a6791c3a18bc9.pdf 8cadb11a4c01808e922c22cffe349ece DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_088.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 88 - 93 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_088.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_01_088.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 IV. Educative Implications</h2> <h5>Sidney Fishman, Ph.D. <br /></h5> <p>From the foregoing discussions, it will be apparent that one of the major purposes of the Upper-Extremity Field Studies was to introduce certain influences into the professional activities of the several groups (physicians, therapists, prosthetists) concerned with the care of the amputee and his reintegration into society. It was anticipated that changes in methods of patient care arising from these influences would in turn affect the welfare of the amputee group. In this sense, therefore, a major aspect of the Field Studies was the educative process involved in the attempt to change the operational patterns of those responsible for amputee care by strengthening the philosophies, attitudes, and skills which had been taught during the short-term courses of instruction. Continued encouragement, assistance, and guidance were required to habituate these groups to the procedures proposed during the instructional courses.</p> <p>The second phase of the Field Studies, the results of which will be discussed in the next issue of Artificial Limbs (Autumn 1958, Vol. 5, No. 2), is most properly considered a research activity. The purpose in this phase of the program was to attempt to evaluate the effects of these efforts on the over-all status of the amputee through the use of objective and subjective measurements. To accomplish this second phase, detailed studies were made of the status of the group of amputees prior to their treatment by the prosthetic clinic and again at a time after the completion of treatment.</p> <p>In approaching the task of estimating the effectiveness, or lack of effectiveness, of a two-pronged (research and education) program of this type, a number of problems arise. In this particular case, fortunately, we have the opportunity of deferring evaluation of the second phase, the research activities, until after those results are presented in a second installment.</p> <p>The results of the educative effort are perhaps best considered in terms of Jesus' parable of the sower, as set forth in <em>The Gospel According to St. Matthew </em> (Chapter 13):</p> <blockquote><p>3 ... Behold, a sower went forth to sow;<br /> 4 And when he sowed, some seeds fell by the way side, and the fowls came and devoured them up:<br /> 5 Some fell upon stony places, where they had not much earth: and forthwith they sprung up, because they had no deepness of earth:<br /> 6 And when the sun was up, they were scorched; and because they had no root, they withered away.<br /> 7 And some fell among thorns; and the thorns sprung up, and choked them:<br /> 8 But other fell into good ground, and brought forth fruit, some an hundredfold, some sixtyfold, some thirty fold.<br /> 9 Who hath ears to hear, let him hear.<br /></p> </blockquote> <p>In some few places and among some persons, no effects are to be noted. Among others minor temporary changes evolved, and in still other instances important permanent improvements were brought about. We may consider these effects under three broad categories-impact on the medical management of the amputee, impact on public and private rehabilitation agencies, and impact on social attitudes.</p> <h3>Impact on the Medical Management of the Amputee</h3> <p>It has been emphasized consistently throughout the foregoing sections that a "prosthetic-clinic approach" to the problem of the amputee was a basic tenet of the field-studies program. In this approach, the fundamental decisions relating to the rehabilitation of the patient were made in concert by a group consisting minimally of a physician or surgeon, a physical and/or occupational therapist, and a prosthe-tist. Whenever possible, vocational counselors and other personnel trained in the psychosocial aspects of rehabilitation also were included.</p> <p>The second aspect of the prosthetic-clinic approach involved an attempt at considerable standardization of the process of patient care and usually included eight more or less formal treatment steps-preprescription examination, prescription, preprosthetic therapy, prosthetic fabrication, initial checkout, prosthetic training, final checkout, and follow-up. As a consequence of these efforts, three major changes occurred in the medical care of amputees- introduction of prosthetic-clinic procedures, staff and patient education, and upgrading of existing services.</p> <h4>Introduction Of Prosthetic-clinic Procedures</h4> <p>Although similar clinical procedures have been developed and practiced in the treatment of other disabilities, and even occasionally in prosthetics, the attempt at systematic introduction of such procedures on a broad basis was a novel one. In addition, experimental exploration and validation of the essential adequacy of such procedures is hardly ever available. As a major outcome of the Field Studies, however, the basic validity of the clinical procedures in the field of upper-extremity prosthetics has been established. In addition to these accomplishments, certain other changes occurred with respect to the patient-care activities of each of the specific professions-the physician and surgeon, the physical and occupational therapist, and the prosthetist-concerned with the handling of the upper-extremity amputee.</p> <h5><i>The Physician and Surgeon</i></h5> <p>As a result of the principles and procedures instituted under the program, the period during which the amputee is considered a patient under medical management was extended significantly. Formerly an amputee was a patient during surgery and through a limited period of postoperative care. Today, the period of medical supervision continues through the entire process of limb prescription, fabrication, training, and evaluation.</p> <p>As an additional outgrowth, a subspecialty within the fields of orthopedic surgery and physical medicine has been developed. A limited number of physicians have become expert in the field of limb prosthetics. Since the amputee represents a relatively small portion of the total population requiring medical service, it is not feasible for large numbers of physicians to specialize in this field. But in order to provide competent service for amputees it was essential that a few physicians in each major population center be thoroughly equipped to provide the care required. Physician specialization in the very restricted field of prosthetic restoration has come about as a direct result of the program.</p> <p>Through the program the physician has learned much concerning the technical specifics of prosthetic restoration. As a result of this education, his respect for the contributions made by the skill and experience of the therapist and prosthetist in the process of amputee rehabilitation has increased. The interdisciplinary approach to the problem of amputation and prosthesis has become accepted and appreciated as a significant forward step in the medical management of the amputee. As a general consequence, the physician has been able to acquaint himself with, adapt, and then apply modern-and gradually higher-standards of prosthetic care for his patients. Knowing, perhaps for the first time, what constitutes and what is involved in providing a good prosthesis, the physician is now able to require a standard of service not previously possible.</p> <h5><i>The Physical and Occupational Therapist</i></h5> <p>For the therapist, the short-term courses in upper-extremity prosthetics filled a gap left by the usual curricula in schools of occupational and physical therapy. Perhaps for the first time, a systematic approach to the amputee problem was taught and practiced. As a result, the therapist has been able to carry out the major responsibility of amputee training with a background of general technical knowledge directly relating to artificial limbs. In addition, closer professional liaison developed between the therapist, the physician, and the prosthetist with regard to the amputee. As a result, in most instances upper-extremity amputees are now routinely referred to the therapist for instruction in the use of the artificial limb, whereas in the preprogram days the number of therapists qualified to give this service and the number of amputees availing themselves of it were both insignificant.</p> <h5><i>The Prosthetist</i></h5> <p>The program sought and helped to provide a proper professional role for the prosthetist. As a group, prosthetists were for the first time exposed to formal university instruction and to closer relations with medical, paramedical, and psychosocial disciplines. Thus the prosthetist has been helped toward a redefinition of his status on a higher professional level.</p> <p>This progress in the direction of a more professional role was aided in no small measure by the acquisition of a new technology involving the use of biomechanical principles, plastics fabrication, and principles of harnessing and controlling artificial limbs. This improved knowledge has resulted in improved service, increased status, and greater interprofessional satisfactions.</p> <p>One cannot say at this early stage in the evolution of this field just what the ultimate or proper interrelations may be between the professions concerned. Certainly the appropriate relationships will tend to vary from location to location, depending upon personnel and situational considerations. There can, however, be no gainsaying the facts that a period of growth has been stimulated, that the adequacy of the present treatment situation far surpasses that of the old, and that there has been developed a climate which gives every indication of providing additional professional status for the prosthetist.</p> <h4>Staff And Patient Education</h4> <p>A second value provided by the studies relates to the matter of staff and patient education. It is as true in limb prosthetics as in the other healing arts that there are no standard procedures which will apply with equal effectiveness to every patient. Moreover, limb prosthetics is still a field in which the contributions of each of the specialists are but partially understood by the others. Consequently, there is an important need for a cross-fertilization of ideas and a distillation of the best thinking for a given patient by the process of group activity. In this sense, an important achievement of the prosthetic clinic may be considered the intraclinic education of the team members.</p> <p>Equally important is the role that the clinic must play in the education of the patient. Most amputees, when arriving for prosthetic care, are subject to wide and varied misunderstandings and misinterpretations as to the procurement and ultimate use and value of a prosthetic device. Clinic personnel have become more effective in educating the patient concerning realistic goals and anticipations, in addition to providing him with the best type of prosthesis for his particular needs.</p> <h4>Upgraing Of Existing Services</h4> <p>In the process of applying and studying clinic procedures experimentally, the last important result evolved-that of an upgrading of existing services, as well as the establishment of services where none had existed previously. In this respect, the major contribution apparently has grown out of the introduction of a coordinated pattern of treatment.</p> <p>Previously, it had not been uncommon for a prosthetist, physician, and vocational counselor, for example, to proceed with the care of an amputee independently of one another. This procedure was often adopted in spite of the fact that in any situation where an individual is receiving treatment from more than one specialist, and where the anxieties are such as to provoke some degree of patient discontent, there is a noticeable tendency for some patients to distort the intentions and contributions of each profession in relation to the others. Such problems are further aggravated in those instances where the patient himself is called upon to act as the means of communication between the professions involved, since we may be sure that there will always be a certain degree of distortion of the patient's perceptions of the treatment processes. The clinic procedures were especially effective in reducing this troublesome method of communication between the specialists.</p> <p>We may also anticipate that the behavior and demeanor of the patient toward the pros-thetist will differ from that he exhibits toward the physician, therapist, or counselor. These differences in overt behavior patterns may easily and logically suggest different patterns of treatment to each of the individual professions. Yet it should be clear that these varying behaviors on the part of the patient are transitory and that the real solution lies in a uniform treatment plan rather than in a number of discrete ones. It therefore becomes clear that, in order to provide amputees with the best available medical and prosthetic service, the contribution of each of the professional specialties is best coordinated and amalgamated with that of each of the others. The prosthetic-clinic procedures, introduced through the studies, permitted a more uniform evaluation of the patient and assisted in circumventing the problems inherent in uncoordinated care.</p> <h3>Impact on Public and Private Rehabilitation Agencies</h3> <p>Many groups who have as their adopted or assigned mission the reintegration of the handicapped individual as a productive member of society have long been aware of the significance of the process of prosthetic restoration as a link in the over-all process of rehabilitation. As a direct consequence of this awareness, and as a necessary outgrowth of their over-all responsibilities in the rehabilitation field, federal agencies such as the Veterans Administration, the Armed Forces, and the Department of Health, Education, and Welfare, the state divisions of vocational rehabilitation, workmen's compensation, and health and public welfare, and such nongovernmental agencies as the state societies for crippled children and adults, rehabilitation centers, insurance companies, and a number of other private agencies have become the largest purchasers of prosthetic services in the United States.</p> <p>Through the NYU Field Studies these groups have been made increasingly aware of the potentialities of prosthetic restoration and have responded by raising their standards in the field of upper-extremity prosthetics. Having been provided with professionally competent avenues for the processing of their beneficiaries through prosthetic prescription, fabrication, training, and evaluation, these agencies have begun to insist that their clients be treated by special amputation teams headed by physicians who are experts in the field. Since these agencies may be considered "consumers" in the sense that they most frequently pay for the prosthetic services provided, they have been instrumental in raising the standards by rejecting prostheses and services that do not meet the minimum standards first set up through the program.</p> <p>A by-product is that the groups mentioned tend more and more to order prostheses from those prosthetists who have fully qualified themselves by virtue of training and experience. In a good many instances, these agencies have shown themselves willing to spend the additional monies required to obtain services of the highest quality. In some instances the program has been instrumental in stimulating the inauguration of local services to avoid the necessity for these rehabilitation agencies to contract for prosthetic services from distant sources. The widespread introduction of the clinic-team concept to the field of limb prosthetics provided the means for greater liaison between rehabilitation agencies and those persons medically responsible for the process of prosthetic restoration. Since the clinic-team meetings ordinarily involve a conference of all of the participants in a given case, the agency itself is frequently represented at such conferences by a professional staff member. This, of course, makes for considerable improvement in the continuity of the rehabilitation process.</p> <h3>Impact on Social Attitudes</h3> <p>Beyond their influence on the medical and rehabilitation agencies, the effects of the Upper-Extremity Field Studies also permeated through other facets of our social structure, although as one departs further and further from the professional groups directly responsible for the care of the amputee the impact of the effort becomes more diffused and less specific. Nonetheless, a number of significant effects remain to be noted. They may be viewed as influencing the attitudes and thinking of sponsoring agencies, scientists concerned with physical disability, other groups of disabled, and society at large.</p> <h4>Sponsoring Agencies</h4> <p>Perhaps one of the most important contributions was the demonstration that within a relatively brief period of time research and development can be accomplished and the benefits therefrom made available to the average patient with a disability. It should be recalled that the entire upper-extremity research program did not get under way until several years after the close of World War II and that the major prosthetic design improvements depended upon several years of fundamental biomechanical research. Thus the entire concept and technology of the care of the upper-extremity amputee has been revolutionized within a remarkably brief period of six or seven years.</p> <p>Such demonstrable progress is of inestimable value to those whose prerogatives require that they decide where substantial private or public monies should be spent in medical or rehabilitation research. Although it is always important to verify or evaluate the results of a broad program of research, this is not always possible. Yet this is precisely what the Upper-Extremity Field Studies have done.</p> <p>In the first instance, scientific evidence has been provided concerning the over-all value and contribution of the six or seven years of research and development. Secondly, and from a more technical point of view, information was brought forth concerning those aspects of the care of the upper-extremity amputee which had progressed most satisfactorily and those phases which require continuous improvement and attention.</p> <h4>Scientists Cconcerned With Physical Disability</h4> <p>The program of research and education also assisted in the general growth of scientific thinking on problems of human disability. Some detailed discussion of these research considerations will be included in the next issue of Artificial Limbs (Autumn 1958, Vol. 5, No. 2), which will deal with the research aspects of the studies. The discussion of the educative aspects of the Upper-Extremity Field Studies would be incomplete without note being taken of the progress that has occurred in the attitudes and thinking of researchers in the field of physical disabilities. These advances have been summarized at the recent conference on the Contributions of the Physical, Biological, and Psychological Sciences in Human Disability sponsored by the New York Academy of Sciences (page 125).</p> <h4>Other Groups Of Disabled</h4> <p>It is clear that a special service was performed for those individuals who have incurred disabilities related to, but not identical with, amputation. These groups are perhaps best typified by those disabilities which require functional restoration by use of braces or other orthopedic appliances.</p> <p>Until the time of these studies, there was very little overt expression of the need for progress in the field of bracing. The prevailing situation was one that had remained static for decades. With limited exceptions, personal unvalidated opinion, professional and otherwise, pervaded and still characterizes the entire field.</p> <p>Partially as a consequence of the broad educative aspects of the Upper-Extremity Field Studies, a spontaneous development of interest and desire for systematic progress arose in this related field, which is often served by the same doctors, therapists, and pros-thetists-orthotists. People who were suffering from these types of disabilities and those who cared for them generated a new feeling of hope and enterprise. The results of these changes in attitudes are just now being translated into planning for active research and education.</p> <h4>Society At Large</h4> <p>Further evidence was provided that the systematic treatment of the disabled is a fundamentally effective and socially desirable process. The "collective concern" which society experiences concerning the physically handicapped tends to be reduced with the knowledge that constructive things can be done, and have been done, for this group in an orderly, scientific manner. Associated with this growth in knowledge is a reduction in anxiety and prejudice concerning the physically handicapped and a corresponding increase in their acceptance by society.</p> <br /> 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 IV. Educative Implications Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D.  https://staging.drfop.org/files/original/387c7a200b8c8e82a1549ac460dc2643.pdf 6cdf715e6bd5043fe4e42bf3b3884a24 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_001.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The NYU Field Studies-A Postscript</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <blockquote> <p>Well, one of the two (who will soon be here)—<br /> But <em>which</em> of the two it is not quite clear—<br /> Is the Royal Prince you married!<br /> Search in and out and round about<br /> And you'll discover never<br />A tale so free from every doubt—<br /> All probable, possible shadow of doubt—<br /> All possible doubt whatever!<br /> —- W. S. Gilbert, 1889</p> </blockquote> <p>In preparing a report on extensive research, a modern investigator faces the same problems as the Grand Inquisitor. He may be able to furnish explicit answers to all the minor questions and to delimit the possible solutions of major problems. Only in fortunate circumstances can he provide final answers to all the questions originally posed.</p> <p>This, the second of two issues of Artificial Limbs to be devoted to the NYU Field Studies of 1953-55 (see issue for Spring 1958), offers a wealth of censuslike information on fascinating problems revealed in the course of studying extraordinarily large samples of upper-extremity amputees and their prostheses. It answers with overwhelming affirmation a critical amd highly pertinent question; Do modern concepts of upper-extremity prosthetics truly represent substantial improvement over previous practices? But this favorable broad conclusion demands by virtue of its own importance respect for certain essential qualifications more or less obvious from the circumstances of study if not from the nature of the study itself.</p> <p>Largely because the samples in the NYU Field Studies included such high percentages of veterans of World War II and Korea, many of the amputees treated had already received organized care and training in military amputation centers. Moreover, many had already reaped some early benefits of the Artificial Limb Program. New and supposedly improved devices and techniques had already been developed and applied progressively over a period of half a dozen years, and the U. S. Veterans Administration was already operating Orthopedic and Prosthetic Appliance Clinic Teams in some 30 key cities. Though at the time members of these clinic teams were concerned largely with the suction-socket program and with lower-extremity problems generally, they were so stimulated by the special courses at UCLA, and so encouraged by the monthly visits of NYU field representatives, as to tackle problems in upper-extremity prosthetics and to expand their perspective from simple application of mechanical gadgets to genuine concern for all aspects of the resulting man-machine system. And consequently the results here given are clearly weighted by disproportionate inclusion of the comparatively young and otherwise healthy adult male with special advantages not ordinarily then to be had by the amputee population at large.</p> <p>The nature of the subject matter is something else again. In any investigation so intimately associated with the individual proclivities of human beings, and particularly one of the magnitude indicated, the variables to be controlled are many and diverse, and the data to be had are especially voluminous. Although census counts may provide clues to major influences, and although modern electronic computers may furnish effective correlations and satisfying proof of statistical significance, prosthetics problems in clinical practice are not apt thus to be fully solved because, as in polio, cancer, and numerous other kinds of human disorder, there is generally no single "necessary and sufficient condition" but instead a rather large number of interrelated factors which, added or subtracted in proportions variously weighted, may easily tip the balance for or against clinical usefulness and research success. Thus effective application of the present findings calls for the exercise of keen discrimination over and above that required by the limitations of the sample studied.</p> <p>Despite the existing correlations, therefore, the NYU Field Studies leave unsolved, or at best still subject to serious debate, some disquieting major questions. Why, for example, did a few amputees prefer their old arms over the newer ones? How well did the new prostheses pass the comfort aspects of the checkout tests required? Are the checkout standards adequate? Were complaints about terminal devices heavily correlated with mechanical failure? Of many such puzzlers, some might be resolved by further analysis and correlation of the mountainous data now embalmed in the form of 29 punched cards for each of several hundred amputees. Others indicate the need for further research in the social sciences, while still others constitute a continuing challenge for designers of devices, developers of techniques, and sponsors of research.</p> <p>Perhaps even more fascinating than the yet unsolved questions of physical and mechanical significance are the hints at the nature of amputee psychology. Still needed are thoughtful studies of the problems of realistic acceptance of amputation losses, of objective appraisal of the possibilities for rehabilitation, of the influence of amputee expectations on success in restoration, and of the potentialities for improvement through counseling and guidance both for the patient and for the public as regards attitudes toward what is still called "handicap." Serious consideration of some of the points raised in the present volume may be expected to temper success with humility and hence possibly to afford a degree of wisdom not otherwise to be had. Here, then, is a byproduct perhaps more valuable in the long view than are the actual conclusions it is now possible to formulate.</p> <p>In these investigations, NYU faced and overcame in the conduct of its own studies many practical difficulties in addition to the complex problems inherent in investigations in limb prosthetics. It recruited from a highly restricted labor force a field staff of persons able to observe and assess clinical procedures effectively and willing to travel two weeks in every four during a period of uncertain tenure. It thereby quickly established relationships with VA facilities throughout the country and, even more important, with the numerous private clinic teams that NYU helped to foster, and it maintained checkout standards despite differences in interpretation from one clinic to another. The correlations and insights here presented have all come from the very persons who helped to collect the data, and the summaries have all been prepared with the help of former field men who have since transferred to other NYU projects or who have now left the NYU facilities entirely.</p> <p>Recognizing residual deficiencies, facing unresolved problems, and yet expressing gratitude for the substantial achievements described in NYU's unprecedented two-number contribution to Artificial Limbs, we may now, in the acknowledged infancy of the art and science of limb prosthetics, justifiably substitute "books" for "babes" in the familiar characterization by the Grand Inquisitor:</p> <blockquote><p>Both of the babes were strong and stout,<br />And, considering all things, clever,<br />Of that there is no manner of doubt—<br />No probable, possible shadow of doubt—<br />No possible doubt whatever.</p> </blockquote> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service, U. S. Veterans Administration, 252 Seventh Ave., New York 1, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The NYU Field Studies-A Postscript Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/caebe3f12ffbae3736dc0772ee55ae46.pdf 2c2ad2a01e8a4dc8c3905be963fdf48c DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_001.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1961_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_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>Syme's Amputation</h2> <h5>Walter Mercer <a style="text-decoration:none;">*</a><br /></h5> <p>This issue of Artificial Limbs is, and always will be, a classical contribution to everything pertaining to Syme's amputation, including, as it does, the most detailed and accurate description extant of the proper method of doing the amputation.</p> <p>It has to be remembered that Syme was the greatest of the pre-Listerian surgeons and, indeed, his operation was developed to combat the disastrous septic complications that so often beset the surgeon who dealt with compound fractures, especially where the bone was divided, in contrast to cases that were disarticulated. The fear of sepsis was no longer a real one after Lister's discovery, but that there were other and great advantages in this operation is proved by the fact that Syme's operation is still recognised by competent surgeons as a method of choice in the suitable case. But there have been criticisms of the operation. Harris has stated the reasons for this difference of opinion. He believes that these lie in the method of the operation and in the after-treatment. Various imperfections of the end-results and the methods of their avoidance are described. Most of these can be avoided by a careful technique, and if this were generally practised there would be fewer complications about this excellent operation.</p> <p>Harris reminds us of an important feature of anatomy not generally recognised. This is the specialised form of elastic adipose tissue developed between the calcaneum and the plantar aponeurosis which is resistant to pressure. There are here pockets of fat enclosed by dense septa of fibrous tissue. These fibrous tissue strands are in the form of the letter "U," with the open end of the "U" pointing towards the calcaneum. If this concept is true, it is obvious why the dissection of the heel flap should be close to the calcaneum, because if these little loculi are opened, as will happen if the dissection is through the subcutaneous layer, the fat content is extruded and an important weight-bearing mechanism rendered useless.</p> <p>All modifications, apart from Syme's own one, have detracted from the good qualities of the Syme stump and, indeed, have often ruined its weight-bearing qualities and brought the modified Syme's operation into disrepute. Kelham and Perkins, of the British Ministry of Pensions, are often quoted for their strong objection to this operation, and they concluded their article by expressing the hope that the modified operations would soon be as dead as the original Syme. But their remarks were not based on the original Syme, and so it is not remarkable that they hoped that their modified operation would become obsolete.</p> <p>Modifications like that of Elmslie only lead to failure by reducing the weight-bearing area and making the positioning and fixation of the heel flap more difficult. The plane of transection of the tibia should be so placed that the minimum of bone is removed and the largest possible cross-section of the tibia remains, and that, of course, should be parallel to the ground.</p> <p>It is good to know that the opinions of the British Ministry of Pensions at Roehampton are now very different. The Chief Medical Officer there believes that a Syme amputation is the operation of choice and he adds that "nobody would persuade me to have a below-knee amputation if I could have a Syme."</p> <p>Opinion on durability, too, seems to have changed. Many of the cases seen at Roehampton have had little or no trouble over 30 and 40 years. Shellswell quotes a case who had no trouble in 74 years of limbwearing and in his investigation of 305 Syme's amputations with an average follow-up of 29.6 years he found that 66 percent had satisfactory stumps.</p> <p>Harris points out that an imperfection that is commonly overlooked is the misplaced heel flap. So often after the operation the patient is sent out of the theatre to have the bandaging and the dressing completed. A little too much pull inwards or outwards produces-and permanently-a flap which is not exactly beneath the centre of the cut lower end of the tibia. Harris secured this correct position by strips of adhesive plaster. A plaster-of-Paris support has also been suggested, and a very secure method is to fix the stump by a nail or pin driven up through the lower end of the tibia.</p> <p>Gordon Dale, who has had an immense experience when in charge of all amputations for the Canadian Department of Veterans Affairs, discusses the use of the Syme amputation in peripheral vascular disease. This is an interesting review of the subject with a detailed description of typical cases. The first Syme amputation for thromboangiitis obliterans was done as far back as 1925, and since then it has been used in such cases whenever it seemed warranted. By 1940 this amputation had been used successfully for a wide variety of conditions, including perforating ulcers, in unrecovered sciatic lesions, cauda-equina lesions, frostbite, arterial occlusion, and gangrene from peripheral arterial disease. Dale showed by demonstration of actual cases the great value and durability of these amputations in active life, and in so doing was able to refute the views on durability expressed by the British Ministry of Pensions.</p> <p>The biomechanics of the Syme prosthesis are reviewed by Radcliffe and particularly the locomotion pattern and the manner of weight-bearing for a Syme amputee. In an analysis of the process of human locomotion, the walking cycle is divided into two phases-the stance phase and the swing phase-and these are reviewed. The energy curves are most interesting and give some insight into the complexity of knee-ankle interaction in normal human locomotion. Because of the inherent limitations in available space in the Syme prosthesis, attempts to introduce ankle action have been for the most part unsuccessful. Because in this limited space the Syme amputee cannot achieve the same degree of function as the above-knee or below-knee amputee wearing a SACH foot, the function will in general represent an improvement over the result to be had with the usual articulated joint. This is perhaps an understatement, for when the knee joint on the prosthetic side assumes a greater proportion of the shock-absorption function as evidenced by increased knee flexion under load just after heel contact there is much less deviation from the normal gait.</p> <p>The actual prosthesis is described in a further article. In a review of the history it is apparent that there has been a gradual improvement since the beginning of the century, though even in 1940 the device was bulky, uncomfortable, and generally subject to mechanical failure. With the introduction of plastic laminates into the practise of prosthetics, research workers have been able to alleviate to a great extent the shortcomings of the designs then currently in use, and now excellent and enduring results have been obtained in a large number of Syme amputations observed in Canada. There seems to be little doubt but that the results in Canada, superior apparently to those in Great Britain, have been due chiefly to adherence to the classical procedure of Syme. In this connection, it is said that "Syme was seldom if ever meticulous as to detail," which is hardly consistent with the views of a famous assistant of Syme's, Joseph Bell, in expressing the special character of Syme's method of operating, nor indeed with his reputation in Edinburgh.</p> <p>The present prosthesis is the result of research undertaken by the National Research Council of Canada, an activity initiated by Dr. Harris in 1944, though it was not till ten years later that the device had sufficient merit to warrant its general adoption. This is known as the "Canadian-Type Syme Prosthesis," or more simply, in Canada, as the "Plastic Syme." Among the essential features is a socket made of laminations of Fiberglas applied to a plastic mould of the stump and bonded with a rigid epoxy resin. It is lined with foam rubber, and the stump is inserted posteriorly. There is no ankle joint, and the foot is of the SACH type. This prosthesis is stronger, lighter, and much neater than anything produced before and is now in general use, and we have in the last two articles the considered opinion on it from Canada and America. It is stated in the first of these that its chief advantages lie in its improved appearance with reduced weight, its improved durability by virtue of a stronger structure, its freedom from mechanical troubles, and its reduced cost.</p> <p>This issue of Artificial Limbs leads one to the conclusion that the Syme's amputation is a very good one when properly carried out and properly cared for afterwards. The limb, too, that is in common use as described is a vast improvement on the older types and permits a gait that is not much short of normal.</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>Walter Mercer </b></td></tr><tr><td class="clsTextSmall">'Bidston,' 7 Easter Belmont Road, Edinburgh 12, Scotland.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Syme's Amputation Creator An entity primarily responsible for making the resource Walter Mercer * https://staging.drfop.org/files/original/c737cb139033e8c4e783bb778fe2e303.pdf afba2b2f06d76842bef498473100a1b1 https://staging.drfop.org/files/original/53a89d8480ff368ebfc6962ec042be72.jpg b2d8f26b2c1cafd28d9b7ad03029a668 https://staging.drfop.org/files/original/2ef1058566b5da2b2e748d2d399df4c3.jpg a8237eb97aeffbee15ffa247a537a667 https://staging.drfop.org/files/original/0e0af5faf2d7d019ccf6efbf80ecc4e4.jpg 81b5c27b0158cb11f17f9b3811ec9ac7 https://staging.drfop.org/files/original/9fae0d917cf822fda036ea66b7f8ff35.jpg 39a6b402d16ad8e2ef8e5667351eef50 https://staging.drfop.org/files/original/fda55ff8d76b3af1f4afc1d3a8cc3787.jpg a25e75a93fc30ecdd9c8b6975d942de6 https://staging.drfop.org/files/original/635c07500a4b3f511b40baacfd0ec89f.jpg adb8ecb8590d21be56e26f5405cf8bf4 https://staging.drfop.org/files/original/881b402166909b183a592b5b932f5677.jpg 7a3a00e45dd8702373b17959937a5126 https://staging.drfop.org/files/original/867e91a41092a8cb68da465cd4034cf0.jpg da1b4fa8505ac79518e6226d88cac8c5 https://staging.drfop.org/files/original/05fd05eb81ff45ee5e7dcdccc396ce52.jpg dc75320f708c13452a69fae429e97894 https://staging.drfop.org/files/original/e6f7b2da3a4fadbf8a3a527edd3b5316.jpg 374c020c738c1a7a0b67d6f9b7e5072f https://staging.drfop.org/files/original/b0841997a49c9c7aab4eec937823c93b.jpg af43b44b1a7974fa376e7e9cc4272e4a https://staging.drfop.org/files/original/3ecc27bcefe23c8876046fa46a244a58.jpg 0cc9e916aae2a19c818aa922e2e9dd6d https://staging.drfop.org/files/original/3f61c1ac694eecb5767bc99734eebdca.jpg 84b791ff84fc7c8e0ba091dd088d83ad https://staging.drfop.org/files/original/6c08a4ed2a642bee3bf78630fcb66ac5.jpg 4dd94891a6ce8096342cf7ecff639b6e https://staging.drfop.org/files/original/b3b7237e745179d1ea21a21d0e3d3ecc.jpg d402232aa9be558b350be8c78a1075dc https://staging.drfop.org/files/original/b8ba70d807eb81df01ce717eb7db28ef.jpg cc62f2333467e76a57f6725f0c159351 https://staging.drfop.org/files/original/9cb3b4e808194b8ed3234d51106c404f.jpg 74505ee95ad7d6144a9d5ef5dff2fc5f https://staging.drfop.org/files/original/67170ee9e96df59048a0de1aa68a16c4.jpg ced97b253b8926ea606e2d78a8c894ab https://staging.drfop.org/files/original/8d01098d0675e6e9c890d0e24af2e450.jpg c3cd02b27f4bda7a2e64bc3d1b4b3807 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_004.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 4 - 30 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_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>Studies of the Upper-Extremity Amputee V. The Armamentarium</h2> <h5>Edward R. Ford, CP. <a style="text-decoration:none;">*</a><br />Earl A. Lewis, M.A., R.P.T. <a style="text-decoration:none;">*</a><br /></h5> <p>One of the most interesting aspects of the evaluation procedures is concerned with comparisons between the prosthetic equipment worn by the participating amputees prior to the NYU Field Studies and that later provided as part of the studies. Some amputees entering the program were found to be wearing modern arms based on the latest components and materials and constructed according to the latest methods of fabrication. Others had outmoded and sometimes outworn prostheses. And a third group either had never worn prostheses before or else were not wearing a prosthesis at the time the program began. Accordingly, the data gathered were not only on the new program prostheses but also on the old arms previously worn, if any, and hence the present analysis deals not only with the effects of program arms but also to a considerable extent with comparisons between the old and the new prostheses.<a style="text-decoration:none;">*</a> Of the 1630 arm amputees involved in the NYU Field Program, 359 were available for comprehensive investigation throughout the period covered by the evaluation studies. Of the 359, which together form the basis for this discussion, 168 were below-elbow amputees, 158 were above-elbow amputees, 23 had shoulder disarticulations, and 10 were bilaterals. Those who had prior experience with prostheses were used to form the comparative analysis of old vs. new.</p> <p>Although the subjects making up the group were generally available for intensive study, it was not possible to obtain from every amputee an answer to every question. In other instances, the investigators received multiple responses to questions. Moreover, certain areas of investigation called for responses in relation to the number of components involved, in which case the number of responses varied with the bilateral group and with those patients who utilized more than one terminal device. Although the reflection of these factors in the data causes some inconsistency in numbers of replies, it does not reduce the over-all value of the results.</p> <p>For purposes of identification, all prostheses worn by the amputees prior to inception of the NYU Field Studies are here referred to as "old prostheses" or "preprogram arms," although in a few cases they were rather new and reflected some of the latest techniques and components. All prostheses fitted during the course of the research studies are identified as "program" or "new" prostheses, although some of the components and techniques had for some time enjoyed either limited or general use in the prosthetics field. While the "old prostheses" represent an admixture of various techniques and components, some old, some new, the "program prostheses" represent the best of the old plus the latest innovations in the field of limb prosthetics at the time.</p> <p>In passing, it should perhaps be noted that the data concerned were for the most part gathered on program prostheses fabricated shortly after the prosthetists' completion of the prosthetics courses at the University of California at Los Angeles. The skills and experience available for handling the latest components, materials, and techniques were therefore somewhat limited during the early days. As experience and attendant skills increased, the quality of the prostheses improved. No apology for the program treatment procedures and prostheses (which, as will be seen, were clearly superior to preprogram efforts), this circumstance indicates that expansion of present gains can be expected as prosthetists and prosthetics clinics continue to accumulate experience with latest procedures.</p> <h3>Terminal Devices</h3> <p>The artificial hand or hook is generally considered to be the most important single component of an artificial arm. A major functional purpose of all other components of the upper-extremity prosthesis is to make it possible for the terminal device to be positioned and the function of grasp to be utilized. Moreover, the hook or hand is important from the standpoint of aesthetics, since it is exposed to view almost constantly and is a matter of curiosity to all who recognize it as a prosthetic device. Today's prosthetic armamentarium presents a choice, from a selection of hooks and hands, of terminal devices most likely to meet the wearer's needs. Within this framework are devices which operate on the voluntary-opening or the voluntary-closing principle<a></a>. Available hands are either essentially cosmetic or else are designed to provide prehension as well as cosmesis<a></a>. Either type permits the functions of pushing, pulling, and holding down objects.</p> <p>Were any one of these devices completely satisfactory, it would enjoy exclusive use by all wearers of arm prostheses. Since such is not the case, amputees frequently interchange two or more terminal devices, say a hand and a hook, and some even interchange two hooks of different shapes and operational characteristics. In any event, many factors influence the selection of terminal devices<a></a>, so that what- ever is chosen usually represents a compromise based upon consideration of the psychological, environmental, and biomechanical circumstances of the individual amputee.</p> <h4>The APRL Hand and Glove</h4> <p>One of the most widely publicized developments in the Artificial Limb Program has been the APRL voluntary-closing terminal devices—the APRL hook and the APRL hand with its companion glove of plasticized polyvinyl chloride<a></a>. Prior studies<a></a> had established the usefulness of these devices, and the Upper-Extremity Field Studies presented a unique opportunity to introduce these items into many more clinics over the country and to obtain additional information concerning the value of the devices to amputees. The APRL hand was therefore prescribed in almost all research cases where a prosthetic hand was indicated (285 out of 291). Four patients expressed strong desires to continue with voluntary-opening hands, while two others elected to continue with passive, cosmetic hands.</p> <p>Tests showed that grasp forces available with the APRL hand, in which grasping force is related directly to the force that can be exerted by the wearer, were much higher than those to be had with other types of functional hands. Almost all wearers of the APRL hand (89 percent) could exceed 20 lb., a force not uncommon in the palmar prehension of non-amputees <a></a>. Voluntary-opening mechanical hands, in which the force is limited to that available from springs or rubber bands, showed a maximum prehension force of 5 lb.</p> <p>When these tests were completed, the subjects were questioned regarding their reactions toward the APRL hand in the areas of usefulness, appearance, ease of operation, and weight.</p> <h5><i>Usefulness</i></h5> <p>Most of the amputees considered the APRL hand to be a useful device or at least one of limited use. Less than 12 percent considered the hand to be of no use. But the pattern of responses clearly indicates that the hand becomes less useful to the wearer as the level of amputa- lion becomes higher, presumably owing to the increased difficulty of using a prosthesis with decreasing stump lengths.</p> <p>The ability to control grasp and to maintain it (by automatic locking) was well received by 50 percent of the amputees for whom APRL hands had been prescribed, and increased function over a wide range of activities elicited important voluntary comments from another 27 percent. The choice of using either the large or the small finger opening prompted positive comments by 11 percent of the sample. When comparisons were made of the amputee reactions to usefulness, the APRL hand was rated considerably higher than other types of hands previously worn. <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 /> <h5><i>Appearance</i></h5> <p>Noted was an exceptionally high degree of amputee satisfaction with the appearance of the APRL hand. As might have been expected, level of amputation did not seem to influence the wearers' reactions in this area. More than 90 percent of all the amputees felt the APRL hand and glove to be either "very satisfactory" or "satisfactory" in appearance. In no other component of the prosthesis do we have such a large number of amputees exhibiting this degree of positive response.</p> <p>The size of the APRL hand was felt by 6 percent of the wearers to be a problem. Discoloration and difficulty in keeping the glove clean elicited negative comments from 12 percent of the subjects. Poor wear characteristics of the glove (abrasion, tearing, rubbing through) elicited negative comments from 9 percent of the sample. When amputee reactions to the appearance of the AFRL hand were compared with the corresponding reactions to the appearance of other hands previously worn, the results were very favorable toward the APRL device.</p> <h5><i>Ease of Operation</i></h5> <p>Almost 72 percent of the amputees for whom an APRL hand had been prescribed felt that it was easy to operate, another 26 percent considered it somewhat difficult to operate, and less than 3 percent found it very difficult to operate. Below-elbow amputees experienced the least difficulty in hand operation. As expected, fewer found the APRL hand "easy" to operate as the level of amputation became more proximal. <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>Some of the amputees had worn other "functional" hands prior to the APRL device. When they compared ease of operation of their old prosthetic hand with that of the APRL hand, the APRL model was preferred. It is interesting to note that the shoulder-disarticulation and above-elbow cases exhibited dramatic changes in their reactions to use of functional hands, a fact which would suggest that the APRL hand has much greater applicability than the older hands. For one thing, in the dual-control system<a></a> the cable-excursion requirements are lower for voluntary-closing devices than for voluntary-opening devices, and this circumstance exerts an important influence on the use of above-elbow and shoulder-disarticulation prostheses. Apparently the additional control motions needed for operation of voluntary-closing devices did not constitute an objection insofar as ease of operation was concerned.</p> <h5><i>Weight</i></h5> <p>Judging from amputee opinions relating to the weight of the APRL hand (15 oz. with glove), the below-elbow group found the weight more satisfactory than did any other. In view of the greater residual anatomy in the below-elbow case, this result is generally understandable even though the short below-elbow case, without assistive forearm lift<a></a> is at a disadvantage. It is significant to note that 42 percent of all amputees for whom a hand had been prescribed felt that the APRL hand was somewhat heavy or very heavy, an indication that further improvements, aimed at weight reduction, are needed. Nevertheless, amputees who had worn other hands considered the APRL hand lighter. All in all, the wearers' reactions consistently favored the APRL hand.</p> <h5><i>Discussion</i></h5> <p>It should be understood that amputee reactions toward the APRL hand were of special interest to the research program. Consequently, many such hands were prescribed not for specific vocational or avocational reasons, nor because of patient interest, but to observe the effects upon a rather large number of amputees who had no specific objections to being fitted on a trial basis. Many confirmed hook wearers were therefore included in the group fitted with APRL hands.</p> <p>The data show that mass fitting (285) of the APRL hand caused an additional 27 percent of the patients to wear hands on a more or less regular basis. Very few amputees expressed serious over-all negative feelings toward the APRL hand and glove.<a style="text-decoration:none;">*</a> Apparently, however, 25 percent of the patients for whom APRL hands had been prescribed wore them less than one day a week. Some, after a brief experience with the hand, declined to wear it at all and preferred to return to exclusive use of a hook. Since this response cannot be related to any specific dislike for the APRL hand and glove, it appears to relate more to a basic preference for a hook.</p> <p>A number of improvements in the APRL hand were suggested during interviews with the amputees. One was that a range of sizes would be most welcome since the one size available at the time was often either larger or smaller than the corresponding normal hand. Amputees with large hands seemed to feel that the APRL hand and glove were too small and effeminate. Another, cited especially by those with the higher levels of amputation, concerned the need for reducing the weight of the APRL hand. Other proposed improvements related to appearance and durability (especially of the glove) and to the complexity of function arising from the double control motion required for locking and unlocking.</p> <p>In brief, the APRL hand, with its two-position prehension range, its voluntary-closing self-locking mechanism, and its cosmetic glove, showed superior grasp forces and was considered to be more useful, easier to operate, and much better in appearance than other mechanical hands. Although the wearers indicated that weight reduction in the APRL hand would be welcomed, the existing hand was considered more satisfactory than other mechanical hands. Despite these positive findings, it was apparent that design changes directed toward weight reduction, improved durability in the cosmetic glove, establishment of a range of sizes, and simplification of operating requirements would improve the device significantly.</p> <h4>Rubber-Band-Loaded Hooks</h4> <p>The type of hook which, historically, is the standard in the prosthetics field, and the one to which all other designs are compared, is the steel or aluminum voluntary-opening split hook in which the fingers rotate about a single pivot and are held in the closed position by the contraction of rubber bands that stretch during opening<a></a>. Addition of more and more rubber bands increases the maximum available finger forces at the expense of added work in opening.</p> <p>Many variations in finger shape are to be had. Some fingers are lined with rubber to reduce slippage, others are unlined. In the studies concerned, prescription of rubber-band-loaded hooks was often on the basis of previous amputee experience. Sometimes clinical judgment favored them, especially for use with bilaterals, because of the simplicity of operation as compared with voluntary-closing, self-locking terminal devices which, although superior in grasp forces, demand additional control motions, a requirement generally considered to be a shortcoming. In tests involving 68 of these simple hooks as worn by amputee subjects, it was found that the rubber bands had been selected to yield prehension forces ranging from 1 lb. to 14 lb. (average, 4.3 lb.), depending on individual preference.</p> <p>With regard to usefulness, appearance, ease of operation, and weight, amputee reactions to rubber-band-loaded hooks are rather consistent regardless of level of amputation. Although in general there is a high degree of acceptance, 21 percent of the below-elbow amputees and 8 percent of the above-elbow cases indicated that rubber-band-loaded hooks are of limited use only. Thus again improvement is needed. The subjects themselves suggested more durable rubber inserts for the fingers, elimination of rubber bands, and reduction in the conspicu-ousness of the hook without reducing its functional value. <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 /> <h4>Sierra Two-load Hook</h4> <p>A relatively new design for voluntary-opening hooks, which traditionally have used rubber bands for closing, is the Sierra two-load hook featuring a spring to close the fingers<a></a>. Heavy or light closing forces are selected by positioning a small mechanical switch located on the post provided for attachment of the control cable. The case which houses the operating mechanism is made of aluminum, and the hook fingers, also of aluminum, are lyre-shaped and lined with neoprene for increased security of grasp.</p> <p>The novel design of the two-load hook, with its simplicity of operation (voluntary-opening) and choice of two grasp forces, interested both clinics and amputees. Consequently, 64 of these devices were prescribed in the study. Data taken on 51 subjects show that pinch forces averaged 3.4 lb. for the light-load setting of the mechanism, 6.6 lb. for the heavy loading.<a style="text-decoration:none;">*</a> <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>Amputee reactions to the two-load hook were generally positive insofar as usefulness, ease of operation, weight, and, to a lesser extent, appearance were concerned. As with rubber-band-loaded hooks, there were indications of need for improvement, for 13 percent of the below-elbow amputees and 12 percent of the above-elbow cases indicated that the two-load hook was of limited use only. That 12 percent of the above-elbow amputees felt the device somewhat difficult to operate is a finding hard to interpret, unless perhaps these particular subjects had been accustomed to extremely light loadings on hooks operated by rubber bands.</p> <p>In general, there was a favorable reaction toward the availability of two levels of grasp force from which to select. Although apparently the light load was used most often, the wearers found that the heavier loading was sometimes very desirable. The indications were that a desirable improvement could be effected if the ranges of prehension force could be made adjustable by the wearer (perhaps by use of a simple tool). When amputee comments were compared (two-load hook versus rubber-band-operated hooks worn previously), there was no clear-cut preference for either type, although the two-load fared slightly better in all areas except appearance. <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 /> <h4>APRL Hook</h4> <p>The APRL hook is, like the APRL hand, a voluntary-closing, automatic-locking terminal device<a></a>. The body and fingers are of aluminum to keep weight within reasonable limits, the fingers being lyre-shaped and lined with neoprene to increase the security of grasp. Opening ranges of approximately 1-1/2-in. or 3 in. are selected by manipulation of a small switch protruding from the hook case. The control cable attaches to a lever arm projecting from the side of the housing for the mechanism. As with the APRL hand, prior studies<a></a> had established the general acceptability of the hook, and the NYU Field Studies presented a unique opportunity to gain additional insight into its application and to introduce it into more climes throughout the country.</p> <p>The basis for prescription was to furnish the APRL hook in a majority of cases where a hook was required. The only exceptions were those cases where a clear contraindication was apparent (for example, in cases of patient refusal to wear any type of hook, or to change from some other type to the APRL hook, or where occupational requirements demanded extremely rugged construction, or where the subject was interested in trying the Sierra two-load hook). Consequently, rather large numbers of amputees in the study were equipped with the APRL hook.</p> <p>The data obtained with 228 hooks were similar to those obtained with the APRL hand when it was compared to voluntary-opening hands. Grasp forces were found to be considerably higher with the APRL hook than with voluntary-opening hooks. Eighty-nine percent of the wearers could exert forces over 9 lb., 54 percent over 20 lb.</p> <p>Although amputee reactions to the APRL hook were generally positive, the present design evidently leaves much to be desired in the area of appearance and, to a lesser degree, in the area of usefulness. In interviews, the amputees mentioned:</p> <ol> <li>The possibility of reducing length and bulk by incorporating the terminal-device mechanism in the forearm.</li><li>Dissatisfaction with the reliability of operation (locking after closing), although some wearers were generally aware that the fault might lie with themselves in not permitting the mechanism to alternate.</li><li>Backlash, which in varying degrees caused some wearers distress.</li><li>The potential advantages (aesthetic as well as functional) of having the hook "thumb" as well as the moving finger on the medial aspect. At present, when the "thumb" is on the medial side the moving finger is on the lateral side and opens away from the wearer's body. If the wearer wants the moving finger to open toward him, the "thumb" is placed on the lateral side.</li></ol> <p>Some interesting points are observed when we compare the responses to the APRL hook with those to the APRL hand. Since in general hooks are conceded to be more functional than artificial hands, it comes as no surprise that in the area of usefulness the APRL hook rated higher than did the hand. As regards appearance, reactions were much more favorable to the hand than to the hook, but, in the case of the latter, amputation level had no apparent effect on amputee feelings. In any event, a significant number of patients found both hand and hook unsatisfactory in appearance. <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 /> <p>More than 80 percent of the amputees wearing the APRL hook indicated that it was easy to operate regardless of amputation level. Conversely, responses by wearers of the APRL hand indicated that operation became somewhat more difficult at the higher levels of limb loss. By far the majority of wearers registered satisfaction with the weight of the hook (8-1/4-oz.), whereas the weight of the gloved hand (15 oz.) was less well received. The higher the level of amputation the more critical weight became. Next to be considered are the reactions voiced in regard to the usefulness, appearance, ease of operation, and weight of rubber-band-loaded hooks (voluntary-opening) worn prior to the studies and of the APRL hook (voluntary-closing) supplied during treatment. The below-elbow and shoulder-disarticulation wearers considered the rubber-band and APRL hooks approximately equal in usefulness, while the above-elbow wearers felt the APRL hook to be somewhat more useful. As for appearance, about 70 percent of the subjects found both APRL and rubber-band hooks generally "satisfactory." Whereas 15 percent indicated dissatisfaction, the remaining 15 percent said that in appearance both hooks were "very satisfactory." When ease of operation was considered, the below-elbow and above-elbow wearers favored the APRL hook slightly, although both hooks were rated highly with regard to operating characteristics.</p> <p>The wearers of shoulder-disarticulation prostheses showed a distinct preference for the APRL hook with respect to ease of operation, probably because of the ease with which closure can be effected and because of the low excursion requirements peculiar to voluntary-closing terminal devices. This finding may indicate that rather light prehension forces are used by most wearers of shoulder prostheses, for were this not the case they would react against the difficulty of reopening the hook. There is no indication from the data that the additional control motions required for use of the APRL hook made hook operation less "easy." <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 /> <p>Hook weight appeared to present no major problem regardless of level of amputation. Although the 8-1/4 oz. APRL hook was generally considered by the wearers to be more satisfactory than the Dorrance No. 555 (3 oz.), the Dorrance No. 5 (7 oz.), or the Dorrance No. 7 (8-3/4 oz.), the responses may have been influenced by the use of a new prosthesis, which very often was better fitted, more comfortable, and more efficient than the old arm with the rubber-band hook.</p> <p>It is apparent from the foregoing discussion that functional, split hooks were rather highly valued regardless of type. In all cases, usefulness, ease of operation, and weight were apparently quite acceptable to almost all wearers. Only in the area of appearance did a significant number of subjects indicate dissatisfaction, and even then most of the amputees accepted prevailing appearance.</p> <p>The amputees who used rubber-band-closing hooks prior to the study and changed over to the APRL hook during the study were in an excellent position to compare terminal devices. The below-elbow amputees felt that the APRL hooks and those of the rubber-band type were approximately equal in usefulness, the responses favoring the APRL hook slightly. The above-elbow cases seemed to favor the APRL hook rather strongly, the responses indicating an attitude considerably more positive toward the usefulness of the new hooks. The shoulder-disarticulation cases seemed to favor the rubber-band hooks slightly with respect to usefulness, but the smallness of the sample (13 patients) prohibits drawing any conclusions in favor of either type of hook for this special group.</p> <p>In sum, it appears that the rubber-band and the APRL types are about equal in usefulness, the data favoring slightly the APRL design. No clear-cut advantage in the use of one over the other is evident from amputee reactions. In all probability, personal preference based on past experience, influence of the clinic team, or other intangibles are contributing factors. The entire area affecting the choice of terminal devices is one that should be given additional study.</p> <h3>Wrist Units</h3> <p>Prosthetic wrist units are designed to facilitate attachment of the hand or hook to the forearm and to permit pronation-supination of the terminal device<a></a>. The most common type (screw-in type) bears a female thread such as to accept the terminal-device stud, and a rubber washer and retaining plate are used to control the tendency toward excessive loosening or tightening when the terminal device is rotated. A newer type of wrist unit, intended to provide not only for easy rotation but also for easier interchange of terminal devices, incorporates a control button which, when depressed, frees the hand or hook for rotation. Further depression of the control button permits removal of the terminal device from the wrist unit, the need for unscrewing being thus eliminated. In still another wrist, also designed for quick interchange of terminal devices, the turn of a knurled ring releases the hand or hook for rotation or removal. <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>In the NYU Field Studies, prescription of wrist units favored the button- or ring-operated wrist (plug-in type) wherever more than one terminal device was to be used. When a single terminal device was prescribed, the screw-in type was generally favored, since then interchange was not a major consideration. Plug-in wrists fitted to 266 research patients and screw-in types fitted to 93 were followed over an average wear period of six to nine months, and amputee reactions were obtained concerning two aspects of wrist function-attachment and removal of the terminal device, and pronation-supination to achieve acceptable attitudes of approach. Of the 359 amputees wearing program arms, those equipped with plug-in units were slightly more satisfied with the attachment function than were those who wore screw-in wrists. Pronation-supination was fairly satisfactory with both types.