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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_020.pdf Text Any textual data included in the document <h2>The Design a<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-09.jpg"></a>nd Testing of a Gradient Pressure Sock for Control of Edema</h2> <h5>Martha Field, M.S.&nbsp;<a style="text-decoration: none;">*</a><br />Joseph Zettl, CP.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Since the fit of a prosthesis on a residual limb influences skin condition, gait, comfort, and even whether or not the prosthesis will be worn, the stability of the limb size is critical. Even in a whole leg, prolonged standing without the 'pumping' action of the leg muscles leaves a poorly supported column of blood within the veins. "The amputated limb has virtually no muscle contraction to aid venous return."<a></a> External pressure, when well applied, does facilitate venous return, reduces hemo-stasis, and provides comfort. Pressure must be sufficient to offset the increased hydrostatic pressure of trauma, standing, or straining and yet not interfere with arterial flow.<a></a> Poorly applied pressure may be injurious. Various investigators have charted the wide range of pressures obtained by elastic wrap and have cautioned against the harmful effects that could result from this edema control method.<a></a> Isherwood states that "elastic wrap bandaging is unreliable and dangerous in terms of pressure and pressure distribution,"<a></a> because pressure can become so great from too tight a wrap that a tourniquet effect results.</p> <p>The use of tubular elastic bandaging results in more predictable and less pressure fluctuation, and requires considerably less skill in application. Especially for below-knee edema problems, Compressogrip<a style="text-decoration: none;">*</a> and similar products, including the Puddifoot method,<a></a> have proven to be effective, inexpensive, easy to apply, and well liked.</p> <p>However, as early as 1961, Beninson recognized that, "Pressure gradient dressings can, in some instances, be used following surgery to hasten healing prior to application of the supports."<a></a> In 1971, Mooney, et al., stated that their study revealed postoperative residual limb care using plaster shell or plaster with pylon resulted in more successful prosthetic fittings than those using soft dressings.<a></a> In 1975, Isherwood defined the requirements of a good dressing by stating that "as intracapillary pressure varies with dependency, the ideal bandage should provide a graded pressure which is maximum at the most dependent distal point, decreasing proximally."<a></a></p> <p>Shaping the residual limb is also recognized as a function of a shrinker sock. Available shrinker socks generally lack the shaping capacity, particularly at the distal end. Our objective, therefore, was to make a shrinker sock which would shape the distal end, have gradient pressure, and be accepted by wearers. This sock would not only accomplish the task of reducing post-amputation edema, but would also control fluids which might recur as the result of illness, injury, or any number of conditions. When any edema is uncontrolled, the tendency is not to wear the prosthesis.</p> <p>In defining the size and shape of the residual limb, two studies were helpful. In the July, 1983 <i>Journal of the American Geriatrics Society</i>, Dr. Clark, et al., described ideal limb characteristics including length below knee (6-8 inches) and above knee (8-10 inches) and shape (cylindrical).<a></a> A Swedish study actually measured 58 below-knee amputations. They found that 66 percent of the residual limbs were conical, 28 percent cylindrical, one percent bulbous, and five percent were other. The length in the supine position from the knee joint, i.e. the anterior rim of the medial condyle to the most distal part of the soft tissues at the end of the residual limb, was six inches (8 to 20 cm.).<a></a> No average measurement has been found in the literature for above-knee residual limbs. This lack of information about residual limb measurements may result from the fact that, in spite of what researchers have said, wrapping has been the most universal method of residual limb reduction. It may be that prosthetists feel no two limbs are identical and each needs to be treated individually. Nevertheless, with cooperation and knowledge, general parameters can be established for socks which will exert the desired graded pressure over a limited measurement range so that standard sizes of socks can be readily available.</p> <p>Although the benefits of using pressure as a prophylactic aid to reduce edema after amputation, or whenever edema develops in a mature stump, have been recognized for centuries, no precise definition of the amount of pressure to be used has been created. Part of the reason is that each researcher has used a different instrument for measurement, and although each instrument can be calibrated to a manometer, certain features of each instrument result in un-comparable readings.