</p> <p>Despite the general amputee acceptance of both types of wrist, however, there was also evidence of substantial dissatisfaction. Interviews with the amputees and observation of their performance revealed that a simpler and faster method of exchanging terminal devices was required, as were also improvements in the cable connections, which were then cumbersome and difficult to manipulate with one hand. Evidently, improved rotation mechanisms were needed to permit easy correction of terminal-device attitude for best angle of approach.</p> <p>When specific wrist features (ease of operation, usefulness, weight, and appearance) were explored (page 16), the wearers were even more positively inclined toward the plug-in wrist unit. The reactions of 138 amputees who had screw-in wrists on their old arms and plug-in wrists on their program arms show that, insofar as exchanging terminal devices was concerned, the plug-in wrists were favored by a greater percentage of the below-elbow wearers than were the screw-in wrists. The opinions of the above-elbow amputees showed only a slight trend in favor of the plug-in wrists. Because only a small number of shoulder-disarticulation cases changed to plug-in wrists, their reactions were not recorded. The responses of 107 amputees who had used screw-in wrists on their old arms and plug-in wrists on the program arms showed that the plug-in type of wrist was considered by below-elbow wearers to be easier to rotate than was the screw-in type.</p> <p>Opinions concerning the locking function of wrist units are of interest since only the plug-in type locks the hook or hand in its selected attitude, the screw-in type depending upon friction to maintain terminal-device orientation. In 106 cases, both below-elbow and above-elbow wearers considered the plug-in type of wrist (with its ability to permit rotation of the terminal device as well as to lock it) somewhat more useful than the screw-in, nonlocking type.</p> <p>In the areas of weight and appearance, the plug-in type was again, and somewhat surprisingly, favored over the simpler, screw-in unit. Despite the fact that the plug-in wrist is actually heavier than the screw-in type, amputees favor it. Apparently the "halo effect" of the new prosthesis with its generally superior comfort, appearance, and efficiency may be responsible for the positive responses in the areas of wrist weight, wrist appearance, and ease of wrist rotation.</p> <p>In summary, the plug-in type of wrist was favored slightly over the screw-in type, first because of the relative ease with which terminal devices could be exchanged and second because the hand or hook could be locked in any desired attitude of pronation-supination. Below-elbow amputees seemed to favor the plug-in type more than did the above-elbow group, an understandable result when it is considered that below-elbow wearers are generally more active with their prostheses and more inclined to exchange terminal devices than is the case with above-elbow amputees. In any event, it was apparent from observations and from amputee remarks that improved cable attachments were needed to facilitate ease of connecting and disconnecting hands or hooks. Despite the fact that some below-elbow wearers considered rotation of terminal devices easier with plug-in wrists, observation leaves little doubt but that the screw-in type is superior in rotation features. It seems clear that attitudes toward the rotational qualities as well as toward the weight and appearance of the plug-in wrist were positively affected by concomitant reactions toward superior locking and attachment qualities. <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 /> <h3>Elbow Joints for Below-Elbow Prostheses</h3> <p>Almost all below-elbow prostheses are suspended from cuffs fitted above the bony prominences of the elbow joint. The cuff and prosthetic forearm are connected by means of mechanical elbow joints, some of which (rigid hinges) are designed to permit flexion and extension only, others (flexible hinges) permitting also pronation and supination.<a></a> Metal hinged joints are generally used for shorter stumps where stability against inadvertent rotation is a major requirement. Flexible leather, steel-cable, or fabric-type joints are generally used in prostheses for longer stumps where residual, natural forearm rotation can be utilized. Short stumps typically have limited purchase in the prosthesis and therefore require a snug, high-fitting socket in order to obtain forearm stability<a></a>. But the high-fitting socket often restricts the wearer's range of flexion owing to crowding of flesh as the forearm is raised. Special joints, known as "step-up" joints<a></a>, are designed to relieve this condition and to produce an increased range of flexion. Since in such a case the range of motion increases at the expense of lifting power, it is sometimes necessary to use an assistive forearm lift similar to that commonly used with above-elbow prostheses <a></a>. Whenever the very short below-elbow stump is un-suited for lifting the prosthetic forearm, it is fitted with locking joints actuated either by movement of the stump or by a cable control similar to that used for the above-elbow case.<a></a></p> <p>Evaluated comprehensively with both old and new prostheses were 136 unilateral below-elbow amputees, the elbow components of the prostheses being as follows: <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>The data show that in general the new arms permitted a greater range of forearm flexion than did the preprogram arms, partly no doubt because of an increased use of step-up joints in the new prostheses and partly because of improved socket shaping to avoid restriction of flexion through crowding of flesh at the brim of the socket. <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>Before the advent of the Upper-Extremity Field Studies, use of flexible elbow joints had been reserved almost entirely for patients with wrist disarticulations or long below-elbow stumps. Of all the amputees in the group investigated, only 17 had had flexible joints in their preprogram arms, and of these only one had a stump shorter than 6-1/2 inches. Moreover, the available stump rotation was rather good, only one having less than 20 deg. of pronation-supination. Experience indicated that even still shorter stumps might retain slight but useful rotation and that patient comfort might be increased and clothing damage decreased with use of flexible hinges. Consequently, during the program many stumps within the group of 136 amputees (74 arms) were fitted with flexible joints even though the rotation possibilities were knowingly limited (22 cases with residual stump rotation of less than 20 deg., 13 patients with stumps shorter than 6-1/2 in.).</p> <p>As expected, the average rotation range for the entire group with the new prostheses decreased as compared with the average rotation range of the 17 who had been provided with flexible hinges on their old arms. But it must be pointed out that many more amputees now had not only the facility of active pronation-supination but also the greater comfort and reduced clothing damage inherent in the use of flexible joints. The 16 amputees who used flexible hinges on both old and new arms exhibited the same range of pronation-supination with the two prostheses. <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>The reactions of the below-elbow subjects to the various elbow joints evaluated during the study were in general very positive in the areas of usefulness, ease of operation, and weight but a great deal poorer in the area of appearance. Although the step-up and stump-actuated joints were unacceptable to a few amputees, negative generalizations are impossible because the size of the sample was too limited (24 step-up joints, 7 locking joints). And indeed these components must be widely acceptable, judging from the overwhelming percentages of positive responses. The negative comments made by wearers of step-up joints indicate an inability to stabilize the forearm sufficiently to obtain effective use of the terminal device. The development of locking step-up joints has been suggested as a means of stabilizing the prosthetic forearm for amputees with short or very short stumps.</p> <p>The principal findings with regard to elbow joints for below-elbow prostheses center around a shift toward increased use of flexible hinges and a corresponding decrease in the number of rigid joints used.<a style="text-decoration:none;">*</a> Of special interest is the finding that stumps shorter than 6-1/2 in. should also be considered for flexible elbow joints. Although the shorter stumps can be expected to provide only minimal pronation-supination, even slight gains in rotation are important for hand and hook positioning. There was no reported instance of socket instability on the shorter stumps fitted with flexible joints on program arms, and the gains in patient comfort and in reduction of clothing damage lead to the conclusion that use of any joint other than flexible should be advocated only after serious consideration of the specific needs of the individual patient. Although the sample using step-up or locking joints was small, and although it is apparent that the joints were generally satisfactory, development of a step-up joint capable of locking the prosthesis in flexion seems quite desirable, since stabilization of the forearm for effective terminal-device operation or for lifting objects appeared to be difficult with the step-up joints used both before and during the study.</p> <h3>Elbow Joints for Above-Elbow and Shoulder-Disarticulation Prostheses</h3> <p>Positioning of the prosthetic forearm and terminal device of a modern above-elbow or shoulder-disarticulation prosthesis in the flexion-extension plane requires that the elbow be unlocked. Locking of the elbow permits control-cable forces to by-pass the forearm lift and to act upon the terminal device.<a style="text-decoration:none;">*</a> Rotation of the prosthesis about the humeral axis to facilitate mediolateral positioning of the forearm is accomplished by means of a turntable incorporated in the elbow and controlled by a friction element which resists free movement.<a></a> In general, about 2 lb. of force and half an inch of cable travel are needed to lock present mechanical elbows, about 5 lb. to unlock. But the exact figures vary slightly from elbow to elbow and from manufacturer to manufacturer. Program arms fitted during the early phases of the study were built around Sierra Model C elbows<a></a>, which had unlocking forces (6.3 lb.) and excursion requirements (9/16-in.) slightly higher than those of the Hosmer E-400 units (4.0 lb. and 1/2 in.), which in turn became available to the clinics later in the study and which were identical in operating principle. Besides this, the Hosmer E-400<a></a> was at the time a new component, clinics were therefore particularly interested in its application, and consequently it was prescribed almost routinely during the latter part of the program. Of the 170 internal elbows fitted and evaluated during the study, 110 were Sierra Model C's, 42 were Hosmer E-400's, and 18 were Hosmer E-300's (an earlier elbow incorporating a locking mechanism of quite different design, now discontinued). External elbow locks<a></a>, intended for amputees with long humeral stumps or with elbow disarticulations, were used in 11 cases.</p> <p>Above-elbow and elbow-disarticulation amputees achieve elbow locking and unlocking by a combined extension-abduction of the humeral stump, a motion which exerts pull upon a control cable attached between the elbow and the shoulder harness.<a></a> Alternate pulls on the elbow-lock control cable result in locking and unlocking or vice versa. Shoulder-disarticulation amputees usually control the elbow lock by elevating the shoulder on the side of the amputation, thus exerting pull on a control cable attached between elbow lock and waistband. <a></a> </p> <p>All of the elbow-disarticulation, above-elbow, and shoulder-disarticulation prostheses provided in the program were equipped with locking elbows of the alternating type. Of the 181 cases (170 internal locking, 11 external locking) available for study, 76 had had prior experience with prostheses incorporating the older manual locks, and 18 had worn arms without locking elbows. Fifty-two had previously used alternating elbows of the type used in the program arms. In 35 cases, either the patient had not previously worn an arm or else the type of elbow was unknown.</p> <h4>Internal-locking Elbows</h4> <p>The data show that a considerable number (36 out of 101) of the preprogram arms provided little or no initial elbow flexion, owing chiefly, no doubt, to fabrication technique and workmanship rather than to the nature of the elbow units themselves. Program arms tended to group around the standard of 10-15 deg. of initial flexion, a feature that tends to make initiation of forearm lift less difficult. Moreover, forearm flexion was restricted in the old arms, less than a third of them being capable mechanically of approaching 135 deg. of flexion. In general, program arms could be flexed to much greater extent, almost two thirds of the subjects reaching or surpassing 135 deg.</p> <p>As for other deficiencies in the new arms, 35 cases exhibited serious impairment of elbow-lock operation, primarily because of harnessing inadequacies. A considerably larger number of prostheses showed less than optimal elbow function, mostly because of poor arrangement of the elbow control cable and the front support strap. In 12 cases, malfunction of the elbow mechanism was apparent, and 37 of the new prostheses required adjustment for insufficient initial elbow flexion. Thirteen arms required attention to correct friction characteristics in the elbow turntables.</p> <p>Generally, then, more careful attention to adjustments and to harnessing detail for elbow-lock operation was obviously required. Direct amputee reactions to the cable-controlled, internally locking elbows were quite favorable, only 4 of the 170 wearers experiencing negative feelings when all aspects of elbow use were considered. Of the few negative comments made (25), the majority related to lack of dependability in elbow operation, probably because of such factors as careless harnessing or inadequate training in the required operational pattern. As might have been expected, the cases with the shorter stumps found operation of the lock more difficult than did those with the longer stumps. Except where the fitting of the short-above-elbow patient was expertly done, the shoulder-disarticulation cases had less difficulty in elbow locking and unlocking by means of shoulder elevation than did the short-above-elbow cases using the same control motion.</p> <h4>External-locking Elbows</h4> <p>External-locking elbow joints are sometimes used for elbow disarticulations and for very long above-elbow cases<a></a>. Although in the study 11 elbow-disarticulation amputees were fitted with external joints, only 8 had had experience with internal-locking elbows on their old arms. From the viewpoint of usefulness, they favored the internal mechanism slightly, perhaps because of the rotation turntable and because of the greater number of available locking positions in the internal elbows. As for appearance, the arms fabricated with outside-locking elbows seemed to be more acceptable than those constructed with internal units because, while the outside-locking units protrude on the medial aspect of the arm, internal units may be fitted to elbow disarticulations and to very long above-elbow cases only by lowering the elbow center abnormally.</p> <p>Ease of operation gave rise to some differences in amputee reactions toward internal as compared with external elbows. Since the forces and control motions are essentially identical in the two types, the discrepancies probably relate more to the nature of the harnessing or to the skill of the patient than to the particular characteristics of the elbows themselves.</p> <p>As one might have anticipated, amputee reactions to weight favored the outside-locking units, which are somewhat lighter than the internal elbows. <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 /> <h4>Summary</h4> <p>To summarize, only 29 percent of the 181 amputees studied were known to have worn on their preprogram arms locking elbows of the alternating type. In the studies, all unilateral above-elbow patients were fitted with the more modern locking units, thus freeing the normal arm from the responsibility of operating a manual lock for the amputated side. Program arms had greater ranges of forearm flexion and were adjusted to provide greater initial flexion so as to make it easier for the patient to lift the forearm. But elbow-lock operation with the new arms was often impaired by poor harnessing arrangements that required correction. While in general the amputees were quite favorably disposed toward the cable-controlled, locking elbows, infrequent negative complaints of lack of dependability related to inadequacies in harnessing and to poor operational patterns on the part of some wearers. A limited number of amputees fitted with external-locking joints provided sufficient positive evidence to ensure the future of these components in the array of items available for long-above-elbow or elbow-disarticulation patients.</p> <h3>Harnessing</h3> <p>If the upper-extremity prosthesis is to be of functional use to the amputee, two basic needs must be met. A suitable attachment of the prosthesis to the body must be made, and power must be provided for operating and controlling the limb. Although the socket is made to conform to the stump, it tends to become displaced, especially during lifting. The prosthesis is therefore suspended from the shoulder by means of a harness which keeps the socket in close contact with the stump and resists any tendency for the prosthesis to shift out of position. Usually the same harness serves as the force-transmitting medium between body sources of power and the cable system of the prosthesis<a></a>. For both above- and below-elbow amputees, two basic types of harness are in common use today-the figure-eight harness and the chest-strap harness <a></a>. Commonly, the chest-strap design is applied in the shoul-der-disarticulation case too <a></a>.</p> <p>Of all artificial arms, the unilateral below-elbow prosthesis is perhaps the simplest to suspend and to power. In the figure-eight method, suspension is obtained by a loop of 1-in. fabric tape passing under the axilla on the sound side and over the shoulder on the amputated side, the front end of the tape being attached to a biceps cuff (which in turn supports the elbow joints connecting to the prosthetic forearm), the other end (the back) to the control cable for the terminal device. Forward rotation of the arm upon the shoulder on the amputated side causes forces to be applied to the cable and gives the excursion necessary to operate the hook or hand. In the chest-strap method, suspension of the biceps cuff is achieved through use of adjustable leather or fabric straps attached to the anterior and posterior aspects of a leather shoulder saddle, and the control cable is attached to an adjustable fabric tape sewn to the chest strap in the region of the seventh cervical vertebra. Although the figure-eight type of harness is used almost universally for the unilateral below-elbow prosthesis, it is considered by some that the chest-strap type, with its broader weight distribution over the shoulder, is indicated for amputees anticipating extremely heavy-duty services or for those who cannot tolerate the axilla pressures typical of the figure-eight loop <a></a>.</p> <p>For the unilateral above-elbow prosthesis, the figure-eight and the chest-strap harnesses enjoy in general a more equal popularity. Program arms tended strongly, however, toward the simpler figure eight, in which the fabric tape loops over the sound shoulder, under the axilla on the sound side, and then over the shoulder on the amputated side <a></a>. It is generally conceded that the above-elbow chest-strap harness, which uses a leather or fabric saddle to reduce the unit pressure on the shoulder, is preferred whenever the patient anticipates activities involving heavy lifting or when he cannot tolerate the axilla pressure characteristic of the figure-eight harness <a></a>.</p> <p>For the unilateral shoulder-disarticulation or forequarter amputation, the most common harness in use today is that of the chest-strap type, elbow locking and unlocking being achieved by elevation of the shoulder on the amputated side. A fabric tape extends from the elbow-lock control cable and attaches to another surrounding the waist. Scapular abduction gives power and excursion for forearm lift or, when the elbow is locked, for terminal-device operation <a></a>.</p> <p>In the evaluation studies, harnesses were individually prescribed according to type and made in accordance with the latest techniques. But because the harness is always a custom-made item fitted by the prosthetist according to the requirements of the individual patient, there were introduced a number of variables involving such intangibles as skill and judgment. Although in program prostheses each harness had to meet certain requirements designed to ensure proper suspension and adequate power and excursion, it was apparent almost from the beginning that serious harnessing problems existed. About 45 percent of all arms showed harness deficiencies at checkout. The above-elbow prostheses were notably troublesome, 375 harnessing faults showing up on the 303 arms going through checkout. The below-elbow prostheses, though considerably simpler, were also a source of difficulty, 150 harnessing faults being discerned on 361 below-elbow patients. The shoulder-disarticulation group of 53 patients had 39 harnessing faults. <b>Table 1</b>, <b>Table 2</b>, and <b>Table 3</b> reflect the types of harnessing faults found at clinical checkout of the program arms.</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>It should be pointed out that the prostheses were rated at checkout according to criteria evolving from material presented at the prosthetics courses offered as part of the program. Accordingly, any deviations from the accepted harnessing practices taught in the courses were considered "faults." But it was recognized that arm harnessing is an individualized procedure and that therefore certain faults might be less critical than others depending upon the amount of deviation from the standard, the physique of the patient, his threshold of tolerance for discomfort, and other intangible considerations. Consequently, it should be made clear that recognition of a fault did not necessarily mean the prosthesis was unusable but, more often than not, that the limb simply was not operating at a peak level of performance and/or comfort. Fortunately, the problems encountered with the harnesses at checkout were markedly reduced as the prosthetists gained experience. Strict adherence to the checkout standards, along with increased understanding and skill, served to ensure that each arm wearer was ultimately harnessed so that he could use the prosthesis in a functional manner. After checkout (and prosthetic corrections, when indicated), the amputees embarked upon a long-term period of wearing the new prosthesis.</p> <p>Amputee reactions to the new arm harnesses were checked with regard to comfort, appearance, and fit as these matters affected the function of the prosthesis. Generally, the wearers' reactions were quite favorable, and it was apparent that the subjects generally had a higher regard for the new harnesses than they had for the old (<b>Table 4</b>). Although program harnesses scored highly with all amputee groups, the above-elbow amputees consistently rated their harnesses slightly lower than did the below-elbow or shoulder-disarticulation groups, probably because the above-elbow figure-eight harness is more com- plex and in comparison with below-elbow harnesses somewhat more snug-fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Interviews with the amputees disclosed that most participants who had worn prostheses prior to the studies felt that the new harnesses were much better than the old ones. Particular comments evidenced satisfaction with reduction in amount of harness needed to obtain satisfactory prosthetic function with the new arms. Some wearers commented upon possible areas of improvement, a response which almost always involved the desire to be burdened with no more harness than necessary to control the arm. A number of subjects indicated discomfort at the axilla, and problems relating to shift of the harness out of place were not uncommon. Although difficulty in operating the elbow lock was corrected in most cases, some wearers felt that other means should be sought for control of elbow lock.</p> <h3>Power-Transmission Systems</h3> <p>To achieve functional use of a prosthesis, the amputee must be able to avail himself of residual sources of body power. Flexion, extension, and abduction of the arm, extension of the forearm, shoulder elevation, scapular abduction, and chest expansion are the most common power sources harnessed by the prosthetist to provide movement of the artificial arm.<a></a> Transmission of the forces thus generated is accomplished by the use of Bowden cables connecting the points of force generation (harness components) and the points of force application (forearm or terminal device). In the below-elbow prosthesis, forward movement of the shoulder on the sound side, flexion of the arm on the amputated side, singly or in combination, exerts against the harness system a force that is transmitted for operation of the terminal device, the forearm being lifted by the stump. Above-elbow and shoulder prostheses utilize the same type of power-transmission system, except that with arms of this type the cable is used also to lift the prosthetic forearm whenever the elbow is unlocked (dual control). <b>Fig. 14</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>Prior to the Upper-Extremity Field Studies, many arm amputees had been using Bowden cable for power transmission. Others used steel cable without housing, nylon cord, leather or rawhide thongs, and other miscellany, as shown in <b>Table 5</b>. But all program arms were equipped with Bowden cable and subjected to checkout procedures to ensure that minimum standards of power-transmission efficiency (below-elbow prostheses, 70 percent; above-elbow and shoulder-disarticu-lation prostheses, 50 percent) were met. When checked, the program arms showed for every amputation level substantial increases in efficiency over the standards shown by the power-transmission systems of the corresponding old prostheses. Indeed, the new arms exceeded the minimum efficiency standards with such regularity that raising of the standards is now indicated.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Full opening and closing of the terminal device was possible for an increased number of amputees through use of the new arms. When function of the terminal device was tested at each of four operating positions (at full extension, at 90 deg. of flexion, at waist, and at mouth), the results showed a marked increase in opening range for each amputee type at all four positions.</p> <p>Doubtless this improvement was due to the use of better harness and belter-fitting sockets, with better transmission of force and excursion through the cabling system, if not to application of the voluntary-closing terminal devices, which inherently use less excursion than do the voluntary-opening hooks that predominated in the old prostheses. <b>Fig. 15</b>, <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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Initial checkout of all patients provided with program arms revealed some problems in application of the Bowden cable (<b>Table 6</b>). faulty placement of retainers, improper cable lengths, and poor. soldering of connections were the main sources of trouble. Of course some of the arms had more than one fault, whereas about half of the 790 arms fitted and checked out in the study had no faults at all in the transmission system.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Those in the study who had used power-transmission systems in both old and new arms (285) generally found the Howden-cable system easy to use, acceptable in noise level and in appearance, kind to clothing, and free of excessive maintenance requirements. Of these amputees, 201 responded to questions intended to elicit preference either for their old or for their new cable systems. Only 10 of the 201 in the group preferred their old power-transmission systems, 103 preferred the new. Yet 88 had no preference, which indicates that a significant number of preprogram arms had the advantage of an adequate power-transmission system.</p> <p>Suggestions for improvement indicated that the amputees would have liked to have seen the cables concealed within the prosthesis, although the existing appearance was not considered unsatisfactory. Easier and quieter operation might also constitute an improvement, although here again there appears to have been no major criticism. <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 /> <h3>The Complete Prosthesis</h3> <p>Thus far we have considered only the individual elements of the prosthesis. A matter of equal importance, however, is the consideration of the prosthetic appliance in its entirety and of the effects of clinical treatment and training with the prosthesis. Although the data presented here concern the below-elbow, above-elbow, and shoulder-disarticulation cases only, findings from the 10 bilateral amputees who were available for evaluation may also be considered indicative of probable trends. The responses of the small bilateral group, consistently positive toward the new program arms, were substantially in agreement with the responses from the other amputees. Although most wearers considered their new arms to be useful, the desire for further improvement was reflected in the significant percentage of wearers who considered the arms to be of limited use only. When the amputees compared the general usefulness of the old prostheses with the general usefulness of the new arms, the new arm was preferred. The greatest improvement showed up in the shoulder-disarticulation and above-elbow groups. When all amputation levels were considered together, only 59 percent of the wearers felt that the old prosthesis was "useful." With the new arms, the figure went up to 79 percent. While nearly 5 percent of the wearers felt the old arm to be of no use, less than 1 percent reacted in this manner to the new arms.</p> <p>Perhaps the most meaningful gains in function were made in the area of harnessing and in routine use of locking elbow joints for above-elbow and shoulder-disarticulation cases. Although harnessing problems existed initially with program arms, the checkout procedures brought the difficulties to light so that suitable improvements could be made. Certainly arm harnessing was a major problem prior to the Field Studies also, as indicated by the fact that the new harnesses were preferred over the old by a ratio of five to one (<b>Table 4</b>). Locking elbow units, which stabilize the forearm and terminal device for above-elbow and shoulder amputees, are obviously superior to nonlocking elbows from a functional standpoint. For without elbow lock, prehension is handicapped, pushing and pulling with flexed elbow are seriously impaired, and carrying with flexed elbow (as in carrying a coat over the arm) is so difficult as to be impractical. Although manual elbow-locking mechanisms are effective, the newer elbows, operated through the harness system, free the sound hand for more important services. But it must be remembered that all these gains, which now bring prostheses for all types of arm amputation to a relatively high level of usefulness, depend upon a number of factors, including prescription of suitable components, quality of design and construction, and training in prosthesis use, all of which doubtless contributed to the positive attitudes displayed by the test wearers.</p> <p>The appearance of the new plastic-laminate arms was accepted in a perfunctory way only, most of the arms being considered "satisfactory." When 266 amputee responses were compared (appearance of new arm vs. that of old arm), it was evident that positive changes in reaction had taken place. In general the amputees favored the newer arms. It is in the area of appearance alone that the responses indicate serious reservations in acceptance of any artificial arm, old or new. Since under certain social conditions amputees might well be inclined to limit their activities rather than bring attention to the fact that an artificial arm is being worn, sensitivity toward appearance is extremely important. Even the best arm prostheses available today fall far short of being cosmetically adequate and cannot hope really to satisfy either wearers or observers. <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>Ease of operation of the new prostheses apparently left something to be desired for a substantial number of the amputees, especially those of the above-elbow and shoulder-dis-articulation types. Simpler elbow-lock operation and reduction in the difficulties of terminal-device positioning (perhaps by providing more mobility at the wrist) were mentioned as important areas requiring improvement. When the amputees compared old and new prostheses with respect to ease of operation, the new arms nevertheless proved superior. Many amputees (59 percent) felt that operation of their old prostheses was "easy." But when later they were asked to comment on the ease of operation of their new arms, 84 percent replied that operation was "easy." Slightly over 7 percent of the wearers felt that operation was "very difficult" with the old arms, whereas less than 1 percent felt that way about the new arms. Although again these important gains were most prevalent among the shoulder-disarticulation and above-elbow cases, significant improvements were noticed among the below-elbow amputees also. <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>Although to date very little attention has been given to study of its significance, the weight of the prosthesis has always occasioned a great deal of interest. Generally speaking, the practice has been to keep weight at a minimum, since amputee weight tolerance has not as yet been determined specifically. The data indicate that the below-elbow arms furnished in the program were slightly lighter than the corresponding preprogram arms (1.8 lb. compared with 2.1 lb.). Above-elbow prostheses weighed an average of 2 3/4 lb., there being no significant differences between the old and the new. The average weight of the new shoulder-disarticulation arms was about 3 1/2 lb., about 1/2 lb. heavier than preprogram types. Amputees at all levels generally felt that the total weight of the new prosthesis was satisfactory, although there were some indications that further weight reduction would be welcomed. About 7 percent of the subjects felt that the prostheses were somewhat heavy, less than 2 percent that they were very heavy. But 33 percent of the wearers considered the new prostheses more acceptable in terms of weight than the old arms, even though only slight differences in actual weight were noted. Such reactions are thought to be related to increased function, improved comfort, better fit, and/or improved weight distribution in the new arms. <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>When comparisons were made between amputee reactions to the old and to the new arms, the data for all levels of amputation clearly favored the newer, program-type, plastic-laminate prostheses. Such endorsement by wearers reflects not only the superior construction and the improved mechanical components incorporated into the newer prostheses but also the values of the patient-management procedures advocated by the program-prescription of carefully selected arm components, checkout to ensure basic adequacy of the fitting, and finally proper training in the use of the prosthesis.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., and Eugene F. Murphy,<i>Prosthetics research and the amputation surgeon</i>, Artificial Limbs, 1(3): 4 (September 1954).</li> <li>Fishman, Sidney, and Norman Berger, <i>The choice of terminal devices</i>, Artificial Limbs, 2(2): 66 (May 1955)</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, 1954.</li> <li>Fletcher, Maurice J., <i>The upper-extremity prosthetics armamentarium</i>, Artificial Limbs, 1(1): 15 (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, 1954.</li> <li>Fletcher, Maurice J., and Fred Leonard, <i>The Principles of artificial-hand design</i>, Artificial Limbs, 2(2): 78 (May 1955).</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, 1954.</li> <li>New York University, Prosthetic Devices Study,Report No. 115.09 [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Field test of the APRL hook</i>, April 1950.</li> <li>New York University, Prosthetic Devices Study,Report No. 115.12 [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Field test of the APRL hand and glove</i>, April 1951.</li> <li>Pursley, Robert J., <i>Harness patterns for upper-extremity prostheses</i>, Artificial Limbs, 2(3): 26 (September 1955)</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, 1954.</li> <li>Taylor, Craig L., <i>The biomechanics of control in upper-extremity prostheses</i>, Artificial Limbs, 2(3): 4 (September 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>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr><tr><td class="clsTextSmall"><b>11.</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, 1954.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, 2(3): 4 (September 1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 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>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, 2(3): 4 (September 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">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 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>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 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>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</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, 1954.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, 2(3): 4 (September 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">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 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>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>5.</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, 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>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>5.</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, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">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, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Dual control. See Pursley 10 or Taylor 11.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">See Artificial Limbs, Spring 1958, p. 77.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 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>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 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">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 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>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 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">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 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>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>5.</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, 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">New York University, Prosthetic Devices Study,Report No. 115.09 [to the] Advisory Committee on Artificial Limbs, National Research Council, Field test of the APRL hook, April 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</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, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The prehension forces of the two-load hook are predetermined at time of manufacture and are not readily adjustable as are those in the simpler hooks, where rubber bands can be added or removed.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Norman Berger, The choice of terminal devices, Artificial Limbs, 2(2): 66 (May 1955)</td></tr><tr><td class="clsTextSmall"><b>3.</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, 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>2.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Norman Berger, The choice of terminal devices, Artificial Limbs, 2(2): 66 (May 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Less than 3 percent had over-all negative reactions to the hand; 6 percent had over-all negative reactions to the glove.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 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>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr><tr><td class="clsTextSmall"><b>11.</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, 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">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, 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>8.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,Report No. 115.09 [to the] Advisory Committee on Artificial Limbs, National Research Council, Field test of the APRL hook, April 1950.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,Report No. 115.12 [to the] Advisory Committee on Artificial Limbs, National Research Council, Field test of the APRL hand and glove, April 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</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, 1954.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and Fred Leonard, The Principles of artificial-hand design, Artificial Limbs, 2(2): 78 (May 1955).</td></tr><tr><td class="clsTextSmall"><b>7.</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, 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>2.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Norman Berger, The choice of terminal devices, Artificial Limbs, 2(2): 66 (May 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>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and Fred Leonard, The Principles of artificial-hand design, Artificial Limbs, 2(2): 78 (May 1955).</td></tr><tr><td class="clsTextSmall"><b>7.</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, 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">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, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The data reported here were all recorded on forms similar to those shown in Appendices IIB, IIIA, and HID of the issue of Artificial Limbs for Spring 1958 (pp. 25-28, 29-31, and 40-45).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Earl A. Lewis, M.A., R.P.T. </b></td></tr><tr><td class="clsTextSmall">Field Supervisor, Prosthetic Devices Study, Research Division, College of Engineering, New York University; formerly Field Representative, PDS, NYU.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 R. Ford, CP. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetics Laboratory, Orthopedic Aids, Inc., Garden City Medical Center, Garden City, N. Y., and Consultant, Prosthetic Devices Study, Research Division, College of Engineering, New York University; formerly Project Coordinator, PDS, NYU.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Studies of the Upper-Extremity Amputee V. The Armamentarium Creator An entity primarily responsible for making the resource Edward R. Ford, CP. * Earl A. Lewis, M.A., R.P.T. * 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/ccadc98869e6d29f1877b5a8fac163d2.pdf 4a2ad8e2d9b2d3bb7c740d25f0dce310 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1962_02_001.pdf Year 1962 Volume 6 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1962_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1962_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Patellar-Tendon-Bearing Prosthesis</h2> <h5>Gabriel Rosenkranz, MD <a style="text-decoration:none;">*</a><br /></h5> <p>Obviously there is no "ideal" leg substitute short of regenerating or transplanting another normal leg. The surgeon, the prosthetist, and the amputee alike have long accepted major deficiencies in leg prostheses as inescapable concomitants of aid in a situation demanding drastic compromise. Substitution of an artificial leg for a natural one involves not only manual skills and the principles of inanimate mechanisms but is also dependent on anatomy, physiology, and biomechanics. Mutual application of these disciplines toward the advancement of leg prosthetics was slow in coming. As the science of astronomy emerged from the superstitions of astrology, so too there is sound reason to hope that the profession of prosthetics will continue to grow increasingly rapidly beyond the great dependence on "experience in the finger tips" of the ancient skill of limbmaking by adding to its art more general application of the discoveries of science.</p> <p>Time after time, like recurrent approaches of a comet from its far-reaching orbit, dazzling prospects of improvements in prostheses for below-knee amputees have illuminated the prosthetics scene. The slip socket, the many attempts at end-weight-bearing, the "muley" leg without side joints or corset, the single sidebar, the various polycentric joints, and the several attempts at below-knee suction sockets have been spectacular objects visible for varying periods in Europe, the United States, or alternately in both regions. Unhappily, these phenomena, like comets, have often receded into outer darkness as abruptly as they appeared, leaving the typical amputee with crutches, peg leg, or the centuries-old "conventional" prosthesis.</p> <p>Pads, straps, locks, and similar devices often reflect either lack of knowledge or incomplete application of such knowledge as there is to control pressure or to overcome instability. Freedom of the human knee joint, distribution of forces in proportion to tolerance of tissues, improved rather than constricted circulation, and better kinesthetic appreciation-all major goals in recent years-demand simplicity of mechanism and reduction of the false joint between the prosthesis and the body by use of an intimate fit.</p> <p>The patellar-tendon-bearing (PTB) prosthesis developed by the Biomechanics Laboratory of the University of California, to which much of this issue is devoted, combines many long-controversial features-each long used by some, yet rejected by others. PTB is almost a code name integrating a long list of elements which the prosthetist through logical principles and teachable techniques employs to distribute forces comfortably. Because of individual variations, not all so-called "PTB prostheses" contain all the major features. The name implies weight-bearing on the patellar tendon, more properly called the patellar ligament. Because in fact the nearby retinacula also share weight, perhaps the name might well be the "patellar-tendon-bearing" prosthesis! Actually, as later pages of this issue describe, many other areas of the socket (notably the closed distal end) are at least in contact with the stump, and some <i>(e.g., </i>the flares supporting the tibial condyles) share substantial portions of body weight.</p> <p>Because of its typical use of cuff suspension, with consequent freedom from thigh corset, the PTB prosthesis is often erroneously identified with the "muley" leg, which has stomped the field for as much as a century and yet has so often developed complications during prolonged use. One may speculate that the common complaints of instability of the knee attributed to the "muley" principle were at least partially related to poor alignment between socket and foot, excessive extension or even hyperextension of the socket axis and hence of the human knee, and needlessly low brim levels offering less than maximum stability to the stump. Careful prescription and medical supervision, not available for the earlier "muley," should also characterize use of the PTB and greatly enhance its chances of success.</p> <p>This writer's personal observations, from visits to the birthplace of PTB and to numerous clinics throughout the United States, have indicated misconceptions of the role of knee flexion in initial alignment of the socket axis. Certainly hyperextension is to be avoided and mild flexion sought. Because the <i>cast </i>is taken with the knee in substantial (possibly excessive?) flexion, some newly trained prosthetists initially aligned the socket bore similarly but with a very large angle of flexion. The horizontal components of forces on the condyles were reduced; but the resulting extreme bent-knee gait was tiring, the quadriceps were unduly stressed in their atrophied state immediately after their release from bondage within the thigh corset, and the unique mechanical stability of the extended human knee was transformed into the capability of substantial horizontal rotation of the flexed knee. In the below-knee amputee lacking an actively steerable ankle and foot, an unimpaired but controlled horizontal rotation in the knee joint must be considered of added importance. Thus neither the rigid "screw-home" of final extension nor the gross instability of major flexion will be as suitable as mild flexion with control of unencumbered hamstrings as internal and external rotators.</p> <p>In many past efforts too little attention has been paid to the popliteal space. The PTB includes logical principles allowing a higher brim in the popliteal space (and indeed on all aspects) than has been customary in a majority of cases yet freedom for action of the hamstrings and avoidance of bulging of tissue during sitting. The high brims medially and laterally, reflecting better appreciation of anatomy and of the force patterns dictated by biomechanics. should give greater mediolateral stability than was typically available with a "muley" limb. Eventual use of brims of tapering flexibility, by avoiding sharp pressure points at the very edge, may ultimately allow still better fitting.</p> <p>No one, especially among its developers, would acclaim the PTB as the ultimate solution. Some of its features represent successive reincarnations over a century, each with a higher survival percentage. Yet the PTB is only an evolutionary step toward greater mechanical freedom under butter neuromuscular discipline. Many apparent failures can be salvaged by careful adherence to the principles and techniques enunciated in the UCB manual and its recent revision and in the following papers of this issue of Artificial Limbs.</p> <p>The conveniences which the PTB leg accords its wearer are so numerous that continued efforts seem assured. Though a single breaker may recede, the tide is surely coming in.</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>Gabriel Rosenkranz, MD </b></td></tr><tr><td class="clsTextSmall">Surgical Consultant, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York 1, New York.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Patellar-Tendon-Bearing Prosthesis Creator An entity primarily responsible for making the resource Gabriel Rosenkranz, MD * https://staging.drfop.org/files/original/76945f6516dcc0545d2b91cfc6caeb8b.pdf c7a89a78b48b8aa9065dc973197081da https://staging.drfop.org/files/original/8272f870d623593975109366a1d714b7.jpg b08648bc765812c399bac1c19cce2712 https://staging.drfop.org/files/original/4b7fd07801fb1d9d0ea15226722773a1.jpg 31e1b3419fb5675d97f4c3ca9ddaef2b https://staging.drfop.org/files/original/648d969a13a9bfcbf9776e7f897bb027.jpg e6e25a69ad3a0eecb8b14f7d3cc6e198 https://staging.drfop.org/files/original/b2768987a6f827aa82820f33774881c2.jpg 3263b9f8e8039406c257c4297c706577 https://staging.drfop.org/files/original/565d4cdb0cb7c3928f0cc609eecabbad.jpg 23623942433011b5212537b43ff50a42 https://staging.drfop.org/files/original/bf659b0d50d8c30b699e980c1f46cfc3.jpg 2a10c2a368eda3fd3271e2c3d0b654bf https://staging.drfop.org/files/original/9ce4a3a221bb7e80fe9d0ac6e9038998.jpg a5593d13ccca338b6ac13c4fa60b0c30 https://staging.drfop.org/files/original/35f43c3f17c550391dc44c8477510bc7.jpg ee2788f57195e89a29eb725640ddf569 https://staging.drfop.org/files/original/1da9a7a00eb343939657082c12fdb22c.jpg 909ebcfb948c3e308eeea4c9c6129fca https://staging.drfop.org/files/original/107f8865b76201e760a87b25a700925f.jpg ac9a63d4f56b0bfe2d3d809c5be4b62a https://staging.drfop.org/files/original/da057c8bdbf8ceb1905f88c4011035d6.jpg 1364e32658239dc95d96ff1f793bc60e https://staging.drfop.org/files/original/142e0aebc5734f02b98738402171591a.jpg 23e4623a64eb2c8d4be159bc6b0f03ac https://staging.drfop.org/files/original/60c955ee13d73d7d06dd7a1ca0a291f1.jpg f9b06353c26a48c7556434f08d6d1a30 https://staging.drfop.org/files/original/d5169c0556a5fc30c968ca2e1bee5b6d.jpg 6222c5563bd9f4c29aa01964ed644fcd https://staging.drfop.org/files/original/21aa54f2cc58f1d7bbbf371460f09293.jpg 91d6c232ce2547fd4a92b2da4bdfa3ce https://staging.drfop.org/files/original/43a8e159de0c26aa574ccfee54b66866.jpg d697bc4196132af4b6a33226ea167054 https://staging.drfop.org/files/original/bbd717fc89481bf516d899e84e674930.jpg fa7da43c15df8f4730367e7d1a28d083 https://staging.drfop.org/files/original/095050e87ef41d2f053cf7fdb2d3f9d8.jpg 8d867d08333393bb2170844cf6d76586 https://staging.drfop.org/files/original/5fd0bdf92a32a8d7b20419407e0a6e07.jpg 0d975f91d4cbfda7367c753e55bfbd73 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_031.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 31 - 87 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_02_031.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_031.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 VI. Prosthetic Usefulness and Wearer Performance</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br />Edward Peizer, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Systematic research in limb prosthetics has, during the past decade, produced not only better prostheses but also improved techniques for their application. Similarly, programs of prosthetics education have provided a new generation of physicians, prosthetists, therapists, and associated professional personnel with a greater appreciation of the amputee's physical and emotional needs and a greater understanding of how best to meet them. But ultimately research and education in the fitting of artificial limbs have real worth only to the extent that the individual amputee can accept and utilize the prosthesis provided him.</p> <p>The degree of acceptance and utilization is governed ultimately by the single consideration : <i>Of what value is the prosthesis to the amputee?</i> While the wearer himself must provide the essential elements of this valuation, his feelings and attitudes about other matters can significantly affect his opinions and judgments about the worth of his prosthesis. Accordingly, data which included both subjective amputee reactions and more objective ratings and judgments of independent observers were collected. Properly analyzed, these data provide a firm assessment of recent achievements in arm prostheses as well as some measure of the effectiveness of the techniques now recommended for the management of arm amputees.</p> <p>The classification, analysis, and interpretation of the more subjective portions of the data (those collected by interrogation of amputee subjects) make up Part 1 of this two-part discussion. Presentation and support of the more objective material (that obtained by tests and observation) constitute Part 2. All of the data reported were recorded on the special forms illustrated in Appendices IIIB and IIIC of Section I of this series (Artificial Limbs, Spring 1958, pp. 32 through 39).</p> <p>The opinions and statements reported in Part 1 and the test results and observations presented in Part 2 relate to the meaning and the value of program prostheses in various tasks normally encountered in everyday life. As a perceptive reader will note, the term "activities of daily living" is used throughout this article to denote that specific context and is not meant to be synonymous with the term "ADL," which through increasing currency has become part of the professional jargon of physical and occupational therapy. As used here, it encompasses a broader range of activities than it does when generally used in the treatment of human disability. Generally ADL is limited to tasks relating to personal independence and self-care in the home; in our context, recreational and vocational activities are included.</p> <h3>Part 1. Amputee Opinions Concerning Utility of Arm Prostheses in Activities of Daily Living</h3> <p>In general, the prosthesis that will be most valuable to the arm amputee will be the one with which he can perform, most efficiently and with the least effort and discomfort, the greatest number of useful activities ordinarily performed with the normal upper extremity. Thus an evaluation of an arm prosthesis can be based upon the usefulness of a prosthesis to the patient as indicated by his need for it in performing daily activities, the activity level of the patient with respect to the number of activities which he performs with his arm, the ease with which he uses the prosthesis, and the frequency with which he uses it for the performance of activities which are important to him.</p> <p>To obtain amputee reactions concerning the general utility of arm prostheses, the participating subjects were intensively interviewed, and the essential data were recorded on two sets of questionnaires. One set was used to record amputees' opinions of the usefulness of their arms in activities of daily living, the activity level as regards the number of different activities they performed, and the degree of ease or difficulty with which they were able to use their prostheses. The second set of questionnaires was used to collect data concerning the use of prostheses in 20 selected bimanual activities, specifically the frequency with which these activities were performed and the importance to the amputee of being able to perform these activities. With certain minor exceptions, the interrogation was conducted with respect both to the old prosthesis (Evaluation I) and to the new (Evaluation II). The time lapse between the two interviews varied for individual amputees; it was never less than six months for any, as much as 18 months for a few, and approximately 12 months for the average case.</p> <h3>Usefulness, Activity Level, and Ease of Use in Activities of Daily Living</h3> <p>In view of the complexities of everyday human activities, almost any attempt to study the circumstances affecting prosthetic utilization is difficult. As a practical approach to the problem, however, the subjects were queried in a pattern designed to elicit their opinions concerning the value of both their old and new prostheses in the key activity areas of eating, dressing, work, social and recreational functions, and home tasks.<a style="text-decoration:none;">*</a> To determine general usefulness, the amputees were asked to rate their prostheses (first the old and then the new) as essential, very useful, of limited use, of no use, or as a hindrance, the purpose being to establish the amputees' own valuations of their prostheses in performing activities in the five activity areas. Secondly, the subjects rendered their own estimates as to the relative number of activities performed with old and with new prostheses, again with respect to the five key areas of activity. Finally, the subjects were asked to estimate the relative ease with which their old and new prostheses could be used in each of the same five areas.</p> <p>The questionnaires regarding usefulness, number of activities performed, and ease of performance with both old and new prostheses were applied to all available types of upper-extremity amputees, unilateral and bilateral. Because the problems of the bilateral arm amputee differ from those of the unilateral, and because the number of available bilateral cases was too small to have statistical significance, the results for 349 unilateral subjects are treated first, those for the 10 bilaterals in a separate section.</p> <h4>Unilateral Subjects</h4> <p>Among unilateral arm amputees especially, the level of use to which an arm prosthesis is put is determined to a considerable extent by the ease and convenience of performance with the prosthesis as compared with the ease and convenience of performance without it or as compared with the ease and convenience of not performing at all. If a particular activity is too difficult or too time-consuming for a given unilateral arm amputee to perform with his prosthesis, he will either avoid it completely or else find some other way of getting it done. If he elects to accomplish the activity without using the prosthesis, he may do so in any of several ways:</p> <ol> <li>He may use the remaining sound hand, with or without assistance from other parts of the residual anatomy or from external objects. Unilateral arm amputees commonly perform with one hand many activities which under normal circumstances would be bimanual (e.g., tying necktie or shoelaces).</li><li>He may use special devices and techniques (e.g., various tools intended for one-handed performance of tasks ordinarily bimanual), again with or without assistance from some other available source.</li><li>He may prevail upon another person either to provide assistance or to perform the task for him more or less completely.</li></ol> <p>Although any one of these alternatives may serve the purpose of accomplishing essential activities, none of them suggests adequate restoration of loss, either in terms of true personal independence or in the sense of normal appearance. In addition, factors such as temperament, disposition, motivation, and habit patterns further influence the simple "ease-difficulty" premise of prosthetic utilization. Though the true state of affairs in any particular case is a highly complicated one, there can be little doubt that the inherent "usefulness" of the prosthesis is one of the prime factors in determining the number and kinds of purposes to which an artificial arm will be put. This first series of studies was therefore designed to discover the activities for which prostheses are used by amputees with unilateral arm loss at various levels and to delineate any changes in use patterns properly attributable to the new types of prostheses fitted during the NYU Field Studies.</p> <h5><i>Eating</i></h5> <p><i>Usefulness</i>. As regards eating, unilateral below-elbow amputees generally thought well of their old prostheses, above-elbow subjects had a considerably lower opinion of their arms, and shoulder-disarticulation amputees viewed their prostheses as being of relatively little value. In almost all cases, the amputee rated the new prosthesis more useful than the old in eating. For all types of amputees, there were fewer opinions that the prosthesis was of "no use" or "a hindrance" and a greater number of opinions that it was "very useful" or "essential." While this shift in opinion was characterized primarily by a considerable decrease in the proportion of unilateral amputees (of all types) who considered their prostheses of "no use" or "a hindrance," there was also an increase in the number of those considering the prosthesis "very useful" or "essential."</p> <p>Of major significance is the fact that even with the newer arms the majority of unilateral amputees (58 percent of the below-elbow amputees, 83 percent of the above-elbow amputees, and 96 percent of the shoulder-disarticulation subjects) felt that the prosthesis was of limited use or no use in eating. Since only 41 percent of the below-elbow amputees, 15 percent of the above-elbow amputees, and 4 percent of the shoulder-disarticulation subjects considered their new prostheses essential or very useful in eating activities, it must be concluded that, although there was some increase in usefulness in the "program" prostheses, considerably greater improvement is necessary if the artificial arm is to have a significant influence upon the eating activities of the majority of unilateral arm amputees. <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><i>Activity Level</i>. Reports from all unilateral amputee groups indicated that the number of eating activities increased for a significant number of amputees while very few subjects experienced a decrease. The increase in usage was greatest for shoulder-disarticulation amputees (45 percent), less marked for the below-elbow group (34 percent), and least for above-elbow amputees (28 percent). <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><i>Ease of Use</i>. As might be expected from the foregoing, a significant number of amputees of all types reported that eating activities were easier with the new prosthesis than with the old, although the increase in facility for the below-elbow and above-elbow groups was less marked than for the shoulder-disarticulation amputees. <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><i>Specific Activities Performed</i>. <b>Table 1</b>, based on responses from 168 below-elbow, 158 above-elbow, and 23 shoulder-disarticulation ampu- tees, presents a composite picture of the specific eating activities for which unilateral amputees of various amputation levels said they used their prostheses. Since the list of activities was compiled from amputees' responses to the unstructured request <i>List activities for which you use your [new] prosthesis</i>, and since in the experience of the authors arm amputees commonly use their prostheses more extensively than they can recall, it may be assumed to be minimal both with respect to number of activities and to incidence of performance.</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 prime significance of these responses lies in their indication of use potential of the prosthesis. For example, the fact that in opening a soda bottle some below-elbow, above-elbow, and shoulder-disarticulation amputees can and do hold the bottle with their terminal device suggests that this activity is not particularly difficult and that it could be performed by most amputees. Why, then, do some amputees prefer to use one hand only or to hold the bottle between the knees to take off the cap? Such questions are worthy of more intensive investigation than was possible in the NYU Field Studies.</p> <h5><i>Dressing</i></h5> <p><i>Usefulness</i>. Amputees' opinions concerning the usefulness of the prosthesis in dressing show a pattern somewhat similar to that found in eating. There is a general shift of opinion toward the positive end of the scale, but the extent of the change varies with amputee type. It is slight in the below-elbow group, somewhat greater in the above-elbow group, and most marked among shoulder-disarticu-lation amputees. When the percentage of amputees who considered the prosthesis essential or very useful is employed as the basis of comparison, the data for new vs. old arm were: below-elbow, 63 percent vs. 59 percent; above-elbow, 24 percent vs. 14 percent; shoulder disarticulation, 17 percent vs. zero. Although because of the small number of subjects involved the data on the shoulder-disarticulation group must be interpreted cautiously, there are definite indications that a significant number of amputees considered the new prosthesis more useful than the one worn previously. It is also apparent that most groups consider a prosthesis <i>more useful for dressing than for eating</i>. The comparative percentages of amputees who considered the new prosthesis either essential or very useful were—below-elbow: dressing, 63 percent, eating 41 percent; above-elbow: dressing, 24 percent, eating 15 percent; shoulder disarticulation: dressing, 17 percent, eating 4 percent. These differences may be attributable to the larger number of discrete tasks involved in dressing as compared with eating. Despite the improved sentiment toward the usefulness of the program arms, however, a considerable proportion of unilateral amputees of all types (below-elbow, 37 percent; above-elbow, 76 percent; shoulder disarticulation, 83 percent) still considered these prostheses of limited use, no use, or a hindrance. Again it is obvious that much room for improvement still exists, particularly for the more severely handicapped above-elbow and shoulder-disarticulation groups. <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><i>Activity Level</i>. An increase in the number of dressing activities performed with the prosthesis was reported by all amputee groups. The proportion of amputees indicating increased use of the prosthesis ranged from 28 percent of the below-elbow category to 38 percent of the shoulder-disarticulation sample. An insignificant number reported decreased usage. <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 /> <p><i>Ease of Use</i>. Since extent of use is undoubtedly related to ease of use, it is not surprising to find that a high proportion of the amputees considered dressing activities easier to perform with their new prostheses than with their old. Easier operation was reported by 52 percent of the below-elbow, 42 percent of the above-elbow, and 55 percent of the shoulder-disarticulation subjects. Very few subjects at any amputation level reported greater difficulty of operation with the program prosthesis, although almost one in twelve below-elbow amputees fell into this category. The use of more complex terminal devices and the change from soft (leather) to hard (plastic) sockets may in some cases have contributed to this minority opinion. <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 /> <p><i>Specific Activities Performed</i>. <b>Table 2</b> presents a tabulation of specific dressing activities in which unilateral arm amputees reported performance with their prostheses. Since this listing is based upon the responses of the subjects to open-end questions, it should be considered minimal and indicative rather than comprehensive.</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 major significance of the data in <b>Table 2</b> lies in their indication of the use potential in existing prostheses. Equally important, however, is the corollary question, <i>Why is this potential not fully utilized by amputees? </i>For example, 88 below-elbow, 51 above-elbow, and 5 shoulder-disarticulation amputees claimed that they held one end of a necktie with the prosthesis while they tied the knot with their "good" hand. This circumstance would suggest that the activity is perfectly feasible for all three amputee types and that it might almost be considered a "typical" or "normal" prosthetic activity. Nevertheless, the fact remains that a considerable number of amputees tie their neckties using the "good" hand alone. Presumably it is "easier" or more convenient for them to employ the one-handed method, but whether the reason is related to prosthetic difficulty, lack of motivation to use the prosthesis, or prior habit pattern is not readily apparent. More intensive study in this area might be extremely fruitful in gaining deeper insight into the problems of prosthetic utilization.</p> <h5><i>Work</i></h5> <p><i>Usefulness</i>. As a result of the research program, all amputee types except the below-elbow showed an increase in positive attitude toward the usefulness of prostheses in their work. The shift in opinion was quite marked in the shoulder-disarticulation group but less apparent with the above-elbow subjects. Although the below-elbow amputees as a whole indicated little change in usefulness between the old and the new prostheses, their opinions of both prostheses were generally high.</p> <p>In spite of apparent improvement with the new prostheses, many of the amputees (below-elbow, 24 percent; above-elbow, 40 percent; shoulder disarticulation, 55 percent) felt that their prostheses were of little or no value to them on the job. Since, however, these percentages are much lower than the corresponding ones for the two activities previously discussed, it would appear that amputees consider their prostheses more useful for work than for either eating or dressing. The reason may be that eating and dressing involve a relatively small number of activities, many difficult to perform with a prosthesis, while vocational activities present a much broader variety of tasks of which perhaps many can be performed better with a prosthesis than without one. <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 /> <p><i>Activity Level</i>. Sixty-eight percent of the shoulder- disarticulation subjects reported that they performed more work activities with the new prosthesis. So did 41 percent of the above-elbow and 29 percent of the below-elbow participants. <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><i>Ease of Use</i>. A major proportion of the amputees believed that the new arm made work activities easier. Holding this opinion were 63 percent of the be-low-elbow subjects, 75 percent of the above-elbow amputees, and 76 percent of those with shoulder disarticulations. Although this result represents a more uniform and significant "positive shift" than that found for either eating or dressing, one in eight of the below-elbow amputees felt that work activities were harder to perform with the program prosthesis. The basis for this minority opinion was not apparent from the data. <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><i>Specific Activities Performed</i>. The specific work activities that amputees can perform with their prostheses, and the kinds of jobs they can hold successfully, are of considerable interest from the viewpoint of vocational re- habilitation. <b>Table 3</b> presents a listing of vocational activities reported by the 168 below-elbow, 158 above-elbow, and 23 shoulder-disarticulation amputees involved in the study. Activities reported by the subjects have been classified arbitrarily as light work {i.e., activities typical of white-collar workers), medium work {i.e., activities typical of artisans and mechanics), heavy work {i.e., farming and other heavy manual occupations), and miscellaneous. Although this listing does not reveal the full story of the employability of unilateral arm amputees, it does indicate trends. While a detailed analysis of the subject is not possible at this time, it is apparent that unilateral arm amputees are capable of a wide variety of work activities and are employable in a wide range of occupations.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An additional interesting aspect of the relationship between vocation and amputation was provided by amputee responses to two questions asked at the conclusion of the study. These questions and the answers provided by 349 subjects in the study were: <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>From these data it is evident that, while one in five amputees changed jobs during the course of the study, few of the changes were attributed to the new prosthesis. Of the total number of subjects in the study, therefore, very few felt that the new prosthesis affected their employment. Consideration of the type of job change made by the amputees also fails to reveal any significant trend. None of the changes reported (student to farm hand, post-office clerk to wholesale manager, hospital attendant to repairman, unemployed to guard, janitor to stock clerk) indicated any marked shift in vocational status, either positive or negative. It must be concluded, therefore, that the prostheses provided in the study had little apparent effect on the employment status of the participants.</p> <h5><i>Recreational and Social Activities</i></h5> <p><i>Usefulness</i>. All amputee groups reported that in recreational and social activities the program prosthesis was an improvement over the old prosthesis. As with the activity areas previously discussed, improvement was least marked in the below-elbow subjects, but even this group showed a change for the better. For example, 72 percent of the below-elbow sample considered that their new prosthesis was either essential or very useful as against 60 percent for the old prosthesis. Shoulder-disarticulation amputees reflected a greater degree of improvement, 33 percent reporting essential or very useful for the new prosthesis as compared with 19 percent for the old. Above-elbow amputees appeared to obtain the most benefit from their new prostheses, the proportions rating their prostheses in the upper two categories of the scale being: new arm, 69 percent; old arm, 33 percent. The proportion of amputees reporting that the prosthesis was of little or no use or was a hindrance in leisure-time activities (below-elbow, 28 percent; above-elbow, 31 percent; and shoulder disarticulation, 67 percent) was greater than for vocational activities but less than for eating and dressing. <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><i>Activity Level</i>. A significant number of amputees used their new prostheses for additional leisure-time activities. One third of the above-elbow and shoulder-disarticulation subjects and one fourth of the below-elbow subjects had found new uses. A very small proportion of above-elbow and below-elbow amputees reported decreased usefulness (3 percent and 5 percent respectively). <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><i>Ease of Use</i>. More than 50 percent of all the amputees felt that the performance of social and recreational activities was easier with the new arm. A small number of below-elbow (7 percent) and above-elbow (3 percent) subjects felt that activities in this area were harder to do. <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 /> <p><i>Specific Activities Performed</i>. <b>Table 4</b> presents a listing of leisure-time activities performed by unilateral arm amputees using a prosthesis. Some of the pursuits listed are performed vocationally also, but the subjects in the study mentioned them more frequently as a hobby than as a vocation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>While an amputee's social or hobby interests are perhaps not of the same level of importance as eating, dressing, and working, they are nevertheless quite significant in his total pattern of living. It is apparent that to many arm amputees a major value of the prosthesis in leisure-time activities resides in its cosmetic contribution, this factor being mentioned most frequently by all types. In addition, many found their prostheses useful in a variety of sports and hobbies, including such relatively active endeavors as hunting, fishing, golf, and baseball.</p> <h5><i>Home Tasks</i></h5> <p><i>Usefulness</i>. Use of a prosthesis at home encompasses a wide variety of tasks, from washing dishes and sweeping floors to gardening, painting, and electrical and plumbing repairs. Some of these activities are, of course, basically of a vocational nature but are performed as avocations on a part-time or intermittent basis. As for improvement in the usefulness of the prosthesis in home tasks, the shift in opinion was relatively small in below-elbow subjects but quite pronounced in above-elbow and shoulder-disarticulation amputees. In home tasks, as in other activity areas discussed previously, a high percentage of below-elbow subjects (70 percent) considered their old prostheses either essentia] or very useful, and this opinion was maintained for the new prosthesis (73 percent). It would appear that for this type of amputee there was less margin for improvement and hence less was achieved, or, the other way round, the old arms available for below-elbow amputees were relatively more satisfactory than were those available for other amputee types. <b>Fig. 14</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><i>Activity Level</i>. Nearly 45 percent of the above-elbow and shoulder-disarticulation cases and a smaller proportion of the below-elbow amputees (28 percent) found new uses in the home for their program prostheses. A small minority of the below-elbow group (6 percent) found fewer uses for their new prostheses. <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 /> <p><i>Ease of Use</i>. The proportion of amputees reporting greater ease in performance of home tasks with the program prostheses ranged between 64 and 75 percent. Shoulder-disarticulation amputees (75 percent) were most favorably impressed, followed by above-elbow (66 percent) and below-elbow (64 percent). A few below-elbow (9 percent) and above-elbow (3 percent) subjects found home tasks more difficult than before. <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><i>Specific Activities Performed</i>. <b>Table 5</b> indicates the types of home activity for which unilateral amputees used their prostheses. From the scope of activities listed, it is apparent that unilateral amputees find a wide range of uses for their prostheses in the home. While the rate or quality of performance is not indicated by the data, several of the tasks performed imply a high degree of dexterity. For example, a number of amputees undertook automobile and electrical repairs and various types of carpentry, and they made use of a wide range of tools, including power equip- ment. Since, as mentioned earlier, many tasks performed in the home by choice or necessity are vocational in nature, a more intensive investigation of this performance pattern would throw further light on the employment potential of arm amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Bilateral Subjects</h4> <p>In the performance of bimanual activities by unilateral arm amputees, the prosthesis serves primarily, as has been seen, to assist the remaining good hand. Similarly, and for various reasons, unilateral arm amputees not infrequently perform with the one remaining hand activities ordinarily bimanual. Bilateral arm amputees quite obviously are faced with an entirely different situation. Since more or less of both upper extremities is lacking, at least one prosthesis must assume more than an assistive role, and one-handed performance of tasks normally two-handed cannot be substituted for use of a prosthesis. Manual activities required of bilateral arm amputees must therefore be done prosthetically if done at all. In a very real sense, then, the performance problems and the adaptations of bilateral arm amputees are quite unlike those of any type of unilateral amputee, and they therefore warrant separate discussion.</p> <p>In the Upper-Extremity Field Studies, data were collected on 10 bilateral arm amputees (7 bilateral below-elbow, 3 bilateral above-elbow/below-elbow). Five of these subjects (4 bilateral below-elbow, 1 bilateral above-elbow/below-elbow) were wearing prostheses bilaterally when admitted. The other five had either one prosthesis only or none at all. Thus, although information as regards program prostheses was obtained on all 10 subjects, comparative data on new vs. old arms are available on only five subjects.</p> <h5><i>Experienced Wearers</i></h5> <p>Although the five amputees who had worn prostheses bilaterally prior to the NYU Field Studies rated their old arms quite useful in all five of the activity areas, they considered the new prostheses equally useful or slightly better than the old ones (<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 /> <p>As shown in <b>Table 7</b>, four of the five experienced wearers of bilateral prostheses indicated equivalent or increased use of their new prostheses as compared to the old, while one reported decreased use.</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 might have been anticipated, the pattern of amputee responses concerning ease of use (<b>Table 8</b>) of the new prostheses as compared with the old was quite similar to that concerning extent of use (<b>Table 7</b>). In general, the evidence indicated somewhat easier operation of the program prostheses, although the improvement was by no means universal.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Those bilateral arm amputees who reported easier operation and more extensive use of their new prostheses attributed the improve- ments primarily to the more secure grasp permitted by the terminal devices prescribed in the Field Studies. Neoprene-lined hook fingers and the heavy-load feature of the Northrop-Sierra two-load hook contributed greatly to this improved grasp security. Other favorable aspects of the new arms, mentioned by different subjects, were lighter weight and better control (faster operation and lower force requirement). The one subject fitted with an above-elbow arm indicated that operation of his new elbow lock was simpler and more efficient.</p> <h5><i>New Wearers</i></h5> <p>The five amputees who had not worn prostheses bilaterally prior to the Field Studies rated their program prostheses quite useful (<b>Table 9</b>). For some reason, however, their ratings showed less enthusiasm than did those of the patients who had previously worn prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Specific Activities Performed</i></h5> <p>At Evaluation II (new prostheses), information on the specific uses to which bilateral arm amputees put their prostheses was obtained from all 10 subjects for each of the activity areas under study. The activities reported by the individual amputees were given as "free responses" (i.e., unprompted and unstructured), and hence the listings may be considered more representative than complete.</p> <p>The available data on the 10 bilateral subjects indicate that they used their prostheses extensively in eating and attained a relatively high level of independence. Two mentioned specifically that they performed all eating activities with their new prostheses (i.e., were completely independent). <b>Table 10</b> presents specific eating activities reported to be performed by the bilateral subjects.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Only one of the 10 bilateral amputees claimed complete independence in dressing, although two other subjects reported the performance of all dressing activities except buttoning shirt sleeves. Two more persons performed all activities except fastening buttons, lacing shoes, and tying neckties. <b>Table 11</b> lists specific dressing activities reported as performed by the bilateral subjects.</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 employability or vocational-placement possibilities of bilateral arm amputees always hold considerable interest. Although the sample was in this instance exceedingly small, it may be worth noting that five of the 10 bilateral amputees were self-employed, that four worked for others, and that only one was unemployed. Of the nine employed subjects, one was a lawyer, one an engineer, one a forester, and one a quality-control inspector. Two were filling-station attendants, and three were farmers. The quality-control inspector, unemployed at the beginning of the program, obtained his position after receiving his new prostheses, and he credited the functional qualities of the limbs for his new employment.</p> <p><b>Table 12</b> lists specific activities reported by the nine employed subjects as being performed with their program prostheses at work.</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 listing of recreational activities performed by the bilateral amputees revealed that with their new arms most were able to drive a car independently and that most engaged in some form of active or passive recreational endeavor. <b>Table 13</b> lists specific activities mentioned by the subjects as being performed with their prostheses.</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 pattern of home activities performed by bilateral amputees (<b>Table 14</b>) does not differ greatly from that of unilateral except that among bilaterals there is a lesser tendency to undertake tasks requiring fine manipulation. Even allowing for the smaller number of subjects involved, it is apparent that the home activities of bilaterals run more to gross tasks, such as pushing a lawnmower or handling a broom, than to precision activities, such as electrical or radio repairing. Since the absence of "at least one good hand" would be a major handicap in work requiring manipulation of small parts, such a situation is quite understandable.</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 summary, the comparative data on five bilateral arm amputees whose preprogram prostheses were replaced by program arms appeared to indicate that:</p> <ol> <li>The five subjects thought well of their old prostheses and used them extensively.</li><li>In four of the five cases there was slight but definite evidence of functional improvement over that provided by the old prostheses. Contributing largely to this improvement appeared to be the better grasp furnished by the Dorrance 5X and Northrop-Sierra two-load hooks, partly because of the neoprene-lined hook fingers and partly because of the heavy-load feature of the Northrop-Sierra device. Other favorable features mentioned by some of the subjects were lightness and ease of operation. The one amputee fitted with an above-elbow prosthesis felt that his new elbow was much more dependable and much easier to operate than the one previously worn. One subject in the group apparently had a left prosthesis very poorly fitted and functionally inadequate, a deficiency which, in view of the rigorous checkout procedures and the close control of fittings by the clinic teams, is hard to explain. Nevertheless, that particular patient was obviously fitted unsatisfactorily, and this circumstance affected his whole reaction to the prostheses provided.</li></ol> <h4>Discussion</h4> <p>An outstanding characteristic of the data thus far presented is general consistency. For all categories of daily-living activities considered (eating, dressing, work, recreational and social life, and home tasks), and for all criteria applied (general usefulness, level of usage, and ease of use), the evidence strongly indicates that the prostheses provided in the program were more useful than those previ- ously worn. But the material also raises a number of interesting questions of which only some can be answered satisfactorily by the available data. For example, the extent of improvement provided by the new prostheses varied considerably from amputee type to amputee type. It was least for the below-elbow subjects, and some few members of this group even expressed a preference for the old prosthesis. For the unilateral above-elbow and shoulder-disarticulation subjects, the increased usefulness of the new prosthesis was considerably more marked and dramatic.</p> <p>When one speculates on the reasons for these differences, it must be borne in mind that the so-called "old" prostheses exhibited a wide range of quality from very poor to excellent. A number of the preprogram arms, particularly those for below-elbow amputees, were probably as good as, in some few cases even better than, those provided in the study. Moreover, some of the below-elbow subjects whose old leather-socket arms had some of the comfort qualities of old shoes or slippers reacted unfavorably to the new plastic sockets. Whatever the reasons, it was evident that some of the old arms provided below-elbow amputees with a relatively high degree of usefulness and that the impact of the research program on these subjects was relatively small. The reverse appears to have been true of above-elbow and shoulder-disarticulation prostheses. Taken as a whole, the old arms for these cases were of comparatively limited usefulness, and hence considerable improvement was effected by the new prostheses. Thus it may be said that the prostheses provided in the field program made the greatest contribution where improvement was most needed.</p> <p>Another thought-provoking finding of the study was that the usefulness of the prostheses obviously varied from one activity area to another, sometimes quite significantly. All three unilateral groups rated their prostheses as being about equally useful in home, work, and social activities but considerably less useful in dressing and of least use in eating. An explanation of these differences may lie in the fact that eating and dressing involve a limited number of specific activities, particularly those which require bimanual effort, and that the majority of these are quite difficult to perform with an arm prosthesis. It may also be conjectured that, in the sometimes quite lengthy time lapse between amputation and receipt of an arm prosthesis, patients build strong habit patterns of one-handed eating and dressing and that these habits carry over after the prosthesis has been supplied. Work, leisure, and home tasks present a much wider and more varied range of activities. Presumably more of these require bimanual performance in which the prosthesis is of definite assistance. Bilateral arm amputees gave uniformly high ratings to their prostheses in all activity groups, but their performance problems are quite different from those of unilateral arm amputees.</p> <p>A third area of interest involves the matter of basic reasons for use or nonuse of the prosthesis. In numerous instances, a particular activity was performed with the prosthesis by a considerable number of amputees of a given type. Why, then, do not all amputees of that type perform that activity with the prosthesis? Here is a question with many implications. It has been suggested that of the factors determining prosthetic usage-such as ease and convenience of performance, motivation, habit patterns-the first named is of basic importance. If, for example, we consider some specific activity such as tying shoelaces, which with prosthetic help apparently can be performed by some amputees of all types, even including a few with shoulder disarticulations, we may assume that this activity presents a certain level of difficulty and inconvenience. For below-elbow subjects the level may be low enough not to discourage more than a few from performing the task with their prostheses. But it must also be high enough so that others, by reason of habit or lack of motivation or some other influence, will tie the laces one-handed, wear loafers or buckle shoes, or in some other fashion avoid use of the prosthesis. For above-elbow and shoulder-disarticu-lation amputees, of course, the difficulty in performing the activity rises progressively and markedly, so that even though the performance potential be available with the prosthesis fewer amputees would be inclined to avail themselves of it. Obviously, then, further study of the factors affecting prosthetic utilization is highly desirable.</p> <p>A fourth area of interest has to do with the vocational potential of arm amputees. The number and variety of tasks that amputees can perform with the aid of an artificial arm is quite surprising. Extensive use of the prosthesis on the job, in activities around the house, and in hobbies suggests for arm amputees a much wider employment potential than is generally recognized. This subject too is worthy of further investigation on a more intensive basis than was possible in the NYU Field Studies.</p> <p>In general, the relation between the pre-treatment (Evaluation I) and post-treatment (Evaluation II) conditions of the five bilateral amputees was quite similar to the corresponding relation for the unilateral below-elbow amputees discussed previously. Since the bilateral sample included predominantly below-elbow fittings (4 bilateral below-elbow, 1 bilateral below-elbow/above-elbow), the similarity is not surprising. The over-all performance patterns of the 10 bilateral subjects would indicate that as a whole these patients achieved a high level of performance in a wide range of tasks. To a very considerable degree they appeared able to operate their prostheses effectively and to meet independently a substantial number of the requirements of daily living.</p> <h3>Extent of Use of Arm Prostheses in Twenty Selected Bimanual Activities</h3> <p>In the preceding section, the evaluation of the utility of prostheses provided arm amputees was based upon an analysis of their usefulness in five key activity areas, changes in activity level, and ease of use. To gain further insight in this matter, additional study was made of how amputees use their prostheses in 20 selected activities which were considered significant on the basis of four criteria:</p> <ol> <li>The activities should be important ones drawn from all five of the areas of daily living previously discussed (i.e., eating, dressing, work, social life and recreation, and home tasks)</li><li>The activities should call for a range of work levels from floor to head.</li><li>The normal performance of the activities should be bimanual.</li><li>Prosthetic performance of the activities should be possible for all unilateral amputee types.</li></ol> <p>The tasks selected were:</p> <ol> <li>Cut food with knife and fork</li><li>Sharpen pencil</li><li>Sweep up dirt with brush and dustpan</li><li>File and clean fingernails</li><li>Tie necktie</li><li>Use telephone (particularly when taking notes)</li><li>Assist someone with coat</li><li>Take bills out of wallet</li><li>Unbutton shirt sleeve</li><li>Carry several packages</li><li>Use "Flit" gun</li><li>Open bottles, jars, and tubes</li><li>Put on glove</li><li>Use paper clip</li><li>Carry cafeteria tray</li><li>Use can or bottle opener</li><li>Tie shoelaces</li><li>Play cards</li><li>Rewire electric plug</li><li>Use hammer and nails</li></ol> <p>With regard both to preprogram and to program prostheses, the subjects were asked concerning each of the selected activities five questions:</p> <ol> <li>How often in your routine of living does the occasion arise for you to perform the activity? (Daily, weekly, monthly, other)</li><li>How important is the activity in your particular pattern of living? (Very important, important, of little or no importance)</li><li>How often do you perform the activity with your prosthesis? (Daily, weekly, monthly, other)</li><li>If you do not perform the activity with your prosthesis every time the occasion arises, why not? (Write-in)</li><li>If you never use the prosthesis to perform the activity, how do you perform it? (Write-in)</li></ol> <p>The material that follows presents amputee responses to these questions and from these responses seeks to determine the extent to which prostheses were meeting amputee needs. In the main, attention is directed toward the new prostheses provided in the study, that particular data being considered as indicative of present status and hence more meaningful. Only in regard to Question 3, and then with respect to unilateral cases only, is a comparison made between old and new prostheses.</p> <p>The subjects in this study were the same as those making up the sample for the previous series of questions. Again, the data on the three unilateral amputee groups are presented first, with those for the bilateral subjects in a separate section following.</p> <h4>Unilateral Subjects</h4> <p>As we have seen, the problem of restoring function to unilateral arm amputees varies from amputee type to amputee type, the extent of restoration generally being related inversely to the degree of anatomical loss. But all three types of unilateral arm amputees usually have left one normal arm and hand, and accordingly the prosthesis needs for the most part only to assist the remaining natural member.</p> <h5><i>Frequency of Occasion to Perform Activities</i></h5> <p>The purpose of the question "How frequently does the occasion arise to perform the activity?" was to ascertain how often amputees were called upon, or had the opportunity, to perform each of the 20 selected activities, regardless of whether they used the prosthesis in the performance of the activity or whether they even performed it at all. For instance, the question "How often do you have occasion to cut food with a knife and fork?" was interpreted as "How often do you have food which requires cutting with a knife?" Responses relative to each of the 20 activities were tabulated in four categories-at least once daily; at least once weekly; at least once monthly; and less than once monthly, or never. Separate tabulations were prepared for below-elbow, above-elbow, and shoulder-disarticulation amputees. On the basis of these tabulations, there was calculated the percentage of amputees (of each type) who reported once daily or oftener as the frequency of occurrence of a particular activity. The percentage figures were then used to arrange the 20 activities in order from those occurring most frequently to those occurring least frequently. It should be emphasized that "most frequently," as used here, means occurring on a daily basis to the largest proportion of amputees.</p> <p><b>Table 15</b> presents the results for the three groups of unilateral amputees. Since these data are based on unverifiable amputee statements concerning their activities, the information in <b>Table 15</b> cannot be considered as presenting any absolute answer. Nevertheless, the data are quite consistent. Percentages for the first nine activities are of the same order for all groups, and that for the tenth shows a slight variation for the shoulder-disarticula-tion subjects only. The 10 tasks on the lower end of the table were performed daily by the least number of amputees. These data showed similar patterns of occurrence for each of the three types of amputees. Thus it would appear that some of the activities on the "selected" list confront a large proportion of all types of amputees on a daily basis. Other activities affect relatively few amputees as often as this.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>How often an activity should occur, or how many people it should affect to be considered "significant" in the lives of amputees, is a philosophical question. On an arbitrary basis we might say that the first nine activities in <b>Table 15</b>, which occur daily in the lives of more than about half of the amputee population, are "significant" activities. Yet who can say that tying a necktie (occurring to one third of the group daily) or even using a hammer and nails (less than one fifth of the population affected daily) are "insignificant" activities? Obviously such tasks could be highly significant to the particular amputees involved.</p> <h5><i>Relative Importance of the Activities</i></h5> <p>In addition to the frequency of occurrence, the degree of importance subjectively attached to being able to perform a specific activity is a second significant factor in determining the usefulness of a prosthesis to its wearer. Accordingly, the ten subjects were also asked to rate each of the 20 selected activities as "very important," "important," or "of little or no importance" to them in their regular activity pattern.</p> <p><b>Table 16</b> presents the percentages of amputees rating the respective activities as either "very important" or "important," the activities being arranged in the approximate order of importance on the basis of these percentages. For example, "cut food with knife and fork" was rated "very important" or "important" by more amputees within each of the three unilateral amputee groups than was any other of the 20 selected activities. Tying a necktie was second in importance to above-elbow and shoulder-disarticulation amputees but fifth in importance to the below-elbow subjects. Thus the ranking of activities in <b>Table 16</b> may be thought of as indicating the general level of importance attached to the activities by the unilateral amputee population as a whole.</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 these terms the 20 activities fall rather obviously into three levels of significance. The first 10 tasks are rated as important by two thirds or more of the sample, cutting food being by far the most significant activity (about 9 out of 10 subjects). The next three activities may also be considered quite significant, almost one in two amputees designating them as important. The final seven tasks may be regarded as having lower general significance, no more than one in three amputees rating them as important. With the possible exception of using a "Flit" gun, however, even these low-ranking activities cannot be considered as completely insignificant. For example, rewiring an electric plug, nineteenth in order on the list, is rated as an important activity by one in five unilateral amputees of all types, a fairly substantial number of people. We may conclude therefore that, while according to the criteria used in this study the 20 selected activities vary widely in importance, all, or almost all, have value to some significant proportion of unilateral arm amputees.</p> <p>It is of interest to compare the data on the importance of activities with those on the frequency of occurrence discussed earlier. <b>Table 17</b> presents the 20 activities in approximate order of frequency of occurrence (from <b>Table 15</b>) and also lists the approximate order of importance for the 20 tasks (from <b>Table 16</b>). A fairly consistent relationship between frequency and importance is apparent at once. Seven of the nine most important activities occur very frequently.</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 can be inferred therefore that, in general, activities which occur most frequently are likely to be regarded as being the most important, but the instances where this principle does not hold are also of interest. Two out of three shoulder-disarticulation amputees said they had occasion to use a paper clip daily, but only one out of three considered the activity important. Less than one in six below-elbow amputees reported that they had occasion to use a hammer and nails on a daily basis, yet two out of three considered the activity important. While only one in three of the below-elbow subjects reported tying a necktie daily, about three in four considered it important to be able to do so. Thus, some activities that occur frequently may be relatively unimportant; others may occur only infrequently but still have great personal significance.</p> <h5><i>Performance of Activities with the Prosthesis</i></h5> <p>Having considered the frequency of occurrence of the 20 selected activities and the relative importance of these activities in the lives of amputees, we come now to the frequency of use of the prosthesis in the performance of the tasks, the point being to evaluate both the extent of prosthetic use and the relationship between this utilization and the two factors previously presented (i.e., frequency of occurrence and importance).</p> <p>Data on use of the prosthesis in the 20 selected activities, obtained from all amputees in the study, were organized to show the percentage of amputees who always, regardless of frequency, used the prosthesis in the performance of a particular activity, the percentage who sometimes used the prosthesis, and the percentage who never used it, a small number of amputees who claimed that they never had occasion to perform a particular activity being excluded. <b>Table 18</b> presents the incidence of use of the program prostheses as reported by the unilateral subjects.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Analysis of <b>Table 18</b> shows that the prosthesis is used extensively by below-elbow sub- jecls in performing the 20 selected activities, all tasks save one being performed by more than 50 percent of the group every time the opportunity arose. With rare exceptions (e.g., carrying packages), the utilization of the prosthesis in performing activities dropped off sharply and progressively from the below-elbow to the above-elbow to the shoulder-disarticulation groups. An intriguing and somewhat unexpected finding is the relatively small percentage of amputees reporting occasional use of the prosthesis. It would appear that amputee use of the prosthesis tends to be on an all-or-none basis. If an amputee uses his prosthesis to perform an activity at all, he tends always to use it for that activity. Even when this general tendency is violated, there are interesting areas for speculation. For example, cutting food with knife and fork has a relatively high incidence of "sometimes" responses. Since we know that cutting food is relatively difficult at all amputation levels, it seems probable that some amputees ignore the prosthesis under some circumstances (e.g., eating at home) but use it on other occasions (e.g., eating out or when they have company) in spite of the difficulty. The fairly general always-or-never use of the prosthesis in the performance of specific activities reinforces a conclusion presented earlier-that there is for each activity a certain threshold, or tolerance, level of difficulty associated with prosthetic performance, that this threshold varies from amputee to amputee and from activity to activity, that if the performance difficulty is within the individual's tolerance limits he will tend to use the prosthesis consistently, and that if the level of difficulty is above his limit he will tend not to use the prosthesis at all.</p> <p>The data in <b>Table 15</b>, <b>Table 16</b>, <b>Table 17</b>, and <b>Table 18</b> may also be viewed as an index of the relative usefulness of the prosthesis in the performance of the 20 selected tasks and, conversely, as a measure of the relative difficulty of the several activities from the standpoint of accomplishment by means of a prosthesis. For instance, the activity "sharpen pencil" appears to be performed (with help from the prosthesis) by 90 percent of below-elbow, 76 percent of above-elbow, and 62 percent of shoulder-disarticula- tion amputees every time the occasion arises. It would appear, therefore, that sharpening a pencil is not too difficult an operation for any type of unilateral arm amputee. The corollary conclusion is that, in pencil-sharpening, the prosthesis is a highly useful assistive device. On the contrary, activities such as cutting food or holding a telephone with the prosthesis appear to be quite difficult for arm amputees at all levels, and the prosthesis is then obviously of less value.</p> <p>If we extend this index-of-usefulness concept to the entire list of 20 activities, we obtain the results shown in <b>Table 19</b>, which presents the percentage of amputees reporting use of the prosthesis every time the occasion arose for performing the activities. If, further, it is assumed that those activities in which there is the highest degree of prosthetic utilization are activities for which prostheses are most useful (or, more simply stated, easiest to perform with a prosthesis), then <b>Table 19</b> indicates that the below-elbow prosthesis is highly useful or well adapted to performance in most of the 20 activities. For above-elbow and shoulder-disarticulation subjects, the usefulness or adaptability of the prosthesis drops off sharply (i.e., the prosthesis has a high level of usefulness for considerably fewer activities). Nevertheless, some consistency in pattern is evident for the three unilateral amputee types in that activities for which the prosthesis is most useful for the below-elbow group tend also to be easiest for the above-elbow and shoulder-disarticulation subjects. Similarly, the activities that are most difficult for below-elbow subjects also present the greatest difficulty for above-elbow and shoulder-disarticulation amputees. Not readily explained is the fact that the activities for which the prosthesis is apparently most useful generally rank low in frequency of occurrence or importance or both, while activities for which the prosthesis is least useful generally rank high in occurrence and importance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Old Versus New</i></h5> <p><b>Table 20</b> compares reports by unilateral arm amputees as regards the extent of use of the old and the new prostheses. It reveals a consistent but by no means universal trend toward greater utilization of the new prosthesis as compared with the old. It is most apparent in the above-elbow subjects (increase for 17 of the 20 activities), less apparent in the below-elbow and shoulder-disarticulation amputees. As regards specific activities, however, there appears to be no systematic pattern of changes in degree of prosthetic utilization, and hence the general evidence here is rather inconclusive.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Reasons for Performing Activities Without Using the Prosthesis</i></h5> <p>In the foregoing material, consideration has been given to the matter of amputee utilization of prostheses in terms of their use always, sometimes, or never in performing each of the 20 activities under study. When an amputee always uses his prosthesis in the performance of a particular activity, some degree of adequacy of the limb for that task may be assumed. When, however, he "sometimes" performs a task without using his prosthesis, or when he "never" uses the artificial arm in the performance of that activity, prosthetic inadequacy to some degree would seem apparent. An understanding of the specific inadequacies of today's arm prostheses with respect to each of the 20 activities would be of great value in prescription and training as well as in planning research. Accordingly, each amputee who indicated less than full utilization of his prosthesis in a given activity was asked why he didn't use his prosthesis every time he had occasion to perform that task.</p> <p>The most specific, although not the most frequent, reason given for not using the prosthesis in the performance of particular activities was that the terminal device was inadequate. For instance, a given terminal device might be capable of holding a wallet or taking out bills but be ill-suited for holding a fork; it might be suitable for holding a necktie but not for handling a telephone. It may therefore be concluded that one major reason for not using the prosthesis in performing certain activities relates to lack of versatility in the terminal device.</p> <p>Another important reason advanced for failure to use the prosthesis was that the terminal device could not be brought to the appropriate functional position and operated there. Although the exact cause of this difficulty is not apparent from the data, it may be related directly to prosthetic inadequacies. As a matter of fact, not many amputees were able to give clear reasons for not using the prosthesis, so that it is possible only to speculate on the implications of the responses Some subjects stated simply that they "could not perform" the task in question. Since this kind of response may indicate either lack of training or genuine prosthetic deficiency or both, full interpretation requires further investigation. In the absence of a more complete examination, it may only be guessed that poor features in the available prosthetic equipment contributed in some way to its disuse.</p> <p>That an activity was "easier to perform without the prosthesis" was the reason given most frequently for failure to use an artificial arm. Although not especially revealing, such statements reaffirm the conclusion reached for other aspects-that for numerous amputees performance of certain activities presents such difficulty that it is "cheaper" in time, effort, and peace of mind to do without the prosthesis. A sharp rise in the number of "easier-without-prosthesis" responses was noted in the above-elbow amputees as compared with the below-elbow subjects-a result in keeping with earlier findings of decreasing prosthetic usefulness at the higher levels of amputation.</p> <p>A number of amputees reported that the prosthesis was not worn at the time a particular activity was performed. This circumstance may be considered as indicating either that the activity was easier to perform without the prosthesis or that performance without the prosthesis presented no particular problems. Were the prosthesis indispensable, it would be worn on almost all occasions when opportunity to perform the listed activities arose. Since it evidently was not, it must be assumed that some amputees could dispense with their prostheses without (to them) significant functional loss.</p> <p>Two other general observations can be made concerning the reasons for nonuse of the prosthesis. Both reinforce evidence presented earlier. One is that the number of "reasons" for nonuse of the prosthesis increased sharply for the above-elbow group as compared with the below-elbow subjects, which is only to say that more above-elbow amputees than below-elbow amputees report "sometimes" or "never" as regards use of the prosthesis. The other is that some "important" activities and some "occurring frequently" (such as cutting food, tying a necktie, using a telephone, taking bills out of a wallet, unbuttoning the shirt sleeve, tying shoelaces, and so on) are also reported by many amputees as being easier to perform without the prosthesis than with it.</p> <p>In summary, it would appear that in general the statements made by all amputee groups point, either directly or by implication, to functional inadequacies of the prosthesis as the basic reason for failure to make full use of it. The specific inadequacies, and the means of correcting them, are of course not directly or fully revealed by the present data. Even the seemingly straightforward problem of inadequate prehension in terminal devices cannot be solved simply by adding rubber bands or by providing a device with a stronger grasp. Experience has shown that for numerous amputees a lightly loaded hook is adequate for most needs and that they therefore prefer it. They object to the necessity for overcoming heavy resistance in every operation just to accommodate needs occurring infrequently. Nor is the voluntary-closing hook always the answer. Evidence presented in Section V of this series shows that such voluntary-closing devices as are currently available also are not without objectionable features. The solution of such problems must await further research into the total area of prosthetic utilization.</p> <h5><i>Manner of Performing Activities Without the Prosthesis</i></h5> <p>When, in a particular activity, an amputee regards the use of the prosthesis as either impossible or too difficult, awkward, or time-consuming, he is faced with the choice of excluding the activity from his routine of living or of finding some substitute means of accomplishing it. In the NYU Field Studies, those subjects who did not use the prosthesis in one or more of the 20 selected activities were asked what they did when confronted with the task or tasks concerned. By far the most frequent response by all classes of unilateral arm amputees was to the effect that they used the remaining hand, either alone or in combination with some other part of the body or some external object. About 3/4 of all responses told of one-handed performance, and the activities which are normally bimanual but for which performance was actually one-handed were essentially the same ones for all three classes of unilateral amputees. Moreover, activities so performed were for the most part the same ones as those reported to be "easier to perform without using the prosthesis" and also the same as those said to be most difficult to perform with a prosthesis (i.e., least facilitated by assistance from a prosthesis).</p> <p>A second alternative to use of the prosthesis, occurring in about 10 percent of the responses, was the use of substitute devices such as combination knife-forks, telephone holders, or playing-card holders-all simply aids to one-handed performance. As for other methods of accomplishing daily tasks without use of a prosthesis, some 15 percent of the subjects indicated that the services of another person were enlisted. Again, as in the case of one-handed performance, the activities most frequently cited were much the same ones for all three groups of unilateral amputees. Although there is no apparent reason behind the choice of activities for which outside help is to be sought, it is possible that the tasks selected are too difficult to perform alone, either with or without a prosthesis. But of course other factors-an overly solicitous wife, general dependency, lack of training- may well be involved.</p> <p>Two important goals in upper-extremity prosthetics are to help the amputee be independent in the performance of the tasks of daily living and to permit him to function bimanu-ally in as "normal" a fashion as possible. Obviously the final achievement level may be below that of a "normal" person, but nevertheless these goals remain the best standard of comparison. Prosthetic utilisation may be viewed as ranging from an optimum of complete independence and bimanual function to less independent performance with the sound arm alone, either with or without assistive devices, to a complete dependence on assistance from others. The employment of this scale of achievement along with additional measures of the quality or appearance of prosthetic performance should provide a useful basis for evaluating the degree of success obtained in amputee rehabilitation.</p> <p>From the material here presented, we may conclude that, in the 20 selected tasks, the most common substitution for prosthetic use involves use of the remaining "good" hand, either alone or in combination with some other part of the body or some external object. One-handedness, with or without the use of substitute devices, avoids the necessity of dependence on others, but it also leaves much to be desired from the standpoint of simulating "normal" performance. Moreover, one-handed performance of such activities as tying a necktie, or unbuttoning shirt sleeves with the teeth, is not easy. If these methods really are "easier" without a prosthesis, then prosthetic use must indeed be unattractive to the individuals concerned. The general findings of the whole study lead, however, to the obvious conclusion that a prosthesis is at best only a partial replacement for a lost limb. In unilateral arm loss, increased usage of the remaining arm and hand has unavoidably to make up, to greater or lesser degree, for existing prosthetic inadequacies.</p> <h4>Bilateral Subjects</h4> <p>As already pointed out (page 49), the 10 bilateral subjects in the Upper-Extremity Field Studies included 7 bilateral below-elbow and 3 bilateral below-elbow/above-elbow cases. Undoubtedly, the general performance level of the group as a whole was higher than it would have been had the sample included bilateral above-elbow and bilateral shoulder-disarticulation subjects. The extent of prosthetic utilization exhibited must therefore be interpreted accordingly. The responses of the subjects concerning frequency of occasion to perform the 20 selected activities, importance of the selected tasks, and frequency of actual prosthetic performance are presented in <b>Table 21</b>, <b>Table 22</b>, and <b>Table 23</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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Frequency of Occasion to Perform Activities</i></h5> <p><b>Table 21</b> presents the responses of the bilateral subjects as to the frequency of occasions for performing the 20 selected activities with prostheses. It will be apparent at once that the activities for which opportunity occurred to the majority of bilateral amputees daily were for the most part the same ones occurring most frequently for unilateral subjects.</p> <h5><i>Importance of the Activities</i></h5> <p>The ratings of the bilateral group as to the significance of the 20 activities are presented in <b>Table 22</b>. On the basis of a composite of the two ratings "very important" and "important," the activities most significant to the bilateral amputees were, with the single exception of sweeping up dirt, the same ones that rated high in importance for the three unilateral groups, and more than half of these were among the ones occurring most frequently. Thus the general pattern of relationship between frequency and importance observed with the unilateral groups appears to apply to the bilaterals also. And again, as with the unilateral cases, the activities of bilaterals that apparently do not conform to this pattern give rise to speculation. A case in point is the matter of using the telephone. Ostensibly an activity which confronts bilateral arm amputees rather infrequently (<b>Table 21</b>), it is rated as significant by all of the ten subjects involved. Either the activity is considered important in spite of infrequent occurrence or, more likely, bilateral amputees avoid use of the telephone because of difficulty in handling it with their prostheses. Avoidance could explain infrequent occurrence.</p> <h5><i>Performance of Activities</i></h5> <p><b>Table 23</b> summarizes the responses of the 10 bilateral amputees as regards utilization of the program prostheses in the performance of the 20 selected activities. The always-or-never characteristic of prosthetic utilization, described earlier for unilateral amputees, is even more evident in the bilateral group. At Evaluation II, only one bilateral amputee reported "sometimes" use of the prostheses in any of the 20 activities. Judging from the proportion that never perform a given activity, the tasks that are the most difficult for bilateral amputees are also among those occurring most frequently for them, or rated most important by them, or both, so that the situation noted earlier for unilateral subjects again applies to bilaterals also. If we take as a basis of comparison the percentage of bilateral arm amputees who always use the prostheses to perform an activity, then as a group bilaterals use their prostheses more extensively than do any of the unilateral groups. The comparative figures, including the apparent anomalies, lead to the logical supposition that, if they can, bilaterals will perform the most difficult tasks in order to be independent but that some tasks may be too complex for them to manage in spite of a strong desire to do so.</p> <h5><i>Reasons for Not Using the Prosthesis and Alternative Ways of Performing Activities</i></h5> <p>Because of the small number of cases involved, and because of the variety of body movements used by bilateral arm amputees to accomplish tasks without prostheses, a detailed analysis of substitution techniques is not warranted, but two general observations may be made nevertheless:</p> <ol> <li>Prosthetic deficiencies related to nonperformance were concerned with inadequate grasp by the terminal device and inability to operate it at the appropriate level.</li><li>The chief remedy for such deficiencies was to have someone else perform the task. Use of substitute devices was confined largely to unbuttoning shirt sleeves, presumably by use of a special buttonhook held in a prosthesis.</li></ol> <h4>Discussion</h4> <p>The NYU Field Studies reveal a number of interesting highlights regarding the utilization of prostheses reported by upper-extremity amputees. With only minor exceptions, the 20 bimanual activities, chosen empirically, occurred in every case with sufficient frequency, and/or affected a large enough proportion of the amputee population, to be considered significant. Among the various amputee groups (unilateral below-elbow, above-elbow, and shoulder-disarticulation cases and bilateral arm cases) there was considerable agreement as to the relative frequency of occurrence of the activities. It must also be noted, however, that among the bilaterals the frequencies of occurrence were much lower than among the other groups. For example, only 10 percent of the bilaterals carried a cafeteria tray as often as once a week, and none of them used a "Flit" gun or rewired an electric plug as often as once a week. Finding such agreement supports the selection of these activities as being highly significant in the activity patterns of upper-extremity amputees.</p> <p>As judged by amputee opinions concerning the importance of the 20 selected activities, the level of significance attached to the individual tasks varied considerably. For unilateral subjects, 10 of the activities were rated as important by 2/3 or more of the group, five were rated as important by 1/3 to 1/2, and five were significant to less than 1/3. For the bilateral group, 11 activities were rated as important by 2/3 or more of the sample. For all amputee types, even those activities rated as important by the least number of amputees could not be regarded as totally insignificant. On the basis of amputee judgments of frequency of occurrence and of importance, therefore, the tasks selected appear to have •constituted a sound basis for study of the patterns of prosthesis usage among arm amputees. Although significant exceptions were apparent, in general the activities occurring most frequently were also rated as the most important.</p> <p>In sum, the data on amputee use of prostheses in performance of the 20 selected activities revealed a number of interesting, if occasionally unexpected, findings. Among these were:</p> <ol> <li>A sharp drop-off in prosthetic utilization from below-elbow to above-elbow to shoulder-disarliculalion amputees, found in an earlier investigation (page 32), was confirmed. While over-all utilization of the prosthesis by all amputee types, including the above-elbow and shoulder-disarticulation cases, was quite remarkable, improved utilization was most striking among the below-elbow and bilateral amputees. More than 50 percent of all unilateral below-elbow subjects reported that they always used the prosthesis in the performance of 19 out of the 20 selected activities (<b>Table 18</b>), and at least half of the bilateral amputees reported 100-percent use in 13 out of 18 applicable activities (<b>Table 23</b>).<br /> Because heretofore prostheses for above-elbow and for shoulder-disarticulation amputees have sometimes been regarded as comparatively useless, the data relating to these types of amputees are perhaps even more dramatic than are the corresponding results for the other two types. In the above-elbow group, 50 percent or more of the sample reported that for widely diverse tasks they always used the prosthesis. In a number of "important" activities, a smaller but still significant proportion of above-elbow subjects always used the prosthesis. If we focus attention on what was done rather than on what was not done, there is considerable evidence that the prostheses had real value even for the shoulder-disarticulation group. Some 50 percent or more of the sample reported that in performing 8 of the 20 tasks they always used the prosthesis. In almost none of the activities could the prosthesis be considered useless. Even for the shoulder-disarticulation amputee, to whom a prosthesis offers the least functional replacement, the fitting and use of a modern artificial arm seems worth while. And a similar conclusion may be drawn from the data presented earlier concerning use of the prosthesis in eating, dressing, and vocational, recreational, and home activities by all classes of amputees, including above-elbow and shoulder-disarticulation cases.<br /> There are, then, two sides to the coin of prosthetic usefulness. One points to the inadequacies of even the most up-to-date equipment and emphasizes the need for much improvement. The other shows that, despite prevailing inadequacies, present-day upper-extremity prostheses are quite useful devices, particularly in those cases once thought incapable of deriving much benefit from any arm substitute.</li><li>An "all-or-none" type of phenomenon in amputee use of prostheses was noted. In any given activity, an amputee tends either always to use his prosthesis or never to use it. While not absolute or universal, the inclination was considered strong enough to be viewed as a general characteristic of prosthetic utilization.</li><li>Paradoxically, the prosthesis was most useful for many activities which occurred less frequently, or which amputees rated as less important. Some of the more frequently occurring, and more important, of the 20 activities, such as "cut food with knife and fork" and "unbutton shirt sleeve," were less frequently performed with the prothesis. This may indicate that the difficulty of performing the task with prothesis influences frequency of prosthetic use more than does the frequency of occasion for use or the importance of the task.</li><li>Although there were definite indications that the program prostheses were used more extensively than were their preprogram counterparts, the increase in utilization was neither universal nor particularly striking. The reasons given by arm amputees for not using their prostheses in the performance of activities pointed generally to prosthetic inadequacies as the basic cause. While lack of a suitable all-purpose terminal device was the only specific item identifiable from the data, it appears that the whole area of amputee use or non-use of an arm prosthesis calls for further and intensive study. Where arm amputees did not use their prostheses in activity performance, the most common substitution among unilateral subjects involved use of the remaining hand, either alone or in combination with some other part of the body or some external object. One-handedness replaced what would normally be bimanual performance. Among bilateral arm amputees, "someone else does it for me" was the most frequent compensation for failure to use prostheses.</li></ol> <p>In the final analysis, the value of any particular set of principles or procedures in upper-extremity prosthetics is reflected by the degree of acceptance and utilization afforded the wearer by the prosthesis after the novelty has worn off and routine operation is expected. As part of the NYU Field Studies, therefore, the opinions of a large and diversified group of arm amputees were obtained on widely separated occasions in response to a series of open-end and multiple-choice questions relating to five key areas of activity considered more or less common to all persons. These reactions, classified and analyzed in terms of amputation type, were augmented by interviewing the same group of subjects with regard to 20 bimanual activities selected empirically as being important and of frequent occurrence in the course of daily living.</p> <p>These two inductive approaches were selected from many possibilities for investigation as being the most practical and appropriate for determining amputee opinions as regards the utility and general value of their prostheses. Though the answers obtained do not provide a completely definitive method for grading success or failure in the rehabilitation of arm amputees, they have nevertheless furnished much useful information on a number of the factors influencing acceptance of prostheses by their wearers.</p> <p>As might have been anticipated, amputees with the more disabling conditions (that is, with higher levels of amputation) were able to employ their prostheses over a smaller range of activities. On the other hand, the greatest increases in prosthetic utilization were found among these very groups. Not anticipated, however, was the indication that, in general, amputees tend to use their prostheses every time they do a given activity or not at all. The frequency of occurrence and the importance of an activity to an amputee were not always indices of the utility of the prosthesis in the particular task. While there were definite improvements in the utilization of program prostheses, a great deal of room for improvement remains, particularly in the bilateral group. Although deficiencies in the prostheses may be responsible, other factors such as training and motivation may also be involved. New studies focused on these questions will be required to illuminate the specific relationships.</p> <h3>Part 2. Amputee Performance With Arm Prosthesis</h3> <p>Since arm amputees, like most people, are not generally capable of a completely realistic self-appraisal, there is an inherent weakness in data which derive solely from verbal reports. For this reason, a second method of evaluation was devised with the purpose of assessing prosthetic use on the basis of more objective information. Based on the assumption that proficiency in use also reflects the value of the prosthesis to the amputee, two types of prosthetic proficiency tests were developed. The first was designed to measure the amputee's skill in prehension and accuracy in positioning the terminal device for prehension. The second was concerned with evaluating skill in performing a series of common daily activities.</p> <h4>Test Rationale and Test Development</h4> <p>Methods of evaluating human performance in physical activities vary from the simple, relatively objective timing of a footrace to the more subjective assessment of figure-skating or fancy diving. In the footrace, effectiveness of performance is determined solely by measuring time, since speed of performance is the main factor. In rating activities of the second type, consideration also is given to such subjective features as timing, rhythm, grace, and form because here both effectiveness and appearance are matters contributing equally to the overall result. Since the total value of performance with a prosthesis involves these two factors, efforts to analyze the quality of prosthetic use in the NYU Field Studies sought information not only on the effectiveness with which the amputee used his prosthesis in activities of daily living but also on his appearance while performing them. In this sense, "effectiveness" refers to the ability to complete a task in a reasonable time. "Appearance" has to do with the relationship between the performance of the amputee and that typical of a normal person.