<a></a> Much of the research on using pressure to alleviate pain and ulcers in cases of deep venous insufficiency supports much higher mmHg readings than those indicated by the fairly limited research on wrapping and tubular elastic bandaging pressures.</p> <p>Our request for information on instruments being used to obtain the pressures printed on packaging of various companies making pressure garments only revealed the use of the Kompritest II (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-01.jpg"><b>Fig. 1</b></a>). We secured that instrument and found it gave readings 15-20 mmHg higher than the CTC 250 we had been using (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-02.jpg"><b>Fig. 2</b></a>). We pursued this with Midwest Research Institute<a style="text-decoration: none;">*</a> and received the following explanation:</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-01.jpg"><strong>Figure 1. Kompritest II for measurement of pressure values of elastic stockings.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-02.jpg"><strong>Figure 2. CTC 250 Digital Pressure Gauge.</strong></a><br /> <blockquote> <p>Both devices accurately measure pressure imposed upon their respecting sensing elements.</p> <p>When placed under an elastic fabric, the devices produce different readings because the Kompritest II (K-II) device distends the elastic fibers surrounding the bulge of its inflated bladder and thus produces a local increase in pressure over the measurement site. This local pressure increase observed using the K-II accounts for the difference between values produced by the two devices, and suggests that the CTC device is the more accurate of the two for measuring the pressures exerted by elastic fabric.<a></a></p> </blockquote> <p>Although some instruments have misrepresented pressures on the high side and some researchers have advocated unusually low pressures,<a></a> a 1985 study by Hendricks and Swallow used stockings "designed to exert graded compression from 24 mmHg pressure at the ankle to 16 mmHg pressure at the calf." They admit that "the optimal amount of compression at the ankle and calf necessary to heal and prevent statis leg ulcers is not known at this time." Their explanation of the value of external compression therapy is that "it compresses the superficial veins and prevents extravasation of fluid into the subcutaneous tissues . . .," thus reducing "swelling of the leg as measured by total leg volume and by lower extremity circumference measurements."<a></a> The study by Varghese, et al., obtained similar results with similar pressure readings using the CTC instrument. To date, capillary and anteriolar blood pressure have not been related for the purpose of establishing pressure values that would reduce edema; nor has the difference between new or mature residual limbs been studied. Different pressure readings have been observed over bony areas versus fleshy areas.²²</p> <h3>Procedures</h3> <p>Since our aim was to develop a sock which would be fashioned to give greater pressure distally, less pressure proximally, and have a rounded toe to shape the distal end, the flat, V-bed type machine was employed. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-03.jpg"><b>Fig. 3</b></a> is a close up of the carriage and the needle bed where needles are picked up or dropped according to machine programming so that wid-enings or narrowings (fashionings) can be made. All standard prosthetic socks are full-fashion knit in this way, with gradual wid-enings up both sides of the sock. To give even greater rounding, a new widening for the toe was programmed. On circular machines, as used for most currently available shrinkers, widening can only be achieved by loosening the knitting tension. Knitting a rounded toe on a circular machine is not possible.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-03.jpg"><strong>Figure 3. Needle bed of knitting machine where widenings and narrowings can be made.</strong></a><br /> <p>The yarn to be used for this sock needed firmness in its stretch so that the desired pressures could be obtained. Softness, strength, and washability were also considered important. A corespun yarn was selected, with Lycra spandex being the core and Avril rayon being the covering.</p> <p>Attempts were made to obtain postoperative edemic residual limb measurements from various facilities. Not enough measurements were obtained to make any generalizations. Therefore, our knowledge was combined with that of the Knit-Rite production manager to formulate an experimental size range (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-04.jpg"><b>Table 1</b></a>).</p> <p>Specifications were made for the knitting machines so that the desired pressures would be obtained when tested over a steel cylinder (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-05.jpg"><b>Fig. 4</b></a>) at the Fits Circumference measurements. Heavy pressure was defined at the top of the effective range, i.e. 25-30 mmHg for the distal pressure and 15-20 mmHg for the proximal pressure. The recognition that some patients could not tolerate heavy pressure, and that some researchers suggested less pressure for nighttime wear, led to the development of a sock having distal pressure in the 15-20 mmHg range and proximal pressure in the 10-15 mmHg range. Socks were identified with color stitching at the top: green for heavy pressure and gray for medium pressure. The increase in pressure caused by the increased stretch over the range was measured to be no greater than the allowed variance. Shrinker socks were sent to many prosthetists who indicated that they would use them and return evaluation forms.