</p> <h4>Abstract-Function Tests</h4> <p>Considering the uses arm amputees make of the various functions provided by modern arm prostheses, it is clear that all artificial arms are employed primarily as prehensile tools. But the ability to grasp with a hook or artificial hand would be extremely limited were the terminal device restricted to one plane or to a single area of operation. The value of other prosthetic functions, whether passively or actively controlled, lies in their usefulness as a means of positioning the terminal device so that work can be performed throughout a large operating sphere. It may reasonably be said that all the motions that can be provided in an upper-extremity prosthesis are capable of classification into one of two functional categories-those involved in the act of prehension itself and those which are used to position the terminal device so that meaningful prehension may be performed. Recognition of these functional divisions led to the development of two tests of abstract function-the prehension test and the positioning test-designed to permit study of some of the factors involved in prehension and positioning. They are tests of "abstract function" in the sense that no purposeful activity is involved and that only the bio-mechanical functions of positioning and operating the terminal device are analyzed. Tests of abstract function were, then, used to assess the amputee's ability to:</p> <ol> <li>operate and control his terminal device in grasping, transporting, and releasing objects.</li><li>position his terminal device accurately and operate it effectively in various places in front and to the side of his body.</li></ol> <h4>Practical-Activities Tests</h4> <p>Tests of practical activities, used in an evaluation of how the amputees performed meaningful activities of daily living, were designed to provide information concerning the facility and appearance of a total performance in order to measure the functional value of the appliance. Selection of the performance tests of practical function was based on three prime criteria-that the activities concerned should normally require bimanual performance, that the activities concerned should be those performed frequently by the subjects being tested, and that performance of the activities should be important to the amputee.</p> <p>Tests of practical function were, then, used to rate:</p> <ol> <li>the effectiveness with which amputees perform common, everyday tasks.</li><li>the naturalness of appearance while amputees perform daily activities.</li></ol> <h4>Standards Of Performance</h4> <p>In the choice of a yardstick with which to measure the quality of prosthetic performance, consideration was given to the purpose of fitting an amputee with an artificial arm. Since the obvious aim is to restore as much as possible of the function lost through amputation, the desired outcome is that the amputee accept and use his prosthesis as naturally and as "normally" as possible. For this reason, normal, two-handed performance of tasks appeared to be a valid criterion. Because, however, it is commonly recognized that an amputee can never attain a completely normal, two-handed pattern of performance, it may reasonably be objected that such a standard is to some degree unrealistic and that the rating of amputee performance in relation to that of other amputees would provide a more reliable comparison. Perhaps it would. But the absence of norms or standards of amputee performance at the time the NYU Field Studies were undertaken precluded any choice in the matter. Consequently, the normal performance pattern was selected as the standard.</p> <h3>Sample</h3> <p>The numbers of below-elbow, above-elbow, and shoulder-disarticulation amputees available for these performance tests varied considerably. Participating in the pretreatment tests were 80 below-elbow amputees, 57 above-elbow amputees, and 4 shoulder-disarticulation amputees representing, respectively, 48 percent, 36 percent, and 17 percent of each amputation type in the sample. Attrition during the pretreatment evaluation was due to nonfunctioning or malfunctioning of arms, amputees appearing for evaluation without prostheses, and breakdown of prostheses during use with consequent inability to complete the test. Owing to the generally better functional condition of arms during the course of the program and to the increase in the number of shoulder-disarticulation and above-elbow amputees wearing arms, the number of subjects available for post-treatment testing was substantially higher: 115 (68 percent) below-elbow, 111 (70 percent) above-elbow, and 17 (74 percent) shoulder-disarticulation cases. To provide the most rigorous analysis that the data will permit, only the performances of the patients available for both pre- and post-treatment evaluations are presented. This restricts the total sample to 75 below-elbow, 51 above-elbow, and 4 shoulder-disarticulation cases. Because there are so few shoulder-disarticulation amputees, their performance ratings are not treated statistically but are described in terms of impressions and trends.</p> <p>All of these amputees took the prehension test, the first to be administered, but somewhat fewer completed the positioning test and the practical-activities tests, either because of breakdown of prostheses during the course of the tests or because of indisposition on the part of the patients.</p> <h3>Procedures</h3> <h4>Abstract-Function Tests</h4> <h5><i>Prehension Test</i></h5> <p>In utilizing his prosthesis in the activities of daily living, the amputee has occasion to grasp objects of various sizes, shapes, weights, textures, and degrees of fragility or hardness. This diversity was recognized by including, in the prehension test, objects which embody many of the variables normally encountered. Of the 12 objects used, six were of metal (five aluminum, one steel) and six of compressible rubber, and all were of one of four basic shapes-cylinders, spheres, prisms, and right-angled forms-in various sizes.</p> <p>In addition, the testing materials included a form board constructed of "Masonite" attached to a three-ply wooden board measuring 17 X 17 in. and into which were cut recesses corresponding to the shapes of the test objects but slightly (1/8 in.) larger. The test objects were arranged on a table near the board and in the same relative position as the recesses in the board so as to reduce the need to search for the proper recess. In the course of the test, the amputee transferred each of the objects from the table to the appropriate recess in the form board. Before the actual test, the amputee was given a trial run to familiarize himself with the objects and to give him an opportunity to decide upon the most efficient way to approach and grasp an object. The test was explained to the amputees as follows:</p> <p>"You are to place each of these objects in the appropriate recess in the form board. Start with the top row and work from left to right. Do each row in the same way.</p> <p>"Work as quickly as you can but also as accurately and neatly as you can; do not waste any time.</p> <p>"If you cannot handle any object after trying for 1 minute, leave it and go on to the next. You will be notified when you have been on any object for 1 minute.</p> <p>"Use only your prosthesis in handling the various objects.</p> <p>"Avoid compressing or distorting the shape of the rubber objects as much as possible.</p> <p>"You are being tested on your ability to grasp the objects and to release them into the recesses in the form board." <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>In the performance of these tasks, the terminal device is first brought into a position which allows for grasp of the object. The next step, concerned with the grasp itself, involves operation of the prehension mechanism, placement of the fingers to obtain a stable grasp, and control of finger pressures to provide appropriate prehensile forces. To complete the activity, the amputee must transport the object and then position the terminal device so that the object is released at the intended place. The general impression that an amputee's performance makes upon the observer depends upon the body move- ments employed, the number of errors made, and the appearance of the control motion. In addition to these factors, the appearance of the total performance is related to the general ease, grace, and accuracy of movement.</p> <p>In an attempt to appraise in each activity both the functional and the appearance value of the amputee's performance, the significant parts of the performance were rated with regard to positioning movements for grasp and release, appearance and effectiveness of control motion, and control of finger pressure. The ratings were then combined in an over-all score on the basis of the following 10-point scale:</p> <p>Excellent (10). Graceful, rhythmic, fast, accurate performance closely approximating the cosmetic value of a performance by a normal person.</p> <p>Good (8). Smooth, rapid performance involving one or two errors and some slight body and limb distortion in several positions.</p> <p>Average (6). Uneven, somewhat inaccurate performance with occasional errors, some effort, and some body distortion.</p> <p>Fair (4). Slow performance marred by errors and uncosmetic limb and body positions.</p> <p>Poor (2). Awkward, strained, slow performance with fumbling, excessive movement, and many errors.</p> <p>The observer interpolated ratings of 9, 7, 5, 3, and 1 when indicated.</p> <p>The ability of the arm amputee to grasp and hold objects securely with a prosthesis is dependent partly upon the amount of power the man-machine combination can furnish and partly upon the structure, size, and shape of the terminal device. The number of errors made during the test was recorded, two kinds of errors being considered-grasp errors and compression errors. A grasp error was counted when the amputee regrasped an object in an attempt to obtain a more secure grasp, when the object, once grasped, fell from between the fingers of the terminal device, or when the object slipped within the fingers to the extent that the amputee had to reduce his speed or otherwise interrupt his performance to avoid dropping it. The ability to control finger pressure was appraised by tallying the number of compressible objects distorted and judging the extent of the distortion.</p> <p>Considered alone, the time taken to perform a particular activity may not be a satisfactory indication of efficiency. When considered in relation to accuracy and appearance, however, it may be an important factor, particularly in view of frequent amputee complaints regarding inability to work rapidly. In the prehension test, the amputee stood at the table and began at his own volition, a stopwatch being started with his first movement. The watch was stopped as the last object was placed in the appropriate recess on the form board, and the elapsed time was recorded.</p> <h5><i>Positioning Test</i></h5> <p>Although prehension may be considered the primary function of both the normal hand and the prosthetic replacement, the ability to position the hand or its substitute in space is a key factor in utilization. The normal, two-handed person has occasion to reach for, grasp, and release objects in three planes. He commonly handles objects at the level of the mouth, the chest, and the mid-thigh, and objects at chest or waist level up to 1-1/2 feet on either side of him are usually within his reach. To study the ability of the amputees to employ their prostheses in these areas, use was made of the positioning test, which involved six common hand positions. The six exercises devised to assess the ability of an amputee to operate his terminal device at different positions required the subject to place a 6- X 3/8-in. dowel into a clip positioned on the wall and so arranged that release of the dowel was required in both vertical and horizontal positions. Before the actual tests, each amputee was given a trial run to familiarize him with the procedures and to let him decide upon the best approach to each of the test situations. <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>In the performance of this test, the amputee was required to remain within a rectangle drawn on the floor 18 in. wide and extending 36 in. from a wall. He stood outside this restraining area until, on the signal to begin, he stepped into it. Although he was required to remain there while performing each of the tasks, he was permitted to reach over the restraining lines. The patient was told:</p> <ul> <li>"Hold this stick in your sound hand and stand behind the restraining line."</li> <li>"When I say 'go,' grasp the dowel in your prosthetic hand (hook), step into the restraining area, and place the dowel in the clip on the wall."</li> <li>"Do this as quickly as you can after you receive the signal, but do it as smoothly and as accurately as you can."</li> <li>"If you drop the stick while trying to place it in the clip, or at any other time, pick it up and continue the test."</li> <li>"You are being tested on your ability to place the stick in the clip as quickly as possible with the least amount of excessive movement."</li> </ul> <p> Proficiency in this test depended upon maintaining a relatively normal posture and appearance while operating the terminal device at varying distances and angles from the body. The cosmetic value of the performance was related to ease, grace, and smoothness of body movements and to associated characteristics in prosthetic control motions, while effectiveness was reflected in the speed and accuracy of positioning the dowel in the clip. Rated individually were body- and limb-positioning movements, appearance of prehension control motion, and appearance of elbow-lock control motion. These were then consolidated into a rating of total performance by use of the same type of 10-point scale as in the prehension test: excellent, 10; good, 8; average, 6; fair, 4; poor, 2. Again, ratings of 9, 7, 5, 3, and 1 were interpolated as necessary. The time required to perform each positioning test was recorded by means of a stopwatch. <b>Fig. 19</b>, <b>Fig. 20</b>, <b>Fig. 21</b>, <b>Fig. 22</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 /><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>Practical-Activities Tests</h4> <p>The practical-activities tests called for each amputee to be tested in the performance of eight activities of daily living selected from the 20 common activities discussed heretofore. For each individual the activities varied in accordance with the criteria of frequency and importance previously mentioned (i.e., each amputee was tested on the eight activities he reported as occurring most frequently in his routine of living). In choosing between activities of approximately equal frequency, those regarded by the subject as of greater importance were selected for test.</p> <p>In the discussion of the temporal sequence of events during performance of the prehension test, it was pointed out that four phases of the performance could be isolated: the positioning movements for grasp, the grasp itself, the transporting of the object, and the positioning movements for release of the object. With one major exception, this breakdown served equally well as a guide to the more complex practical activities. Here, unlike the situation prevailing in the prehension test, the amputee must not only transport an object but must also make sure it arrives at a position where it can be used or manipulated purposefully. Moreover, the nature of the prehension test forced the amputee to pick up each object from the table without use of the sound hand, a feature that made it necessary to position the body and the prosthesis so that the object could be grasped with the terminal device. In routine practice, however, the amputee frequently picks up an object with his sound hand and places it in his terminal device, thus eliminating many of the positioning movements otherwise required for grasp.</p> <p>With special reference to practical-activities tests, therefore, we may speak of "positioning movements for use," as distinct from "positioning movements for grasp or release," to mean the sequence of motions adopted by an amputee to bring an object into position for the performance of a useful task. Each activity was rated according to the normalcy of the pregrasp positioning movements, the security of the grasp, and the adequacy of positioning for use. The first two were scored on the same basis as in the prehension test; the degree of awkwardness in the positioning movements was rated and the number of errors tallied.</p> <p>Positioning for use, however, refers to the manner in which an object is grasped as that relates to the intended manipulation or use of the object. For example, when the normal hand holds a telephone, both mouthpiece and receiver are positioned close to the face for ease and comfort in hearing and speaking. The artificial hand of an amputee may hold the telephone at some distance from the face, thus necessitating some undue amount of compensatory head-bending. Or the hearing end of the telephone may be held against the ear while the mouthpiece is at eye level rather than mouth level. Errors such as these in positioning an object for use may be due either to faulty judgment on the part of the amputee or to limitations inherent in the prosthesis. Whatever the cause, the adequacy of positioning in relation to ultimate use was rated in terms of the deviation from normal position and of the degree of compensatory movement necessitated by the position of the object in the appliance. These scores were then combined in an over-all rating of the functional and cosmetic value of the amputee's performance in each activity. Rating was accomplished on a 10-point scale as follows:</p> <p>Excellent (10). Object position does not deviate from position for normal use, nor are compensatory body and limb positions necessary.</p> <p>Good (8). Object deviates slightly from position in which the normal hand would use it; slight deviations in body and limb positions may also be present.</p> <p>Average (6). Object deviates somewhat from normal position, and some compensatory deviation in body or extremity position is necessary to use the object.</p> <p>Fair (4). Object shows marked deviation from normal position for use and necessitates somewhat awkward body and limb positions to accomplish the task.</p> <p>Poor (2). Object shows marked deviation from normal position for use, accompanied by strained, awkward, or obtrusive body and limb positions.</p> <p>The observer interpolated ratings of 9, 7, 5, 3, and 1 whenever it was felt to be necessary. In the accompanying annotated illustrations are depicted the materials, instructions, and procedures utilized in the administration of the 20 activities comprising the test series. Every time the amputee began one of the practical tests, he was first requested to perform the task in his customary way. He was told that the series of tests was a means of determining how he performed those tasks normally as part of his activity pattern. It was pointed out that he was being rated on how well he did the entire task regardless of the specific use he made of the prosthesis. The basis for rating the over-all appearance of the performance was the same as that for the prehension test, and the time taken to complete each test activity was recorded. <b>Fig. 23</b>, <b>Fig. 24</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 /> <h3>Results</h3> <h4>Reliability And Validity</h4> <p>Fundamentally a test is an instrument for measuring the extent or absence of a trait or attribute. To be most meaningful, test results must be both reliable and valid.</p> <p>The reliability of tests which are scored by means of judgmental ratings depends upon the use of consistent standards in rating performances, and ordinarily precautions are taken to ensure a comparable frame of reference among the raters. During the course of these studies, the reliability of the raters' judgments was evaluated periodically and found to be reasonably satisfactory. A stringent statistical analysis at the completion of the studies (Appendix I) confirmed the reliability of the ratings on the abstract-function tests. But because too few practical-activity tests were scored by each rater, the reliability of the practical-activities ratings could not be assessed in the same way.</p> <p>The validity of a test rests upon the degree to which it actually measures what it is designed to measure. Selection of the abstract-function tests was based upon an analysis of the functional requirements of prosthetic utilization, the skills involved being those necessary to operate the prosthesis under any circumstances. Since these tests were designed to evaluate proficiency of prosthetic use by direct measurement of meaningful performance with prostheses, they have a certain amount of face validity. The validity of the practical-activities tests appears to be self-evident, since the amputee's ability to perform a given task was in this case determined by having him actually perform it in the presence of the raters.</p> <h4>Abstract-Function Tests</h4> <h5><i>Prehension Test</i></h5> <p>As might have been anticipated, the ratings of below-elbow and above-elbow cases in the prehension test clearly indicated that performance was related to amputation level. That is to say, the average below-elbow performance level was consistently better than above-elbow performance in both pre- and post-treatment evaluations (<b>Table 24</b>). An important point reflected by these data is that the discrimination of differences by the prehension test may be regarded as evidence supporting the validity of the test. Experience indicates that the below-elbow amputee generally accomplishes more with a prosthesis and performs in a smoother and easier way than does the above-elbow amputee. Since it distinguishes these two groups clearly, the prehension test may be said to measure those qualities which distinguish the adequacy of performance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Comparison of performance ratings in the pre- and post-treatment evaluations, presented in <b>Table 24</b>, reveals a definite but not always statistically significant improvement in prosthetic function. For the 75 subjects comprising the below-elbow sample, the mean for the new arms was 5.8 as compared with 5.5 for the old. Although this difference is not significant statistically, closer study of the scores made at the two evaluations indicates a small but definite improvement in performance, especially through the middle of the score range, where there was a marked decrease in the number of amputees receiving ratings of 4 and 5 and a sharp increase in those receiving ratings of 6. It appears then that, although the treatment program had little effect on below-elbow amputees who exhibited very poor or very superior skills with their old arms, it did improve the "low-average" performers. <b>Fig. 25</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 reported in Part 1 of this Section, the below-elbow group as a whole felt that their new arms were somewhat more useful and easier to operate than the old. But this improvement was less marked than that at other levels of amputation, and some below-elbow subjects even felt that the new prosthesis was inferior to the old. The data thus tend to corroborate an earlier conclusion that for the less severely handicapped below-elbow amputee the improvement in prehension skill was not outstanding. By contrast, the 51 above-elbow cases showed a decided improvement in prehension performance with the prostheses fitted in the Field Studies. Statistically, the 4.9 average achieved with the program prostheses was significantly higher than the 4.0 average attained with the old arms. A comparison of the scores at the two evaluations revealed a clear-cut and consistent shift in the direction of improvement of performance. There was a marked decrease in the number of amputees scoring below 5 and a sharp increase in those scoring above 5. It may therefore be concluded that there was a general elevation of the level of above-elbow performance, the greatest improvement being evidenced among those of low and low-average skills. With only four cases available for analysis, the findings for the shoulder-disarticula-tion amputees are of limited significance, although among the four there was also a definite trend toward improvement in post-treatment performance.</p> <p>In general, the results obtained in the functional tests of the above-elbow and shoul-der-disarticulation amputees correspond to the verbal reports, which strongly indicated that the program prostheses were more useful, easier to operate, and more extensively used. Improvement in these two groups was more marked than in the below-elbow group, and it may therefore be concluded that the more severely handicapped segments of the amputee population derived the most benefit from the program prostheses and that the benefits accrued principally to the poorer performers. <b>Fig. 26</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 speed with which amputees performed the prehension test was also related to level of amputation, the below-elbow subjects taking significantly less time than the above-elbow cases to complete the test at both pre- and post-treatment evaluations. For no group (below-elbow, above-elbow, or shoulder-dis-articulation) did the average amount of time taken to perform the prehension test decrease significantly after treatment. The data for the below-elbow and above-elbow subjects are presented in <b>Table 25</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>According to these findings, improvement in performance skill was not reflected in an appreciable increase in performance speed, but the reasons for this apparent inconsistency are not clear. One possibility has to do with the increase in the number of subjects using APRL terminal devices at Evaluation II as compared with Evaluation I (below-elbow, from 14 to 37; above-elbow, from 8 to 31). The "double-shuffle" control motion involved in this type of device, and the consequent increase in the time required to operate it, may account for the failure to increase speed along with skill and ease of operation. At the same time, however, there is a suggestion that slower operation with APRL devices is accompanied by smoother and easier prehension.</p> <p>Two kinds of errors, grasp and compression, were recorded. Grasp errors were counted when an object slipped or fell from the terminal device or when it had to be regrasped. Compression errors were scored when the rubber objects were distorted by poor control of finger pressure. On both pre- and post-treatment evaluations, the below-elbow cases made fewer grasp errors than did the above-elbow amputees (<b>Table 26</b>). The shoulder-disarticu-lation cases made substantially more grasp errors than did either the below-elbow or the above-elbow subjects. The below-elbow subjects made fewer grasp errors after treatment (average: 8.0) than at Evaluation I (average: 9.2), but the difference was not significant statistically. There was little difference in the number of grasp errors made by above-elbow amputees before (10.0) and after (9.7) treatment. While the shoulder-disarticulation cases showed a stronger trend toward improvement in grasp security than did either of the other two groups, the result should be interpreted cautiously because of the small number of subjects involved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Thus it would appear that, despite the changes made in terminal devices, harnessing, and control-system alignment, grasp security was not greatly influenced by the treatment process. Perhaps the principal limitation was the lack of "all-purpose" versatility in the hook, its rigid structure preventing it from being completely suitable for handling a variety of objects.</p> <p>Unlike grasp errors, compression errors decreased in frequency among both below-elbow and above-elbow cases after fitting with program arms (<b>Table 27</b>), and the shoulder-disarticulation amputees appeared to follow the same trend. Below-elbow and above-elbow cases made the same number of compression errors (6.2) in the pretreatment evaluations. After the treatment procedure, there was again little difference between the scores of the two groups, the averages being 4.5 and 4.8 respectively. As one would expect, the shoulder-disarticulation cases made more compression errors than did either below-elbow or above-elbow subjects.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Better control of finger pressure may be explained by the large proportion of APRL devices fitted in the treatment program and also by the contributions from improved harness and control systems. The apparent influence of APRL terminal devices in improving control of finger pressure without also improving grasp security suggests a deficiency in hook size or shape and perhaps also a general lack of emphasis on training for the proper approach in prehension activities.</p> <h5><i>Positioning Test</i></h5> <p>Skill in performance in the positioning test, as in the prehension test, was related to level of amputation, the below-elbow amputees making consistently higher scores, and the positions in which the below-elbow subjects performed best differed from those in which the above-elbow subjects were most effective (<b>Table 28</b>). The below-elbow amputees were most effective at mouth and waist levels in the centerline (Positions 1 and 2); at chest and waist levels toward the prosthetic side (Positions 4 and 5); somewhat less effective toward the sound side (Position 6); and poorest at mid-thigh level in the centerline (Position 3). Above-elbow subjects were most proficient at two waist-level positions (Positions 2 and 5); somewhat less effective at waist level on the sound side (Position 6), at chest level toward the prosthetic side (Position 4), and at mid-thigh in the centerline (Position 3); and poorest at mouth level in the mid-line (Position 1), all of which suggests that the most efficient use of the above-elbow prosthesis is to be had at 90 deg. of forearm flexion and that less efficient operation occurs when the forearm is flexed appreciably more or appreciably less than 90 deg. Shoulder-disarticulation subjects were most proficient in handling objects at waist level, either in the mid-line or toward the prosthetic side (Positions 2 and 5).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Among both above- and below-elbow patients, skill in operating the terminal device in different positions improved significantly after treatment, a result more positive than that obtained from the corresponding prehension test, where improvement was statistically significant for above-elbow amputees only. Analysis of the pre-and post-treatment ratings of the below-elbow amputees revealed significant improvements (<b>Table 29</b>) in the ability to operate their terminal devices in three positions-at waist level in the mid-line (Position 2), at chest level toward the prosthetic side (Position 4), and at waist level toward the sound side (Position 6).</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 time required by the amputees to complete each of the six tests did not appear to be related to the particular position involved, nor did performance time seem to be affected by the treatment process (<b>Table 30</b>). For the below-elbow cases, mean performance times for all six tests varied between 5 and 7 sec. in both pre- and post-treatment evaluations. Similarly, the above-elbow cases performed each of the six tests in approximately the same average time (10 to 16 sec. at Evaluation I, 9 to 14 sec. at Evaluation II).</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 by definition the positioning test is "abstract," the level of performance in the several positions bears a relationship to the ability that may be expected in the performance of practical activities in the same positions. Improved performance in the test should be reflected either in greater ease in use of the prosthesis or else in the ability to perform more activities with it. Since in all cases there was an improvement in test performance after treatment, there is strong indication that treatment resulted in im- proved skill in utilizing a prosthesis in the positions required for the pursuit of the normal pattern of daily activities. While the available evidence is not wholly definitive, the distinct shift toward higher scores after treatment must be taken as indicating a general improvement in achievement level.</p> <h4>Practical-Activites Tests</h4> <p>In contrast to the abstract tests of prehension and of positioning a prosthesis, the practical-activities tests were designed to evaluate the amputees' ability to integrate the mechanical operations of prehension and positioning into the efficient performance of a complete and meaningful task. From the list of 20 tasks there were selected for each amputee eight specific test activities which, according to the subject's own statements, occurred most frequently for him in his normal activity pattern and to which he himself attributed the most importance. By virtue of these criteria some tasks were tested less frequently than others. The present analysis involves only those activities performed by 10 or more subjects.</p> <p>On this basis, the below-elbow subjects received substantially higher scores than did the above-elbow cases, a fact which only substantiates the superior ability of the below-elbow amputee in coping with daily needs. The average, weighted, pretreatment performance rating was 6.4 in below-elbow cases, 5.0 in above-elbow cases. After the treatment program, the corresponding figures were 7.0 for the below-elbow and 6.2 for the above-elbow patients (<b>Table 31</b> and <b>Table 32</b>). The scores of the few shoulder-disarticulation cases tested were far below those of either below-elbow or above-elbow amputees.</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>If we consider that a score of 10 represents normal nonamputee performance, then the average score of 7.0 obtained by the below-elbow population for all 20 activities represents a creditable performance. For some tasks, of course, the average was higher than 7.0, and certain individual amputees consistently outperformed the average. It may thus be con- cluded that below-elbow subjects generally perform common daily tasks in a smooth, relatively unobtrusive, errorless manner. Although they never attain a level of skill equal to that of the nonamputee, they (and particularly the better performers in the group) tend to approach that level of performance.</p> <p>The post-treatment skill of the above-elbow group, represented by an over-all weighted-average rating of 6.2, indicates a relatively high level of performance. While the need for an elbow-lock control motion, together with the greater body distortion that results from the lack of an anatomical elbow, reduces the functional level of the above-elbow amputee to less than that of the below-elbow group, the above-elbow patient is nevertheless capable of more or less skillful use of a prosthesis.</p> <p>In the post-treatment evaluation, the below-elbow subjects generally performed better in all of the 15 activities studied. Increases in the ratings ranged from a low of 0.1 point to a relatively significant 1.5 points. Although the average increase (0.6 point) was not substantial, all of the changes were in the expected direction, an increase of a full point or more being achieved in five of the activities. A similar trend characterized the performance of the above-elbow subjects, where improvement (ranging from 0.1 point to 2.8 points) occurred in all 11 activities studied. In eight of the activities there was a gain of at least one full point, the average for all 11 being 1.2 points. The magnitude of the gains and the number of activities in which significant improvement occurred were both greater than in the case of the below-elbow subjects.</p> <p>It should be noted that most of the 20 shoul-der-disarticulation amputees taking the test at the post-treatment evaluation were capable of performing six to eight of the 20 activities. Apart from considerations of the quality of performance, this outcome represents a significant increase in the number of activities those subjects were capable of performing.</p> <h3>Discussion</h3> <p>Proficiency in the use of arm prostheses is clearly related to level of amputation. The performance of the below-elbow amputees in the NYU Field Studies was found to be consistently better and faster than that of the above- elbow amputees, who in turn performed better and faster than did the few shoulder-disarticu-lation amputees involved. Differentiation of performance was apparent in all tests, both before and after treatment.</p> <p>The most important single reason for the superior performance of the below-elbow amputee lies in his retention of the natural elbow. The above-elbow amputee is required to operate a mechanical elbow scarcely designed to provide all the functions of the natural elbow. Coupled with this mechanical limitation is the relatively high degree of skill required to operate present-day mechanical elbows smoothly and unobtrusively. Together these two factors impose upon the level of above-elbow prosthetic performance an insurmountable upper limit. The difficulty is only magnified in the case of the shoulder-disarticulation amputee, who must operate both a terminal device and a mechanical elbow by scapular abduction, a motion more gross and yet more limited than the humeral flexion normally available to both above- and below-elbow amputees. Further development and refinement of existing elbows and an increased emphasis on amputee training could conceivably elevate the level of above-elbow and shoulder-disarticulation performance to some degree. But radical changes to bring the above-elbow or shoulder-disarticulation amputee functionally up to par with the below-elbow case must await new concepts and designs in the development of components and control systems.</p> <p>As a result of the treatment program in the NYU Field Studies, the ability of all the amputee subjects to use their prostheses improved to varying extent. The superiority of the newer components and newer fabrication procedures, and the systematic training given to each patient as a routine matter, contrived to produce a general benefit differing only in degree from subject to subject and from amputation level to amputation level. That the improvement in performance among the below-elbow amputees was relatively small indicates that as a group they derived the least benefit from the new developments, for the obvious reason that their relatively high level of proficiency prior to the studies discounted their ability to profit greatly from the program. The more significant gains made by the above-elbow and shoulder-disarticulation amputees identified these groups as the major beneficiaries of the Field Studies. Although as a group the above-elbow subjects never quite attained the achievement level of the below-elbow amputees, the gap between them was significantly smaller after the treatment program, and as individuals the few shoulder-disarticulation cases improved markedly.</p> <p>The prostheses prescribed in the program were designed to provide maximum comfort, freedom of movement, and optimal replacement of lost function. The more significant improvements included higher, better-fitting, and better-appearing sockets; more useful and more easily operating elbows; improved efficiency of force transmission through better cable alignment and use of more stable materials; lighter, freer, and more comfortable harnessing; and a marked increase in the use of terminal devices offering improved control of grasp force. The advantages offered by these features were apparent in the prehension test, in which the objects to be manipulated remained stationary and the amputee was required to place himself and his terminal device in the best position for grasp and release. The need for compensatory body movements, which tend to lower performance ratings, was clearly reduced by the increased freedom and mobility of the new arms. The increased control of finger pressure offered by the new devices was reflected in the general and significant decrease in the number of compression errors made at the second evaluation.</p> <p>The value of the newer elbows seemed to be demonstrated by the improvement in performance of the above-elbow cases in the positioning test. The higher scores on the second test were based on more accurate positioning of the terminal device with lessened body contortion-a function of the elbow unit. It is interesting to note that, while performance ratings improved after treatment, speed of performance remained static. With the wider use of APRL devices on the second evaluation, an increase in the time required might have been expected. Since operating time did not increase, improved control of finger pressure was achieved without a concomitant slowing of performance.</p> <p>The similarity in performance patterns in the abstract-function and practical-activities tests may have important clinical consequences. Further study is warranted to see whether proficiency in the practical utilization of a prosthesis is related to, and perhaps reflected by, performance in abstract-function tests. Should such a relationship be found, it would be possible to convert the easily administered abstract-function test from a research tool to a clinical instrument. A combination of the more sensitive and selective elements of the tests could provide the foundation for a reliable system of measuring achievement and proficiency in amputee training.</p> <p>As a result of the Upper-Extremity Field Studies, it is now possible to establish a set of proficiency norms based upon amputee per- formance but retaining as its main criterion the skill patterns of nonamputees. The therapist who trains an arm amputee to use a prosthesis could thus have available a realistic and relatively objective standard against which to evaluate the progress and achievement of each patient, since she would be comparing his performance with that of hundreds of amputees of a similar type. The resulting improvement in the evaluation of training effectiveness should permit a judicious allocation of training time and services. Despite its inadequacies of crude-ness and of administrative difficulty, the performance-evaluation system described here established for the first time a logical plan for ascertaining the degree of functional restoration offered amputees by modern prosthetics services, a problem heretofore frequently bypassed for lack of reliable and valid methods.</p> <h3>Concluding Remarks</h3> <p>Refinement of the existing research tools on the basis of past experience, reapplication of these methods in the light of present knowledge, and the further correlation of results may well make it possible to predict the anticipated outcome when specific prosthetic components are applied to a particular arm amputee. Such an eventuality may lead to major changes in the principles of arm prescription and fitting as currently embodied in the art-science of upper-extremity prosthetics.</p> <p>The results of these studies, which have been analyzed and interpreted in the discussion sec- tions on pages 54-61, 99-103, and 143-149, are not resummarized here by way of concluding this article. It is perhaps sufficient to close with the remark that there has been presented in this article a large volume of information providing new insights-some clear, some tentative-into the over-all problem of evaluating arm prostheses. The surface of this broad field has been partially mapped along with some scattered probings of the substrate; but certainly the way has been opened for those who may elect to pursue this problem a little further.</p> <h3>Appendix I Reliability and Validity of the Test Methods</h3> <h4>Reliability</h4> <p>It is well known that test results are subject to a variety of influences and that therefore errors of measurement are to be expected under the best of experimental conditions. The tests used in the NYU Field Studies were at the time in a developmental stage, and in anticipation of errors tending to reduce reliability several precautionary steps were taken.</p> <p>Three measures were employed in scoring the performance tests-performance rating, number of errors, and time. The reliability of the last two is not open to serious question, since such errors as are likely to occur in counting errors or in reading a stopwatch are not usually of significant magnitude or of a systematic nature and can be expected to vary randomly and "average themselves out." Performance ratings, being based on judgment, are more variable, so that errors tending to reduce reliability are to be expected. Some of the principal sources of bias in this study may have been:</p> <ol> <li>Errors of Leniency. Judges tend to rate higher in the desirable traits the subject they actually know.</li><li>Errors of Central Tendency. Judges hesitate to give extreme ratings and so tend to displace subjects in the direction of the average for the entire group, thus misrepresenting the true variation in the group.</li><li>Halo Effect. We tend to judge in terms of the general mental attitude toward the test situation. Knowing, for example, that a subject is being tested for the second time, with an intervening period of fitting and training, a judge may tend to upgrade the performance unduly.</li><li>Normal Variation in the Attitude of the Judge. As individuals, we are continuously influenced by our physical environment and emotional status, and the net effect may produce variability in judgment.</li><li>Variations in Judges' Values. A judge's preconception about the relative difficulty of activities, or of the value to be placed upon efforts in relation to achievement, may bias his judgment.</li></ol> <p>During the course of the studies, 12 NYU Field Representatives conducted the performance tests over a 3-year period between 1953 and 1956. At no one time were all of the judges active in the work, and as a result they did not conduct equal numbers of tests. Nor was it always possible for the pre- and post-treatment evaluation of a patient to be judged by the same rater. Steps were therefore taken to maintain the reliability of the ratings by familiarizing judges with probable sources of error and by firmly establishing the judgment criteria. In addition, all judges were highly qualified members of the NYU staff, with previous research experience in testing and assessment. All were either graduates of the course in upper-extremity prosthetics at UCLA or else had been given similar instruction at New York University. Moreover, the criteria for evaluating performance were carefully studied in formal sessions by all the judges to aid in the development of consistent standards of judgment. The effectiveness of these steps in maintaining reasonable reliability was gauged by statistical analysis.</p> <p>Evidence of reliability was obtained by comparing periodically the independent but simultaneous ratings of a single performance as arrived at by several judges. The ratings thus obtained were evaluated by means of a statistical procedure involving Kendall's Coefficient of Concordance,<a style="text-decoration:none;">*</a> which indicates the degree to which a number of raters are applying essentially the same standard. Kendall's coefficient (W) is used to evaluate the difference between the variability in a set of ratings actually obtained and the variability to be expected in a hypothetical set of ratings if there were perfect agreement among all the raters. The resulting single measure of the extent of agreement among several judges is usually expressed as a chi-square function [x2 = p(m - 1) W, where m = number of judges and p = number of scores]. If the difference (in degree of variability) between the obtained and the hypothetical sets of ratings is significant (by statistical test), we may assume that not all of the raters were applying the same judgmental standard. Since of the original 12 raters in the Field Studies only eight rated enough cases for the results to be valid, only these eight were included in this and succeeding analyses of homogeneity. The statistical findings (x2 = 14.47; df = 7; P &lt; 0.05) indicated that a hypothesis of no relationship between the sets of ratings given by each rater is untenable. This may, therefore, be considered as indicative of a satisfactory degree of consistency in the judgments of the raters at those times. To test the reliability of the scores given by the judges during the entire test period, another technique, "analysis of variance," was used.</p> <p>"Analysis of variance" is a statistical procedure by which a number of independent samples or sets of scores may be tested simultaneously to determine whether or not they are sufficiently similar to be pooled. It is an efficient method for evaluating inter-rater reliability when more than two raters are involved. The test is expressed in terms of a ratio, F, which describes the relationship between the variability of the scores among the several raters (between groups) and the variability of each rater's scores from the mean of all raters (within groups). Simply stated, it is a test of a hypothesis that the scores given by any one rater did not vary significantly from the average of the scores given by all the raters. As shown in the relationship the larger the variance from one rater to another (between groups) as compared with a single rater's variance from the common mean (within groups), the larger the fraction (F). A large F signifies a great difference between the raters; an F of low value indicates homogeneity in the group. A low ratio therefore indicates that performances were consistently rated, that the raters are therefore interchangeable, and accordingly that all the ratings may be considered as having been given by the same rater. <b>Fig. 27</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>Because of the small number of cases involved, this technique could not be applied to the data from the practical-activities tests or from the abstract-function tests for the above-elbow sample at the pretreatment evaluation. It was applied to the ratings given the below-elbow cases on administration of both the prehension and the positioning test and to the ratings given the above-elbow cases at the post-treatment evaluations (<b>Table 1</b>). There were thus 21 tests in which individual raters had scored enough cases for reliability studies to be made by this means. Used were only those ratings given to subjects evaluated on both pre- and post-treatment tests by the same group of raters. Which is to say that, although an individual rater may not have scored the same subject on both evaluations, he was a member of a group of raters who had given all the ratings.</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 21 tests, 17 were not significantly different (0.05 level). That is, the extent to which they varied is well within the relatively narrow limits of chance fluctuation, which indicates an acceptable degree of consistency and reliability among the raters. Four, footnoted in <b>Table 1</b>, were statistically significant beyond the 0.05 level of confidence (i.e., there was enough variation in the ratings in these tests to raise a question about the consistency of rating standards).</p> <p>Despite the significant F value obtained in the four questionable tests, all results were used in this report. While the lower statistical reliability of the four may indicate rater unreliability or instability due to smallness of the sample (which would suggest the possibility of eliminating either these tests or the extreme raters), they were retained because the results clearly followed the trend of those tests appearing more reliable statistically. Since, furthermore, all of the tests are, or were, in a developmental stage, no theoretical reason could be adduced for their low reliability. There seemed to be greater value in retaining all of the tests and analyzing the conditions affecting reliability than in discarding some tests on statistical grounds alone. Considering the implications of the findings from all 21 tests, the ratings seemed homogeneous enough to warrant pooling.</p> <h4>Validity</h4> <p>To establish the validity of a test on empirical rather than logical grounds requires a previously established independent criterion with which to compare the test in question. The degree of correspondence between the two (i.e., the extent to which the test measures the same variable as does the independent criterion) is the extent of test validity. External criteria usually are: a specific outcome or product of an activity (as, for example, the number of words typed by a typist in a specific time is a criterion of typing speed), or the activity itself (as illustrated by the speed of a runner as a criterion of fleetness of foot), or the judgment of persons qualified in a given field. The abstract-function tests-the prehension test and the positioning test-require activities which correspond closely to the skills being measured (i.e., to the ability to grasp a very wide variety of objects and to operate a terminal device in several useful planes). No other criteria appear more germane. The practical-activities tests derive their validity in the same fashion-each activity is a valid test since it is itself the skill being measured.</p> <p>To go a step further and to determine whether all or none of these tests are also useful measures of "prosthetic utilization" or of "extent of functional restoration" or of "rehabilitation" requires broader study and the use of other criteria. The presently available judgment of qualified clinic personnel may be the most useful criterion with which the tests may be compared. If, for example, the way in which amputees were classified on the basis of the test results was closely related to qualified judgment about amputee achievement, it would tend to establish the validity of the test as a measure of prosthetic utilization. Such an analysis is beyond the scope of the present work but remains as an interesting avenue for further study.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Siegel, S., Nonparametric Statistics for the Behavioral Sciences, McGraw-Hill, New York, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">The five kinds of tasks selected were considered as encompassing the major undertakings in which an arm amputee might use a prosthesis in the course of daily living.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 Peizer, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Associate Director, Children's Prosthetic Study, Research Division, College of Engineering, New York University; formerly Field Supervisor, PDS, NYU.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Associate Director, Prosthetic Devices Study, Research Division, College of Engineering, New York University; formerly Field Supervisor, PDS, NYU.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-027.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-029.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-030.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-028.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-031.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-032.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-033.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-034.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-035.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-036.jpg Figure 11 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-037.jpg Figure 12 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-038.jpg Figure 13 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-039.jpg Figure 14 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-040.jpg Figure 15 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-041.jpg Figure 16 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-042.jpg Figure 17 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-043.jpg Figure 18 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-044.jpg Figure 19 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-045.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 VI. Prosthetic Usefulness and Wearer Performance Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * Edward Peizer, Ph.D. * https://staging.drfop.org/files/original/79a235e1d4c4ac4171b6ad7c96f90851.pdf 7d14943ca2f5c25f952db617169ffdde https://staging.drfop.org/files/original/d93a7f5e6bfbb40a83f52c51fc6a67a0.jpg db9f1ea0b3a5c0dae6916c1ef66fda44 https://staging.drfop.org/files/original/7cfe500718aa89f77b72e9954ceaa92a.jpg bc918fbb4fd53f2e78ad4605c3abc065 https://staging.drfop.org/files/original/f998e66b14d6b1f834d759185e8e31cc.jpg 690db42406a21e4599e9835f0033c37a https://staging.drfop.org/files/original/559362f3b4c65498619fab8d04b2e42d.jpg f404f1ed2a48fcbad91850fac32efb17 https://staging.drfop.org/files/original/7af014f5d48267ea4832e4f0ba735e65.jpg 609b9bfd8cf0cad72c5cf2fd2ea68995 https://staging.drfop.org/files/original/6da85b1d4d85e1ce07a103930d4575b1.jpg c18a528ba271b6327ebd72aa14550653 https://staging.drfop.org/files/original/1c2e54190c5087e85a7fbc06ef5d358c.jpg 475202f1811c126dfb0443740358cd5a https://staging.drfop.org/files/original/77afa88f7126e3389bfeddccc24b5a2f.jpg 96215102b821993251b391e9acb6d3f2 https://staging.drfop.org/files/original/2371fc89399f73ef4387072b2b40d799.jpg 18b9d437398b6a98ea408c303b0a1ee2 https://staging.drfop.org/files/original/d8cedb74083df4c71c32c360d03b67b8.jpg 5808de98d275b210021d7c661d2ff3d9 https://staging.drfop.org/files/original/163c3b8f65e454aba7ec0bfafdbca66a.jpg 0cb901d66c2c9cdede16bf37b1b551a7 https://staging.drfop.org/files/original/345ce876e71543363ff3c14412c219fb.jpg 8d1848456d7991653f7e3dcad092df20 https://staging.drfop.org/files/original/24ae1765809e82da9084f33c1af4ad5d.jpg 45f56fde2581a9b627c3e7b20f49bae8 https://staging.drfop.org/files/original/684aa5896d82c06bec7a0f958890cadb.jpg b8ce7048f8e79c9339b98b24877b4692 https://staging.drfop.org/files/original/c0e25772039790e312707e0a3e972640.jpg 74351e8b3732f843b1e09d0acc3a1e30 https://staging.drfop.org/files/original/fa307185379e510f725ef82250490487.jpg 90909e24310f83b7ade0e3c07b5cd24b https://staging.drfop.org/files/original/339a789db42e3eea242dd8c322350790.jpg 50a04b08971e95aabb20ffd944f2163c DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1962_02_004.pdf Year 1962 Volume 6 Issue 2 Page Number(s) 4 - 15 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/1962_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1962_02_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>Anatomical and Physiological Considerations in Below-Knee Prosthetics</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br />A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>One of the most difficult problems in the design of prostheses is the development of the best means of attaching the prosthesis to the wearer. In lower-extremity cases, transmission of forces between stump and prosthesis is of primary importance. To effect efficient transmission of forces, a stable connection between stump and prosthesis is necessary. At the same time comfort and freedom of motion must be maintained to as high a degree as possible. All of these goals are affected by anatomical and physiological characteristics of the stump and the next proximal joint, and often of the joint above that.</p> <p>Stability is provided most often by encasing the stump in a socket to a point near the first proximal joint. The soft tissues of the stump are not especially ideal for providing resistance to the torques and moments imposed on them by a socket during use of a prosthesis. If the tissues are compressed in an attempt to provide maximum stability, circulation will be impaired; if the socket is too loose, a false-joint effect is produced resulting in abnormally high unit pressures at proximal and distal points, chafing, and a reduction in ability to control the prosthesis. Thus, extreme care must be exercised in socket design and fabrication if the optimum condition is to be obtained.</p> <p>When weight-bearing can be achieved through the long bones, as in the case of many disarticulations and certain special types of amputation, the socket is designed to permit loads to be carried through the end of the bone in the stump. If most of the weight-bearing needed cannot be achieved through the end, some other areas must be found to provide the transmission of forces necessary during standing. For all of these reasons, then, it is extremely important that prosthetists and others responsible for the design of sockets take into consideration certain anatomical and physiological factors in the management of the amputee. In no other case is it more important than in that of the below-knee amputee.</p> <h3>Function of the Below-Knee Stump</h3> <p>Because most of the insertions of the muscles and ligaments that control the knee are located on the tibia and fibula at points close to the knee joint (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>), amputation below the knee rarely affects the function of the knee joint. An exception is the gastrocnemius which originates from the posterior portion of each of the femoral condyles and has for its insertion the Achilles tendon, thus acting as a flexor. Upon amputation, however, the distal end of the gastrocnemius often becomes reattached to the tibia, and the remaining musculature is thus available to assist the flexors and perhaps to aid in preventing dislocation of the fibula with respect to the tibia. Thus the moment that can be generated about the knee in the parasagittal plane by a typical below-knee amputee is approximately the same as that before amputation. Because, in general, the ligaments are left untouched, mediolateral stability of the below-knee amputee usually is not affected.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Posterior view of left knee joint, showing anterior ligaments. Redrawn from Gray's <i>Anatomy.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The major muscles that flex and extend the knee joint. From <i>The Patellar-Tendon-Bearing Below-Knee Prosthesis (4).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. X-rays of a typical below-knee slump <i>. A,</i> Anterior view; <i>B,</i> medial view. Courtesy <i>Veterans Admlnistration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Those muscles which have origins on the tibia and fibula, and which control ankle and foot motion, have been severed and consequently atrophy, resulting generally in a bony, conical-shaped stump (<b>Fig. 4</b>). The amount and type of atrophy that takes place depend of course upon surgical technique and postoperative care.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Lateral and anterior views of a typical well formed, right below knee stump Courtesy <i>Veterans Ad-ministration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In very short below-knee stumps, removal of the fibula (<b>Fig. 5</b>) is sometimes performed to prevent lateral and posterior deviation with uncomfortable protrusion at the distal end. Such deviation is generally thought to be caused by frictional engagement on the socket wall (with inadequate relief) or by action of the biceps femoris. In any below-knee amputee, the distal ligamentous attachment near the ankle is missing, and in short stumps the interosseus membrane (<b>Fig. 6</b>) between the remnants of the tibia and the fibula is presumably inadequate, partly because the proximal opening for the vessels leaves only a small amount of the membrane, and particularly because atrophy of intervening muscles leaves some slack in the membrane. Removal of the fibular head, though, implies that the tendon of the biceps femoris, as well as the fibular collateral ligament, should be reattached with appropriate lengths and at suitable centers on the tibia. A bone bridge from fibula to tibia that would restore stability between tibia and fibula as well as increase the possibilities for bearing weight on the end of the stump would seem to be preferable to removal of the fibula.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Roentgenogram of a short below-knee stump in which lateral deviation and rotation of the fibula have taken place. <i>Courtesy University of California Medical School.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6. Anterior ligamentous structure of the right knee.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Knee Joint</h3> <p> The knee joint formed by the condyles of the femur and tibia (<b>Fig. 3</b>, <b>Fig. 7</b>) allows about 160 dcg. of flexion. It is classified as a synovial joint, or one that is provided with synovial Quid, and the friction developed between the moving surfaces of an unimpaired joint is of an unusually low magnitude as compared with moving joints in machinery.<a></a> It is not a simple hinge joint with a single axis of rotation. Because movement of the tibia with respect to the femur is a combination of gliding and rolling actions, and because of the shape of the contacting surfaces, the instantaneous center of rotation of the knee varies with each degree of flexion. Though the exact course of the instantaneous centers for different individuals cannot be described with present knowledge, a general idea of the typical area through which they move can be had (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Major structures that form the knee joint. From <i>The Patellar-Tendon-Bearing Below-Knee Prosthesis (4).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8. Section through the medial condyle of the femur and through the tibia. The center of curvature is shown for three parts of the articular surface. As gliding occurs in the joint, the instantaneous center moves along the curve connecting these centers of curvature. From Elftman (2).</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For many years it has been common practice to divide the responsibility of weight-bearing between the below-knee stump and the thigh by use of simple hinge joints (located along the medial and lateral aspects of the knee) connecting a thigh corset to the socket and shank (<b>Fig. 9</b>). But, because the center of rotation of the knee moves constantly while flexion or extension takes place, any artificial joint attached on the outside of the leg and thigh that does not follow the complex pattern of the human joint will cause relative motion between the body parts and the prosthesis. Since there is not available an artificial joint that simulates normal movement, it appears highly desirable to provide the below-knee amputee with a prosthesis that does not require side joints, even though the tissues in the stump and thigh are capable of absorbing the effects of some relative motion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9. Some examples of the so-called "conventional" below-knee prosthesis offered by prosthetists for more than a century. Note the sidebars, corset, relatively low brim, and free space at distal end of socket.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Weight-Bearing</h3> <p>If sidebars are to be avoided, obviously all of the weight-bearing loads must be transmitted through the stump to the skeletal system. Some areas on the stump are better suited to assume these loads than others. In the light of present knowledge and technology it is necessary to design and construct the socket so that the pressures imposed on specific areas, whether by normal repeated loads encountered during walking or whether by single emergency loads, are not of values that exceed the varying tolerances of the different tissues of the stump. And just as obviously some means other than sidebars and thigh corset must be found to maintain the limb on the stump. If, however, the necessary mediolateral stability is not present, there is no known recourse except to use at least one sidebar and generally two.</p> <h4>The Patellar Ligament</h4> <p>Extension of the knee is effected by the contraction of the quadriceps muscle, so named because it has four distinct components. However, they merge into a single tendon which inserts on the anterior portion of the tibia just below its head (<b>Fig. 6</b>). Embedded in this tendon is the patella (<b>Fig. 7</b>), which is therefore a sesamoid bone, the largest in the body. Its function is twofold. While acting as a guide for the quadriceps tendon by following the vertical groove between the femoral condyles, it also tends to increase the lever arm of the quadriceps acting about the knee axis. Its cartilaginous underbody tends to produce very little friction as it slides over the anterior surface of the femur. That part of the quadriceps tendon between the patella and the insertion, frequently referred to as the patellar ligament (<b>Fig. 10</b>), is composed of extremely tough fibers which stretch insignificantly under normal tensile loads along the long axis and is particularly suited to take compressive loads anteroposteriorly. Because of the inextensible quality of the quadriceps tendon, there can be little or no relative motion between the patella and the tibia when the quadriceps develops tension, a condition which permits compressive loads over the quadriceps tendon, perpendicular to the fibers, up to the proximal edge of the patella. The sharp lower edge of the patella, though, is relatively unsuited for weight-bearing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Schematic drawing showing the nearly complete lack of relative motion between patella and tibia during flexion of the knee. The inextensibility of the patellar ligament prevents the patella from moving proximally with respect to the tibia. From Marks <i>(3).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Branching out from the quadriceps tendon on each side above the patella are the lateral and medial retinacula (<b>Fig. 6</b>), which insert on the flares of the tibia. Like the patellar ligament, these tendons are capable of weight-bearing.</p> <p>If the socket wall contains an indentation (<b>Fig. 11</b>) between the lower edge of the patella and the tendinous insertion, some initial tension is placed on the tendon. The upper surface of the indentation also permits the tendon to assume a load with a larger vertical component than would be the case if the indentation were not present (<b>Fig. 12</b>). Moreover, when the socket is aligned so that a slight amount of initial flexion is present when the wearer is in the standing position, both initial tension in the quadriceps tendon and the vertical components of load-bearing are enhanced.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11. Vertical cross-section of anterior portion of socket designed to take maximum advantage of patellar ligament for transmission of weight-bearing loads. Compare with Figure 12.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12. Vertical cross-section of anterior portion of socket with little provision for use of the patellar ligament for transmission of weight-bearing loads. Note the small vertical component of the force between socket and stump in this area as compared to the condition shown in Figure 11.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Flares of the Tibial Condyles</h4> <p>By virtue of its wedgelike shape and the nature of its thin, tough, overlying tissues, the upper portion of the tibia can assume part of the weight-bearing load by distribution of pressure over the medial and lateral flares of the condyles. Because part of the lateral flare of the tibial condyle is obscured by the head of the fibula, the medial flare offers most of the weight-bearing area.</p> <p><b>Fig. 13</b> shows horizontal cross sections of the tibia below the condyles superimposed on each other. Thus it can be seen that there is available potentially a considerable difference in horizontal area over which to distribute vertical forces to balance body weight. If the socket is aligned so that the stump is forced into a slightly flexed position when the wearer is standing erect, the horizontal components are reduced, the requirements for counter-pressure over the posterior wall are less, and therefore the risk of pressure over the major vessels and nerves in the rear is reduced. Proximity to relatively sensitive zones like the head of the fibula (typically present under the lateral flare), the sharp tibial crest, and the rough tibial tubercle greatly reduces the useful area on the anterolateral portion. The medial flare, though seemingly smaller than the lateral, is quite effective in providing support.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Horizontal cross-sections of leg at four different levels. View below leg shows level <i>A</i> superimposed on level <i>D</i> to illustrate the horizontal area potentially available for vertical support along the sloping areas of the tibia. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Tibial Crest</h4> <p>The shaft of the tibia is roughly triangular in horizontal section, one apex, the tibial crest, lying in the anterior portion of the leg (<b>Fig. 13</b>). The anteromedial wall of the tibia is covered with a thin layer of tissues and is admirably suited to assume some of the weight-bearing stresses. In the normal limb, the anterolateral wall of the tibia is covered by the tibialis anterior, which inserts in the region of the foot. Upon amputation, the tibialis atrophies but can still transmit, without discomfort, considerable load to the anterolateral wall. But the tibial crest itself cannot assume a weight-bearing load because of the high unit pressures that would necessarily develop over the knifelike ridge. For the same reason, compressive stresses cannot be tolerated either at the lateral aspect of the distal end of the fibula or at the anterior aspect of the distal end of the tibia.</p> <h4>The Head of the Fibula</h4> <p>Because the common peroneal nerve passes on the lateral side below the head of the fibula, only very low pressure can be tolerated in that area. Also, for bony stumps it is sometimes necessary to provide a groove proximally from the region of the head of the fibula in order to permit entry of the stump into the socket. <b>Fig. 14</b> shows in a somewhat exaggerated way how a socket is shaped to preclude the application of pressure in tender areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14. Cross-section showing typical method of avoiding pressure between socket and tender areas on stump, in this case the area about the head of the fibula.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Distal End of the Stump</h4> <p>Few below-knee stumps will tolerate very much pressure on the distal end, presumably because of the shearing stresses developed between soft tissues and the cut end of bone. Short stumps, where amputation was made through cancellous bone, and those cases where a bridge of bone has formed between the distal ends of the tibia and fibula, accidentally or surgically, are exceptions to the rule.</p> <h3>Stability</h3> <p> Vertical pressures on the areas projected on the horizontal plane, and hence total vertical forces, unhappily can be obtained only as <i>components</i> of the larger unit pressures and total forces exerted at right angles to the obiquely sloping surfaces of the stump, the thin but tough underlying tissues, and ultimately the bone (<b>Fig. 15</b>). Because these surfaces slope, there must be forces <i>in</i> the horizontal plane. Because the slowly curving surfaces slope generally <i>inward</i> toward the longitudinal axis of the tibia, in the frontal plane that fraction of the horizontal components of the sloping forces from the socket acting on the broad medial aspect of the condyles must oppose the corresponding components of the force acting on the more limited lateral aspect, resulting in over-all compression or constriction of the stump. Any net imbalance near the condyles may be counteracted by a distal horizontal force to yield in the frontal plane a moment balanced elsewhere. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 15. Schematic drawing showing the approximate direction of forces acting on the flares of the tibial condyles. The vector representing the force on the lateral side is shown in true view in the lower sketch. Note the components developed in the horizontal plane. The components shown must of course be balanced by other forces in the horizontal plane.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Because both the medial and lateral condyles slope generally <i>backward,</i> the horizontal components in parasagittal planes would tend to force the stump backward and hence allow it to slip downward off the sloping shelves matching the tissues overlying the condyles. Similarly, forces on the patellar ligament and retinacula have components directed rearwardly. Obviously, counterpressures from the rear wall must be so distributed over the stump as to develop adequate counter-forces without pressure sufficient to cause pain at any point, restrict return circulation, or interfere with adequate knee flexion during sitting. Superimposed on these forces acting in the horizontal plane as a result of vertical weight-bearing there generally are other forces, high on one aspect of the stump and low on the opposite, forming couples related to mediolateral stability, forcible knee extension, and so on. </p> <p>The optimum level for the rear brim of the socket is the popliteal crease. Though as high a brim as feasible is desirable to provide greater area for horizontal counterpressure, a rigid socket brim above this level on the posterior aspect will seriously restrict knee flexion; one below results in bulging of the tissues over the brim during flexion.</p> <p>The medial and lateral aspects of the socket wall should be carried to about the level of the proximal edge of the patella to enhance mediolateral stability.</p> <h3>The Hamstrings</h3> <p>The most important flexors of the knee are the hamstrings, which have two areas of insertions-one on the posterior aspect of the medial tibial condyle, the other on the posterolateral aspect of the head of the fibula (<b>Fig. 2</b>). As flexion occurs and the tibia and fibula rotate with respect to the femur, the hamstrings move away from the center of the femur. To prevent bunching of the tissues in the popliteal space during substantial knee flexion, especially during sitting, the brim of the socket should be brought precisely to the level of the popliteal crease. Because the two insertions of the hamstrings are below this level, interference between the hamstring tendons and the brim of the socket would occur when the knee is flexed were appropriate grooves, or cutouts, not provided in the rear portion of the brim. The medial groove is generally deeper than the lateral because the insertion of the semi-tendinosus is more distal on the tibia than the insertion of the biceps femoris is on the fibula.</p> <h3>Edema</h3> <p> One of the causes of edema is an unbalanced condition in the interchange of materials between blood and body cells by way of the capillary and lymphatic systems, <i>i.e.,</i> more fluid is pumped temporarily into the exchange system than is pumped out. An imbalance can be the result of either mechanical or biochemical factors. The wearing of a limb is not likely to lead to the formation of chemicals that produce edema, but it can produce mechanical factors that do. The action of voluntary muscle working within the normally intact fascial envelope is responsible in part for the return of the blood to the venous system via the capillary and lymphatic systems, and hence factors that alter normal muscle activity can contribute to the formation of edema. Further, concentrated pressures in one area can cause edema in a distal area either by inhibiting muscle action or by restricting the low-pressure venous or lymphatic return systems and thus are to be avoided. For this reason, when relief is required for bony prominences or tender areas, the indentation in the socket wall should be flared gently. Relief should never be provided by a hole or window which removes external counterpressure from a localized area while maintaining support or even constriction elsewhere. </p> <p>Also to be avoided is a combination of a tight fit in the proximal portion of the socket and a loose fit distally. Under such circumstances the venous and lymphatic systems can be constricted to the point that edema is produced.</p> <p>Gentle external pressure on soft tissues offers a mechanical aid to the return of blood to the venous system. The equivalent can be obtained by encasing the entire stump with the socket in such a manner that at least a slight amount of pressure is brought to bear over the soft tissues as the prosthesis is used.</p> <h3>The Composite Socket</h3> <p>The shape of the socket in which the anatomical and physiological factors discussed above are taken into account is shown in <b>Fig. 16</b> and <b>Fig. 17</b>. The anterior brim is brought to the level of the center of the patella; a horizontal indentation is provided at the midpoint of the patellar ligament to induce tension in the ligament and at the same time to afford a more horizontal weight-bearing surface; the lateral and medial aspects of the brim are brought about level with the proximal edge of the patella to assist in providing mediolateral stability; grooves are incorporated into the posterior brim of the socket to accommodate the hamstring tendons during flexion; the entire stump is encased; and areas for relief of bony prominences are flared gently to avoid radical changes in pressure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 16. Cutaway view of the patellar-tendon-bearing socket incorporated in a thin-walled plastic shank. Note especially cuff-suspension strap, high lateral and medial walls, and the total-contact feature.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 17. Posterior view of brim of PTB socket for a right stump. Note that the medial wall is slightly lower than the lateral. Not shown is the soft inner liner commonly used.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The socket shown was developed by the Biomechanics Laboratory of the University of California<a></a> after a thorough study of previous practices and after an analysis of the anatomical, physiological, and biomechanical factors involved. The socket is installed in the prosthesis so that the knee is in some 5 to 8 deg. of flexion when the patient is standing erect. This slight degree of initial flexion not only places the weight-bearing loads on the stump in a direction that reduces the unit stresses and shearing forces but also relieves the popliteal area of some pressure as well. In addition, use of the quadriceps is encouraged, and the risk of overloading ligaments as a result of excessive hyperextension is reduced. </p> <p> Because of the difficulty in achieving a truly intimate fit, and for lack of an accurate method of measuring forces between the stump and the socket, use of a soft liner is recommended. The liner, usually of sponge rubber 1/8 in. thick on the sides, slightly thicker on the end, and covered with leather, reduces the chances of abrupt changes in stress. </p> <p>Suspension usually can be effected by a simple cuff above the femoral condyles attached to the shank by flexible straps, but a waist belt or sidebars and corset may be used if necessary.</p> <p>The entire prosthesis has come to be known as the "patellar-tendon-bearing leg," or simply the "PTB leg," perhaps useful as a code name but an unfortunate nomenclature if taken literally, not only because it describes only a part of one functional aspect offered by the prosthesis but also because even that portion would more rightly be termed "patellar-liga-ment-bearing" or "quadriceps-tendon-bearing."</p> <p>Sidebars and corset may be indicated in cases where rather extreme mediolateral instability of the knee is present or where muscles which control the knee have been impaired to the extent that exercise will not strengthen them. Sidebars and corset with ischial support may be indicated either for cases where bone or joint impairments prevent any of the long bones from assuming weight-bearing loads or for those where the skin is of such nature that the imposition of the required loading is simply out of the question. In addition, certain occupations might be carried out more readily if sidebars were used. Except for such limitations, virtually all below-knee amputees with healthy stumps can derive benefit from the PTB prosthesis with cuff suspension, provided the clinic team fully understands the underlying principles in the design and provided also that the prosthetist has the skill necessary to incorporate the essential features into the finished prosthesis.</p> <h3>Acknowledgment</h3> <p>The authors wish to acknowledge the gracious assistance and guidance afforded by Herbert Elftman and Gabriel Rosenkranz in the preparation of this article.</p> <p><b>References:</b></p> <ol> <li> Charnley, John, <i>The lubrication of animal joints,</i> in <i>Symposium on Biomechanics,</i> The Institution of Mechanical Engineers, London, 1959, pp. 12-22. </li> <li> Elftman, Herbert, <i>The functional structure of the lower limb,</i> Chapter 14 in Klopsteg and Wilson's <i>Human limbs and their substitutes,</i> McGraw-Hill, 1954. </li> <li> Marks, George E., <i>Treatise on artificial limbs,</i> A. A. Marks Co., New York, 1899. </li> <li> University of California, Biomechanics Laboratory (Berkeley and San Francisco), <i>The patellar-tendon-bearing below-knee prosthesis,</i> 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>4.</b> </td><td class="clsTextSmall"> University of California, Biomechanics Laboratory (Berkeley and San Francisco), The patellar-tendon-bearing below-knee prosthesis, 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>1.</b> </td><td class="clsTextSmall"> Charnley, John, The lubrication of animal joints, in Symposium on Biomechanics, The Institution of Mechanical Engineers, London, 1959, pp. 12-22. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Staff Engineer, Committee on Prosthetics Research and Development, National Academy of Sciences - National Research Council, 2101 Constitution Avenue, Washington 25, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Avenue, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-17.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 Anatomical and Physiological Considerations in Below-Knee Prosthetics Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/35801aa99143213c24197cf394e4d956.pdf 5639c70b68cbd0e4326be89301a23af7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_044.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 44 - 51 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_044.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_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>Syme's Amputation for Gangrene from Peripheral Vascular Disease</h2> <h5>Gordon M. Dale, M.B. <a style="text-decoration:none;">*</a><br /></h5> <p>Peripheral vascular disease as a cause of amputation was first forcefully brought out in Canada by the many cases of acute thromboangiitis obliterans occurring in young men after World War I. In the early days of the 20's, amputation for this disorder was carried out at knee level (Gritti-Stokes), an operation itself considered a daring innovation at the time, the site of election in such cases then being viewed as the junction of the upper and middle thirds of the thigh. In the present series, the first Syme amputation for gangrene of the foot was performed in 1925 in a case of thromboangiitis obliterans. Since that time, the Syme amputation has been used in Canada in such cases whenever it seemed warranted.</p> <p>By 1940, Syme's amputation had been used successfully for many and varied conditions, including infected and perforating ulcers in unrecovered sciatic-nerve and cauda-equina lesions, septic and tuberculous arthritis of the ankle joint, frostbite, arterial occlusion, and gangrene owing to peripheral arterial disease. When, after the beginning of World War II, the question of amputations once again became prominent, we were able to refute the views expressed by the British Ministry of Pensions in regard to Syme's and other end-bearing amputations generally.<a style="text-decoration:none;">*</a> We showed, by demonstration of actual cases, the great value and durability of these amputations in active life. We were fortunate in having an excellent prosthetic service started during World War I and concentrated in February 1919 at the Dominion Orthopaedic Hospital (later Christie Street Hospital). It had constantly been improving our prostheses, and to that group we owe much of our success.</p> <p>During the period 1920-1956, many new factors modified our views and methods of treatment. In 1930, lumbar ganglionectomy was adopted in vascular disease, and it is thought that doing so saved or postponed many major amputations. Embolectomy and anticoagulants saved some limbs. Sulfa drugs, penicillin, and later antibiotics bolstered our courage. Although the incidence of infection was no lower after than before the use of such agents, there were operated upon during World War II cases that in World War I would not even have been considered for surgery. Now arterial grafting promises well in selected cases. Advances in anesthesia and in medicine generally have of course helped a great deal. Of the problems facing the Department of Veterans Affairs today, one is senile gangrene owing to the advancing age of veterans.</p> <h3>CASE HISTORIES</h3> <p>The case histories that follow represent most of the Syme amputations performed for gangrene owing to thromboangiitis obliterans, diabetic gangrene where there was also peripheral vascular disease, and senile gangrene from arteriosclerosis <i>per se. </i>Omitted are those cases whose files were destroyed after death, but all failures are recorded. Included are 23 Syme amputations and one mid-tarsal amputation, all for vascular disease and all with gangrene. Six have undergone reamputation.</p> <p>Cases 3, 6, and 7, listed under thromboangiitis obliterans, each underwent reamputation within six months and must therefore be classified as failures. Two cases (17 and 22) listed under arteriosclerotic gangrene are doubtful operative failures. The first underwent reamputation after his stump had healed and he had walked quite well. The reason for reamputation apparently was not breakdown of the stump. The stump of the second healed <i>per primam. </i>Fitted at an early date, the patient bore his weight chiefly on the stump for 18 months. Case 9, discussed under diabetic and arteriosclerotic gangrene, is considered a success. Not only did he wear his limb for nine years but his stump breakdown was occasioned by neglect and later circulatory failure from myocardial infarction. Cases 16 and 19 (arteriosclerotic gangrene) had well-healed stumps and were fitted but never wore their limbs to any useful extent. They are therefore recorded as failures.</p> <p>There are thus seven failures in 23 cases (roughly 30%). So marked is the prevalence of myocardial infarction in thromboangiitis obliterans at all ages that an electrocardiogram and cardiovascular examination are now part of our routine examination.</p> <h4>CASES OF THROMBOANGIITIS OBLITERANS</h4> <p>CASE 1. (W. E.)</p> <blockquote><p>Male, born 1891. Served in the Imperial Army, 1914-19. Wounded and had trench feet in service. On discharge, complained of painful feet and occasional cramp in right calf. Had two attacks of phlebitis. Was doing heavy work.</p> <p>Admitted to Christie Street Hospital 1924 with localized gangrene, dorsum of right foot, arising from infection between second and third toes. Severe pain. No pulse below the femoral on the right side, weak pulsation in dorsalis pedis and posterior tibial arteries on the left.</p> <p>Right Syme amputation 1925, healed <i>per primam. </i>Case followed until 1947, when patient returned to England. No trouble with stump. Increasing disability in left leg had forced change to light work. Arterial pulsation below the femoral had disappeared. Left radial pulse absent. Patient had not smoked since 1924.</p> <p>Patient failed to communicate further as promised.</p> </blockquote> <p>CASE 2. (R. G.)</p> <blockquote><p>Male, born 1900. Served in Army, 1915-19. V.D.S. on service. Subsequently worked as teamster in the bush. Had frequent mild attacks of frostbite. Patient's feet were cold in winter, scalded in summer. Had claudication of left leg 1934. In the winter of 1934-35, left foot was frozen, and gangrene of the left great toe developed. Amputation of toe was performed at local hospital. Wound did not heal for nine months.</p> <p>In February 1936, right foot was frozen, right fifth toe amputated. Wound failed to heal and gangrene extended. Patient was referred to a city hospital, where thromboangiitis obliterans was diagnosed and a right lumbar ganglionectomy was done in March 1937. In May and November, same year, toes were amputated. Gangrene extended slightly.</p> <p>In November 1937, patient was admitted to Christie Street Hospital with gangrene involving the distal third of the right foot. Marked equinus deformity. No palpable pulsation in arteries below the femoral on either side. Vein filling on the right, two minutes. Patient had suffered great pain and was practically a morphine addict.</p> <p>Right Syme amputation in December 1937. Slight necrosis at center of wound, but stump healed well. Patient fitted and walking in March 1938.</p> <p>Patient readmitted in April 1939 for disabling claudication of left leg. Findings as before, except that vein filling was 90 seconds. Left lumbar ganglionectomy done with excellent result. Patient seen February 1940, March 1943, April 1945, December 1946, and January 1947, all for minor infections, left foot, due to lack of cleanliness, a carbolic-acid burn, and an artefact. Left Syme amputation, performed July 1947, healed <i>per primam.</i></p> <p>Review in June 1948 showed excellent stumps. Patient walking well and working at woodcutting. Doing well 1953, when photograph of stumps (<b>Fig. 1.</b>) was taken. Death for coronary thrombosis in 1954.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Case 2 (R. G.). Anterior view of bilateral Syme stumps. Right (viewer's left), 16 years after amputation; left (viewer's right), six years. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>CASE 3. (T. A.)</p> <blockquote><p>Male, born 1886. Served in Army 1914-19. V.D.S. on service. Alcoholic. Onset vague pains in feet 1915. Nothing definite noted on discharge. Subsequent attacks of phlebitis, diagnosed as thromboangiitis obliterans 1928. Patient then had absence of pulsation both arteries right foot and in the left dorsalis pedis. Erythromelia was marked. Vein filling, 30 seconds. Admitted to Christie Street Hospital 1936. Right lumbar ganglionectomy in November 1936. Much improved. Admitted Christie Street in February 1937. Sudden onset gangrene right foot and leg. Right Gritti-Stokes amputation performed in March 1937. Healed well. Fitted with limb and walking, June 1937.</p> <p>Admitted Christie Street Hospital in February 1938. Gangrene of toes, left foot. No pulse below femoral. Left lumbar ganglionectomy, performed in March 1938, produced some improvement, but patient complained greatly of pain. Left Syme amputation, May 1939. Heel flap did not slough, but wound healed slowly. Well healed in November. Patient refused to bear weight on Syme stump and complained so bitterly of pain that a left Gritti-Stokes was carried out.</p> <p>Patient thereafter made no attempt at walking. Remained an invalid until death from coronary thrombosis.</p> </blockquote> <p>CASE 4. (R. E. C.)</p> <blockquote><p>Male, born 1909. In 1947, patient was admitted to a city hospital for a nonhealing infection, right great toe nail. Thromboangiitis obliterans diagnosed and bilateral lumbar ganglionectomy performed. Right great toe was later amputated, and wound healed slowly. In 1949 and 1950, two other toes, right foot, were amputated. Right below-knee amputation, done later in 1950, healed fairly rapidly with some sloughing of the flaps. Four months after amputation, patient was fitted with a prosthesis and walked well. Shortly thereafter stump broke down.</p> <p>Admitted to Sunnybrook Hospital, March 1951, with complete breakdown of end of below-knee stump. No pulsation below the femoral on either side. Left foot blanched sharply on elevation. Vein filling, 25 seconds.</p> <p>Right Gritti-Stokes amputation in May 1951. Healed <i>per primam. </i>Fitted with prosthesis August 1951, and walked well. Readmitted in 1952 with minor infection of left foot requiring only few days to heal.</p> <p>Working steadily as engineer, March 15, 1953. Sudden, severe pain in left foot, which rapidly changed color. Admitted to Sunnybrook Hospital. Purple discoloration, distal half of left foot, which did not change on application of pressure or on elevation. Discolored area insensitive. Vein filling, 25 seconds. Weak femoral pulse. Pain very severe in left leg and foot.</p> <p>Treated by rest, heat, dry dressing, Buerger's exercise, whiskey, and papaverine. Pain not controlled and gangrene extended. Left Syme amputation in April 1953. Healed well with slight necrosis in small area around scar. Patient fitted in June 1953. In September 1953, developed stump abscess, which was opened widely and packed open. Secondary suture, done one month later, healed well.</p> <p>Patient was walking well in June 1954. Returned to full-time work. Died suddenly in October 1954 from acute coronary thrombosis.</p> </blockquote> <p>CASE 5. (W. S.)</p> <blockquote><p>Male, born 1914. While in Army, developed phlebitis in right foot, and claudication ensued. Symptoms increased, and thromboangiitis obliterans was diagnosed. Right lumbar ganglionectomy done and patient discharged.</p> <p>Admitted to Christie Street Hospital in September 1947 with gangrene of left great toe and whole right foot extending to the leg. Condition grave. Had had steadily increasing doses of morphine but obtained little relief. No pulsation below the femoral, either side. Right guillotine amputation at level of tibial tuberosity, October 1947. Patient's condition improved rapidly and pain was largely relieved.</p> <p>Left lumbar ganglionectomy six days later with good result. Disarticulation of the left great toe in November, flaps left open. Right Gritti-Stokes and left Syme December 1. Gritti-Stokes healed <i>per primam, </i>Syme showed slight necrosis at suture line but was well healed in seven weeks.</p> <p>Patient was walking well in August 1948 (<b>Fig. 2.</b>). Has worked as limbfitter ever since. No trouble, either stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Case 5 (W. S.). Anterior and lateral views of left Syme stump 11 years after amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>CASE 6. (H. T. O.)</p> <blockquote><p>Male, born 1910. Sprained right ankle while in Army, pain and phlebitis in right leg subsequently. Thromboangiitis obliterans diagnosed and right lumbar ganglionectomy performed in 1943. Twice admitted to Sunnybrook Hospital in 1946, first with gangrene of fourth toe (amputated and healed), second with gangrene of great toe (amputated but did not heal). Right Syme amputation in January 1947. Heel flap did not slough, but wound did not heal. Right Gritti-Stokes, May 1947, healed promptly.</p> <p>In 1951, patient underwent left lumbar ganglionectomy and amputation of a gangrenous great toe, then passed into other hands. Subsequent history includes left mid-tarsal amputation, 1952; left Syme, 1953; left below-knee, 1954; left Gritti-Stokes, 1956.</p> </blockquote> <p>CASE 7. (W. P.)</p> <blockquote><p>Male, born 1899. Discharged from Army in 1919 with history of painful feet. In September 1939, developed phlebitis of right leg with rapidly increasing claudication. Three weeks after onset, patient could walk only a dozen yards.</p> <p>Admitted to Christie Street Hospital in November 1939 with ulceration and gangrene of fourth and fifth toes, right foot. Acute phlebitis at calf and at dorsum of foot. No pulsation in arteries below femoral, either side. On elevation of limb, color faded in two minutes. Vein filling, one minute.</p> <p>Old thrombosed veins on dorsum of left foot and in left calf. On elevation of limb, purplish color remained for three minutes. Vein filling, 30 seconds. Right lumbar ganglionectomy November 17, 1939. Right Gritti-Stokes December 19, 1939. Left lumbar ganglionectomy April 5, 1940.</p> <p>After the last operation, patient returned to work as repair man. No trouble until October 1949, when he had acute onset of pain in left foot and leg. Able to walk only a few steps. Left great toe was gangrenous, left foot livid, cold, and insensitive. Left Syme amputation performed April 1, 1950, at patient's request and against professional advice. Flap remained viable but never regained natural color; wound did not heal completely. Left Gritti-Stokes, performed June 1, 1950, healed <i>per primam.</i></p> <p>Walking on two Gritti-Stokes prostheses, patient was discharged in December 1950. Died August 1957, acute coronary thrombosis.</p> </blockquote> <p>CASE 8. (B. P. H.)</p> <blockquote><p>Male, born 1923. While in Army in 1944, sustained superficial wound of left leg. Healed, but scar frequently broke down. Patient was in Christie Street Hospital on another service in 1948 because of phlebitis and breaking down of wound scar. X-rays showed no retained foreign bodies. Femoral vein was ligated.</p> <p>In a 1949 diagnostic, examination was negative except for erythromelia. Diagnosis of thromboangiitis obliterans was indefinite but patient was advised to stop smoking.</p> <p>Admitted to Sunnybrook Hospital 1952. Two months previously had infection of the left great toe nail. Claudication appeared shortly thereafter. No pulse below femoral on left side. On elevation of limb, color faded slowly. Vein filling, 40 seconds. Marked erythromelia. All pulses palpable on right side. Vein filling, 15 seconds. Left lumbar ganglionectomy done with good result. Three weeks later guillotine amputation of the great toe was effected, and a month after that the stump of the great toe was disarticulated and flaps sutured. Wound healed in three weeks, and patient returned to work.</p> <p>Sudden onset of pain in right leg in December 1953 following infection and gangrene of right great, second, and third toes. Admitted to Medical Service and put on anticoagulants, Priscoline, and heavy doses of morphine. Medication discontinued upon transfer to Orthopaedic Services and papaverine and whiskey substituted. When blood coagulation was again normal, right lumbar ganglionectomy was performed. Eight days later, guillotine amputation of the distal half of foot was done. Right Syme amputation, three weeks after that. Good healing. Patient was walking well on prosthesis in May 1954. Has worked steadily since and has had no trouble.</p> </blockquote> <h4>CASES OF DIABETIC GANGRENE WITH ARTERIOSCLEROSIS</h4> <p>CASE 9. (R. G.)</p> <blockquote><p>Male, born 1901. When patient enlisted in 1940, it was noted that the left third toe had been amputated. Subsequently, it was found that he had had diabetes prior to enlistment. Lues evident. Admitted to Christie Street Hospital in October 1940 with osteomyelitis of the tarsus and gangrene of toes. Many sinuses. Dorsalis pedis pulse absent. Weak posterior tibial. Marked neurotrophic changes. Patient emotionally unstable.</p> <p>Left Syme amputation, 1941, healed well. Patient, fitted with prosthesis and able to walk well, neglected diabetic treatment and was readmitted in 1950 with ulceration in the amputation scar. Ulcer excised, stump healed. While still in hospital, patient had severe myocardial infarct and wound broke down. Gritti-Stokes was carried out.</p> <p>Patient never was active, although he walked fairly well. Died in August 1954 from acute coronary thrombosis. Autopsy showed marked aortic degeneration with mural thrombus. Peripheral vascular endarteritis.</p> </blockquote> <p>CASE 10. (A. E.)</p> <blockquote><p>Male, born 1893. Truck driver. Diabetes discovered in 1948 and patient put on diet. While in local hospital for fractured right tibia, was put on insulin. Admitted to local hospital in 1952 with ulcer on sole of right foot. With incomplete healing, patient returned to Iwork. Perforating ulcer developed, and patient was admitted to Sunnybrook Hospital in January 1955.</p> <p>Examination showed extensive soft-tissue infection about a perforating ulcer. No dorsalis pedis pulse. Weak posterior tibial. X-rays showed extensive osteomyelitis (neurotrophic foot). Marked calcification of vessels. Culture showed organisms resistant to all antibiotics except terramycin.</p> <p>Right Syme amputation January 31, 1955. Healed <i>per primam. </i>Fitted and walked well. Returned to work in November 1955. No trouble since.</p> </blockquote> <p>CASE 11. (W. W.)</p> <blockquote><p>Male, born 1900. Diabetes recognized in 1932. In 1949, following lapse in diet, developed gangrene and osteomyelitis of right foot. Much neurotrophic change. Pulses in feet weak. Right Syme 1949. Wound healed well. Patient worked as caretaker until December 1951, when he developed infection in a callus on the left foot. Ten days later was admitted moribund to Sunnybrook Hospital. Discharging sinuses on sole of left foot, lymphagitis, and femoral adenitis. No sensation in foot. Abscess in sole drained. Patient put on antibiotics, and carbohydrate metabolism improved.</p> <p>Guillotine amputation of left foot January 10, 1952, followed by marked improvement. Left Syme January 22, 1952. Some wound infection, but healed well in six weeks.</p> <p>Patient is still walking on two prostheses. Is not now working, but can walk to bathroom on stumps alone (<b>Fig. 3.</b>). Sectioned arteries in both stumps show marked endarteritis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Case 11 (W. W.). Front and side views of bilateral Syme stumps. Right stump (viewer's left), after nine years; left stump (viewer's right), after six yeais. Corresponding x-rays show bony proliferation from subperiosteal dissection of the flaps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>CASE 12. (W. C.)</p> <blockquote><p>Male, born 1886. Diabetes diagnosed in 1948. Admitted to Sunnybrook Hospital in 1951 on Medical Service. Diagnosis: "Arteriosclerotic heart disease; peripheral vascular disease; diabetes with peripheral neuritis; lues; gangrene of right foot." No arterial pulsations below the femorals. Gangrene in distal half of foot. Right Syme done and well healed. Fitted with artificial limb on which patient walked well.</p> <p>Admitted 1953 with congestive heart failure and ulcer of left foot. Healed with bed rest.</p> <p>In 1954, dyspnoea, swelling of limbs, nephritis, ulceration (hot-water-bottle burn) on dorsum of foot.</p> <p>Admitted February 10, 1956. Died. Autopsy showed marked peripheral vascular disease, arteriosclerotic heart disease, and myocardial infarction.</p> </blockquote> <p>CASE 13. (A. J.)</p> <blockquote><p>Male, born 1886. Admitted to Sunnybrook Hospital in September 1949. One month previously had developed ulcer in bunion on left foot. Two weeks later great toe "became black." Patient was found to have severe diabetes, had recently lost much weight. Femoral pulse present, no pulse below. X-ray showed osteomyelitis of first and second metatarsals.</p> <p>Treated by bed rest, antibiotics, and dry heat. Fever continued, and pain increased. Great toe disarticulated October 5, 1949, and wound left open. Temperature normal 10 days later, patient much better.</p> <p>Left Syme amputation April 18. 1950. Arteries sectioned showed marked endarteritis obliterans. Stump healed well. Patient fitted in June 1950, discharged in September walking well.</p> <p>Patient admitted February 1951 with uncontrolled diabetes and jaundice. Had discontinued his insulin three months previously. Died June 10, 1951</p> </blockquote> <p>CASE 14. (W. R.)</p> <blockquote><p>Male, born 1872. Medical graduate. Diabetes diagnosed 1941, symptoms of polyuria and foot drop. Patient was put on diet and insulin. Did not follow diet strictly and stopped insulin in 1944.</p> <p>In September 1954, patient pared corn on right great toe. Infection spread over foot. Treated self. Healed in nine months.</p> <p>Infection, right great toe, December 1955. Hospitalized. Healed January 1956.</p> <p>Admitted to Sunnybrook Hospital February 26, 1956, with gangrene of great and second toes, right. Systolic blood pressure, 210; diastolic, 90. No pulsations other than femorals in right and left lower extremities. Treated by rest and antibiotics.</p> <p>Right lumbar ganglionectomy April 13, 1956. Right Syme May 3, 1956. Healed <i>per primam. </i>Fitted in August 1956. Patient gets about well on limb and states he is still (December 1958) fairly active.</p> </blockquote> <p>CASE 15. (R. C.)</p> <blockquote><p>Male, born 1896. Discharged from Army 1919. Diabetes diagnosed 1927. Did well on diet alone for three years. Then noticed numbness and coldness of feet. Health was poor. In 1941, patient developed septic arthritis of left knee and, later same year, of right ankle. Drained at local hospital.</p> <p>Admitted to Christie Street Hospital in February 1942, very ill. Sedimentation rate, 147 mm. X-rays showed destruction of outer condyle of left tibia and erosion of lower end of right tibia and upper margin of right astragalus. Ankle joint drained and knee drainage improved. <i>Staph, aureus </i>cultured from both.</p> <p>Condition improved, and carbohydrate metabolism was balanced in July 1942. Right Syme then performed, but destruction of lower end of tibia required section somewhat higher than usual. Stump healed in three weeks.</p> <p>In September 1942, left knee was excised. Patient fitted with prosthesis and walking well by January 1944. Continued to wear leg until sudden death in 1947, cause unknown.</p> </blockquote> <h4>CASES OF ARTERIOSCLEROTIC GANGRENE</h4> <p>CASE 16. (J. E. N.)</p> <blockquote><p>Male, born 1896. Was in good health until 1945, when intermittent claudication in left calf was noted on walking half a block. In June 1950, patient was put on Priscoline. In July, developed gangrene of fourth and fifth toes. Admitted to local hospital in August 1950 for left lumbar ganglionectomy. Fifth toe amputated, but wound failed to heal. In January 1951, patient underwent transmetatarsal amputation.</p> <p>Admitted to Sunnybrook Hospital September 20, 1951, in poor condition and in great pain. Stump foul with protruding bones. No arterial pulsations below femoral. Patient given choice of gamble with a Syme or almost certainty with a Gritti-Stokes. Left Syme performed September 24, 1951. Stump healed slowly but well. Patient discharged November 5, 1951, returned for fitting. Died of coronary thrombosis before limb could be issued.</p> </blockquote> <p>CASE 17. (L. G.)</p> <blockquote><p>Male, born 1880. Admitted to Sunnybrook Hospital in May 1954. Two years earlier had noticed claudication of left leg. Left inguinal herniotomy performed at local hospital in January 1954. Six weeks later, patient developed infection and gangrene of left third toe. Upon amputation of toe, gangrene spread rapidly involving distal third of foot.</p> <p>Weak femoral pulses. No pulsation in arteries, either foot. Left lumbar ganglionectomy May 12, 1954. Left Syme amputation May 26, 1954. Stump healed slowly but with little necrosis. Patient developed moderate flexion deformity at knee despite all efforts but was walking quite well in March 1955. Patient refused Veterans' care but did not wish to be discharged. Finally discharged walking well, September 1955.</p> <p>Patient returned to home town, where for reasons unknown leg was amputated at mid-thigh level. Syme stump had not broken down. Referred back to Sunnybrook in March 1956, patient had a 45-deg. flexion deformity of the hip and could not be fitted.</p> </blockquote> <p>CASE 18. (F. E.)</p> <blockquote><p>Male, born 1885. Worked as stableman. In summer of 1949, patient noticed fissure in skin on medial side of first tarsometatarsal joint, right. Consulted physicians and chiropodists, but an ulcer formed and increased until, when patient was admitted to a city hospital, it measured 1 in. x 1 1/2 in.. Given bed rest and antiluetic treatment, patient did not improve. Right lumbar ganglionectomy was performed with poor result.</p> <p>Admitted to Sunnybrook Hospital February 3, 1950. No pulsation below the femorals. Ulcer was inflamed and had become larger. Very severe pain. After treatment of a flexion deformity of the knee, a right Syme amputation was done in March 1950. Healing was complete by May. Slight marginal skin necrosis along suture line.</p> <p>Discharged September 1950 walking well on a prosthesis, patient has had no further trouble.</p> </blockquote> <p>CASE 19. (R. E.)</p> <blockquote><p>Male, born 1887. In 1939, had claudication in right leg. Right lumbar ganglionectomy done at a city hospital in 1940. Considerable improvement. In 1950, a left lumbar ganglionectomy was done for similar symptoms on the left side. In January 1951, left great toe nail became infected and was removed. Toe became red and swollen. Redness spread over whole foot, and toe became black. Large doses of morphine gave no relief for the severe pain.</p> <p>Admitted to Sunnybrook Hospital in March 1951 with gangrene affecting toes and distal third of foot. No pulsation below femoral, either limb. Left Syme amputation April 3, 1951. Completely healed May 13. Patient returned for fitting November 1951, died 1952 of coronary thrombosis.</p> </blockquote> <p>CASE 20. (G. E. O.)</p> <blockquote><p>Male, born 1881. Admitted to General Surgical Service, Sunnybrook Hospital, November 1950, intoxicated. Shotgun wounds both feet-superficial on left side, marked bony destruction on right. X-ray showed bony defect in right os calcis, numerous lead pellets in region of right heel. Wound debrided and plaster cast applied. Despite antibiotics, wound became infected and foot gangrenous.</p> <p>When, in February 1951, patient came under care of Orthopaedic Services, distal portion of right foot was gangrenous, and marked edema and cellulitis extended to ankle. No pulsation below femoral artery. Patient very ill. Abscess drained February 19, 1951. Eusol dressings. Right Syme February 28, 1951. Standard operation, except that no section was made of lower end of tibia or of malleoli. Wound left open. Pathological report on sectioned vessels: endarteritis obliterans. Patient improved rapidly.</p> <p>Right Syme completed March 14, 1951. Malleoli removed, but tibia not sectioned. Healing good, although a small sinus persisted until May 1951. Fitted in June, patient walked well.</p> <p>Hospitalized June 4, 1953, for infection about residual shot pellet. Discharged. Readmitted November 30, 1955, for bronchopneumonia and empyema. Discharged. No further trouble with stump, though health is poor.</p> </blockquote> <p>CASE 21. (J. A. S. J.)</p> <blockquote><p>Male, born 1876. A blind vagrant who had slept in an open boxcar while intoxicated, patient was admitted to Sunnybrook Hospital December 27, 1951, in moderate state of shock. Toes of right foot mottled but fairly warm. Distal third of left foot purple and showing no color change on application of pressure or on elevation of the limb. Left toes livid. No sensation in distal third of left foot. Edema in left leg up to knee. No arterial pulsation below the femorals.</p> <p>X-ray showed marked arterial calcification. Patient treated expectantly by antibiotics, rest and dry heat. Well-marked line of demarcation, left foot, by February 16, 1952. No loss of tissue of note, right foot. Left mid-tarsal amputation proximal to line of demarcation, March 4, 1952. Wound healed well. Stump was good, but patient walked poorly. Died February 1954.</p> </blockquote> <p>CASE 22. (W. R.)</p> <blockquote><p>Male, born 1890. Complained in 1953 of coldness and pain in feet, left being most affected. Admitted to a city hospital, where left lumbar ganglionectomy was performed. In 1954, following myocardial infarction. developed gangrene in the second and third toes on the left.</p> <p>Patient admitted to Sunnybrook Hospital in April 1955 on the Medical Service. Weak pulsation in arteries, right foot. Posterior tibial absent; weak dorsalis pedis, left foot. Gangrene extended and caused great pain.</p> <p>Left Syme amputation, March 1, 1956, healed <i>per primam. </i>Fitted with a prosthesis, patient had no trouble with stump. Right foot broke down, and weight was borne mainly on the amputation stump. By October 1957, patient walked with crutches and took weight on the stump only.</p> <p>By January 1958, stump showed bluish discoloration and was cold. Deep fluctuation appeared and was aspirated. Two c.c. of serosanguinous fluid were obtained. Skin was intact. Disarticulation at the left knee was carried out January 29, 1958. Wound healed <i>per primam, </i>but patient has not walked since.</p> </blockquote> <h3>SUMMARY</h3> <p>Between October 1920 and May 1956, I personally conducted or else supervised all Syme amputations performed in the DVA Hospitals at Christie Street and Sunnybrook. Uniformly satisfactory, they resulted in durable and stable stumps. In the cases owing to vascular disease with gangrene, the amputations were equally satisfactory. Six cases (2, 6, 7, 9, 17, and 22) required reamputation. Only two were subjected to amputation for failure of healing. One (Case 9) is considered a success. Two cases (16 and 19), while healed and fitted, died before use of their prostheses and are considered failures. Stumps were in active use for periods of 22, 17, 7, 12, 4, 9, 10, 7, 5, and 5 years, others for shorter periods.</p> <p>From my experience, I would venture to suggest:</p> <ol> <li>Lumbar ganglionectomy at an early date in all cases of thromboangiitis obliterans and, should gangrene develop, Syme's amputation.</li><li>In diabetic gangrene where carbohydrate balance can be maintained and where minor amputations have failed, Syme's amputation.</li><li>In selected arteriosclerotic (senile) gangrene where ganglionectomy and arterial resection and graft have failed to arrest gangrene, Syme's amputation. These patients should understand the great risk of failure.</li><li>In all cases of gangrene with infection, and in diabetics with infection where carbohydrate-metabolism disturbance is not yielding to treatment, a preliminary guillotine amputation.</li><li>Success in the Syme, or other type of tarsal amputation, gives a degree of activity otherwise impossible. Such cases may expect trouble in the other limb.</li><li>Amputation between the knee and ankle (below-knee) is not advisable in cases of severe vascular disease.</li><li>Amputations through the knee (Gritti-Stokes) are almost always successful in healing and give good walking comfort where the patient's condition warrants. Such patients frequently have severe cardiac and cardiovascular lesions, and activity may result in sudden death.</li></ol> <p>-G. M. D.</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.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Artificial Limbs and Their Relation to Amputations,British Ministry of Pensions, His Majestys Stationery Office. London. 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Gordon M. Dale, M.B. </b></td></tr><tr><td class="clsTextSmall">Present address: 84 Woodlawn Ave., E, Toronto, Ontario, Canada. Until his retirement in May 1956 as Chief of the Orthopaedic Service at Sunnybrook Hospital, Toronto, Dr. Dale had for more than 35 years (since October 1920) been in charge of all amputations for the Canadian Department of Veterans Affairs at Christie Street Hospital and at Sunnybrook. His patients have been drawn not only from World Wars I and II, the Korean War, the Boer War, and the Northwest Rebellion but also from many lesser campaigns in many parts of the world, from the Canadian Mounted Police, from the Canadian Department of Indian Affairs, and, until recently, from Canada's active Army. The cases here reported upon are of interest for at least two reasons-first because a goodly number were followed for periods ranging from five to 22 years (or until death from other causes), second because Dr. Dale either has performed the operation himself or else has served as the supervisor.-Ed.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Syme's Amputation for Gangrene from Peripheral Vascular Disease Creator An entity primarily responsible for making the resource Gordon M. Dale, M.B. * https://staging.drfop.org/files/original/c0d0eca6feaf1da610d7cb20b544cd80.pdf 4ab0cc41972a01f65f7db078a1de828c https://staging.drfop.org/files/original/b6d2f7ed0ba556ec7090952c752fbbc5.jpg 41c792470fa9bf7060831ecdd6c6bebc https://staging.drfop.org/files/original/a3f76296fb4dd3889147b7e76d279fd1.jpg 7fdba66f3090467035423319664668ed DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_117.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 117 - 127 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_02_117.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_117.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 VIII. Research Implications</h2> <h5>Sidney Fishman, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>It was the purpose of the NYU Field Studies to explore the matter of the upper-extremity amputee in a broad and comprehensive way. To this end there was devised a research program consisting of three phases-survey studies, clinical studies, and evaluation studies. The first of these consisted of the single examination of each of 1630 upper-extremity amputees for the purpose of developing normative, descriptive data concerning the status of the upper-extremity-amputee population at the beginning of the research program. Through the vehicle of an organized program of prosthetic management, 769 of the 1630 amputees surveyed were provided in the clinical studies with what at the time was a new type of upper-extremity prosthesis, the purpose being to study the varieties of prostheses provided, the prescription procedures used, the preprosthetic treatment employed, the adequacy of prosthetic fabrication and fitting, the effects of training, and the results of initial and final checkouts. Finally, in the evaluation studies, the prior status, mental and physical, of 359 individuals selected from the clinical study was compared with their corresponding status after participation and treatment. The procedures used in each of these studies, and the objectives sought in the work, have all been discussed in detail in Section I of this series (Artificial Limbs, Spring 1958, p. 4).</p> <p>While the variety, scope, and degree of completeness of the resulting data all increased as work progressed from the survey studies through the clinical studies and on to the evaluation studies, the size of the experimental sample decreased. The survey studies were limited to the normative data that could reasonably be gathered by means of a onetime interview and examination of the largest possible sample of upper-extremity amputees. The clinical studies supplemented the normative data with observational information concerning 769 amputees receiving prosthetic treatment. The evaluation studies included normative, observational, and research procedures. Only in the last series of studies did control of any research variables become possible. The major focus of the evaluation studies was, then, to obtain information on possible changes in the individual resulting from the application of new and experimental procedures in the management of the upper-extremity amputee.</p> <p>The types of information sought in each of the three phases fell into one or more of five broad categories:</p> <ol> <li><i>The physical and personal characteristics of the amputees.</i>Included identifying data (age, height, weight, residence, marital status); educational level; vocational, avocational, and recreational pursuits; amputation etiology; amputation type; and the strength, ranges of motion, and general characteristics of the stump.</li><li><i>The prosthetic components and fabrication techniques utilized.</i>Included information concerning the functional and mechanical characteristics as well as the advantages and disadvantages of each component of the artificial arm.</li><li><i>The treatment factors.</i>Included data concerning the frequency of prescription of various components, pre-prosthetic therapy, prosthetic training, and checkout.</li><li><i>Amputee performance.</i>Concerned with testing the individual's proficiency in accomplishing the basic activities of prehension, positioning, and release of objects from grasp and with amputee reports concerning the usefulness and importance of the prosthesis in various practical activities of daily living.</li><li><i>Psychological considerations.</i>Involved an assessment of amputee attitudes and personality factors as they affect reactions to prosthetic restoration as well as the social consequences of living with a disability.</li></ol> <p>While data within these five areas of interest were gathered in all three phases of the investigation, the comprehensiveness and sophistication of the measurement techniques varied from phase to phase. In view of the wide range of matters investigated, it is clear that the problems involved in their accurate measurement were considerable. Some factors <i>(e.g.,</i>mechanical characteristics of prosthetic components, results of checkout, certain personal identifying data, etc.) lent themselves rather conveniently to so-called "objective measurement," while in the light of presently available techniques other factors could be appraised only through subjective observation and rating by trained observers <i>(e.g.,</i>amputee performance, quality of prosthetic training, quality of prosthetic fabrication, etc.). Still other factors <i>(e.g.,</i>attitudes, personality factors, opinions concerning prosthetic components and treatment methods, etc.) could only be inferred from the verbal reports of the amputees themselves. As a consequence, the resulting data are of three kinds-objective measurements, observations and ratings, and amputee verbalizations. It should, however, be pointed out that no relationship necessarily exists between the significance and value of various data and their objectivity. Quite often the most objective data are the easiest to obtain but are also the least revealing. Yet certain data obviously subjective and barely capable of meeting any standards of precision provide the greatest insights and understanding.</p> <p>With several relatively minor exceptions, all five subject areas have individually been the topic for separate analyses and discussions and have culminated in five corresponding articles (Sections II, III, V, VI, and VII) in this series. Section II (Artificial Limbs, Spring 1958, p. 57) dealt with the descriptive characteristics of the sample. Section III (Artificial Limbs, Spring 1958, p. 73) was concerned with the evaluation of the treatment process. Section V (page 4) reviews the specific components and fabrication techniques that go to make up a prosthesis. Section VI (page 31) describes the performance or functional capabilities of the amputee subjects, while Section VII (page 88) analyzes the psychological attributes of the amputee group.</p> <h3>Studies Completed</h3> <h4>The Sample (Section II)</h4> <p>The initial point of interest is that there were in the nationwide, somewhat urban sample almost as many above-elbow as there were below-elbow amputees (41 percent as compared with 51 percent). The remaining cases consisted of shoulder-disarticulation amputees (5 percent) and bilateral arm cases (3 percent). Within each of these four basic amputee types, a further detailed breakdown is presented. For example, the below-elbow cases are classified and discussed as very short, short, medium, and long, and as wrist disarticulations. A similar breakdown is offered for the above-elbow and shoulder-disarticulation groups.</p> <p>It is important to emphasize that 73 percent of the participating subjects were veterans of military service who had lost limbs in World War II, a matter having a strong influence on the characteristics of the sample- on age, height, weight, educational level, and vocational status as well as on other physical characteristics.</p> <p>Although certain amputees continued to pursue agricultural and mechanically oriented occupations, amputation generally resulted in a shift away from agricultural, manual, and mechanical occupations toward clerical, sales, and managerial activities, and there was in addition a very significant increase in the extent of unemployment (from 1 percent to 19 percent). Such a finding raises the question whether these shifts are caused chiefly by the physical inability to perform and compete in certain activities or primarily by socioeconomic factors.</p> <p>An overwhelming majority of the subjects were found to have in their residual anatomy sufficient strength and sufficient range of motion to use an upper-extremity prosthesis. Despite this physical potential, 25 percent of the below-elbow, 39 percent of the above-elbow, and 65 percent of the shoulder-dis-articulation amputees were not wearing arm prostheses at the time of the survey studies. Typically, those who did wear prostheses used Dorrance hooks, Miracle or APRL hands, and friction-type wrist units. The below-elbow prostheses typically consisted of a leather socket, rigid metal elbow hinges, and a figure-eight harness. The above-elbow and shoulder-disarticulation prostheses had in general plastic or leather sockets, manually operated or harness-controlled elbows (in about equal proportions), and chest-strap harnesses with shoulder saddles.</p> <h4>The Treatment Process (Section III)</h4> <p>Before the advent of the Upper-Extremity Field Studies, only some 17 percent of the group had had arms prescribed for them by a clinic team consisting of a physician, a therapist, and a prosthetist. In the NYU program, where prescriptions were written and filled in this manner routinely, all the professional groups concerned and 94 percent of the amputee subjects heartily approved of the multidisciplinary, clinical approach.</p> <p>With respect to prosthetic components utilized there were several very significant shifts, such as the tendency toward the use of the APRL hook (from 12 percent to 61 percent of the sample) and toward the APRL hand (from 11 percent to 80 percent of the sample). There was also a marked increase in the use of positive-locking wrist units as compared with friction types, a strong shift toward the use of flexible hinges instead of rigid hinges for the below-elbow amputees, and an increase from 46 percent to 100 percent in the proportion of above-elbow amputees wearing harness-operated elbows. Plastic laminates were used exclusively for fabrication of the nonoperating parts of the prostheses, and the harness patterns tended to be of the figure-eight type. In point of fact, it may be said that the whole pattern of prosthetic prescription for the upper-extremity amputee was revolutionized in the course of the Upper-Extremity Field Studies.</p> <p>Introduction of the checkout procedures met with considerable success. Clinic personnel considered checkout a valuable management tool, and more than 90 percent of the amputees thought it useful. Whether initial checkout or final checkout, almost 70 percent of the arms passed on the first trial. The remaining cases required two or more visits to resolve all problems, the major deficiencies uncovered being in the areas of socket fit, harnessing, and alignment of control systems.</p> <p>Application of the training procedures was not nearly so successful. Some 40 percent of the group thought that the results of training could be improved by extending the instruction over a longer period and by including more and varied practice in the regimen. The finding that during the training period 54 percent of the sample needed adjustments or corrections in the prosthesis suggests the great value of supervised training-that is, of training in a situation so controlled that specific difficulties can be uncovered and resolved with a minimum of difficulty. Although the length of the training period was greater for bilateral cases than for shoulder disarticulations, greater for shoulder disarticulations than for above-elbow amputees, and so on, the time allotted for shoulder disarticulations and for above-elbow cases over that allowed below-elbow cases did not seem to be in keeping with the increase in operating difficulty known to accompany loss of the natural elbow.</p> <p>All in all, the system of amputee management introduced as part of the Field Study was accorded a high degree of acceptance both by the amputees and by the professional personnel charged with their care. Perhaps the strongest recommendation for the management procedures lies in the fact that, with appropriate revisions and variations, they are now in widespread use in amputee clinics throughout the country.</p> <h4>The Armamentarium (Section V)</h4> <p>The data concerning the prosthetic armamentarium tend to be encyclopedic and documentary. Each component of the upper-extremity prosthesis has been considered in terms of appearance, usefulness, ease of operation, and weight, and this information has been supplemented by data on the ranges within which the components functioned and on the magnitudes of the activating and resulting forces. The adequacy of the fabrication techniques utilized in making the upper-extremity prosthesis was also reviewed. These data provide the biomechanical basis upon which to revise a number of the checkout standards.</p> <p>Lastly, the new components that go to make up the present armamentarium (terminal devices, wrist units, elbow hinges for below-elbow arms, elbow joints for above-elbow arms, control systems, and harnessing equipment) have been compared with corresponding components in the prior art. Amputee reactions toward the conventional preprogram arms have been compared with the reactions toward the new program prostheses. The amputees felt that the program prostheses are characterized by:</p> <ol> <li>Higher, better-fitting, and better-appearing sockets.</li><li>More useful and easier-operating elbows.</li><li>Improved efficiency of force transmission reflecting better cable alignment and more stable materials.</li><li>Lighter, freer, and more comfortable harnessing.</li><li>A marked increase in terminal devices offering improved control of grasp force.</li></ol> <p>Of the 290 amputees who had an opportunity to wear both types of arms, 261 preferred the new, 25 the old, while 4 expressed no preference.</p> <h4>Amputee Performance (Section VI)</h4> <p>Section VI has been concerned with the functional value of arm prostheses, the uses to which they are put, and the skill and efficiency with which arm amputees can utilize them. From interrogation of the subjects, it became apparent that the usefulness of an arm prosthesis varied considerably from activity to activity in the five broad areas of daily living (work, home, recreation, dressing, and eating). In the numerous activities that go to make up work, recreation, and home life, prostheses tended to have wide applicability and to be most helpful to the wearer. As a matter of fact, use of the prosthesis in a variety of jobs and hobbies was much more extensive than is usually recognized, and we must therefore conclude that the functional potential of the upper-extremity amputee is also a good deal greater than commonly thought. But in the activities of dressing and eating, which for the most part involve a limited number of relatively difficult operations performed close to the body, prostheses tended to be considerably less useful. An interesting note is that, as regards the performance of any one given task, prosthetic usage tends to be on an all-or-none basis. Either the amputee uses his prosthesis every time he is confronted with a given task, or else he never uses it for that task. "Sometimes" usage is reported infrequently.</p> <p>To shed further light on the comparative values of below-elbow, above-elbow, and shoulder-disarticulation prostheses, 20 selected bimanual activities, considered both by the examiners and by the amputees to be significant in terms of frequency of occurrence and of importance, were used in an attempt to determine how widely prostheses were used. In summary, the results showed that:</p> <ul> <li>Over 50 percent of the below-elbow amputees always used their prostheses for 19 of the 20 tasks.</li> <li>Over 50 percent of the above-elbow amputees always used their prostheses for 13 of the 20 tasks.</li> <li>Over 50 percent of the shoulder-disarticulation subjects always used their prostheses for 8 of the 20 tasks.</li> <li>Over 50 percent of the bilateral arm amputees always used their prostheses to accomplish 15 of 18 tasks (two tasks not applicable).</li> </ul> <p>These and other data show clearly that the higher the level of amputation for which an arm prosthesis is intended the less the utility of the prosthesis. The sharp distinction between the usefulness of prostheses for below-elbow amputees and that of prostheses for above-elbow and shoulder-disarticulation amputees can be explained readily in terms of the limited function to be had from the mechanical elbow and the concomitant need for a comparatively high order of skill in order to use it properly. The difference in apparent usefulness is clearly due to the loss of the normal anatomical elbow. This circumstance re-emphasizes the need for more practically oriented and more extended training for above-elbow and shoulder-dis-articulation amputees.</p> <p>While contemporary below-elbow prostheses appear to be more useful than are the corresponding prostheses for above-elbow amputations and for shoulder disarticulations, arms for the higher levels of limb loss still offer a significant measure of utility. It should also be noted that not all amputees of a given type use their prostheses to the same extent or for the same activities. Obviously, then, the prosthesis varies in value and convenience for the individual wearer, and this factor also helps to determine the amount of use made of the limb by the individual wearer.</p> <p>Through a series of tests of abstract function (prehension and positioning viewed as ends in themselves) and of the performance of practical activities of daily living, a systematic, observational method of rating amputee performance was developed. Although the tests are not as precise as might be desired, an initial step in the measurement of amputee function has been taken. One direct result has been the establishment, for the upper extremity, of a set of norms which may be used as a point of comparison in evaluating amputee performance and in setting reasonable goals for prosthetic training.</p> <p>The data from these tests clearly indicate that, in general, more could be accomplished with the new arms than with the old and that more skillful and more natural performance with the new prostheses was usually obtained without any increase in performance time.</p> <p>The advantages of the experimental arms over the older, conventional arms were most noticeable in above-elbow and shoulder-disarticulation prostheses, less so in below-elbow prostheses. In the below-elbow case, apparently, prosthetic function is very much less dependent upon the quality or precision of arm fabrication, or on the specific components included in the prostheses, or both.</p> <p>While in general the results point up the inadequacies of even our most advanced devices and techniques and thus emphasize the continued existence of much room for improvement, they also show that present-day upper-extremity prostheses are quite useful devices despite the inadequacies, especially for those types of amputees heretofore thought incapable of deriving much benefit from any prosthesis. Since we seem now to have exploited the existing concepts of upper-extremity prosthetics, there would seem to be little more to be gained by continued redesign of current prosthetic equipment. Instead, there is now a need for dramatic, if not drastic, new concepts in approaching the problem of rehabilitating the upper-extremity amputee.</p> <h4>Amputee Attitudes And Reactions (Section VII)</h4> <p>Section VII attacked the problem of prosthetic restoration from the point of view of the psychological characteristics of the amputee and tried to evaluate the subjects on the basis of nine personality variables, to explore a number of factors influencing prosthetic wear and function in social situations, and to study the amputees' attitudes toward prosthetic wear before and aftei fitting with a prosthesis The predominant finding as regards the personality functioning of the amputees was that, no matter which aspect was studied, the subjects appeared to try consistently to maintain feelings of bodily integrity and adequacy by denying many of the personal, vocational, and social consequences of amputation. They consistently de-emphasized their physical difficulty, rejected notions of abnormality, and set their cosmetic and functional desires in line with those of normal people. Superimposed on this general positive tone of the amputees' statements concerning adjustment was the additional positive effect of the treatment program on many of the personality variables, as evidenced by consistent indications of some decrease in expressed feelings of sensitivity and frustration, increased feelings of functional and social adequacy, and greater acceptance of their disability.</p> <p>One problem associated with this aspect of the study was that, because of the limitations of the experimental design, the data were based entirely upon the voluntary expressions of the subjects themselves, who consistently tended to color their responses by hiding any attitudes which might be viewed as "negative." Aware of this difficulty in the measurement of the social and functional factors affecting prosthetic wear, the experimenters attempted a somewhat more indirect approach in the form of cartoons depicting a series of ambiguous, potentially sensitive, situations. The amputees were asked to respond to these situations, the expectation being that they would "project" their attitudes in a less inhibited form. Probably the major finding of this line of inquiry developed from the answers given when the amputees were requested to react to the cartoons as prosthesis wearers and then as nonwearers. The data show consistently positive attitudes toward prosthetic wear, the feeling being expressed that the prosthesis makes the amputee more effective and independent functionally, more self-reliant, more secure, more self-accepting, less shy, less easily embarrassed, and more adaptable. One may, of course, ask whether the amputees held these attitudes fundamentally or whether they were merely expounding an expected "cultural norm." On the basis of the available data it is not possible to answer the question.</p> <p>In a comparison of the preprosthetic expectations of amputees with the actual degree to which these expectations were fulfilled after fitting, it was concluded that:</p> <ol> <li>Normally, little prosthetic information is available to the new amputee, and this deficiency encourages the development of unrealistic expectations concerning prosthetic wear.</li><li>Anticipations which tended to be overly optimistic were in most cases modified downward (with considerable personal disappointment and regret) after the individual had an opportunity to wear a prosthesis.</li></ol> <p>The last question studied had to do with whether or not the postfitting behavior of the amputee toward his prosthesis is related to, and whether or not it can be predicted on the basis of, his prefitting attitudes, a matter that would seem to have significant practical implications. Should preprosthetic attitudes turn out to exercise a determining or controlling influence over later prosthetic acceptance, performance, and use, it would be desirable to attempt to influence early attitudes so as to obtain the best possible rehabilitation results. Investigation did indeed show that those amputees holding favorable attitudes before ever having had a prosthesis tended to maintain favorable attitudes after wear and use; those at first negatively disposed continued to react negatively after receiving a prosthesis.</p> <h3>Future Studies</h3> <p>Although the amputees in the NYU Field Study have thus far been assessed rather thoroughly in terms of five broad areas (physical and personal characteristics, prosthetic components and fabrication techniques, treatment procedures, prosthetic performance, and psychological orientation), little has yet been done toward exploring the relationships that may exist either within or between the several categories of data. As a matter of fact, the data reported and discussed here constitute a phenomenological picture of observed events and are therefore basically descriptive in nature. While data of this type are valuable in that they focus attention on significant occurrences and reveal what is taking place and what is changing during the period of observation, the reasons why the events occur, and the nature of the causal train producing them, can be learned only by more detailed and more definitive study.</p> <p>The only studies of this more detailed variety which have been performed thus far are as follows:</p> <ol> <li>A substantial segment of the findings concerning the unilateral amputees have been analyzed and presented in terms of the three basic amputee types- below-elbow, above-elbow, and shoulder-disarticulation amputees. But there is still a need for further analyses of this variety using finer categories in the amputee-type classification system (such as wrist disarticulation, long below-elbow, medium below-elbow, short below-elbow, very short below-elbow, etc.).</li><li>A number of attitudes toward prosthetic wear held by the amputees prior to prosthetic fitting have been studied and presented in relation to postfitting attitudes and psychological adjustment.</li></ol> <p>Whatever cross-correlations are attempted, however, it must be remembered that the subject matter deals with the complex interactions between a human being, the patient, and an involved environmental process, the treatment procedure. Man is not composed of a series of discrete traits and attributes, nor does he represent the simple sum of such features Taken as a whole, the configuration is more exponential that additive. Similarly, the treatment procedures at any given level of observation may represent a series of obvious events simply measured and simply described, or they may be seen more subtly as sets of behavior of professional people- physicians, prosthetists, therapists, others- directed toward another individual, the amputee. In this light, distinctions and comparisons drawn between the patient, the treatment process, and the restorative result are unavoidably arbitrary to the extent that they tend to be abstractions from the intricate network of human behavior. Since in practice, however, analyses must be performed at some level not fully reflecting the human interactions at work, attempts at further study require some kind of conceptual framework within which to consider the data.</p> <h4>A Conceptual Framework</h4> <p>When the mass of available data is reviewed,<a style="text-decoration:none;">*</a> the individual elements fall naturally into two groups-those which describe the factors contributing to the over-all result of prosthetic restoration and those which describe the result itself. The data in the first category, those dealing with the causal factors, seem in turn to constitute two separate subcategories-the individual characteristics, which the patient brings to the restoration regimen, and the treatment process, which describes the management procedures applied. Together the interaction of these two contributing factors (variables) produces the over-all result of prosthetic restoration. Thus:</p> <p>Amputee Characteristics + Treatment Process = Over-All Result of Prosthetic Restoration</p> <p>But each of these three broad factors consists, again in turn, of a number of more specific considerations that were the subject of investigation in the NYU Field Studies. It is therefore possible to recast the formula into somewhat more specific terms, whereupon the three factors in the original relationship are found to consist of seven different types of data. Thus: <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>Further expansion of such a breakdown leads to <b>Table 1</b>, which reflects in greater detail the kinds of information available. All told there are some 60 variables on which data have been collected.</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 data having been thus classified, it is now necessary to find the means with which to develop whatever significant interrelationships may exist within and between the various categories. Analyses may be performed at any of the three levels of complexity, but those best undertaken first would tend to consider the segmented types of data listed in the lower portion of <b>Table 1</b>. Contrary to first impression, they are in reality by far the simplest to investigate. To study the earlier, more general, and apparently less complex relationships shown in the first two formulae will require the development of suitable means for consolidating individual sets of data in some meaningful way to describe the composite concepts utilized. Accordingly, analyses of the data will vary in complexity depending on whether we wish to study the relationships between discrete variables or those between increasingly composite, and therefore complex, conceptualizations. As the chosen formulation becomes clinically more meaningful, the complexity of the statistical analysis increases. Conversely, the simple selection of a pair of variables and the study of their interrelationship is easiest to effect statistically.</p> <h4>Two-Variable Analyses</h4> <p>When the available data are considered, the area of primary interest that comes at once to mind concerns the question of what factors in the amputee and/or in the treatment process tend to influence the over-all restoration result in a significant way, positively or negatively. Since the final level of prosthetic restoration is a composite measure made up of two different types of data, we can study various individual factors, one at a time, as they influence one segment of the rehabilitation result (use of the prosthesis by the amputee) or the other segment (the amputee's postfitting patterns of psychological adjustment). In the study of these relationships, the data concerning prosthetic performance (or those concerning amputee adjustment, one or the other) are organized and then compared systematically with data describing a variety of possible causal factors.</p> <p>Since any of some 40 individual factors may influence either segment of the final result of prosthetic restoration, it becomes a matter of judgment as to which of the many possible relationships are worth checking. On the basis of previous experience, the prefitting considerations which seem to have the greatest potential significance, and which would seem to be most worth while exploring in relation to each part of the prosthetic restoration result, are as follows:</p> <p>I. Personal characteristics: age, residence, education, marital status, vocation, hobbies, recreational activities.</p> <p>II. Psychological characteristics: acceptance of loss, identification with the disabled, functional adequacy, independence, sensitivity, acceptance by others, sociability, frustration, optimism, security, prosthetic expectations.</p> <p>III. Physical characteristics: etiology, dominant or subdominant loss, amputation level, stump strength, stump motion.</p> <p>IV. Prosthetic-component characteristics: voluntary-opening <i>vs.</i>voluntary-closing terminal devices, canted <i>vs.</i>lyre-shaped fingers, range of pinch forces, friction <i>vs.</i>locking-type wrist units, step-up <i>vs.</i>nonstep-up elbow hinges, single-axis <i>vs.</i>polycentric hinges, figure-eight <i>vs.</i>shoulder-saddle harnesses, quality of prosthetic fabrication (as revealed by checkout).</p> <p>V. Management procedures: extent of training, time lapse before training, extent of preprosthetic therapy, behavior and attitudes of clinic personnel (physician, therapist, prosthetist).</p> <p>In this analysis, the factors included under headings I through V may be considered "predictor" variables, while the data listed under headings VI and VII may be looked upon as "criterion" information. If firm relationships can be established between the data in the first group of categories (I-V) and those in the second group (VI-VII), the former information may be used as a basis for predicting the outcomes of the prosthetic restoration process. The choice of predictor variables to be studied depends, of course, upon the segment of the prosthetic restorative result (prosthetic use or psychological adjustment) selected for study. It is, for example, quite enlightening to relate stump factors to prostehtic usage, but there would be less reason to select stump factors when we are interested in predicting psychological adjustment. Whatever variables are ultimately selected for study, however, the basic analytic approach remains unchanged.</p> <p>A second important type of two-variable analysis can very well involve a study of what relationships exist between the two aspects of the post-treatment result itself (prosthetic use <i>vs.</i>psychological adjustment). Is there, for example, any relationship between an amputee's sense of independence and the extent to which he uses his prosthesis? Is the quality of prosthetic performance related to the individual's social sensitivity? Any number of relationships of this variety could be the subject of study, and the results would contribute to the solution of one of the problems of amputee rehabilitation. Does extensive prosthetic usage of high quality imply good general adjustment, or does good adjustment give rise to efficient prosthetic use? Or is there in fact no significant relationship between these two important aspects of successful amputee rehabilitation?</p> <p>A third variety of two-variable analysis stems from the fact that even within the individual areas of prosthetic usage and of amputee behavior there are important relations to be studied. How, for example, does the amputee's performance with a prosthesis relate to the importance which he attributes to a given activity? What is the relationship between the efficiency of prosthetic use as reflected by tests (actual usage) and the efficiency as reported verbally by amputees (reported usage)? In the psychological area, what is the relationship between an amputee's feelings of sensitivity and his sense of identification with the disabled? To what extent do feelings of frustration affect the amputee's sense of functional adequacy? All these are examples of significant relationships which may exist within the given segments of the prosthetic restoration result and which may very well be amenable to study.</p> <p>In addition to all these possibilities, there remains a fourth type of two-variable analysis, one concerned with the relationships between the various amputee characteristics and data concerning the treatment process. Do amputees with similar occupations, hobbies, and/or recreational pursuits receive similar prosthetic prescriptions, or is the prescribed prosthesis unrelated to these matters and more dependent upon the personal attitudes of the clinic personnel? Are the variations in prescription, training, and checkout procedures based on geographic factors, age of patient, etc.? Relationships such as these are also worth exploring.</p> <p>There is no question but that a considerable amount of knowledge is to be gained from the segmented type of analytic approach described. But a major limitation and a fundamental weakness is inherent in these techniques. When correlations are limited to no more than two factors at a time, the variables concerned are unavoidably isolated out of the large complex of continuously interacting forces known to exercise control over the final result of prosthetic restoration in any given case. In separating, out of the entire data, pairs of variables that may happen to interest us, we ignore the well-known clinical observation that the whole result of prosthetic rehabilitation is the consequence of a number of simultaneous, interdependent influences. In effect the other factors are treated as "constants" at any given time, an expedient admittedly not in keeping with the facts. Were the data made up of a large number of independent variables (factors independent of other influences in a situation), the difficulty would be less critical. But we find in fact that only comparatively few of the items are truly independent of one another.</p> <p>Although this limited analytical approach will not provide the ultimate in understanding of the prosthetic restoration process, it will provide information concerning the more salient relationships existing within the data. The technique of two-variable analysis can be carried one last step by combining selected distributions of data in order to develop indices of more general factors in the prosthetic-restoration complex. Data concerning performance on prehension tests, positioning tests, practical-activity tests, and reported use of the prosthesis may, for example, be combined to provide a composite measure of amputee performance. This combination factor may then be studied in relation to other discrete variables or other composite factors. But before one goes very far along this path he comes face to face with the desirability of attempting a "global analysis."</p> <h4>Global Analysis</h4> <p>In view of the weaknesses in the two-variable approach, it would seem desirable to be able to explore the interaction of all the various factors, each with the others. That is to say, it would be helpful to be able to gauge the extent to which each factor in the prosthetic-restoration complex affects the others and to determine to what extent the total pattern of interdependence affects the final result. In any such study of interactions of variables, we are of necessity drawn to relatively sophisticated methods in statistics, such as multiple correlation, analysis of variance, and possibly factorial analysis. That analysis by these methods would be completely fruitful is by no means assured. For unless the relationships within the data are reasonably clear-cut, the statistical procedure may not be discriminating enough to bring them to light. Deficiencies in the sampling, weaknesses in the measuring instruments, and other technical shortcomings would also tend to obscure the results.</p> <p>This known risk notwithstanding, such an effort is clearly worth while and will be undertaken in view of the <i>possibility</i>of approximating the significance to be afforded various considerations involved in the prosthetic-restoration potential of an individual. Success in this more ambitious approach would shed light on the relative influence that various factors, within the amputee and within the treatment process, have on the final result. Although it is well understood clinically that not all patient characteristics or all treatment methods influence the final outcome equally, no scientifically validated picture of the relative significance of the causal factors exists to date. From further studies, one might hope to learn what combinations of amputee characteristics and treatment procedures make for the best prosthetic-restoration results and, by the same token, what combinations dictate poor results. An understanding of these matters would permit reasonable predictions as to the probable success of the restorative effort, suggest modifications of the treatment process the better to fit the needs of the individual patient, and make it possible to identify and to grade "optimum" restoration results in any given case.</p> <h3>Conclusion</h3> <p>It is clear then that this presentation constitutes an overview of the information evolving from the NYU Field Studies and suggests that a considerable amount of additional data analysis will be required before the available material will have made its final contribution to the field of upper-extremity prosthetics. Many of the remaining analyses are already in process, and it is planned to publish these results as the work is completed. It must, however, be recalled that the NYU Field Study was essentially research "in breadth" and that this approach should not be expected to answer all questions relating to the upper-extremity amputee. For many of the issues needing resolution, research embracing the study of individual cases "in depth" will be required. Meantime, it is in order to express appreciation for the singular opportunity of studying such a large group of upper-extremity amputees. Because of the nature of the disability associated with arm loss, it usually is very difficult to gather large numbers of arm amputees in any one location, and it is almost impossible to be able to subject such a group to a systematic pattern of treatment. Although it would be gratifying if it could be said that the most had been made of the unusual opportunity afforded, afterthought and hindsight tell otherwise. Unfortunately the problems of research into the unknown do not cast their shadows before, and the path to discovery remains exceedingly narrow. Until better methods of dealing with the complicated manifestations of the human being become available, we must be content with studies and analyses that can shed even small light on the challenging problems of prosthetic restoration.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Almost all of the data developed during the NYU Field Studies have been codified and punched on IBM (International Business Machines Corp.) cards, and all of the major analyses presented in this (Vol. 5, No. 2) and the preceding (Vol. 5, No. 1) issue of Artificial Limbs have been performed through the use of IBM electromechanical data-sorting techniques. Any future analyses may be accomplished conveniently through the same means.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Sidney Fishman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetic Devices Study, Research Division, College of Engineering, New York University; Director, Prosthetics Education, NYU Post-Graduate Medical School; Adjunct Professor of Psychology, Fairleigh-Dickinson University, Rutherford, N. J.; member, Committee on Prosthetics Research and Development and Committee on Child Prosthetics Problems, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_02_117/aut1958-117-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_02_117/aut1958-117-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Studies of the Upper-Extremity Amputee VIII. Research Implications Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D. * https://staging.drfop.org/files/original/25d7008c03dbf5520812970f5e24a3b8.pdf 5e4f5d62d004e9714dae9287001a5288 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_088.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 88 - 116 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_02_088.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_088.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, VII. Psychological Factors</h2> <h5>Jerome Siller, Ph.D. <a style="text-decoration:none;">*</a><br />Sydelle Silverman, M.A. <a style="text-decoration:none;">*</a><br /></h5> <p> With the possible exception of the introductory Section I (Artificial Limbs, Spring 1958; Vol. 5, No. 1), the foregoing presentations in this series have in general been concerned with the biomechanical aspects of the man-machine entity in prosthetic restoration. If, however, our understanding of amputee needs and limitations is to be comprehensive, we must inquire also into the mental and emotional characteristics of the man served by the machine. Consideration of the psychological factors in amputee rehabilitation was therefore an important aspect of the Upper-Extremity Field Studies, and the results of these investigations are summarized in this three-part article. The first part, <i>Personality Dynamics of Amputees,</i> discusses a number of the psychological variables that are relevant to amputation. The second deals with <i>Social and Functional Factors in Prosthetic Wear.</i> And the final one, <i>Attitudes Toward Prosthetic Wear, Before and After Fitting,</i> describes the attitudes shown toward arm prostheses by amputees who had never before worn an artificial arm. The rationale of the study, and the data-collecting instruments here referred to as "appendices," are all to be found in Section I (Artificial Limbs, Spring 1958; Vol. 5, No. 1; pp. 46 through 56). </p> <h3>Personality Dynamics of Amputees</h3> <p>At present no single theory, or combination of theories, encompasses all the central problems arising in man from the loss of a limb. One reason for this circumstance is that the special problems and needs of the amputee have never been defined adequately. What does an amputation mean to the amputee? What does it mean to his family, friends, and co-workers? What reaction does the amputee have to his loss? How is he affected socially, vocationally, emotionally? Does his amputation cause basic psychological changes? What major needs are frustrated? What new needs arise? Does prosthetic restoration affect personality restoration? These are but some of the questions that seem pertinent and to which answers were sought during the NYU Upper-Extremity Field Studies.</p> <p>A probing of specific amputee problems was considered to be the most fruitful approach, and accordingly a set of questions was designed to elicit information about areas in which the amputee might be expected to have significant problems. By means of a 57-item, multiple-choice questionnaire (Appendix IIIE), supplemented by a 9-item instrument calling for narrative answers (Appendix IIIF), nine personality variables (acceptance of loss, identification with the disabled, functional adequacy, independence, sensitivity, appraisal of acceptance by others, sociability, frustration, and optimism) were identified and defined. Of 359 adult male amputees who responded in this phase of the investigation, all but 55 were currently wearing prostheses or had worn one in the past.</p> <p>Each of the nine personality variables has many ramifications, and it was possible to investigate a limited number only. Moreover, a preliminary analysis indicated that the data did not differ significantly for different levels of amputation, and accordingly the responses of the three groups (below-elbow, above-elbow, and shoulder-disarticulation) were combined. The results therefore represent only an early exploration of the field with two principal purposes-first, to stimulate further inquiry, and, second, to build a more general awareness of the psychological aspects of treating and dealing with amputees. While the central concept of each variable is discussed here, emphasis has been placed on principles of theoretical and practical interest to those concerned with the management of amputees. Whenever possible, the interrelationships between a particular concept and other variables are examined, and an effort is made to bring out implications for research and practice. Vocational attitudes provided an additional area of interest, as did also the shifts in the valuation of prosthetic service.</p> <p>The data presented are chiefly those gathered after the period of treatment and fitting. Although the treatment procedure produced few measurable changes of any consequence, where such changes were observed they are also discussed.</p> <h4>Acceptance of Loss</h4> <p>"Acceptance of loss" refers to the amputee's ability to accept the physical limitations that result from his injury, to avoid depreciating or pitying himself, and to recognize the social implications of his loss without exaggerating or denying them. This matter was explored by means of questions relating to the amputee's adaptation to his loss, his wishful thinking about the lost limb, and his reaction to the artificial one.</p> <p>When the treatment period was over, most of the subjects claimed to be adapted to their loss:</p> <table> <tbody><tr> <td> <p><b> To what extent do you feel that you have become adapted to the loss of your limb?</b> </p> </td> </tr> <tr> <td> <p>Completely</p> </td> <td> <p>42%</p> </td> </tr> <tr> <td> <p>Almost completely</p> </td> <td> <p>32</p> </td> </tr> <tr> <td> <p>Considerably</p> </td> <td> <p>16</p> </td> </tr> <tr> <td> <p>Somewhat</p> </td> <td> <p>5</p> </td> </tr> <tr> <td> <p>Slightly</p> </td> <td> <p>5</p> </td> </tr> </tbody></table> <p>Before the treatment period, only 35 percent of the amputees said that they felt completely adapted to their loss. The increase to 42 percent after completion of the treatment program would seem to indicate that the fitting of the artificial limb had a strong positive effect upon the adaptation of at least a small number of amputees.</p> <p>Although 90 percent of the amputees claimed either complete, almost complete, or considerable adaptation to their respective losses, it is doubtful that so many had really achieved it. While some may truly have accepted their physical loss and its implications, there were surely many who were trying to maintain feelings of bodily integrity and adequacy by denying the personal and social concomitants of amputation. Clearly, they preferred to de-emphasize regret and any hint of abnormality and difference. In keeping with this feeling, 86 percent of the amputees said that they rarely, very rarely, or never felt sorry about their loss:</p> <table> <tbody><tr> <td> <p><b> Do you feel sorry that you're an amputee?</b> </p> </td> </tr> <tr> <td> <p>Most of the time</p> </td> <td> <p>1%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>13</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>12</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>33</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>41</p> </td> </tr> </tbody></table> <p> But it should be noted that many amputees <i>do</i> admit that they have fantasies about the matter: </p> <table> <tbody><tr> <td> <p><b> Do you find yourself wishing you were a two-handed person?</b> </p> </td> </tr> <tr> <td> <p>Much of the time</p> </td> <td> <p>8%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>45</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>28</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>10</p> </td> </tr> </tbody></table> <p>A second question also explored this phenomenon :</p> <table> <tbody><tr> <td> <p><b> Do you ever think of how much better off you would be if you had not lost an arm?</b> </p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>6%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>32</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>16</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>32</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>14</p> </td> </tr> </tbody></table> <p> Thus it appears that, although most amputees try to avoid thinking about themselves as amputees, regrets over their loss <i>do</i> come out in fantasy. Other indications of this subconscious process can be seen in the contradictory data resulting from different avenues of questioning. About half of the amputees indicated that they frequently tried to perform with their prostheses tasks which they knew would be difficult, and approximately the same number said that what bothered them most was "the inability to perform as I used to." Both of these reactions, which persisted throughout the entire period of participation in the program, seem to represent the amputee's attempt to retain his status as an active, competent, and self-sufficient person. But an amputee who frequently tries to use his artificial arm for a task that he knows will be difficult must have an unrealistic attitude toward his physical limitation. He is evidently demonstrating an unwillingness to accept the full implications of his loss. </p> <p>Among the many considerations involved in the loss of an arm, the most obvious is the inability to perform at one's previous level. Others are the loss of normal appearance and the thought of not being like other people. Although 57 percent of the amputees said that performance was their most bothersome problem, while only 15 percent mentioned the other two considerations, it is difficult to accept such a response at face value. It is likely that the loss of normal appearance and the thought of not being like other people bother amputees far more than they are willing to admit.</p> <p>Two factors lead us to this belief. First, we are convinced that people (and men in particular) hesitate to admit that they are concerned over their appearance or over the thought of not being like other people. An amputee probably finds it much more acceptable, both personally and socially, to seize upon the very real functional and vocational problems caused by his amputation and to use them as the "real" causes of his distress. Secondly, an amputee who admits to being bothered by his inability to perform is really also saying that he is concerned about being different from others, since performance difficulties as well as altered appearance make one "different."</p> <p>Amputation has also other, less obvious aspects that are even more difficult for the amputee to accept. These involve the subconscious effects of the loss, such as the thwarting of life goals, threats to masculinity-femininity identifications, and the arousal of latent fears of castration. Although the reality and importance of these problems have repeatedly been demonstrated clinically, controlled investigation designed to explore them is exceptionally difficult and has not yet been undertaken. Hence most of the subconscious effects of amputation cannot yet be evaluated systematically, even though it seems clear that they exert a great influence upon the amputee's acceptance or nonacceptance of his loss.</p> <p> In general, it may be concluded that an amputee's acceptance of loss depends upon many factors, the most important usually being beyond his own control. His ability to accept depends upon his conscious and subconscious interpretation of his status. If he feels that his amputation has relegated him to an inferior social and vocational status, that he can no longer achieve his principal goals, that he is inferior, and that he has been reduced in functional and sexual potency, he will naturally attempt to reject the implications of his loss. If he looks upon his amputation as a means of escaping from the competition of everyday life, he may accept his loss. If it justifies catering to his need to feel dependent, he may even derive satisfaction from it. But when the amputee is able to look upon his experience as primarily a major frustration that must be overcome-and that <i>can</i> be overcome by his own efforts, in cooperation with family, friends, and rehabilitation personnel-then the stage is set for a real acceptance of loss. </p> <p> Although it seems clear that when first seen many of the participating amputees had not achieved full acceptance of their loss, experience shows that, after the early postamputa-tion period of readjustment, and after satisfactory prosthetic fitting, most amputees <i>do</i> accept their loss to a significant degree. </p> <h4>Identification with the Disabled</h4> <p>"Identification with the disabled" refers to the degree to which the amputee considers his abilities, general appearance, and personality similar to those of other persons physically impaired. To a great extent this factor serves as the basis for his interaction with others.</p> <p>The basic question exploring this matter was:</p> <table> <tbody><tr> <td> <p><b> I think of myself as a:</b> </p> </td> </tr> <tr> <td> <p>physically abnormal person....</p> </td> <td> <p>1%</p> </td> </tr> <tr> <td> <p>normal person except for a major physical defect....</p> </td> <td> <p>18</p> </td> </tr> <tr> <td> <p>normal person except for a slight physical defect....</p> </td> <td> <p>29</p> </td> </tr> <tr> <td> <p>normal person except for a very slight physical defect....</p> </td> <td> <p>24</p> </td> </tr> <tr> <td> <p>completely normal person...</p> </td> <td> <p>28</p> </td> </tr> </tbody></table> <p>Obviously the subjects tended to describe themselves as normal persons and to de-emphasize their physical defects. Of particular interest are the 28 percent who described themselves as completely normal, not even conceding a "very slight" defect.</p> <p>Few of the subjects admit that amputation is of considerable consequence:</p> <table> <tbody><tr> <td> <p><b> Do you think being an amputee makes:</b> </p> </td> </tr> <tr> <td> <p>a considerable difference?</p> </td> <td> <p>7%</p> </td> </tr> <tr> <td> <p>some difference?</p> </td> <td> <p>31</p> </td> </tr> <tr> <td> <p>a slight difference?</p> </td> <td> <p>19</p> </td> </tr> <tr> <td> <p>a very slight difference?</p> </td> <td> <p>26</p> </td> </tr> <tr> <td> <p>no difference at all?</p> </td> <td> <p>17</p> </td> </tr> </tbody></table> <p>In keeping with their expressed tendency to place the fact of amputation in the background, and to consider themselves physically normal persons, most claimed that they often forgot about their amputations:</p> <table> <tbody><tr> <td> <p><b> I forget that I am an amputee:</b> </p> </td> </tr> <tr> <td> <p>never.</p> </td> <td> <p>7%</p> </td> </tr> <tr> <td> <p>rarely.</p> </td> <td> <p>4</p> </td> </tr> <tr> <td> <p>sometimes.</p> </td> <td> <p>21</p> </td> </tr> <tr> <td> <p>most of the time.</p> </td> <td> <p>61</p> </td> </tr> <tr> <td> <p>all of the time.</p> </td> <td> <p>7</p> </td> </tr> </tbody></table> <p>Still tending to play down any differences, 67 percent of the subjects said that they thought amputees had about the same number of personal problems as did nonamputees. At the start of the treatment program, only 57 percent of the amputees felt that way. But even then a sizable minority (30 percent) believed that amputees did have more personal problems than nonamputees. In any case, it is noteworthy that, in an area where one might reasonably expect some expression of difference, so large a percentage of the subjects denied any difference at all. A strong tendency to reject any hint of abnormality or "difference" appears throughout the study.</p> <p>In setting goals and evaluating achievements, most of the amputees would like to be considered as nondisabled persons:</p> <table> <tbody><tr> <td> <p><b> In deciding what you should be physically able to do, do you compare yourself with:</b> </p> </td> </tr> <tr> <td> <p>very active nonamputees?</p> </td> <td> <p>16%</p> </td> </tr> <tr> <td> <p>active nonamputees?</p> </td> <td> <p>53</p> </td> </tr> <tr> <td> <p>inactive nonamputees?</p> </td> <td> <p>2</p> </td> </tr> <tr> <td> <p>active amputees?.</p> </td> <td> <p>28</p> </td> </tr> <tr> <td> <p>inactive amputees?</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <p>Over two thirds seem to feel that their physical abilities should be comparable to those of active or very active nonamputees. In short, amputees want to be considered normal and would like to discount their physical defects. Since most arm amputees can function in society without serious disadvantage, they would seem to have a sound basis for de-emphasizing their handicaps.</p> <p> There is, of course, a stigma attached to those who are "different," and this circumstance also gives the amputee a strong reason for rejecting identification with the disabled. Thus he tends to maintain that being an amputee does not really "make a difference," although what is certainly implied is that he feels it <i>should not</i> make a difference. It is difficult to believe that so many can forget a fact of such consequence as amputation. But obviously they would <i>like</i> to forget it, and many <i>do</i> forget it, at least intermittently. For them to repress the amputation completely would be to deny the loss rather than to accept it, and this would be an equally unrealistic type of adjustment. From clinical observation, we have the impression that few amputees wear their loss as a badge, but the fact of amputation does seem to underlie a good part of their behavior. Whether this results in a neurotic fixation or is viewed as one more of life's frustrations to be overcome depends upon the individual. </p> <p>The fact that 30 percent of the amputees seem to feel that they have more personal problems than do nonamputees should not be taken as showing that amputees are more poorly adjusted than nonamputees. Other studies on physical handicap and amputation have indicated that, although particular problems of adjustment differ, there is generally no marked difference in adjustment between those who are handicapped and those who are not.<a></a></p> <p>An amputee has mixed conscious and subconscious identifications both with disabled and with nondisabled groups. Whichever group he primarily identifies with provides the basis for his concept of himself, the goals he sets, the aspirations he has, and the way he interacts with others. The amputees in the NYU Field Studies overwhelmingly elected a non-amputee, nondisabled frame of reference. In such a course lie dangers for them-dangers of self-deception, of denial and distortion of reality. Yet advantages follow too. Identifying with the nondisabled provides stimulation and drive to actualize the potential that each amputee has. It helps to combat defeatist attitudes and withdrawal into lethargy and invalidism. The amputee who is able to recognize and accept his identifications with both the disabled and the nondisabled groups maintains the soundest approach to personal adjustment.</p> <h4>Functional Adequacy</h4> <p>"Functional adequacy" refers to the amputee's estimate of his level of competence in performing physical activities. Questions were asked exploring the amputee's evaluation of his physical abilities. As has already been seen, over two thirds of the amputees seemed to feel that their physical abilities should be comparable to those of active or very active nonamputees. How well did they think that they met this exacting standard? Generally speaking, they said that they were able to achieve their high goals:</p> <table> <tbody><tr> <td> <p><b> As compared to nonamputees, I am generally able to do:</b> </p> </td> </tr> <tr> <td> <p>much less.</p> </td> <td> <p>2%</p> </td> </tr> <tr> <td> <p>somewhat less.</p> </td> <td> <p>35</p> </td> </tr> <tr> <td> <p>as much.</p> </td> <td> <p>49</p> </td> </tr> <tr> <td> <p>somewhat more.</p> </td> <td> <p>14</p> </td> </tr> <tr> <td> <p>much more.</p> </td> <td> <p>0</p> </td> </tr> </tbody></table> <p> Only about one third conceded that they could not do as much as nonamputees. Furthermore, 68 percent of the amputees said that "very little effort" or "a little extra effort" was required to keep up with nonamputees. Ten percent even claimed that <i>no</i> extra effort was required. But 21 percent did admit that "a lot of extra effort" was necessary to keep up with others. </p> <p>In response to other questions, 92 percent said that they believed their work to be as good as or better than that of their nonamputee co-workers, and 66 percent said they felt they could be employed in jobs requiring "almost as much use of the prosthesis as of the normal hand."</p> <p>Comparing their present abilities with those had before amputation, 83 percent said they found doing things only "slightly more difficult now." Speaking of the things they could do before their loss, 96 percent said that they could still do "many," "almost all," or "all" of them. Only 8 percent said that being an amputee restricted their capacities "considerably." But 97 percent believed that they could do as much as, or more than, most other amputees.</p> <p>Here again the optimistic responses show some increase after the treatment period, and there are still other indications that the amputee's feelings of competence are related to the use of the new type of prosthesis. After treatment, 81 percent of the amputees said that they were "very much; or ;completely" satisfied with their prostheses, whereas at the beginning of the treatment program only 58 percent said so. Improved prosthetic equipment and better management procedures seem largely responsible for the favorable results.</p> <p>Generally speaking, we may describe the picture as follows. The amputee sets high limits to his physical accomplishments, most often aiming to equal the nonamputee. He will sometimes concede that he can do less than a nonamputee, but more often than not he will claim that he can do as much or more. While he almost never admits to a substantial inferiority, he will acknowledge that it takes a little extra effort to keep up with nonamputees. He feels competent to handle the daily routine of living, and he expresses no deprivation associated with his functional limitations. Finally, his estimate of his own abilities increased as a result of participation in the research program.</p> <p>Taken at face value, this self-picture by the amputee seems a blissful one. But experience indicates that, while some amputees do approach the ideal state, the average patient is far more concerned about his functional adequacy than the responses show. Some of the amputee's description of his high level of competence must certainly be the result of wishful thinking. Concerned with maintaining his self-esteem and confidence, he surely must often distort reality so as to diminish the gap between what he imagines he can do and what he actually can do. And his feelings of great competence may also reflect certain changes in his habits since his amputation-changes that have brought his activities more into line with his new physical abilities.</p> <p>Complete analysis of functional adequacy requires both objective and subjective estimates of competence and a study of the effect that the difference between the two has upon the amputee's adjustment. In the absence of such an investigation, the data presented are best considered as the responses of people who are concerned with maintaining their self-esteem, their feelings of confidence, and their sense of adequacy. The responses show what the amputee subconsciously desires in the way of treatment from nonamputees. In effect, what we have here is the collective mask that amputees present to the public-and often to themselves. The extent to which we can accept this mask, or how we need to modify it, is a clinical problem that can be resolved only when the amputee's real and fancied achievements are considered in the light of his basic needs.</p> <h4>Independence</h4> <p>"Independence" refers to the extent to which the amputee can make a reasonable effort to be self-sufficient while still feeling free to call for assistance or to use help that is offered. It has been seen that the amputees in this study tend to characterize themselves as self-sufficient. When the amputee knows himself to be capable of handling a situation, he usually declines offers of help:</p> <table> <tbody><tr> <td> <p><b> When I know that I am capable of handling a task, I:</b> </p> </td> </tr> <tr> <td> <p>never accept help.</p> </td> <td> <p>28%</p> </td> </tr> <tr> <td> <p>very rarely accept help.</p> </td> <td> <p>34</p> </td> </tr> <tr> <td> <p>rarely accept help.</p> </td> <td> <p>12</p> </td> </tr> <tr> <td> <p>sometimes accept help.</p> </td> <td> <p>22</p> </td> </tr> <tr> <td> <p>frequently accept help.</p> </td> <td> <p>4</p> </td> </tr> </tbody></table> <p>In keeping with this desire for self-sufficiency, almost three quarters of the amputees said that they rarely or very rarely solicit help:</p> <table> <tbody><tr> <td> <p><b> How often do you call for help from others?</b> </p> </td> </tr> <tr> <td> <p>Never.</p> </td> <td> <p>5%</p> </td> </tr> <tr> <td> <p>Very rarely.</p> </td> <td> <p>57</p> </td> </tr> <tr> <td> <p>Rarely.</p> </td> <td> <p>14</p> </td> </tr> <tr> <td> <p>Occasionally.</p> </td> <td> <p>23</p> </td> </tr> <tr> <td> <p>Frequentrly.</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <p>Two facts are of particular interest here. First, the course of treatment provided by the program increased from 49 percent to 57 percent the proportion of those who claimed they very rarely called for help. Secondly, none of the most physically disabled patients (bilateral and shoulder-disarticulation cases) reported frequent calls for help. In answer to other questions, only 1 percent of the amputees said that they refuse help under any circumstances. More than half said that they accept help only when it means the difference between success or failure. About one quarter said they accept help if it makes the task easier. And 14 percent said they accept help even if it does not make the task easier.</p> <p>It is clear that the amputee is vitally concerned about his sense of independence. He tends to depict himself as a self-sufficient individual who rejects offers of help whenever he can and who asks for help only occasionally. Despite the stress he places on self-sufficiency, however, the amputee almost always accepts the fact that complete independence is impossible. But he will be practically certain to reject any suggestion of serious dependence.</p> <p> Why does the amputee value his independence so highly? The answer seems to lie with our society, which places a high premium on personal competence and achievement. The dependent person often finds himself assigned an inferior status in his group. The amputee, constantly faced with this prospect, feels a strong need to prove that he is self-sufficient and that he does not differ from other people. In any case, a handicapped, dependent person is seriously restricted in his ability to reach simple goals that are easily achieved by others.<a></a> </p> <p> Before the amputee can judge the extent of his handicap, he must go through an extensive trial-and-error period, particularly in the early stages of his loss. Depending on how realistically he views his limitations, dependency will or will not become a critical problem. At this point, three kinds of reactions are possible: he may appraise realistically his functional capacities and limitations; he may partly deny his limitations, at the same time often attempting to compensate for them; he may deny his limitations completely. <a style="text-decoration:none;">*</a> Underlying all three of these reactions is the basic need of all persons to maintain feelings of self-sufficiency-if necessary, by distorting reality. Thus an amputee may distort the extent of his dependence on others and exaggerate his abilities to fulfill society's demands for independence. Conversely, some amputees may distort reality in the other direction, emphasizing their loss in order to help them think of themselves as dependent, affection-seeking persons. In general, however, the amputee's ability to make a realistic appraisal of his capacities, to recognize a certain amount of dependency where it is inevitable, and to ask for help when necessary will depend above all on his feelings of basic security. The amputee who is insecure will be more likely to seek help indiscriminately or to reject it unreason-ably.<a></a> </p> <p> To avoid overdrawing the negative effects of reality distortion, a distinction must be made between extreme distortion of reality and its temperate shaping. We tend to admit into our perceptions things in line with positive self-feelings and to eliminate or modify those which might cause anxiety. This is a form of adaptive, nonpathological distortion involving control of situations so that, when reality must be faced, it may be done despite the temporary pain associated with the process. Some avoidance of harsh reality is sometimes necessary in order to preserve equanimity in the face of many daily frustrations. In some cases, however, the amputee displays an extreme form of dependence that has been called "invalidism."<a></a> When this happens, the amputee exploits those about him by harping on his incapacities more than his injury warrants. He uses his handicap to avoid responsibilities. While it is true that anyone might be tempted to plead illness to avoid an unpleasant experience, in invalidism the individual employs his loss as a constant way out. Invalidism can also be an attention-getting device as well as an attempt to obtain love that the amputee is not sure of having otherwise. It is used to threaten and control other persons and sometimes provides the disabled person with the means of taking revenge upon others by limiting their freedom of action and making them anxious and guilty. </p> <p> Whatever the reaction, the family plays an important role in the amputee's attempts to achieve self-sufficiency and yet to fulfill his needs for dependency. The attitude of the family is often thought to be at least as important as the physical injury itself in determining the amputee's reaction to his disability.<a></a> The amputee's attitude toward his family is a combination of a drive for independence and a plea for aid, explicit or implicit. In the ideal family relationship, both needs will be satisfied. But the stress should be upon helping the amputee to take his place in society as a self-respecting, adequate person. </p> <h4>Sensitivity</h4> <p>"Sensitivity" refers to the amputee's subjective appraisal of the effect of his physical condition on others and to the feelings of self-consciousness he experiences as a result of this appraisal. Sensitivity about disability may therefore be related to two sources: perception of the negative appraisals of others, and the individual's own self-rejection. These two factors are of course not entirely independent, since an amputee's notions of what others think of him may largely determine what he thinks of himself.</p> <p>The majority of the amputees in the study readily admitted concern about the opinion of others, but it is noteworthy that almost a fourth of the group refused to admit anything more than a "little" sensitivity:</p> <table> <tbody><tr> <td> <p><b> How much do you care about what others think of you?</b> </p> </td> </tr> <tr> <td> <p>Considerably.</p> </td> <td> <p>53%</p> </td> </tr> <tr> <td> <p>Somewhat.</p> </td> <td> <p>23</p> </td> </tr> <tr> <td> <p>Little.</p> </td> <td> <p>8</p> </td> </tr> <tr> <td> <p>Very little.</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>Not at all.</p> </td> <td> <p>7</p> </td> </tr> </tbody></table> <p>The clinical treatment program had the effect of reducing the self-consciousness admitted. Amputees who said that they never, rarely, or only sometimes felt self-conscious about their personal appearance went from 59 percent before treatment to 72 percent afterward. But 28 percent still said they felt self-conscious most of the time or almost always.</p> <p>Twenty-one percent of the amputees said that they felt they looked "the same as most people," and 62 percent answered "almost the same as most people." In keeping with this attitude, most of the amputees claimed that they did not feel themselves to be conspicuous. But a significant 22 percent confessed that the idea occurred to them with some frequency:</p> <table> <tbody><tr> <td> <p><b> The idea that people are looking at me:</b> </p> </td> </tr> <tr> <td> <p>is almost always on my mind.</p> </td> <td> <p>2%</p> </td> </tr> <tr> <td> <p>sometimes occurs to me.</p> </td> <td> <p>20</p> </td> </tr> <tr> <td> <p>rarely occurs to me.</p> </td> <td> <p>17</p> </td> </tr> <tr> <td> <p>very rarely occurs to me.</p> </td> <td> <p>38</p> </td> </tr> <tr> <td> <p>never occurs to me.</p> </td> <td> <p>23</p> </td> </tr> </tbody></table> <p>The majority of the amputees said that they expected other people to discuss the disability. Only a few believed this occurred frequently, and even fewer denied its existence:</p> <table> <tbody><tr> <td> <p><b> Do you think that people talk about your disability?</b> </p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>3%</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>30</p> </td> </tr> <tr> <td> <p>Occasionally</p> </td> <td> <p>57</p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>Always</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <p> Most amputees (67 percent) denied that they felt any resentment over the curiosity of other people. The rest maintained a ratio of three positive reactions <i>(e.g.,</i> pride in demonstrating the prosthesis, appreciation of interest) for every negative reaction <i>(e.g.,</i> self-consciousness, resentment, nervousness). In all, reactions of annoyance caused by people's curiosity decreased significantly by the end of the treatment period. </p> <p>Although 99 percent of the amputees said that they seldom or never tried to hide the fact of their amputation, the overwhelming majority said they would not tell a new acquaintance about it unless asked.</p> <p>The question of whether to fit a hook or a hand is often decided on the basis of the amputee's sensitivity. Those particularly sensitive about their amputation might be expected to reject a hook because of its appearance. The majority of the amputees in this study (61 percent) said that they believed hooks to be mechanical-looking but not unsightly, while a significant additional number (25 percent) expressed a more negative attitude concerning their appearance. But only 1 percent said they would not use one under any condition:</p> <table> <tbody><tr> <td> <p><b> I think that a hook is :</b> </p> </td> </tr> <tr> <td> <p>so ugly I would never wear one...............................</p> </td> <td> <p>1%</p> </td> </tr> <tr> <td> <p>so ugly I would never wear one when I'm with other people...</p> </td> <td> <p>2%</p> </td> </tr> <tr> <td> <p>unsightly but not enough to prevent me from wearing one...</p> </td> <td> <p>23%</p> </td> </tr> <tr> <td> <p>mechanical looking but not unsightly..............................</p> </td> <td> <p>61%</p> </td> </tr> <tr> <td> <p>as natural looking as any artificial hand........................</p> </td> <td> <p>13%</p> </td> </tr> </tbody></table> <p>The composite data indicate that, although the amputees showed considerable awareness of their appearance, they did not brood about it. When asked directly, they were much more likely to deny being sensitive than to admit being preoccupied with their condition. They were well aware that amputations and prostheses arouse curiosity, but they maintained that they (the amputees) were "normal" and so did not feel resentful toward these attentions. Amputees who do acknowledge self-consciousness are most likely to do so in situations where there is no social pressure against displaying sensitivity.</p> <p>On the basis of other evidence, there seems to be considerably more indication of sensitivity and of hostility toward the curious person than is revealed by the questionnaire. This is to be expected, for clinical situations induce greater rapport and permit the amputee to express hostile feelings with less fear of social criticism. Thus, it is quite likely that the amputee's sensitivity is much greater than he is willing to admit.</p> <p> The universal unwillingness of amputees to admit that they differ from others rests in part on the fact that in many respects they are indeed no different from other people. But it also may represent a "whistling-in-the-dark" attitude, an attempt to deny something that the amputee really believes to be true <i>(e.g.,</i> that he <i>is</i> handicapped or inferior), and may reflect the amputee's resistance against the social consequences of being "different." </p> <p>As has already been mentioned, amputees are likely to incorporate the negative attitudes of others into their own self-concept. Most amputees recognize that nonamputees are more comfortable when the fact of amputation is not conspicuous, and they will attempt by various means to "spare the feelings" of others by trying to reduce the visual "shock" for the nonamputee. Many of the subjects are not, however, merely responding appropriately to social cues but rather are using this explanation as a rationalization for their own self-rejecting thoughts. The same self-rejection may be responsible for the denial of sensitivity, which the questionnaire data show to be characteristic of a sizable minority of the sample.</p> <h4>Appraisal of Acceptance by Others</h4> <p>Appraisal of acceptance by others" refers to the amputee's evaluation of the effect his disability has on the approval others may give him. Less than 5 percent of the amputees said that they felt they were being treated any way different from that in which they had been treated before amputation. Almost all of the subjects claimed that their amputation had had little or no effect upon their acceptance by others. They rejected overwhelmingly the suggestion that their amputation merited them either special treatment or discrimination in their job, family, or social relationships. Most of them said they did not feel that people paid them undue attention. In general, the data indicate that amputees feel they receive sufficient but not excessive attention in social situations. A small percentage admit that some sympathetic behavior is displayed consistently in their job and family relationships.</p> <p>The amputee claims to be accepted by others on the same basis as anyone else, and he rejects strongly the suggestion of "different" treatment. But he will more readily admit to being favored than to being rejected. The treatment program seemed to bring a slight increase in the number of those who felt they were accepted on the same basis as other people. But little change was noted among those who claimed to be the recipients of either favoritism or antagonism. The data suggest that the treatment program was psychologically beneficial to those who were "uncommitted" on the first testing but that it had no effect on those who were convinced of their "different" status.</p> <p> The cumulative evidence about the social position of the disabled person strongly suggests that the results of the survey again represent the amputees' <i>wishes</i> rather than the actual situation, a finding supported by the fact that, when asked indirectly how they thought amputees should be treated, the majority revealed that they preferred to have little made of their physical handicap: </p> <table> <tbody><tr> <td> <p><b> If you were a nonamputee, how would you react to an amputee?</b> </p> </td> </tr> <tr> <td> <p>I would ignore the fact that the person is an amputee</p> </td> <td> <p>16%</p> </td> </tr> <tr> <td> <p>I would treat him as a normal person who just happens to have lost an arm or hand</p> </td> <td> <p>72</p> </td> </tr> <tr> <td> <p>I would expect less from him physically</p> </td> <td> <p>6</p> </td> </tr> <tr> <td> <p>I would be more kind and thoughtful of his feelings</p> </td> <td> <p>5</p> </td> </tr> <tr> <td> <p>I would know that, as an amputee, he requires special treatment</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <h4>Sociability</h4> <p>"Sociability" refers to the extent to which the amputee seeks, and derives pleasure from, social relationships. In this connection, the subjects said that they looked forward to social functions and enjoyed them. The treatment program had the effect of increasing by about one fourth the number of amputees who said that they "always" enjoyed these functions. All but a very few of the subjects said that they had greater social confidence with their new prostheses. Neither before the treatment period nor after, however, did more than S percent confess to any lack of social confidence. Over three quarters of the amputees said that neither their amputations nor their prosthesis-wearing had caused any change in their social relationships. Those who did report changes were almost unanimous in claiming that the changes were toward greater sociability.</p> <p>These results reaffirm the earlier observations that the amputee tends to deny he has any major problems of acceptance. He usually claims that he engages in social activities eagerly and freely and experiences no prejudice because of his disability. But here again it is possible to read these results as expressing not so much the real facts as the wishes of the amputee to be accepted fully into the nonamputee world. Nevertheless, the indications are clear that the amputee tends to have more social confidence after suitable prosthetic fitting and treatment, the implications being that superior prosthetic equipment provides the basis for the ability to meet others with less trepidation and with greater feelings of personal adequacy. It also confirms indirectly the significance of feelings of functional adequacy and of ability to be independent.</p> <h4>Frustration</h4> <p>"Frustration" refers to the amputee's experience resulting from his inability to achieve personal, social, and vocational goals because of his amputation. The term refers both to whatever blocks or interferes with the amputee's strivings and to his subjective feelings of annoyance, confusion, or anger when he is thwarted. While 58 percent of the amputees said they rarely or never were prevented from achieving their goals, the other 42 percent claimed to feel frustrated from time to time as a result of amputation:</p> <table> <tbody><tr> <td> <p><b> Does being an amputee prevent you from doing things you really want to do?</b> </p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>20%</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>27</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>11</p> </td> </tr> <tr> <td> <p>Someties</p> </td> <td> <p>37</p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>5</p> </td> </tr> </tbody></table> <p>When, however, absence of a limb prevented performance of a task, a considerable proportion of the amputees (86 percent) felt annoyed. They almost unanimously (98 percent) said that they did not give up trying to do something because it was difficult, or that they gave up only after repeated failures.</p> <p>As for vocational goals, a majority of the amputees refused to admit more than slight difficulties. Some 40 percent indicated that there was some substantial interference:</p> <table> <tbody><tr> <td> <p><b> Do you feel that your amputation interferes with your getting a job?</b> </p> </td> </tr> <tr> <td> <p>Not at all</p> </td> <td> <p>27%</p> </td> </tr> <tr> <td> <p>Very slightly</p> </td> <td> <p>15</p> </td> </tr> <tr> <td> <p>Slightly</p> </td> <td> <p>18</p> </td> </tr> <tr> <td> <p>Somewhat</p> </td> <td> <p>29</p> </td> </tr> <tr> <td> <p>Seriously</p> </td> <td> <p>11</p> </td> </tr> </tbody></table> <p>Here the fact that the more seriously disabled (bilateral and shoulder-disarticulation cases) responded as did the other amputees seems to suggest that the results do not accurately reflect the real situation.</p> <p>The relatively small degree of frustration the amputees reported is surprising in view of the many frustrating situations they encountered. It suggests that many of the responses were given because they seemed socially desirable and because the test situation did not encourage the amputee to express freely his aggressive or negative feelings. But it is also possible that repeated experiences of frustration, together with the strong motivation to be "like anyone else," which is so characteristic of the subjects studied, can produce in many amputees a truly high level of frustration tolerance. To this must be added the active efforts to avoid situations potentially frustrating.</p> <p>Any interference with goal-directed activity constitutes a frustration. But interpreting frustration in others has certain dangers because what frustrates one individual may not frustrate another. The nonamputee who fails to consider this circumstance is likely to make toward the disabled person unnecessary offers of help. The amputee may take such overtures as indicating that people believe him to be incompetent and may, consequently, feel downgraded in his status as a functioning person. In a sense, the real frustration in this particular situation is the nonamputee's lack of awareness of the amputee's competence.</p> <p>The intensity of an amputee's frustration depends upon how important his thwarted goals are to him. And while he may not feel seriously deprived if he cannot accomplish some trivial task, his frustration may be great if the particular failure happens to symbolize his inability to reach some more important goal. A minor frustration may assume importance if it symbolizes a general downgrading of status. Furthermore, when frustration is chronic the setting is ripe for the development of neurotic symptoms that represent the amputee's attempt to escape from an intolerable situation. It is considerably easier for anyone to deal with a short-term frustration than to adapt to a long-term one. Amputation is permanent and hence can lead easily to chronic frustrations and to neurotic solutions for the frustrations.</p> <p>The amputees in question showed two general types of reaction to frustration. One was concerned with overcoming the obstacles that interfere with the attainment of goals. In the other, the concern had more to do with preserving self-esteem and warding off anxiety than with achieving thwarted objectives. The first, or goal-directed, reaction to frustration is characterized by the amputee's ability to accept the reality of his amputation with a minimum of self-deception. In this type of reaction, the amputee seeks goals that are in line with his reduced capabilities and takes whatever steps he must to overcome the barriers imposed by his amputation. When questioned, he admits to being frustrated sometimes, but he shows a high toleration for frustration and tends to give up only when a task is clearly beyond his abilities, at which time he is willing to accept appropriate help. Besides, he will probably accept himself as a person and neither brood over nor resent his situation.</p> <p> In the second, or "ego-protective," reaction to frustration, the amputee refuses to accept reality. Instead, he distorts it and tries to create situations in which he can be at ease and relatively free of anxiety. If necessary, he will go so far as to deny his disability. He tends to set such low limits for achievement that he can avoid frustration, and he often sharply restricts his involvement in life as he seeks to eliminate opportunities for frustration. Such protective action is likely to lead to neurotic symptoms-to hypersensitivity, invalidism, defeatism, somatic complaints, anxiety, social withdrawal, and so on. In an earlier publication, Siller <a></a> observed that amputees who achieved good adjustment were often strongly oriented toward compensating for their loss. They were, in other words, showing a goal-directed reaction to frustration. It was also observed that amputees who adjusted poorly often directed their efforts toward avoiding the implications of their loss, thus showing an ego-protective reaction to frustration. </p> <p>As a result of the treatment program in the NYU Field Studies, there was a small increase in the number of amputees who reported a moderate degree of frustration tolerance combined with the ability to recognize their limitations clearly. While in answering the test questions the amputees undoubtedly had a tendency to deny unfavorable feelings and behavior, the subjects as a whole still showed a rather high tolerance for frustration.</p> <h4>Optimism</h4> <p>"Optimism" refers to those feelings of adequacy, of self-confidence, and of positive future outlook that the amputee experiences. The negative aspects of this personality variable are pessimism, depression, and feelings of inadequacy and inferiority. While the subjects in the study tended to stress their positive feelings of optimism and to de-emphasize their pessimistic feelings, few denied that they experienced depression at times:</p> <table> <tbody><tr> <td> <p><b> How often do you feel "down in the dumps" or "blue"?</b> </p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>3%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>29</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>21</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>39</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>8</p> </td> </tr> </tbody></table> <p>The treatment period had the effect of increasing from 33 percent to 39 percent those amputees who answered "very rarely," and in general the fitting of new prostheses increased slightly the claims of optimism. Most of the amputees professed to be very optimistic about their future prospects, and none at all said that they expected to be unsuccessful:</p> <table> <tbody><tr> <td> <p><b> Does your future promise to be:</b> </p> </td> </tr> <tr> <td> <p>extremely successful?</p> </td> <td> <p>14%</p> </td> </tr> <tr> <td> <p>moderately successful?</p> </td> <td> <p>66</p> </td> </tr> <tr> <td> <p>slightly successful?</p> </td> <td> <p>11</p> </td> </tr> <tr> <td> <p>neither successful nor unsuccessful?</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>unsuccessful?</p> </td> <td> <p>0</p> </td> </tr> </tbody></table> <p>Throughout the questionnaire, the subjects tried to avoid responses indicating pessimism, depression, and feelings of inadequacy or inferiority. They were more likely to admit feelings of superiority than of inferiority, but in general they avoided admitting extreme feelings in either direction:</p> <table> <tbody><tr> <td> <p><b> Do you ever have feelings of:</b> </p> </td> </tr> <tr> <td> <p>Inferiority?</p> </td> <td> <p></p> </td> <td> <p>Superiority?</p> </td> </tr> <tr> <td> <p>38%</p> </td> <td> <p>Never</p> </td> <td> <p>29%</p> </td> </tr> <tr> <td> <p>28</p> </td> <td> <p>Very rarely</p> </td> <td> <p>22</p> </td> </tr> <tr> <td> <p>12</p> </td> <td> <p>Rarely</p> </td> <td> <p>15</p> </td> </tr> <tr> <td> <p>20</p> </td> <td> <p>Sometimes</p> </td> <td> <p>30</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>Frequently</p> </td> <td> <p>4</p> </td> </tr> </tbody></table> <p>The amputees tried of course in their answers to place themselves in a socially favorable light-to shun answers with negative implications. But we may still estimate the feelings of the average amputee. He resists, rejects, and resents any suggestion that as a person he differs from anyone else; at the same time he acknowledges some (but not too much) physical difference and handicap. If he senses that the nondisabled people about him consider him "different" because of his loss, he may often go to extremes to deny pessimistic feelings which in a more relaxed environment he might well acknowledge.</p> <p>Amputees are not alone in their desire to be placed in a favorable light. The tendency to respond in a socially desirable manner seems to be characteristic of all groups when tested under conditions similar to those of the present study. Nevertheless, when we consider the very real handicaps amputees must face, we may conclude that those studied here are for the most part maintaining an optimistic outlook.</p> <h3>Social and Functional Factors in Prosthetic Wear</h3> <p>The attitudes of amputees toward prostheses have in the past received little systematic study. The amputee's preferences in artificial limbs, and his habits in using them, are evidently not based entirely upon his objective assessment of his functional and social needs. They are influenced also by emotional factors arising from the meanings he attaches to the wearing of artificial limbs. Little organized information is available about these attitudes, whether rational or irrational, and we know little as yet about the specific effects that an amputee attributes to his prosthesis once he has accepted and worn it. What difference does he think it makes in his daily life?</p> <p> The prosthetic-reaction test (Appendix IIIG), designed to explore in a systematic way some of the attitudes and reactions underlying prosthetic wear, attempted to gauge, in various situations, the amputee's response, both when he is considered to be <i>wearing</i> an artificial arm and when he is considered <i>not</i> to be wearing one. In a series of nine different pictures, a fictitious amputee, "John," was shown in some everyday situations-some in which his sensitivities as an amputee might be expected to be aroused. Below each picture were from five to nine statements indicating possible responses that John, the amputee in the picture, might make to the situation depicted. The subjects under test were asked to select the statement most nearly describing what John might say, feel, or do in each case. The assumption, of course, was that the amputees would attribute to the imaginary John some of their own feelings and reactions. It was thought that, as the amputees thus responded to specific life situations through the medium of this other person, their attitudes might be expressed more freely than they would be through direct questioning. </p> <p> The test was administered to each of the amputees three times, once at the beginning of the research program (Evaluation I) and twice at the end of the studies (Evaluation II). In Evaluation I, and at the first administration during Evaluation II, the subjects were asked to select John's response <i>"if he were wearing a prosthesis as he usually does."</i> Immediately after the amputees had completed the test for the first time during Evaluation II, they took it again but now were asked to select John's response <i>"if he never wears a prosthesis."</i> For convenience, we shall refer to these three administrations of the test as El, E2a, and E2b. Together, the three provide data for the study of three major questions: </p> <ol> <li>In the difficult social situations that an amputee faces daily, what are his most frequent responses and his most commonly held attitudes?</li><li>What changes, if any, in his attitudes and reactions came as a result of his being fitted with a new prosthesis and taking part in the research program?</li><li>In these difficult social situations, how does the wearing of a prosthesis affect the amputee's responses?</li></ol> <p>Each of these problems shall be taken up in turn.</p> <p>The prosthetic-reaction test touches upon a number of aspects of an amputee's performance. Foremost is the general area of "security," which involves the amputee's basic acceptance of himself and others, particularly his personal adjustment to the loss of his arm. Included within the concept of security were such constructs as self-acceptance (the ability to view the loss without self-pity, exaggeration, or denial, and without resorting to maladaptive means of defending self-esteem) and reality-facing (the ability to appraise environmental situations as they are). In addition, there was evidence that several of the cartoons strongly measured a second variable, "independence," which describes the amputee's motivation to be self-sufficient and to function adequately with a minimum of assistance.</p> <p> Psychologically, strivings for independence are likely to stem from the individual's feelings of security, and as such the two must be considered related phenomena. But since the need to be independent is a major concern of amputees, separate analyses of the data concerning independence were made whenever appropriate. Each statement in the test was therefore rated first for "security" and, when indicated, for "independence." Four psychologists ranked from 1 to 5 all possible responses according to the extent that the individual variables were reflected therein. <a style="text-decoration:none;">*</a> Personal differences in ranking were resolved through mutual discussion among the four. </p> <p>Responses rated 1 or 2 were considered "high." A rating of 3 was considered "intermediate," a rating of 4 or 5 as "low," and the terms "high," "intermediate," and "low" were used as relative terms to describe the individual's position along the "security" and the "independence" scales. For example, Picture VI (Appendix IIIG) showed an amputee in a restaurant with a steak that seemed too tough for him to cut. The seven statements given beneath the picture were ranked and judged as shown in the following tabulation:</p> <p>The prosthetic-reaction test, then, tells us how amputees appraise various social situations and what they think about the worth of artificial arms in these situations. It also gives us some indication of their feelings of independence and security, both when they are wearing prostheses and when they are not. What light does this information shed upon the three major problems already mentioned?</p> <h4>Amputee Responses to Everyday Social Situations</h4> <p> The most outstanding finding of this study was that the amputees overwhelmingly-in fact, almost invariably-selected the most positive responses to the situations depicted in the cartoons, particularly when the amputee was assumed to be wearing an artificial arm. For almost every situation of the series, the statement most frequently chosen was one extremely high in both independence and security. Moreover, for most of the pictures well over half the sample responded with statements that were judged "positive" <i>(i.e.,</i> high in security or independence). Even in E2b, where positive responses were considerably fewer, they still accounted for a large segment of the sample. Typical percentages of amputees showing high, intermediate, and low "security" and "independence" responses to each cartoon are shown in <b>Table 1</b> , where the data are derived from E2a (post-treatment) and refer to circumstances in which John was supposed to be wearing a prosthesis. For the sample as a whole, there were negligible differences between the El (pretreatment) and the E2a (post-treatment) data. </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 /> <p> For every situation, more than 60 percent of the sample chose positive responses, and in only one instance did more than a negligible proportion choose a statement reflecting definite insecurity. As for that item, many of the respondents had not correctly interpreted the other person to be the amputee's wife. Even more striking is the fact that from a fourth to a half gave as their response the single most positive statement. It is clear, then, that the majority of the amputees wished to be viewed as functionally independent, having confidence in their ability, with a desire to demonstrate their functional achievements, and willing to accept some aid if it is found to be needed. The vast majority of the responses expressed an acceptance of the loss of the limb, a willingness to discuss the amputation with others, and a general self-assurance in social situations. ( <b>Fig. 1</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In general, the most popular responses were those which emphasize functional effectiveness, self-confidence, and lack of sensitivity about amputation. Reactions suggesting any admission that the amputee considered himself at all "different" from anyone else were extremely rare. It seems clear that the subjects readily recognized the socially desirable responses and favored them overwhelmingly. To what extent this eventuality represents the true feelings and behavior of the group, and to what extent it represents wishful thinking, cannot be determined from these data-a situation that reflects a weakness in the prosthetic-reaction test as currently conceived. Evidence indicates that amputees are very much concerned with conforming to the important cultural values of self-reliance and self-confidence and that they abhor any suggestion of a departure from complete normality. <b>Table 1</b> </p> <h4>Changes in Responses as a Result of Fitting</h4> <p>For the group as a whole, there were virtually no significant differences between El and E2a, even though the latter was administered after a considerable period of time had elapsed. This result would suggest that the treatment program had little or no effect on the expressed attitudes of the group. But when we consider separately those amputees who were being fitted for the first time and those who had worn prostheses before, some changes can be detected among the new wearers. Since the number of amputees being fitted for the first time was small (only 55), no extensive quantitative analysis can be made. Nevertheless, a few general conclusions can be drawn.</p> <p>First of all, the responses after fitting indicated that new wearers were slightly disappointed in the functional efficacy of their artificial arms. While initially (on El) a large number of these amputees revealed expectations that the prosthesis would enable them to do "almost everything," particularly in their occupational roles, the E2a responses indicated more modest attitudes. But these changes were not toward more negative responses. Rather, they reflected the fact that the amputees concerned had indulged in unrealistic expectations for the prostheses and then had adjusted to a more realistic view after some experience with their new arms. There were, moreover, indications of a greater degree of security in social situations. After fitting, some of the new wearers indicated an increased acceptance of their amputation-a greater ability to talk about it, less tendency to withdraw from situations revealing the disability, and less expectation of pity from others. Besides this, they expressed a greater readiness to ask for help without apology or embarrassment.</p> <h4>Effects of Fitting Upon Responses to Everyday Situations</h4> <p> As has already been indicated, the primary aim of the prosthetic-reaction test was to evaluate the amputee's feelings about the part that an artificial arm plays in the common difficult situations of his life. The statements the subjects chose as describing John's behavior may therefore be taken as reflecting aspects of their own behavior. Consequently, if we compare the results of E2a (in which John is considered to be <i>wearing</i> a prosthesis) with those of E2b (in which he is considered <i>not</i> to be wearing one), both tests having been administered at the end of the studies, we discover some of the effects that wearing an artificial arm has on the daily life of an amputee. Toward this end, the two personality variables, independence and security, were considered. In separate analyses of the data from the "nonprevious prosthesis wearers" (referred to as NPPW's) and the "previous prosthesis wearers" (PPW's), it was found that the two groups did not differ in their responses except as discussed specifically hereafter. <a style="text-decoration:none;">*</a> </p> <p> A review of the E2a (prosthesis worn) and E2b (prosthesis not worn) responses follows: <b>Fig. 2</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Greater tolerance of curious strangers is exhibited when a prosthesis is worn. In E2a the amputees appear better able to view the situation without misinterpretation, to be more sure of themselves and less likely to pity themselves or to expect pity from others. The PPW's are somewhat more secure in the E2a situation than are NPPW's, even though both groups were wearing prostheses at the time of the tests. The most reasonable explanation for this difference would seem to he in the fact that the period of prosthetic wear for the NPPW group was insufficient for feelings of conspic-uousness to disappear.</p> <p> <b>Fig. 3</b> , <b>Fig. 4</b> , <b>Fig. 5</b> , <b>Fig. 6</b> , <b>Fig. 7</b> , <b>Fig. 8</b> , <b>Fig. 9</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Differences between the E2a (with prosthesis) and E2b (without prosthesis) responses were considerable throughout the entire test, both for amputees who were being fitted for the first time and for those who had previously worn prostheses. We may thus conclude that the positive acceptance of prostheses reflects not merely the enthusiasm of new wearers but rather the genuine value of prosthetic wear in its own right.</p> <p>The indications are clear that amputees regard a prosthesis as a definite asset in functionally demanding situations and that they think of it as something enabling them to be more independent, more secure, and more willing to accept their condition. In the potentially threatening situations that an amputee must face from time to time, a prosthesis contributes to his ability to handle himself easily and self-confidently, even in cases where the prosthesis does not have immediate functional value.</p> <p>The data for "emotional" situations indicate that the amputees' positive expressions of security were definitely greater when the protagonist was wearing a prosthesis than when he was not. An artificial arm apparently gives many amputees an increased confidence in their functional adequacy. This in turn helps them to achieve a greater self-acceptance, enables them to face their disability more realistically, and lets them view the reactions of others without feeling quite so threatened.</p> <p>Of the two personality variables considered, independence and security, independence appears to be the more strikingly affected by prosthetic restoration. The subjects tend to expect that the amputee who wears a prosthesis will be more effective functionally, more self-sufficient, and generally more adaptive than the nonwearer. When the matter of security is concerned, the role of the prosthesis is less pronounced. Still, most of the amputees think of prosthesis wearers as more self-accepting, less shy, and less easily embarrassed than non-wearers.</p> <p>The responses to the prosthetic-reaction test strongly indicate that amputees feel there is both functional and psychological advantage in the wearing of a prosthesis. They consistently attribute more positive responses to the amputee wearing an artificial arm than they do to the nonwearer in the same situation. But of course all of these findings are merely projections upon a fictitious amputee pictured in a cartoon; we do not yet know the precise extent to which these projections reflect the actual responses amputees make in life situations. Nevertheless, it is clear that the wearing of a prosthesis has a positive effect upon the way an amputee perceives and reacts to many social situations in his daily life.</p> <h3>Attitudes Toward Prosthetic Wear, Before and After Fitting</h3> <p> The discussion thus far indicates that the amputee believes strongly in the importance of wearing an artificial arm. He tends to feel that a prosthesis increases his functional capabilities and helps him to cope with social situations. He retains these beliefs, even reinforces them, after participating in the research program. To analyze still further amputee attitudes toward the wear and use of a prosthesis, additional studies were designed to seek answers to the questions <i>Are the expectations of nonprosthesis wearers fulfilled by a prosthesis?</i> and <i>Can the postfitting attitudes of amputees toward their prostheses be predicted on the basis of their prefitting expectations?</i> </p> <p>As for the first of these queries, the amputee who does not wear a prosthesis holds certain preconceived opinions about the value of an artificial limb before he ever undertakes to wear and use one. If these expectations are fairly realistic, his experience with his prosthesis may be gratifying. But unrealistic expectations can interfere with the successful wearing of a prosthesis. For this reason, a study was made of the alterations in attitudes of nonwearers after they had used a new prosthesis. As for the second question, it is reasonable to expect that the opinion an amputee holds about prostheses before he receives one will be related to his opinion after he has been fitted. If these relationships are stable enough to be predicted, potential problems may be anticipated and perhaps avoided. It is well known that a negative attitude on the part of an amputee interferes with his wholehearted participation in the rehabilitation process and thus reduces the probability of success. Identifying such a situation is the first step toward correcting it.</p> <h4>Are the Expectations of Nonprosthesis Wearers Fulfilled by a Prosthesis?</h4> <p>Among the subjects for whom data were available in this aspect of the study were 45 amputees who had never worn prostheses before their participation in the research program. About half of them were relatively "new" amputees who at the time may not yet have had an opportunity for fitting. The other half consisted of persons who had been amputees for from one to 27 years and who were therefore considered to have had ample opportunity to obtain prostheses had they wanted to. Although it is possible that some in the latter group may have been discouraged long ago by the lack of adequate prostheses for shoulder disarticulation and for certain other types of amputation, some had stumps relatively easy to fit, and accordingly factors other than lack of prosthetic equipment seem to have been present.</p> <p>Because this study was only one phase in a more general investigation of the conditions underlying the wear or nonwear of a prosthesis, use was made of a broad approach in which was collected information generally related to amputation and to prosthetic restoration. Gathered by means of a questionnaire probing prior beliefs and attitudes on a variety of matters relating to prostheses (Appendix IIIH), the data sought included sources of prosthetic knowledge and an estimate of its extent, functional expectations, opinions of the appearance of prostheses, opinions of the comfort of prostheses, attitudes toward prosthetic training, attitudes toward the general value of artificial arms, and anticipated difficulties with prostheses. Approximately six months after the fitting of a prosthesis to these patients, the questionnaire was given again to obtain post-fitting attitudes.</p> <h5> <i>Sources of Prosthetic Knowledge and Estimate of Its Extent</i> </h5> <p> The extent of prosthetic knowledge claimed by the subjects increased only slightly after they had participated in the program. Before fitting, 95 percent said they knew little or nothing about artificial arms; after fitting 85 percent still said so. Even after some six months of having worn prostheses, only 14 percent said they knew "much" about the subject. These findings may of course only reflect restraint and modesty. If they reflect the situation accurately, the amputees are indeed poorly informed. To determine whether the sources of information had any bearing on the state of amputee enlightenment, the subjects were asked to name their principal source of information, As can be seen in <b>Table 2</b> , the answers were rather diverse. Mentioned were five major sources of information before fitting. Three of these (other amputees, friends, self) are generally unreliable in matters of prosthetics. Friends and one's own self are hardly qualified without special training, and other amputees, as has been indicated already, are not necessarily well informed. Medical personnel, including physical therapists, occupational therapists, and nurses, were cited by only one amputee as a source of information. But after the amputees had participated in the program, the picture changed sharply. Then most of them mentioned medical personnel as the main source of information, while "other amputees" were not mentioned at all. <b>Table 2</b> </p> <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>Although the extensive list of pretreatment sources of information may indicate that the amputees were alert, receptive, and inquisitive, seeking information from all quarters, it may on the contrary mean that they used all these sources because they were not given information by those most competent to provide it. The general impression is that adequate information about prosthetics is not readily available to the average amputee and that there is therefore a real need for a more thorough prosthetics education of medical personnel. We might even suggest that more attention be given to improving knowledge of prosthetics among new amputees. One approach would be to furnish literature portraying different types of prostheses-along with a sober appraisal of the utility, as well as of the disadvantages, of current prosthetic equipment. Doing so would help the patient to acquire more realistic expectations, to eliminate some of his trepidation, and to fill his individual needs more successfully.</p> <h5> <i>Functional Expectations</i> </h5> <p> Experience tends to modify any overly ambitious ideas the amputee may have about the value of the prosthesis. Most of the amputees in the study had more realistic expectations after they had been fitted with their artificial limbs than before: ( <b>Fig. 10</b> ).The 73 percent who before fitting said they believed prostheses were essential included 21 percent who said they thought artificial arms were "as good as normal limbs." Among those who after fitting said they believed prostheses to be very important, there were still 10 percent who said they thought their prostheses were as good as normal limbs. Apparently the fitting of the prosthesis reduces the number of amputees who deny reality but does not eliminate that group completely.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Before they were fitted, the amputees tended to expect that artificial limbs would take a considerable expenditure of energy for effective operation, but experience showed them that these estimates had been too pessimistic: ( <b>Fig. 11</b> ), ( <b>Fig. 12</b> ) </p> <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 /> <p>Those who deal with prospective wearers should make use of the general tendency among amputees to believe that prostheses are helpful. But unless the limitations as well as the advantages of artificial arms are explained, false hopes and unreasonable expectations will result.</p> <h5> <i>Opinions on the Appearance of Prostheses</i> </h5> <p>Judgment of appearance is a complex and subjective process. The phrase "acceptable appearance" means many things to many people because the component factors are not often defined. In this study, three factors were identified. The first relates to the appearance of the prosthesis itself-to the degree to which it resembles the natural limb. The second relates to the readiness with which the artificial limb is recognized by observers. And finally the third relates to the appearance of the prosthesis when it is actually in use by the amputee.</p> <p>Roughly 75 percent of the subjects said they believed that their prosthetic arms and hands closely resembled normal limbs. Although the remainder said they found no strong resemblance, it was clear that in general the amputees accepted the appearance of their prostheses. One patient alone gave "unfavorable appearance" as the reason for not wearing a prosthesis.</p> <p>At this point it is perhaps worth noting that medical personnel who see many varieties of prosthetic equipment tend to develop, out of their own experience, personal sets of standards about the appearance of prostheses and sometimes impose these standards upon an amputee. But the patient, having had very little experience with prostheses, bases his opinions on quite personal factors, and these may be at great variance with those which influence the judgment of the clinic team. We must therefore strive to fulfill the actual needs of the individual amputee rather than to satisfy our own honest but at times inappropriate standards.</p> <p> Initially, most of the amputees said they expected to be recognized as amputees even when wearing prostheses, an expectation apparently confirmed by experience: ( <b>Fig. 13</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These findings are especially interesting when we recall that about 75 percent of the amputees said they thought their prostheses closely resembled natural arms and hands. Yet only a few of the subjects, either before or after fitting, said that they believed they could be taken for nonamputees. It seems apparent, therefore, that more than just the physical appearance of the artificial arm was involved. A strong similarity may be thought to exist, but generally the amputee does not believe similarity alone will enable him to pass as a nonamputee.</p> <p> Data from studies by Dembo and Tane-Baskin <a></a> on the noticeability of a cosmetic glove indicate that noticeability depends upon the "intensity" of the situation, that is, upon the closeness of the amputee's social and physical contact with others at any particular time. In view of this observation, it is clear that the inability to discriminate between situations of varying intensity keeps us from interpreting the present data any further. The amputees' responses in the study came from their experiences in both casual and intense situations, and we cannot distinguish between the two. </p> <p>Ease and smoothness of operation constitute another important factor in the general appearance of the amputee. The well-trained, smoothly functioning amputee contrasts strongly with a less-trained, uncoordinated, and awkward one. Full evaluation of appearance must, therefore, also take into account the dynamic factor, the impression given by smooth, normal-appearing movement as contrasted with that given by halting, uncoordinated motions.</p> <p>We see, then, that there are at least three important considerations involved in any judgment of an amputee's appearance-the actual appearance of the prosthesis apart from its functioning (the "static factor"), the naturalness with which the prosthesis is used (the "dynamic factor"), and the intensity of the amputee's situation (the "situational factor"). Treatment personnel usually place greatest emphasis on the appearance of the limb itself; the amputee may base his impression more upon the other two considerations.</p> <h5> <i>Opinions on the Comfort of Prostheses</i> </h5> <p> The amputees' statements about the comfort of artificial limbs did not change very much with experience. Both before fitting and after some period of wear, about 25 percent of the subjects claimed considerable discomfort, while 50 percent or better had no complaints on this score: ( <b>Fig. 14</b> ). For three quarters of the prosthesis users, comfort does not appear to be an important problem, and expectations of comfort seem to be borne out by actual experience. But the 25 percent who complained about discomfort <i>do</i> represent a very significant problem because discomfort is a common cause for rejection or infrequent use of artificial limbs. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At present, research aimed at eliminating discomfort focuses on prosthetic and physiological factors, an emphasis that seems appropriate in view of the fact that the principal objective causes of amputee discomfort are related to fit of the socket and harness and to weight of the prosthesis. But the problem has several other aspects, and these might also be explored profitably. There is for example the question of education-of how to prepare the amputee to expect at least some degree of initial discomfort. Another possible factor relates to the early use of the new prosthesis unwisely and too well. The mere statement, "At first this may be uncomfortable," may be insufficient warning for the new user. This phase of orientation needs more emphasis. Otherwise there is always the danger that amputees not fully aware of the difficulty of initial adjustment may give up with the feeling that prostheses are not for them.</p> <p>In addition to all these matters, there are psychological problems related to the amputee's pain tolerance. The way the amputee reacts to pain is influenced by such psychological factors as his acceptance of the amputation and his unrealistic hopes for the prosthesis. Finally, there is a need to recognize the special social attitudes that an amputee elicits when he expresses discomfort.</p> <h5> <i>Attitudes Toward Prosthetic Training</i> </h5> <p> Training to operate a prosthesis effectively requires a period of time ranging from a few hours to many hours, as correctly anticipated by all but three percent of the subjects: ( <b>Fig. 15</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig.15</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As we have seen, the subjects of study generally knew little about the potentials of prosthetic restoration. When, on top of the amputee's functional disability, there is superimposed the unavoidably new and ambiguous situation, anxiety and feelings of dependency are created. Since at a number of points in the rehabilitation process the physical and occupational therapist is in closest contact with the patient and is offering direct functional assistance, he is one of the natural recipients of these negative reactions. It should be possible during training for the therapist to use these dependency feelings and other factors to instill in the patient an attitude of realistic independence. Moreover, the training situation offers the amputee opportunity to develop and to demonstrate his functional competence under professional guidance. Regulated training routines have many advantages. Learning is quicker and more efficient, and the number of successful experiences can be maximized while failures are held to a minimum. For the amputee, the training experience should result not only in proficiency with the artificial limb but also in a realistic functional independence and a general sense of adequacy and personal competence.</p> <h5> <i>Attitudes Toward the General Value of Artificial Arms</i> </h5> <p>In an effort to determine the significance that artificial arms had for the amputees, the subjects were asked to express their opinions in terms of three frames of reference the advantages of using a prosthesis, the general functional help of a prosthesis, and the importance of the artificial arm.</p> <p> <i>Advantages.</i> The overwhelming opinion among the amputees, both before and after fitting, was that artificial arms have more advantages than disadvantages: ( <b>Fig. 16</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 16</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>General Help.</i> The prosthesis enabled the amputees to get along better. Most of them maintained that they could get along <i>much</i> better. A few said that it hindered them slightly. No one said that it really interfered. But among the amputees who had expected to find extreme advantages, there were indications of marked changes of opinion. That the group with the highest expectations dropped from 78 percent to 59 percent illustrates the development of more realistic values through experience. The same kind of change is illustrated by the increase in the number of amputees who said they thought a prosthesis could help them to get along "about the same" or "slightly worse": ( <b>Fig. 17</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 17</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Importance.</i> Despite a drop of 9 percent in the two most favorable categories of response, over 70 percent of the amputees said after fitting that they still believed it "very important" or "extremely important" for them to wear artificial arms. There was, however, an increase from 4 percent to 12 percent in the number of amputees who said they thought their prostheses "not at all" or only "slightly" important: ( <b>Fig. 17</b> ) </p> <p>It seems clear that the amputees retain favorable attitudes toward their prostheses after a period of wear. They appear to consider prostheses generally helpful, to believe that the advantages far outweigh the disadvantages, and to be convinced of the importance of artificial arms.</p> <p>If these findings are accepted as showing the general feelings of the amputees, the next step is to relate these attitudes to the amputees' actual use of their prostheses. The relevant factors here are the amount and type of use, the situations in which prostheses are worn and employed, and the amputee's reasons for discarding a prosthesis.</p> <h5> <i>Anticipated Difficulties With Prostheses</i> </h5> <p>As regards the wearing of an artificial arm, the amputees foresaw certain difficulties. They anticipated problems in becoming accustomed to wearing the arm, in learning to operate it, in dealing with fatigue, and in avoiding awkwardness. With the exception of the second difficulty, learning to operate the arm, all of these turned out to be real problems, and some additional ones, such as mechanical failure of the prosthesis, stump pain, and excessive heat, developed.</p> <p>The difficulties that amputees experience with their artificial arms range from relatively trivial annoyances to serious complications. Most of them may be placed in either of two categories-problems related directly to mechanical, functional, or medical disorders, and problems related to emotionally based preoccupation with conditions otherwise insignificant. Those in the first category disappear when the relevant conditions are corrected. Those in the second category reflect personality variations. In the interests of clarity and emphasis, these emotion-laden complaints have been classified in accordance with six hypothetical kinds of personality. Although having no value in themselves the stereotypes thus created are not intended as "pigeon-holes," they serve nevertheless as organizing aids for identifying the problems.</p> <p> <i>The Unmotivated.</i> The unmotivated amputee does not expend the effort necessary to overcome obstacles in using a prosthesis. The person without drive wears and uses his prosthesis so long as everything operates smoothly, but when even slight difficulties arise he lacks the motivation to continue with the limb and to expend any extra effort needed to operate it. Wear and use are thus limited. In justification of his action in discarding the prosthesis, the amputee may present many rationalizations in the form of spurious complaints about comfort and effectiveness. </p> <p> <i>The Ghost Story.</i> Complaints derived from phantom sensation are likely to occur among amputees who are unaware of the common phenomenon and who consequently do not anticipate it. Still others, on experiencing the phantom, fall prey to misconceptions about it and fail to acknowledge the experience for fear of implying that they are disoriented or are suffering from mental disturbances. Through ignorance, such patients may attribute their phantom sensation or phantom pain to poorly fitting sockets or harnesses. Complaints usually disappear when the amputee has been well informed. </p> <p> <i>Mind Over Matter.</i> People vary in the amount of discomfort they can accept. Since it is probably impossible to eliminate discomfort entirely, some dissatisfaction is inevitable. But this common difficulty may be reduced to some extent if, before fitting, the amputee develops realistic attitudes toward whatever discomfort he cannot escape. Forewarning the amputee may help him to avoid disappointment and exaggeration of his discomfort. </p> <p> <i>The Exaggerators.</i> Some amputees tend to elaborate upon their complaints and to distort the situation out of all proportion to its real significance. They develop fixations about relatively unimportant details or symptoms, and they are not open to persuasion or logical argument. Most often such a complaint is based upon a personal need, as for sympathy or attention, perhaps only remotely related to the actual prosthetic condition. But until this personal need is satisfied, little success can be expected in handling the related prosthetic or medical conditions. </p> <p> <i>Motor Trouble.</i> Difficulties associated with the actual operation of a prosthesis result from two conditions-from poor neuromuscular endowment, or from tensions and anxieties producing awkwardness and lack of coordination. In the first condition, the amputee possesses in balance and coordination basic deficiencies which together operate to reduce his functional potential. Owing to the effects of banging and twisting in awkward and erratic movements, the prospects of prosthetic maintenance tend to increase. In such a case, faults that are apparently prosthetic are really human faults. </p> <p>The second condition typifies the anxious person who always anticipates something bad. He looks upon every squeak, every irritation, and every temporary malfunction as a sign that the prosthesis is falling apart or at least is in need of adjustment. He differs from the exaggerator in that his reactions are much more diffuse and not nearly so emphatic. Anxiety induces characteristic muscular tension, which interferes with function in much the same way as does an innate psychomotor inferiority. Since the latter condition offers a poorer prognosis and dictates a different course of care, it is necessary to make a distinction based upon etiology.</p> <p> <i>The Comparison Shopper.</i> Every prosthetist knows of amputees who are always looking for something better. Sometimes such persons channel their needs constructively and make a contribution by entering the field of prosthetics development. More often, however, they dissipate their energies going from limbshop to limbshop looking for satisfaction they probably cannot get. These amputees are apt to become a matter of professional concern, for they often tend to depreciate the efforts, skill, and integrity of the art. </p> <p> <i>Recapitulation.</i> It is likely that a single explanation runs through several of the foregoing categories, for the amputee's subconscious nonacceptance of his amputation may underlie lack of motivation, phantom sensation, over-reaction, and inability to be satisfied. The problems of phantom sensation and of low discomfort tolerance may be accounted for physiologically, and the conditions of over-reaction and constant apprehension may be traced to personality factors more general than refusal to accept amputation. In any event, the categories can be made more useful, or at least revised constructively, if conceptual and experimental analysis is undertaken to establish the extent of each category, the etiological backgrounds, and the best manner of treatment in each case. </p> <p>Two general considerations should govern the follow-up of complaints-improvement of undesirable conditions, and the identification and description of the "complainers." The first is limited only by the present state of technical knowledge and skill in the field of limb prosthetics. The second has received only casual attention in the past. Further work in this area of psychology could prove to be fruitful.</p> <h4>Can the Postfitting Attitudes of Amputees Toward their Prostheses be Predicted on the Basis of their Prefitting Expectations?</h4> <p> As we have seen, the attitudes held by the amputees before they had participated in the program were modified by their subsequent experience with prostheses. The shift was generally toward a more realistic opinion of the results that could be obtained with prostheses. In addition to these changes, however, the attitudes of the amputees both before and after fitting showed that they placed a great deal of importance on the desirability of wearing a prosthesis. The next step, then, was to study the relationship between an amputee's attitude before fitting and his attitude afterwards. Our aim was to determine whether or not it is possible to predict an amputee's postfitting adjustment from a knowledge of his expectations before he is fitted. To this end, the question was asked: <i>Are the prefitting attitudes of amputees toward prosthetic restoration related to the attitudes they hold after fitting and a period of usef</i> Or, to put the question more specifically, will the amputee who approaches the fitting with a positive attitude about prostheses tend to maintain that attitude after he has worn and used an artificial arm, and, conversely, will the amputee who starts with a less positive, ambivalent, or negative attitude toward prostheses persist in that attitude after wear and use? </p> <p> Appendix IIIH, used previously to determine the degree of satisfaction of amputee expectations, was now applied to test whether or not postfitting attitudes could be predicted from the corresponding prefitting attitudes. <a style="text-decoration:none;">*</a> Selected for this analysis were 42 amputees, none of whom had worn a prosthesis before participating in the program. They included 18 below-elbow, 18 above-elbow, and 6 shoulder-disarticulation cases ranging in age from 17 to 54 years, in education from none to postgraduate school, and in the year of amputation from 1916 to 1955. The group was, in short, highly diverse. According to their combined expectancy scores, the subjects were placed on a continuum ranging from high to low in prosthetic expectation and were then divided into three equal groups representing high, intermediate, and low prosthetic expectancy. For comparative purposes, only the upper third, representing high expectancy, and the lower third, representing low expectancy, are used in the following analyses. </p> <h5> <i>Combined Expectancy Score of High Group Compared With That of Low Group</i> </h5> <p>The first step was to determine whether the initial attitudes of the high-expectancy and low-expectancy groups were maintained after prosthetic experience or were modified by it.</p> <p> Accordingly, the attitudes of the high and low groups were compared before and after fitting, <a style="text-decoration:none;">*</a> as indicated in <b>Table 3</b> ]. </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>In both instances, the difference between the average combined expectancy scores of the high-expectancy group and of the low-expectancy group was found to be statistically significant (P 0.05). Moreover, the mean score for each group did not change significantly after fitting (P 0.05). Thus in general positive or negative attitudes within the group were maintained after fitting.</p> <p>The individual items of the questionnaire were studied in an effort to determine why within each group there was only insignificant change in the combined expectancy scores from before fitting to after fitting. Was this result owing to lack of systematic differences between evaluations? Or were gains in positive feelings toward some items canceled out by loss of positive feelings toward other items?</p> <h5> <i>High and Low Group Comparisons for Individual Items</i> </h5> <p> Within each group an analysis was made of the way in which the responses to individual questionnaire items changed after fitting. The opinions expressed by the high-expectancy group and by the low-expectancy group about each item before and after fitting are listed in <b>Table 4</b> , where it may be seen that the nine items originally used to differentiate high prosthetic expectancy from low continued to differentiate the two groups, the "high's" in every instance remaining more favorably disposed than the "low's." </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 /> <p>Inspection of the data indicates that the lack of change from prefitting to postfitting evaluations, as measured by the combined expectancy score, does not result from the cancellation of negative changes by positive ones. The average score of both the high-expectancy and the low-expectancy groups increased (became less positive) on most items. The conclusion may thus be drawn that experience with prostheses led both groups to expect less in the way of functioning (items 1 and 2), to expect less resemblance between prostheses and natural arms (item 3), and to expect artificial arms to be more uncomfortable (item 5). On the other items, the average score either decreased or remained about the same. Both groups said that the artificial hand more closely resembled the normal hand than they had expected (item 4). The "low's" apparently found (more so than the "high's") that they had not sufficiently appreciated the advantages of wearing prostheses (item 8). Of considerable interest were the group differences in response to item 6 (the importance of wearing an arm). The "high" group showed a lessening of positive opinions, and this decrease corresponded to a decline in negative attitudes among the "low's."</p> <h5> <i>Certainty of Response</i> </h5> <p> Throughout the questionnaire, the amputees had been asked to indicate by code the degree of certainty they felt about each of their responses. After the initial investigation, a study was made of the certainty with which any particular response had been expressed. In the code <i>AS</i> (absolutely sure), <i>VS</i> (very sure), <i>FS</i> (fairly sure), <i>SU</i> (somewhat unsure), <i>VU</i> (very unsure), <i>AS</i> was arbitarily assigned a weight of 1; <i>VS</i> a weight of 2; <i>FS,</i> 3; <i>SU,</i> 4; and <i>VU,</i> 5. Thus was obtained an average certainty score for each person in each group. The mean certainty scores for each group, prefitting and postfitting, are shown in <b>Table 5</b> . </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 5</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Amputees with high expectancy express themselves as being a good deal more certain of their responses than do the low-expectancy amputees, although both are generally quite affirmative. Since in general the amputees admit to very little prosthetic knowledge, one may wonder about the basis for such certainty. After they had acquired experience with their prostheses, both groups became even more certain in their responses, as might have been expected. But the increase in certainty among the "low's" was considerably less than the increase expressed by the "high's." There would seem to be much value in further analysis of the relationship between attitude toward prostheses and certainty of response.</p> <h5> <i>Relationships Between Expectancy and Other Factors Related to Amputation</i> </h5> <p> In order to learn whether or not there were systematic relationships between prosthetic-expectation level and certain other factors, the "high" and the "low" groups were compared with regard to amputation type, hand dominance, marital status, age, educational level, and age at time of amputation. Analysis indicated no statistically significant differences<a></a> between the group with high expectancy and the group with low expectancy. <a style="text-decoration:none;">*</a> It would appear that, for this sample, the amputees who expect considerable returns from prosthetic service and those who do not expect very much are not greatly different in the factors of amputation type, handedness, marital status, age, education, and time since amputation. The suspicion that "attitudes held by amputees about prosthetic restoration before fitting are related to the attitudes they hold after fitting and a period of use" is therefore confirmed by the data. The findings also substantiate the more specific hypothesis: <i>The amputee who approaches the fitting with a positive attitude about prostheses will tend to maintain that altitude after he has worn and used one; the amputee who starts with a less positive, ambivalent, or negative attitude toward prostheses will persist in that attitude after wear and use.</i> </p> <p>It must be emphasized that these findings relate to the amputees' general attitudes toward prosthetic restoration. Any particular reaction will be a function of the general prosthetic attitude and also of the specific factor involved, whether it be that of appearance, of function, or of something else.</p> <h5> <i>Relationships Between High and Low Expectancy and Other Attitudes of Amputees</i> </h5> <p>In the course of the studies, information also was gathered describing the attitudes, experience, and expectancies of the subjects. Not all of these data were thought to be directly related to the question of what the amputees expected from prosthetic restoration. But in continuation of the study of amputee attitudes toward prosthetic service, they were examined anyway. A nonstatistical comparison, made between high-expectancy and low-expectancy groups to detect differences with respect to other reactions, uncovered the following distinctions:</p> <ol> <li>On the whole, the group with the high expectations reported a great deal of improvement in performance. But the low-expectation group said that performance of a number of activities was impaired after prosthetic treatment. The degree of negative change reported by the "low's" was not as great as the degree of improvement reported by the "high's." Activities showing the greatest amount of change were eating, dressing, driving, and participating in sports. The "low" group expressed the most disappointment about eating, dressing, and sports activities. The "high" group reported its greatest improvements in the areas of dressing and driving.</li><li>The "low's" expected more difficulties than did the "high's" (18 to 12), and in the evaluations after fitting they continued to report more difficulties (19 to 14).</li><li>More "high's" than "low's" reported having had favorable comments made to them about the appearance of their prostheses.</li><li>More "low's" than "high's" admitted to negative changes in feelings since amputation.</li><li>Before wearing a prosthesis, four "low's" felt resentful when new acquaintances asked about the amputation; none of the "high's" expressed any negative feelings. After wear, the "high's" still did not express resentment, although three "low's" did.</li><li> The most outstanding difference between the "high" and "low" groups was manifest in response to the question, <i>If you don't consider appearance, do you think that you could get along as well without a prosthesis as with one?</i> Before fitting, none of the 28 subjects responded in the negative (perhaps because they were getting a free prosthesis). Three of the "high's," however, gave extremely positive responses ("The prosthesis is like a part of my body; I cannot do without it."), while the rest of the "high's" and all of the "low's" answered more temperately ("It facilitates things, increases independence."). In the postfitting evaluation, one of the "high's" said that he could do without a prosthesis, as his was not too helpful; two of the "high's" gave extremely positive replies; and the rest were more moderately positive. The "low's" presented a much more negative picture in the postfitting evaluation. Four said that they felt they could do without a prosthesis, and only one expressed himself as being oriented very positively. </li></ol> <p>The validity of the group division appears to be supported by the sample findings from the rest of the psychological data. Although we are concerned at present with establishing points of difference between the "high" and the "low" groups, it is well to add that in many other variables, such as social sensitivity and reactions to frustration, use of these measuring instruments revealed no differences.</p> <p>In conclusion, then, the hypothesis was confirmed that the attitudes of nonwearers toward prosthetic restoration are related to their attitudes after they have worn prostheses. Through the use of a set of questions, it was found possible to differentiate between favorable and unfavorable attitudes. The division of the amputees on the basis of their general attitudes toward the usefulness of prostheses gave some indication of being related to other than prosthetic factors. But judging from the results, the establishment of predictive indicators of attitude toward prosthetic restoration appears to be feasible. It should be possible to develop a predictive scale which will have clinical and research utility and which at the same time can be administered and interpreted in a relatively simple way.</p> <h3>Summary</h3> <p> Throughout this section a number of recurrent themes have been encountered. Chief among these has been the amputees' need for unprejudiced recognition by nonamputees. In order to gain this recognition, the amputees consistently present themselves in a manner which only partially represents their true feelings. The interpretation of the data has therefore been that the amputees utilized the questionnaires more to express their feelings about how an amputee <i>should</i> be regarded than to state how he actually <i>is</i> treated. From this point of departure the information has been handled at two levels-the first involving the assumption that the data are valid and meaningful in themselves, the second based on the premise that the responses reflect the conscious and subconscious wishes of the subjects. </p> <h4>Personality Dynamics of Amputees</h4> <p>Although 90 percent of the amputees said that they were adapted to their loss, it is doubtful that so many had really achieved this result. Evidence seemed to indicate that many of the amputees were trying to maintain feelings of bodily integrity and adequacy by denying the personal and social concomitants of amputation. Any implication of abnormality was overwhelmingly rejected. Their physical defect was consistently de-emphasized, and their goals and values were those of the normal, nondisabled person.</p> <p>In almost all instances, amputees portray themselves as being as able an nonamputees. While almost never admitting to being substantially inferior to nonamputees, they do acknowledge that some extra effort is necessary to keep up with them. Other evidence confirms that amputees are, in the main, correct in stressing their ability. But their consistent refusal to acknowledge limitations reflects their own self-concern. Apparently they must exaggerate to maintain a social and vocational status equal to that of nonamputees.</p> <p>Considerable stress is placed upon self-sufficiency. Amputees say they resist accepting help because it is generally unnecessary. Unexpressed, but no less important, is the feeling that to accept help makes one dependent and lowers one's status.</p> <p>Sensitivity about physical prowess and appearance is one of the crucial influences in the psychological functioning of the amputee. The subjects in this study readily admitted their concern about the opinions of others, but few were ready to admit any considerable amount of sensitivity. They claimed not to resent curiosity about their appearance and to expect people to look at them. Clinical experience, however, indicates that amputees are much more sensitive and hostile toward the curious person than was indicated by the data. Not infrequently such sensitivity is denied not only to others but also to themselves.</p> <p>Amputees claim to be accepted by others on the same basis as anyone else, and they reject strongly the suggestion of "different" treatment. Mostly, the subjects did not feel that amputation had been a serious source of frustration. They felt they usually could do the things they wanted. When they were unable to perform because of the amputation, their usual reaction was to try all the harder.</p> <p>Finally, the general tone of the amputees is to give the impression of being optimistic about their abilities, acceptance by others, and future goals.</p> <p>The positive effect of the experimental treatment program on many of these variables was demonstrated. Although no radical personality changes were observed, there were consistent indications that some decrease in sensitivity and frustration resulted from the improved management procedures and from the improved prostheses. In addition, some degree of greater acceptance of loss, increased feelings of functional adequacy, and greater ease in social situations were noted.</p> <h4>Social and Functional Factors in Prosthetic Wear</h4> <p>The prosthetic-reaction test resoundingly confirmed the data from the questionnaires. It was clear that participation in the treatment program resulted in an increase in those responses indicating greater independence and increased feelings of security. The amputees believed there was both functional and psychological advantage in the wearing of a prosthesis. They viewed prostheses as providing the wherewithal for independent functioning. Increased confidence in their functional adequacy helped them to achieve greater self-acceptance, enabled them to face their disability more realistically, and let them view the reactions of others without feeling quite so threatened. They expected nonwearers to be more shy, more easily embarrassed, and less adaptive.</p> <h4>Attitudes Toward Prosthetic Wear, Before and After Fitting</h4> <p> In the final phase of the investigation two questions were asked: <i>Are the expectations of nonprosthesis wearers fulfilled by wearing a prosthesis?</i> and <i>Can the postfitting altitudes of amputees toward their prostheses be predicted on the basis of their prefitting expectations?</i> </p> <p>A number of avenues of approach were utilized to answer the first question. It was found that the extent of prosthetic knowledge claimed by the amputees was very small. The implications of the lack of information were discussed, with stress upon the opportunity ignorance presents for the development of unrealistic expectations (which may influence negatively future attitudes toward prostheses). Overly ambitious ideas as to the value of prostheses were modified with experience, and after being fitted most of the amputees had more realistic expectations of the advantages to be derived from prosthetic wear.</p> <p>General acceptance of the appearance of the prosthetic components was clear. There was little change in opinion regarding the extent to which prosthetic arms and hands resembled normal members. Three important constituents to the final judgment of amputee appearance were identified-the static factor of the cosmetic value of the prosthesis irrespective of function, the dynamic factor of natural appearance in use, and the situational factor of the intensity of the contact.</p> <p>Preconceptions regarding comfort did not change markedly with experience. Although comfort appears to be no important problem for three fourths of the amputees, the remaining one fourth found their prostheses to be uncomfortable.</p> <p>The amputees retained favorable attitudes toward the prostheses after a period of wear. Prostheses were considered to be generally helpful and very important to the amputees, the advantages far outweighing the disadvantages.</p> <p>With the exception of "learning to operate," most of the difficulties anticipated in wearing an arm actually developed. In addition, other problems evolved, such as mechanical failure, stump pain, and excessive heat. A number of hypothetical personality types were described to help identify complaints based upon emotional factors as contrasted with those directly related to prosthetic or medical problems. The second question was directed toward the idea that attitudes held before prosthetic fitting may influence the valuation of prosthetic usefulness regardless of experience. Tested and confirmed was the hypothesis that attitudes held by amputees about prosthetic restoration before fitting are related to the attitudes held after fitting and a period of use. Amputees holding favorable attitudes before using prostheses tended to maintain those attitudes after wear and use; subjects negatively disposed continued to be less favorably inclined.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li> Barker, R. G., B. A. Wright, L. Meyerson, and M. R. Gonick, <i>Adjustment to physical handicap and illness: a survey of the social psychology of physique and disability,</i> Social Science Research Council, New York, Revised 1953. </li> <li> Cameron, N, and A. Magaret, <i>Behavior pathology,</i> Houghton-Mifflin, Boston, 1951. </li> <li> Dembo, Tamara, and Esther Tane-Baskin, <i>The noticeability of the cosmetic glove,</i> Artificial Limbs, 2(2) :47 (May 1955). </li> <li> Dembo, Tamara, Gloria Ladieu Leviton, and Beatrice A. Wright, <i>Adjustment to misfortune - a problem of social-psychological rehabilitation,</i> Artificial Limbs, 3(2) :4 (Autumn 1956). </li> <li> Ladieu, G., E. Hanfmann, and T. Dembo, <i>Studies in adjustment to visible injuries: evaluation of help by the injured,</i> J. Abnorm. and Soc. Psychol., 42:169 (1947). </li> <li> Meyerson, L., <i>Physical disability as a social psychological problem,</i> J. Soc. Issues, IV(4):2 (Fall 1948). </li> <li> New York University, Prosthetic Devices Study, Report No. 115.07 [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Social usefulness of the cosmetic glove: its notice-ability and appearance,</i> October 1949. </li> <li> New York University, College of Engineering, Research Division, Prosthetic Devices Study, Report No. 115.21, <i>Surveys of child amputees at the Mary Free Bed Hospital, Grand Rapids, Michigan,</i> Prepared for the Prosthetics Research Board, National Research Council, May 1957. </li> <li> Siegel, S., <i>Nonparametric statistics for the behavioral sciences,</i> McGraw-Hill, New York, 1956. </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Kolmogorov-Smirnov and Fisher Exact Probability Tests (Siegel) indicated P&gt;0.05 in all instances.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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"> Siegel, S., Nonparametric statistics for the behavioral sciences, McGraw-Hill, New York, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be remembered that expectancy scores approaching 1 indicate favorable prosthetic attitudes, those approaching 5 indicate unfavorable attitudes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 measurement of prosthetic expectancy was obtained by a system of scores and ratings similar to that used in the analysis of the results obtained with Appendix IIIG. Each question in Appendix IIIH had five possible answers ranging from one that expressed very positive feelings to one expressing very negative feelings. The response reflecting the most favorable attitude was given a score of 1, that reflecting the least favorable attitude a score of 5. There was thus obtained a score for each item as well as an average score for the questionnaire as a whole (combined expectancy score). Each amputee was then assigned a rating which represented the direction and intensity of his feelings about prosthetic restoration and which was therefore a measurement of his prosthetic expectancy.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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"> Dembo, Tamara, and Esther Tane-Baskin, The noticeability of the cosmetic glove, Artificial Limbs, 2(2) :47 (May 1955). </td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall"> New York University, Prosthetic Devices Study, Report No. 115.07 [to the] Advisory Committee on Artificial Limbs, National Research Council, Social usefulness of the cosmetic glove: its notice-ability and appearance, October 1949. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be remembered that on the average E2 was administered about six months after fitting. It is probable that, had this test been administered to the NPPWs before they received and used artificial arms, considerably greater differences between PPWs and NPPWs would have been found.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Six of the nine cartoons portrayed situations not relevant to independence and were therefore rated for security only. See Table 1, page 102.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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"> New York University, College of Engineering, Research Division, Prosthetic Devices Study, Report No. 115.21, Surveys of child amputees at the Mary Free Bed Hospital, Grand Rapids, Michigan, Prepared for the Prosthetics Research Board, National Research Council, May 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall"> Barker, R. G., B. A. Wright, L. Meyerson, and M. R. Gonick, Adjustment to physical handicap and illness: a survey of the social psychology of physique and disability, Social Science Research Council, New York, Revised 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>2.</b> </td><td class="clsTextSmall"> Cameron, N, and A. Magaret, Behavior pathology, Houghton-Mifflin, Boston, 1951. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall"> Dembo, Tamara, Gloria Ladieu Leviton, and Beatrice A. Wright, Adjustment to misfortune - a problem of social-psychological rehabilitation, Artificial Limbs, 3(2) :4 (Autumn 1956). </td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall"> Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and Soc. Psychol., 42:169 (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">The third reaction represents an extremely poor adjustment, for it leads to withdrawal from any situation that might point out the true extent of dependency. Typically, such amputees are characterized by sharply restricted behavior and a limited involvement in life.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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"> Meyerson, L., Physical disability as a social psychological problem, J. Soc. Issues, IV(4):2 (Fall 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>1.</b> </td><td class="clsTextSmall"> Barker, R. G., B. A. Wright, L. Meyerson, and M. R. Gonick, Adjustment to physical handicap and illness: a survey of the social psychology of physique and disability, Social Science Research Council, New York, Revised 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>Sydelle Silverman, M.A. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic Devices Study, Research Division, College of Engineering, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Jerome Siller, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Associate Research Scientist, Prosthetic Devices Study, Research Division, College of Engineering, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Studies of the Upper-Extremity Amputee, VII. Psychological Factors Creator An entity primarily responsible for making the resource Jerome Siller, Ph.D. * Sydelle Silverman, M.A. * https://staging.drfop.org/files/original/3448d7dd1f3b869e445982db2d59f981.pdf 56435bb25ac8133541df9f7615933fde https://staging.drfop.org/files/original/b92e747ec2d4c7fcbfb142f3b21fe188.jpg 15743c372ab5f5bfd9b131b52786f267 https://staging.drfop.org/files/original/162bfd1cff0200013041316cd03e4205.jpg 503fcd8d3eb91b82ee443d8c094e848d https://staging.drfop.org/files/original/649c45f292a3e6abbcfd67f3e7cad646.jpg bc5d177879ac5d8d63ba74148f139e50 https://staging.drfop.org/files/original/f8c103b59e1186b3debc06b41e7fa8da.jpg ff5d40912d24dc4437c5e3e86637ad0f https://staging.drfop.org/files/original/5bd55cdc8130e022cb74e9ef9310851c.jpg 877f6a2bef161af85baa70b0a7e0fc56 https://staging.drfop.org/files/original/5a13f50435edc580bd20bc0b92e39199.jpg f36ffbe912c1327a31adc0871b9584a2 https://staging.drfop.org/files/original/09f2f692fb4fb8baed50b8c404c39ff4.jpg 95dc00e192231965d2df32a4557237c3 https://staging.drfop.org/files/original/98186d2e80f51ab2c05b8e921e8b4a7c.jpg 6a7d4c0dc2f96f891e8d6f648eccb65a https://staging.drfop.org/files/original/cfb1f9e83cd52dba6e8367990403d0e7.jpg cb6459e8aa8f964867d06e310b8fb963 https://staging.drfop.org/files/original/a7526ae779090df35051bf5f19108e0f.jpg 157c3ae9edb18f10067093236eef0ecd https://staging.drfop.org/files/original/6000d92905f47758878821ee2247dd59.jpg 97191c9616d9b52f95fe7c1f3d48d26d https://staging.drfop.org/files/original/05be51461b9c231a36fab727850aafb9.jpg d2ac320312732a0ac60358b403acf8c6 https://staging.drfop.org/files/original/3d81a73baf2da2320112f7beab21a3f5.jpg 79eaca67e92aeaf4a3255846ed2f5c2d https://staging.drfop.org/files/original/3d6a53a092ad8f47d3ba47cba434cce8.jpg 0b274fe90d766da8a3eca6a1f8cbb030 https://staging.drfop.org/files/original/645ce73fcf7da4e641a02f0187a49867.jpg 7ce207a9c89481e48d4da20607137601 https://staging.drfop.org/files/original/e1898cc9379d33c5f9b2be176e2cdc18.jpg 674e6e6f3c9cfc86f882142cd90c70ad https://staging.drfop.org/files/original/1706a0b2db516be5330eec15cb82cf18.jpg 87ba92355dc1039809f33e711d681192 https://staging.drfop.org/files/original/1078a3e62aee9846acde9c3a5e792575.jpg b6a854f1571ededd167b2be93409c9d2 https://staging.drfop.org/files/original/90c35927fcd50eee702738338ce53b66.jpg da617dcbd9573aa9f0636c23afc99e41 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_052.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 52 - 75 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1961_01_052.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_052.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Prostheses for Syme's Amputation</h2> <h5>A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>Whereas detailed information on Syme prostheses prior to the turn of the 20th century is not readily to be had, the catalogs issued by limb manufacturers in the early 1900's seem invariably to include a description of a prosthesis for the Syme stump. Of many different designs offered, some used articulated ankles (if space were available below the stump and socket), some used rubber feet without ankle joint. Wood sockets, steel-reinforced leather sockets, and even cast aluminum sockets were available. Though most manufacturers showed prostheses with a full-length anterior opening for entry of the stump, there also were designs employing a partial anterior opening, and at least one used a full-length posterior opening.</p> <p>The descriptions accompanying the catalog presentation of these devices indicate that the originators were themselves aware of most of the problems involved in designing a prosthesis for the Syme stump. One design of the Winkley Artificial Limb Co.<a></a> had no ankle joint because, according to the designer, in many cases no known ankle unit small enough to fit into the available space could withstand the high stresses involved. When ankle joints were provided (<b>Fig. 1.</b>, left), a steel-reinforced leather socket was used; when space limitations precluded use of an ankle joint (<b>Fig. 1.</b>, right), use was made of a willow wood socket, presumably to provide a base for attaching the felt or sponge-rubber feet available at the time.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Two types of Syme prostheses offered by the Winkley Artificial Limb Company, Minneapolis, <i>circa </i>1910. Design at left incorporates an articulated ankle, that at right a foot without ankle joint, presumably of rubber. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Gaines-Erb<a></a> used a wood socket with a full below-knee socket at the top and only a partial opening on the anterior aspect so that it was possible to make any desired distribution of weight-bearing between distal and proximal areas of the stump <b>Fig. 2.</b>. Marks<a></a> was aware of the need for distributing uniformly along each side of the tibia the loads developed on the stump during roll-over and, realizing that this requirement was rarely met with an anterior opening and lacing, attempted to solve the problem by using a cast aluminum socket with appropriate relief for the tibial crest and other sensitive areas <b>Fig. 3.</b>. A leather cuff closing the posterior opening encircled the shank to an anterior lacing, and the Marks rubber foot must have permitted a good cosmetic effect. An earlier version of the Marks foot, one of wood, illustrates the extent to which the inventor went to achieve resistance to the high forces developed in the area of the ankle <b>Fig. 4.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Syme prosthesis offered by the Gaines - Erb Company, Denver, <i>circa </i>1915. Note provision for weight-bearing about the proximal portion of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Syme prosthesis offered by A. A. Marks, Inc., New York, early in the 20th century. The shank-socket, cast from aluminum, contained a posterior opening. A rubber foot was used routinely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. An early version (<i>circa</i> 1889) of a Syme prosthesis manufactured by A. A. Marks, Inc. Socket and keel were formed from a single piece of wood so selected that the grain afforded maximum strength. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In a 1919 design by Bowler,<a></a> dorsiflexion bumpers were replaced by a strap between the posterior surfaces of the socket and the foot <b>Fig. 5.</b>, a feature also suggesting an appreciation of the high stresses involved in the ankle-joint mechanism. Not only were the unit stresses in the resisting material thus reduced but during dorsiflexion the forces on the ankle joint itself remained compressive instead of becoming tensile, a condition favoring longer life. Instead of being in the usual medial and lateral positions, the metal straps reinforcing the leather socket were anterior and posterior, where they were least bulky and most effective structurally. A Syme prso-thesis available from the Columbus Artificial Limb Company<a></a> employed the posterior strap patented by Bowler and added an anterior elastic strap, presumably to maintain compressive forces on the ankle joint during plantar flexion <b>Fig. 6.</b>, but the idea of anterior and posterior reinforcing straps, as proposed by Bowler, was discarded.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Syme prosthesis patented by Bowler<a></a> in 1919. First known attempt to improve appearance by use of an opening on the side of the socket, reinforcing straps on the anterior and posterior surfaces. A flexible cable, another novel feature, provided resistance to dorsiflexion without placing the ankle parts in a state of tension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Syme prosthesis offered by the Columbus Artificial Limb Company, Columbus, Ohio, <i>circa </i>1925. Some of the features of the Bowler patent<a></a> are incorporated. Cf. Fig. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In almost all cases, lack of materials easily molded and with adequate strength but light in weight resulted in a certain bulkiness and heaviness that tended to produce a certain amount of discomfort for the wearer even if the fit itself were comfortable. In an effort to decrease weight and size, some prosthetists fabricated devices with marginal strength characteristics, devices which seldom lasted as long as comparable ones intended for leg amputations at other levels. The prosthesis that by 1940 seems to have been fitted almost routinely in both the United States and Canada consisted of a leather socket, reinforced with steel straps along the medial and lateral sides and made with a lacer and soft leather tongue along its anterior aspect <b>Fig. 7.</b>. Feet were generally of the so-called "conventional" type employing a single-axis ankle joint (often placed lower than usual) and incorporating foreshortened rubber bumpers. It was often uncomfortable, usually bulky because the sidebars projected beyond the bulbous end of the stump, and highly subject to mechanical failure of the sidebars.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Syme prosthesis typical of the era before introduction of plastic laminates into the fabrication of Syme prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the introduction of plastic laminates<a></a> into the practice of prosthetics, research workers at the Prosthetic Services Centre of the Department of Veterans Affairs, Toronto, were quick to realize that the use of plastic laminates might well result in the development of a Syme prosthesis to a great extent free from the shortcomings of Syme prostheses previously used. Prior attempts to use laminated wood-veneer sockets had failed to produce practical prostheses owing to the difficulty of molding about the bulbous end, but the results encouraged the investigators to proceed with the then newly developed fabric-plastic laminates. The first model that showed promise<a></a> consisted of a socket molded of a polyester-Fiberglas laminate with a neoprene-crepe foot reinforced by a polyester-Fiberglas keel extending from the distal end of the socket <b>Fig. 8.</b>. To provide more comfort along the anterior aspect of the stump, the opening for entry of the stump was cut out of the rear section of the socket, stability being obtained by replacing the cutout section and holding it in place by a metal fitting at the bottom and a strap and buckle at the top.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. An early version of the Canadian-type plastic prosthesis for Syme's amputation. The nonarticulated foot was in this instance constructed of a neoprene crepe of uniform density. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although use of plastic laminate materially reduced bulkiness, and although the nonartic-ulated foot eliminated many of the problems associated with the so-called "conventional" unit, mechanical failure in the socket where the cutout was largest occurred too frequently for the new prosthesis to be adopted as a standard item.<a></a> Fiberglas roving (loosely spun cords of Fiberglas molded in place along the edges of the cutout) increased the strength of the socket, but it was necessary to substitute epoxy resins (much better adhesion to the glass fibers) for the polyesters before fully adequate strength could be obtained. With a few refinements, this prosthesis <b>Fig. 9.</b> is in use routinely today by the Canadian Department of Veterans Affairs.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The Syme prosthesis now adopted as standard by the Canadian Department of Veterans Affairs. The plastic laminate consists of Fiberglas cloth and roving impregnated with an epoxy resin, and the posterior opening extends the length of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Attempts by workers in the Artificial Limb Program in the United States to employ the Canadian technique using polyester-Fiberglas laminates led to the same kinds of mechanical failures experienced by the Canadians.<a></a> In addition, a good proportion<a></a> of the Syme cases fitted could not continue to assume full end-bearing comfortably throughout the entire day. This experience, coupled with a reluctance to employ Fiberglas if the more convenient nylon stockinet<a></a> could be used, or to use the first-available epoxy resins because of the inherent toxicity of the wet, uncured resin when mixed with the hardener, [*The recent introduction of polyamide hardeners has since greatly reduced the risk of the fabricator's contracting dermatitis.] led to the development of the "Medial-Opening Plastic Syme Prosthesis" <b>Fig. 10.</b> at the Veterans Administration Prosthetics Center.<a></a> To reduce the unit stresses along the periphery of the cutout necessary for entry of the stump, the cutout was made in the medial wall of the socket (page 68). Unlike the posterior cutout in the Canadian version, the medial opening does not extend upward to the brim of the socket but resembles a door, an arrangement which permits the Syme case to be so fitted that all or any part of the weight may be carried along the brim of the socket. The foot is a commercially available version of the SACH foot.<a></a>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Syme prosthesis developed by the Veterans Administration Prosthetics Center, New York. The nylon-dacron-polyester socket is provided with an opening in the medial wall. Weight-bearing may be divided, in any proportion, between the proximal rim and the distal portion of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Concurrent with the development of the medial-opening plastic Syme prosthesis at the Veterans Administration Prosthetics Center, the Prosthetics Research Center of Northwestern University introduced into the Canadian technique a number of refinements which might also be applied in fabricating and fitting the medial-opening type of prosthesis. Of especial interest are a new method of obtaining casts of Syme stumps and a method of attaching a SACH foot to permit greater latitude in alignment of the foot with respect to the socket, including also a method of reinforcing the keel of a SACH foot should that be necessary in individual cases.</p> <p>Manuals<a></a> containing detailed, step-by-step procedures for fabricating, fitting, and aligning the Canadian and the medial-opening Syme prostheses are available, and details of the Northwestern techniques have been published.<a></a> An outline of all of these procedures is given here so that any might be adopted singly or in combination to meet the requirements of individual patients.</p> <h3>THE CANADIAN-TYPE PLASTIC SYME PROSTHESIS</h3> <h4>TAKING THE MEASUREMENTS AND MAKING THE MODEL</h4> <p>All anatomical measurements necessary for constructing the Canadian-type plastic Syme prosthesis are taken while the patient bears his body weight on the end of the stump. Placed under the stump is a block of wood of such thickness as to maintain the pelvis in a horizontal position, and the anteroposterior dimension, the width, and the circumference of the stump are recorded, all at the level of the largest part.[*A special device, consisting of two wedges that can be moved with respect to each other so as to provide for rapid adjustment <b>Fig. 11.</b>, has been found to be a useful improvement over the single wood block.] For use later on in the alignment procedure, a line perpendicular to the floor and passing through the mediolateral center of the patella <b>Fig. 12.</b> is marked on the stump with indelible pencil for eventual transfer to the plaster model.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Special device used in taking measurements of the Syme stump while the stump is bearing weight. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Stump measurements required for fabrication of socket for the Canadian-type plastic Syme prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After all sensitive areas and bony prominences, including the tibial crest throughout its length, have been similarly marked with indelible pencil, a cast is made using plaster-impregnated bandage, a longitudinal cut being made along the posterior mid-line to permit removal of the cast. Thereafter, a model of the stump is made by filling the cast with liquid plaster of Paris, a bar or pipe being inserted in the soft plaster at the proximal end to provide an extension to be used later in holding and handling the model.</p> <h4>MODIFICATION OF THE MODEL</h4> <p>Upon removal of the cast, a finishing nail <b>Fig. 13.</b> is driven all but 1/4 in. into the bottom of the model at the intersection of an anteroposterior extension of the vertical reference line and a medio-lateral line bisecting the area on the bottom of the model. The bulbous end is now built up by adding plaster until the dimensions conform to those recorded while the stump was bearing weight. At the same time, in order to allow space for a sponge-rubber pad in the finished socket, a layer of plaster 1/8 in. thick is added to the bottom portion and faired in, leaving the nail protruding 1/8 in. So that a recess to receive a foot nut will be formed in the finished socket, a piece of leather or other suitable material 1/8 in. thick and 1 1/4 in. in diameter is pierced at its center and positioned on the protruding nail. To provide relief for the sensitive areas and bony prominences, skived leather patches are added to the model as appropriate.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Plaster model of stump just before application of Fiberglas. It is easier to modify the model before the plaster has hardened completely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The path of the sawline to be used in forming the cutout for stump entry is marked on the model, and metal wedges <b>Fig. 14.</b> are inserted to facilitate the later re-establishment of the sawline on the exterior of the socket. The saw-line itself is located by establishing on each side of the model a point 3/8 in. behind the anteroposterior mid-line of the model at the top and another point 1/4 in. behind the same mid-line at the level where the stump begins to bulge <b>Fig. 13.</b>. Two metal wedges are inserted well apart on each of these lines, 1/4 in. being left to protrude. After the model has dried thoroughly and three coats of cellulose-acetate lacquer have been applied, it is ready for use in fabricating the prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Steel wedge used to outline cutout, shown twice actual size. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>LAMINATION</h4> <p>In the lamination of Fiberglas with epoxy resins, rapid work is essential to obtain the best structural results, and accordingly it is desirable here that this operation be performed by two persons working together. The model is held vertically in a vise, a brush coat of epoxy resin is applied, and a length of 10-strand Fiberglas roving is laid along the anterior side of each of the vertical portions of the sawline and fanned out over the end of the bulbous portion of the model <b>Fig. 15.</b>. The multiple-strand roving is held in place by encircling the model and roving with a piece of single-strand roving.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. First layup of Fiberglas roving and cloth. Note that roving is fanned out over ball of model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A piece of Fiberglas cloth 4 in. longer than the length of the model and 2 in. wider than its circumference at the largest part is laid up over the model so that the surplus length is placed distal to the bulbous end, and the whole is tied in place with single-strand roving <b>Fig. 15.</b>. The surplus length is then slit vertically every 2 in. along the periphery and laid over the bulbous end of the model, and the entire piece of cloth is saturated with the resin. Three additional pieces of Fiberglas cloth of the same size are applied in the same manner but are so placed that none of the vertical overlaps coincide.</p> <p>To complete the lamination, four pieces of Fiberglas cloth 2 in. wide and about 2 in. longer than twice the length of the model are applied, one at a time, with the transverse centers of the strips located over the bulbous end and positioned approximately 45 deg. apart <b>Fig. 16.</b>. The entire assembly is held in place by a spiral wrapping of single-strand roving, and after application of a final brush coat of resin a snugly fitting sleeve of polyvinyl alcohol film (PVA) is pulled over the layup, the lower end being tied snugly to the holding rod, the top end model. To compress the laminate and to re-trimmed to a point 5 in. from the end of the move air and excess resin, the layup is wrapped tightly in spiral fashion with a strip of PVA 2 in. wide, the wrap starting from the holding end of the model <b>Fig. 17.</b>. To the excess resin thus forced upward into the top end of the sleeve there is now added as much chopped roving as possible so as to form an extension around which the foot may be fabricated.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Layup of longitudinal strips of Fiberglas cloth just before application of PVA bag. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Lamination for socket, ready for curing. Note extension for keel, formed by introducing resin and chopped Fiberglas roving into end of PVA bag. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After curing for 30 min. at room temperature (or 45 min. at 250° F. if time is important),[*In an alternate, and preferable, procedure, the layup is allowed to gel at room temperature overnight and then, after the cutout has been made, replaced over the model, fastened in place by suitable straps, and cured for 30 min. at 225° F.] the laminate is cut, with a cast cutter or other suitable device, along the lines defined by the protruding wedges. At the lower portion of the cutout, large radii are used, and the lowest point reached is just proximal to the point of maximum anteroposterior socket diameter.</p> <h4>MAKING THE FOOT</h4> <p>After the laminated parts, socket and cutout, have been removed from the model, the extension is so shaped by grinding that the foot may be built around it. By means of a standard foot nut and a bolt 1 1/4 in. in diameter <b>Fig. 18.</b>, the keel <b>Fig. 19</b>, formed from a strip of aluminum alloy (7075-T6) 1 1/4 in. wide and 0.128 in. thick, is fastened to the extension at the point indicated by the recess formed in the bottom of the socket. For most adults, two thirds of the length of the keel is placed ahead of the center of the socket, but the proportion may be varied to suit individual cases. To provide reinforcement during the fitting procedure, a piece of wood is bonded temporarily to the keel and socket extension by use of epoxy paste.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Standard steel foot nut used by the Canadian Department of Veterans Affairs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Cross-section of foot and lower end of Canadian-type plastic Syme prosthesis. Before final assembly, the wood block is replaced by epoxy resin and chopped Fiberglas roving. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A 4-ply rubber-fabric belting 4 in. wide and four pieces of 18-iron neoprene sponge are now laminated (with Barge's cement) to the configuration shown in <b>Fig. 19</b>, the neoprene layers being slotted to receive the keel. A wood block 4 in. wide and shaped to conform to curve A-A in <b>Fig. 19</b> should be used to assist in holding the layers in place while bonding is effected.</p> <p>When the initial bonding of the neoprene and belting is fully set, a layer of 9-iron neoprene sponge is bonded to the underside of the belting, and a wedge of some resilient material is added to form the heel. Material for the heel, selected to meet the particular requirements of the individual patient, may be neoprene sponge, rubber sponge, solid rubber, or some other elastomer. Finally, the foot is cut and ground to the shape necessary to fit the shoe.</p> <h4>ALIGNMENT AND ASSEMBLY</h4> <p>Temporary attachment of the foot to the keel <b>Fig. 20</b> is effected by driving a 1/8-in. steel pin transversely through the heel section just ahead of the end of the keel <b>Fig. 19</b>. The corset, the portion of the socket that has been cut out, is now provided with the means for holding it in place-a tongue-and-slot arrangement at the bottom <b>Fig. 21.</b> and an encircling leather strap in the calf area <b>Fig. 9.</b>. Details of the parts required are shown in <b>Fig. 22.</b>, <b>Fig. 23.</b>, and <b>Fig. 24.</b>. The metal pieces are bonded and riveted to the laminated parts. Two buckles are recommended as a precaution against the possible loss of use of a particular eye in the strap <b>Fig. 9.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Insertion of keel into neoprene portion of foot. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Tongue-and-slot method of holding corset in place. Tongue and slot are held in place temporarily by the bolts and wing nuts. Epoxy resin and rivets are used for permanent attachment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Slot, shown actual size. Aluminum 0.040 in. thick. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Tongue, shown actual size. Aluminum 0.125 in. thick. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Double-buckle assembly used to secure corset in place. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After a pad of felt or neoprene sponge, carved to fit the bottom of the socket and the end of the stump, has been placed in position, the prosthesis is ready for final alignment. The relationship between the keel and the socket may be changed by removing the attaching bolt and keel and changing the configuration of the socket extension, either by grinding or by adding shims. When the desired alignment has been obtained, a 1/8-in. hole is drilled through the aluminum keel into the socket extension, and a 1/8-in. dowel of cold-rolled steel <b>Fig. 19</b> is driven into the hole. The established alignment may thus be reproduced upon reassembly during the finishing process. To achieve maximum rigidity of the keel, the temporary wood block is removed, two steel rods each 1/8 in. diameter are inserted into holes drilled in the anterior surface of the socket extension and allowed to extend into the cavity, and the cavity is filled with a mixture of epoxy resin and chopped Fiberglas roving.</p> <p>The aluminum surfaces must be clean to ensure an adequate bond. All gaps between keel and neoprene are filled with epoxy resin, and a fairing between the foot and socket is fashioned from a mixture of epoxy resin and fine sawdust, which after curing can be ground and sanded to shape. If desired, small holes may be drilled through the socket wall to furnish ventilation. When, after sanding, the outside of the socket and corset have received a coat of enamel, and when the neoprene parts of the foot have been sealed with two light coats of cellulose-acetate lacquer, the prosthesis is ready for use <b>Fig. 25.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Completed Canadian-type plastic Syme prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>THE MEDIAL-OPENING PLASTIC SYME PROSTHESIS</h3> <h4>TAKING THE MEASUREMENTS</h4> <p>The anatomical data considered necessary for fabrication of the medial-opening socket are somewhat more extensive than are those suggested as being needed in the Canadian technique. In addition to determining the distance from the end of the stump to the floor while the stump is bearing half of body weight,[*Because a neoprene sponge-rubber pad will be used later in the end of the socket, it is recommended by VAPC that a sponge-rubber pad 1/4 in. thick be used between the stump and the supporting block <b>Fig. 26.</b>.] circumferential measurements of the stump are made at 1-in. intervals in the first 5 in. of the stump while it is in the weight-bearing condition. Besides this, circumferences at these five levels and also circumferences at 2-in. intervals from a point 5 in. from the end of the stump to the medial tibial plateau are read while the stump is free of weight-bearing. At each level measured, marks are made with indelible pencil. A form for recording the required information is shown in <b>Fig. 26.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Form for recording measurements and other information necessary for fabrication and fitting of a Syme prosthesis (VAPC type). From Iuliucc.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>MAKING THE CAST AND THE MODEL</h4> <p>To protect the stump from the plaster of Paris used in making the cast, a length of cotton stockinet, sewed at one end, is pulled over the stump and secured by an elastic band above the knee. Outlines of sensitive areas and bony prominences are made on the stockinet with an indelible pencil so that they will be transferred to the cast and in turn to the model for guidance in making appropriate modifications.</p> <p>Although the particular method of obtaining a cast is not critical provided a faithful model of the stump can be obtained ultimately, the Veterans Administration Prosthetics Center suggests a method wherein the cast is made in two pieces, so as to eliminate the need for cutting the plaster to remove the stump.[*The same technique can, of course, be applied in obtaining any cast that requires separation for removal of the stump.] To obtain the two-piece mold, the end of the stump is first wrapped with 3-in. plaster bandage to the level of greatest circumference <b>Fig. 27.</b>. A slab of five layers of plaster bandage 6 in. wide is then molded against the entire anterior half of the stump and secured in place by a few turns of 3-in. plaster bandage at the narrow part of the shank and again at the area just below the patella <b>Fig. 28.</b>. So that the cast, and hence the model, will approach the configuration of the stump in the weight-bearing condition, the plaster is allowed to harden while the patient bears weight through the distal end <b>Fig. 29.</b>, a sponge-rubber pad being placed between the bottom of the cast and the supporting block. As the plaster hardens, the edges should be faired to the stump. Lateral and medial centerlines are now drawn on the anterior portion of the cast for guidance in forming the parting line, petrolatum is applied to the exposed stockinet, and a similar slab of plaster bandages is molded to the posterior portion of the stump up to the lateral and medial centerlines <b>Fig. 30.</b>. Lines drawn transversely across the seams at several levels serve at reference points for proper reassembly of the cast after removal from the stump. Before pouring of the model is started, the indelible marks on the interior of the cast should be retraced to ensure a satisfactory transfer. For the pouring operation, the two halves may be held together by a wrapping of plaster bandage.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. First step in obtaining a plaster impression of a Syme stump. A plaster bandage 3 in. wide is applied over the end of the stump to the level of greatest circumference. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Application of a slab of plaster bandage to anterior surface of stump to provide one half of a two-piece casting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Stump under weight-bearing conditions while anterior and distal portions of plaster impression are allowed to harden. The posterior portion of the impression is applied later. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Application of plaster-bandage slabs to form posterior portion of two-piece casting. Note parting line drawn on anterior casting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>MODIFICATION OF THE MODEL</h4> <p>So that the finished socket will fit snugly along the sides of the tibia and yet not press unduly on its crest, plaster is removed from the model along each side of the area representing the tibial crest <b>Fig. 31.</b>, and a long leather patch, skived in the usual manner, is glued in place on the plaster. Skived leather patches also are attached at the points representing the malleoli, over areas corresponding to the flare of the condyles, and at any other points that will require relief in the finished socket <b>Fig. 32.</b>. Then the posteroproximal end of the model is flattened somewhat to provide for stability between socket and stump about the longitudinal axis. Finally, to make certain that the distal end of the socket will be of the proper volume to accommodate a sponge-rubber pad for cushioning the end of the stump, a circular piece of sponge rubber 1/4 in. thick is skived and glued to the distal end of the model (<b>Fig. 33.</b>) All modifications of the model are made with reference to the circumferential measurements taken earlier, <i>i.e., </i>the measurements over the distal 5 in. of the stump during weight-bearing and those above during relaxation are maintained.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Model showing where plaster should be removed so that in finished socket forces may be taken along each side of the tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Model with skived leather patches applied to provide in finished socket relief for sensitive areas. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Model with socket liner and sponge-rubber pad applied. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>THE SOFT SOCKET LINER</h4> <p>To provide more comfort for those patients expected to take some or all weight-bearing along the proximal end of the socket, a liner of neoprene sponge rubber covered with horse-hide is provided. When a liner is to be used, a horsehide sleeve is molded around the model upward from a point 5 in. below the medial tibial plateau. Sponge-rubber sheet 1/8 in. thick is formed over the horsehide, 3/4 in. of the distal end of the leather being left exposed <b>Fig. 33.</b>. The distal end of both the horsehide and neoprene are skived.</p> <h4>LAMINATION</h4> <p>Unlike the procedure described for fabrication of the Canadian-type plastic Syme prosthesis, wherein the corset (or cover for the cutout) consists of the laminate that was cut from the socket, in the VAPC prosthesis the socket and the cover for the cutout may be laminated separately. Thus, it is here possible to begin with a socket cutout a little too small, trim away only as much material as necessary to permit easy entry of the stump, and still have available a piece of laminate large enough for a cover.</p> <p>To prevent adherence of laminate to the sponge-rubber pad (and to the soft socket liner if one is used), a snugly fitting sleeve of polyvinyl alcohol is pulled over the model and tied neatly at each end. The recommended laminate filler consists of two layers of dacron felt inside and ten layers of nylon stockinet outside. Like the PVA, the dacron felt must also be tailored into snugly fitting sleeves. If the nylon stockinet is cut into lengths slightly more than twice the length of the model, and if each length is then sewed transversely at the middle, a very neat layup can be obtained by successively pulling one half of a length over the model as far as possible and then pulling the other half over while turning it inside out. Instead of coinciding with one another, the individual transverse stitchings should be spaced equally as spokes in a wheel, the second being 36 deg. away from the first, the third 36 deg. away from the second, and so on <b>Fig. 34.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Application of stockinet over model in preparation for laminating. Two layers of dacron felt have already been applied. Note seam sewed across stockinet to form neat layup at distal end of socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A sleeve of PVA film is now drawn over the layup, and a polyester resin is introduced. To date, best strength characteristics have been obtained from a mixture of 70 percent of the "rigid" type of resin and 30 percent of the "flexible" type.<a></a></p> <p>Material for the medial cover is made by laminating three layers of nylon stockinet over the socket layup after it has been allowed to stand for one hour at room temperature. Resin is introduced on the medial side only (or only in that area selected for the cutout). After an additional hour of curing at room temperature, the entire assembly is subjected to a temperature of 180-190° F. for 25 min. The outer shell can now be cut and removed and the impregnated portion saved for use later <b>Fig. 35.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Removal of laminate to be used later in fabrication of cover for opening in socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>MAKING THE OPENING</h4> <p>The socket opening can best be cut out while the laminate is still warm. In order that the opening shall be the minimum needed for introduction of the stump, the initial aperture is deliberately made undersize, later enlarged by trimming the edges little by little until the patient can insert the stump without experiencing discomfort. The outline of the initial opening is determined by a horizontal line 1 in. above the point of maximum circumference of the bulbous portion of the socket, two lines parallel to and medial to the line of the tibial crest (one being 3/4 in. medial, the other medial by 3/4 in. plus 1/4 of the circumference of the bulbous portion 1 in. above its maximum circumference), and a horizontal line at that point on the socket where the circumference is the same as that 1/4 in. above the point of maximum circumference at the bulbous end <b>Fig. 36.</b>. Because further trimming will be necessary, the dimensions of the radii at the corners are not critical at this stage.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Outline of initial cutout in socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the initial cutout has been made, the excess material trimmed away, the plaster removed, and the proximal border of the socket trimmed, the cutout is enlarged enough that the patient can introduce his stump <b>Fig. 37.</b>. The radii of the corners should now be kept as large as possible, and the edges of the cutout should be smooth so as to contribute to the strength of the finished product by eliminating the high-stress areas commonly associated with mechanical nicks and notches.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Introduction of stump in socket to determine trim lines of cutout and, later, of proximal border. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>ALIGNMENT AND ASSEMBLY</h4> <p>In most instances, satisfactory use can be made of one of the commercially available SACH feet constructed especially for Syme prostheses. If not, a suitable SACH foot can be fabricated in accordance with the instructions given in the Canadian manual<a></a> or in the University of report, or use can be made of the reinforcement technique introduced by Northwestern University.<a></a> <!-- (page 71) --></p> <p>When the commercial version is used, it is first shaped to fit the shoe, and a guide hole 1 1/4 in. in diameter is drilled in the keel to a height above the heel sole equal to the height of the block used while the anatomical measurements were taken <b>Fig. 38.</b>. The keel and neo-prene crepe are then hollowed out to receive the bulbous end of the socket. Because of the tendency of Syme stumps to bow toward the cen-terline of the body, usually both guide hole and hollow should be offset medially. Moreover, the foot should be placed as far forward as possible with respect to the socket and be set in a small amount of dorsiflexion <b>Fig. 39.</b>, and care should be taken to ensure that the bottom surface of the heel is parallel to the floor <b>Fig. 40</b>. Such alignment should be effected by actually having the patient don the socket, place the distal end into the recess in the SACH foot, and assume a position of normal standing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Simplified cross-section of SACH foot showing certain modifications needed for use in Syme prosthesis. A hole 1 1/4 in. in diameter is drilled in keel to a depth corresponding to the height of the block used when measurements were taken [link26]. The hole is used as a guide in removing material at top of foot to accommodate socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Alignment of foot and socket in lateral view. Usually a slight amount of dorsiflexion results in best performance. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Alignment of foot and socket in posterior view. The foot must be so located that the sole is parallel to the floor when the wearer stands in his own habitual position with hips level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When initial, or static, alignment has been achieved, reference marks are made on the socket and foot to be used as a guide in reassembly, and masking tape <b>Fig. 41.</b> is applied around the juncture of the two units to hold them in place while a 3/8-in. hole is drilled through the keel and socket to receive the attaching bolt. The hole in the socket is now enlarged to 5/8 in., and the hole in the keel is provided at the bottom with a 5/8-in. countersink to accommodate the nut <b>Fig. 42.</b>, both operations best being done with the prosthesis disassembled. A cover that will overlap the socket opening 3/4 in. around the periphery is cut from the section of laminate made for the purpose. After two single-buckle straps have been riveted to the cover, a felt pad exactly fitting the opening is glued to the concave side, and the entire inner surface of the closure is lined with thin horsehide, care being taken to effect a rabbetlike contour along the periphery of the felt <b>Fig. 43.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Application of masking tape to secure foot to socket for drilling alignment hole through socket. Note reference marks used to ensure same alignment upon reassembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Simplified cross section of foot and lower end of VAPC prosthesis showing attachment of foot to socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Final step in fabrication of cover for opening in side of socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the prosthesis has been assembled, dynamic alignment is effected under conditions of actual walking. Inserted into the socket in the form of contoured discs of sponge rubber is enough distal padding to distribute the forces as desired between the proximal end of the socket and the end of the stump. Slight changes in alignment can be brought about by enlarging the hole in the end of the socket.</p> <p>Final finishing of the prosthesis includes bonding the foot to the socket, building up a smooth transition between foot and socket by use of a mixture of epoxy resin and chopped Fiberglas, and gluing the soft liner in place in the proximal area of the socket.</p> <h3>DEVELOPMENTS AT NORTHWESTERN UNIVERSITY</h3> <h4>TAKING THE CAST</h4> <p>Plaster of Paris in one form or another has been used for nearly a century in making impressions of limb stumps, and especially with the relatively new, quick-setting formulations it has proved to be fairly satisfactory. There are nevertheless certain disadvantages inherent in the use of plaster. Unless a separating medium is used, plaster will adhere to the skin. Cured plaster of Paris is extremely rigid, so that when plaster is used to take a cast of a stump like the Syme it is necessary either to cut the cast or to form it in two pieces. Furthermore, plaster is very dense and therefore heavy and comparatively hard to manage.</p> <p>In an effort to overcome some of the difficulties associated with plaster, the Prosthetics Research Center at Northwestern University's Medical School has developed a procedure for taking a cast of a Syme stump with alginate, a material used by dentists in taking impressions of the gums and teeth. Because when mixed with water alginate gels rather rapidly into a rubbery solid, it seems especially useful in taking casts of bulbous stumps and of those intended to take end-bearing. To enable the gelled material to yield when the stump is withdrawn, the impression is made in a rigid, tapered cylinder lined with an oversize canvas bag which can be withdrawn so that the rubbery alginate is left free to be displaced as the bulbous portion is pulled through the narrow section of the impression <b>Fig. 44.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Removal of stump, alginate mold, and canvas bag from canister. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since alginate solidifies so rapidly, and since so many factors (such as temperature and various impurities in the water used[*In certain areas best results can be obtained only with distilled water.]) affect the rate of gelling, it is important always to check the gelling time on a small sample before actually taking an impression. The correct mixture should gel in about six minutes. A tapered can about 20 in. long, 5 1/2 in. in diameter at the bottom, and 6 1/4 in. in diameter at the top has been found satisfactory for taking impressions in adults. The impression is taken while half of the body weight is borne by the stump, <i>i.e.,</i> while the pelvis is level and the patient is standing with feet together.</p> <p>After the stump has been removed, the bag and alginate are replaced in the conical can for pouring of the model, which should take place as soon as possible because the alginate has a tendency to shrink rather rapidly after gelling.</p> <h4>INSTALLATION OF THE SACH FOOT</h4> <p>To provide for wider degree of alignment adjustment than has been the case heretofore between the socket and the commercially available SACH foot, there has been developed a method of attachment employing a bolt with a spherical head <b>Fig. 45.</b>. Combined with an oversize hole in the socket, it permits some swivelling action between socket and foot. Adequate bearing area for the spherical bolt head is provided by laminating into the end of the socket a spherical washer <b>Fig. 45.</b> having the same spherical radius as the head of the bolt.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Spherical-head bolt (top) and spherical washer used in attaching SACH foot to plastic socket to permit relatively wide range of adjustment. Spherical washer and spherical part of bolt head can be made using plastic-laminating techniques. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Both washer and bolt head can be fabricated easily by use of plastic-laminating techniques. A mold suitable for forming both pieces can be made by immersing in wet plaster of Paris a PVA-covered rubber ball, or other spherical object of suitable size, to a depth equal to about a third of its diameter <b>Fig. 46.</b>. The washer is formed by placing in the mold about eight layers of Fiberglas cloth saturated with epoxy resin, then placing the ball in the cavity and weighting it, and then curing the resin. Trimming the periphery of the washer and drilling a 1-in. hole in the center completes the job. The spherical bolt head is constructed by placing under the head of a standard 3/8-in. machine bolt 10 discs of Fiberglas cloth drilled with 3/8-in. holes, screwing the bolt into a hole drilled into the plaster mold, filling the cavity to the top of the bolt head with epoxy resin, and curing the plastic. When curing is complete, the top may be finished by sanding.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Mold used in fabricating spherical washer and spherical bolt head. Convex portion consists of a rubber ball covered with PVA film. Concave portion is formed from wet plaster of Paris by pressing the ball in to a depth equal to approximately one third its diameter. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>So that the spherical washer may be laminated into the socket, it is attached to the plaster model of the stump with beeswax <b>Fig. 47.</b>, care being taken at this point because the location of the washer with respect to the model determines the location of the foot with respect to the socket in a horizontal plane.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Placing the spherical washer on the plaster model of the stump so that it may be laminated into the socket. Beeswax is used both to support it in the proper position and to fasten it to the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To enable the socket to be attached to the foot, a bandsaw is used to make in the keel of the foot a cutout conforming to the radius of the bulbous portion of the socket <b>Fig. 48.</b>. When the length of the stump dictates that the keel be so cut away as to weaken it significantly, the keel must be reinforced. In such a case, a wood screw is used to fasten the socket to the remaining portion of the keel <b>Fig. 49.</b>. The heel wedge and balata belting are peeled back, some nine layers of Fiberglas cloth, tailored to fit the keel and the end of the socket (which is covered with PVA film to prevent adherence), are laid up and saturated with epoxy resin, and the balata belting is screwed back in place <b>Fig. 50.</b>. After curing of the resin has been effected, a 3/8-in. hole is drilled through the keel reinforcement and the socket at the center of the spherical washer, the foot is removed, and that part of the hole which is in the socket is enlarged to 1 in. so as to match the hole in the spherical washer <b>Fig. 51.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. View showing the type of cut made in the top portion of a SACH foot to accommodate a Syme socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Fastening the socket to the keel of the SACH foot with a wood screw. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Fiberglas cloth, used to reinforce keel of SACH foot, being tailored to fit bottom of keel and socket. Note PVA film placed over socket to prevent adherence to Fiberglas during laminating process. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Cross-section of completed prosthesis showing spherical head bolt, spherical washer, modified keel, and laminated Fiberglas reinforcement. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Finally, a hole 1 1/4 in. in diameter is formed in the heel wedge and sole in such a way as to receive the wrench needed to tighten the attachment nut <b>Fig. 51.</b>. The heel wedge having been modified to fit the contours of the reinforced keel and then cemented in place, the socket and foot can be assembled for walking trials. When all necessary adjustments have been made, the socket is bonded to the foot with epoxy resin and the space around the socket is filled with a mixture of resin and sawdust which, when cured, is ground and sanded to provide a suitable contour.</p> <h3>CONCLUSION</h3> <p>The several methods presented here for fabrication of a prosthesis for Syme's amputation have all been found to be useful. It seems reasonable to believe that some of the features of each method may be combined in order to suit the equipment of the individual prosthetist as well as to meet most effectively the requirements of the individual patient. For example, the technique offered by VAPC for fabrication of a cover for the cutout might well be applied to fabrication of a prosthesis with a full-length posterior cutout as used by the Prosthetic Services Centre. The use of alginate as an impression material may be the method of choice for some prosthetists, while others may find the two-piece mold best for their use, especially if the local water supply contains certain minerals. The measurement-and-modification techniques described might be combined advantageously. Thus most of the individual methods are interchangeable between the basic prostheses described.</p> <h3>ACKNOWLEDGMENT</h3> <p>Any reliable article on the recommended methods of construction of a limb prosthesis must necessarily be based on the cumulative experience and the collective judgment of many workers in many places. Most of the material for this article was drawn from three pre-existing publications-<i>Construction of the Plastic Symes Appliance </i>(Technical Bulletin No. 32, Prosthetic Services Centre, Canadian Department of Veterans Affairs, Toronto, August 1959), <i>VAPC Technique for Fabricating a Plastic Syme Prosthesis with Medial Opening </i>(U. S. Veterans Administration, New York, September 1959), and <i>Recent Developments in the Fitting and Fabrication of the Syme Prosthesis (Orthopedic and Prosthetic Appliance Journal,</i> March 1960). Much valuable advice and counsel was forthcoming from a number of highly accomplished persons, among them R. M. Turner, of the Canadian Department of Veterans Affairs, Ottawa, and C. S. Boccius, of the Prosthetic Services Centre, Toronto; Colin A. McLaurin and Fred Hampton, of the Prosthetics Research Centre of Northwestern University in Chicago; and Anthony Staros and Louis Iuliucci, of the U. S. Veterans Administration Prosthetics Center, New York City. Of the 51 illustrations, the drawings not credited to original publications are the work of Annette Kissel, illustrator for the Veterans Administration Prosthetics Center in New York City, and of George Rybczynski, freelance artist of Washington, D. C. Miss Kissel executed Figures 26 through 43. Mr. Rybczynski prepared Figures 11, 12, 13, 14, 15, 16, 17, 19, 22, 23 and 24. The cooperative efforts of all these individuals are gratefully acknowledged and duly appreciated.</p> <p><b>References:</b></p> <ol> <li>Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</li> <li>Columbus Artificial Limb Company, catalog, Columbus, Ohio, ca. 1925.</li> <li>Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, <i>Syme's amputation and prosthesis, </i>January 1, 1954.</li> <li>Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, <i>Construction of the plastic Symes appliance, </i>Technical Bulletin No. 32, August 1959.</li> <li>Foort, J., <i>The Canadian type Syme prosthesis</i>(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 1956.</li> <li>Gaines-Erb Company, catalog, Denver and Pueblo, Colo., ca. 1915.</li> <li>Gardner, Henry F., <i>A report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual. </i>Veterans Administration Prosthetics Center, New York, January 31, 1958.</li> <li>Gardner, Henry F., <i>First addendum to the January 31, 1958, report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual, </i>Veterans Administration Prosthetics Center, New York, May 1, 1958.</li> <li>Hampton, Fred, <i>Recent developments in the fitting and fabrication of the Symes prosthesis, </i>Orthopedic and Prosthetic Appliance Journal, March 1960, p 45.</li> <li>Iuliucci, Louis, <i>VAPC technique for fabricating a plastic Syme prosthesis with medial opening, </i>Veterans Administration Prosthetics Center, New York, September 1959.</li> <li>Kay, H. W., and A. Staros, <i>Plastic laminate. Syme prosthesis, </i>Prosthetic Devices Study, New York University, and Veterans Administration Prosthetics Center, New York, January 1960.</li> <li>Marks, A. A., Inc., <i>Manual of artificial limbs, </i>New York, 1889.</li> <li>Marks, A. A., Inc., <i>Manual of artificial limbs, </i>New York, 1931.</li> <li>New York University, Prosthetic Devices Studies, College of Engineering, <i>Progress report, test of the Canadian type plastic Syme prosthesis (modified)</i>, New York, December 1958.</li> <li>University of (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>2nd ed., William R. Santschi, ed., 1958.</li> <li>Winkley Artificial Limb Company, <i>Artificial legs with the patent adjustable double slip socket, </i>descriptive catalog, Minneapolis, Minn., ca. 1910.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., The Canadian type Syme prosthesis(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, Construction of the plastic Symes appliance, Technical Bulletin No. 32, August 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Kay, H. W., and A. Staros, Plastic laminate. Syme prosthesis, Prosthetic Devices Study, New York University, and Veterans Administration Prosthetics Center, New York, January 1960.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">University of (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed., 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Hampton, Fred, Recent developments in the fitting and fabrication of the Symes prosthesis, Orthopedic and Prosthetic Appliance Journal, March 1960, p 45.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, Construction of the plastic Symes appliance, Technical Bulletin No. 32, August 1959.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., The Canadian type Syme prosthesis(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Kay, H. W., and A. Staros, Plastic laminate. Syme prosthesis, Prosthetic Devices Study, New York University, and Veterans Administration Prosthetics Center, New York, January 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">University of (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed., 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Studies, College of Engineering, Progress report, test of the Canadian type plastic Syme prosthesis (modified), New York, December 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., The Canadian type Syme prosthesis(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 1956.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Gardner, Henry F., A report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual. Veterans Administration Prosthetics Center, New York, January 31, 1958.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Gardner, Henry F., First addendum to the January 31, 1958, report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual, Veterans Administration Prosthetics Center, New York, May 1, 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, Construction of the plastic Symes appliance, Technical Bulletin No. 32, August 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">University of (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed., 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Columbus Artificial Limb Company, catalog, Columbus, Ohio, ca. 1925.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Marks, A. A., Inc., Manual of artificial limbs, New York, 1889.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Marks, A. A., Inc., Manual of artificial limbs, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Gaines-Erb Company, catalog, Denver and Pueblo, Colo., ca. 1915.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Winkley Artificial Limb Company, Artificial legs with the patent adjustable double slip socket, descriptive catalog, Minneapolis, Minn., ca. 1910.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Staff Engineer, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., Washington 25, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1961_01_052/c001.jpg Figure 2 http://www.oandplibrary.org/al/images/1961_01_052/c002.jpg Figure 3 http://www.oandplibrary.org/al/images/1961_01_052/c003.jpg Figure 4 http://www.oandplibrary.org/al/images/1961_01_052/c004.jpg Figure 5 http://www.oandplibrary.org/al/images/1961_01_052/c005.jpg Figure 6 http://www.oandplibrary.org/al/images/1961_01_052/c006.jpg Figure 7 http://www.oandplibrary.org/al/images/1961_01_052/c007.jpg Figure 8 http://www.oandplibrary.org/al/images/1961_01_052/c008.jpg Figure 9 http://www.oandplibrary.org/al/images/1961_01_052/c009.jpg Figure 10 http://www.oandplibrary.org/al/images/1961_01_052/c010.jpg Figure 11 http://www.oandplibrary.org/al/images/1961_01_052/c011.jpg Figure 12 http://www.oandplibrary.org/al/images/1961_01_052/c012.jpg Figure 13 http://www.oandplibrary.org/al/images/1961_01_052/c013.jpg Figure 14 http://www.oandplibrary.org/al/images/1961_01_052/c014.jpg Figure 15 http://www.oandplibrary.org/al/images/1961_01_052/c015.jpg Figure 16 http://www.oandplibrary.org/al/images/1961_01_052/c016.jpg Figure 17 http://www.oandplibrary.org/al/images/1961_01_052/c017.jpg Figure 18 http://www.oandplibrary.org/al/images/1961_01_052/c018.jpg Figure 19 http://www.oandplibrary.org/al/images/1961_01_052/c019.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prostheses for Syme's Amputation Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. *