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-05.jpg"><strong>Figure 4. Testing cylinder with pressure sensing device in position.</strong></a><br /> <h3>Results</h3> <p>Forty-five evaluations were returned representing 43 patients. All but three of these evaluations were for below-knee amputees (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-06.jpg"><b>Table 2</b></a>). Of the 42 below-knee evaluations, 17 had toe measurements ranging in circumference from eight inches to 11 inches; 18 had toe measurements ranging from 11 1/8 inches to 13 5/8 inches; four had toe measurements ranging from l4 1/2 inches to 16 inches; and three did not give measurements (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-07.jpg"><b>Table 3</b></a>).</p> <p>The significance of grouping the measurements in this way was so they would correspond with the size range we had developed for testing purposes. A smaller toe circumference measurement was encountered than had been anticipated, but the actual toe sizing ranges could be compared with the experimental toe sizing ranges in the narrow, medium, and wide. Top measurements were ranged as they corresponded with toe measurements in each size (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-07.jpg"><b>Table 3</b></a>). Note, the actual tester range of top circumference measurements was both larger and smaller than the experimental sizing range for the narrow and the regular, but was only smaller for the wide (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-05.jpg"><b>Table 1</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-07.jpg"><b>Table 3</b></a>).</p> <p>Pressure measurements were again taken which defined ranges of each size as reported for the wearers. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-08.jpg"><b>Fig. 5</b></a> shows pressure measurements of heavy shrinker socks at circumferences one inch from the distal end. These pressures should relate to pressures exerted on those fitted with the narrow, the medium, and the wide as indicated by the rectangles. Our KU study indicated laboratory pressure measurements over steel cylinders are approximately ten percent higher than pressure measured on patients, or control volunteers making these pressures in agreement with our criteria, if the larger circumference in each specified Fits Circumference range is the cut off point; therefore, if 11 inches is the larger suggested circumference, 11 1/8 circumference inches would be fit with the next size unless greater pressure is desired.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-08.jpg"><strong>Figure 5. MmHg of pressure exerted by heavy shrinker sock on inch from distal end.</strong></a><br /> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-09.jpg"><b>Fig. 6</b></a> shows pressure measurements of heavy shrinker socks at circumferences six to eight inches from the distal end. These pressures should relate to pressures exerted on those fitted with the narrow, the medium, and the wide as defined by the rectangles. These pressures are less than the distal end pressures. However, particularly in the narrow size, some readings were at the 20 to 25 mmHg level. Since some wearers' residual limbs were exceeding the suggested range in top circumference measurement and were obtaining greater proximal pressure than might be desired, patterns were made using the measurements given for each limb. These were grouped by shape. As a result of comparing these shapes and listening to comments from several facilities, a double tapered shrinker was developed. Comparison to the regular taper is shown in <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-10.jpg"><b>Fig. 7</b></a> where the dotted lines represent the regular tapered sock and the three toe lengths represent the 10, 12, and 14 inch sock lengths.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-09.jpg"><strong>Figure 6. MmHg of pressure exerted by heavy shrinker sock six to eight inches from distal end.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-10.jpg"><strong>Figure 7. Scale of regular and double taper.</strong></a><br /> <p>When knitted, the regular taper and double taper can be compared as in <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-11.jpg"><b>Fig. 8</b></a>. The toe is the first consideration for fit using the Fits Circumference range as the guide. Then, if the top circumference exceeds the recommended limit of the regular range, a double taper should be ordered or at least considered.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-11.jpg"><strong>Figure 8. Comparison of regular and double taper shrinker sock (14 inch length).</strong></a><br /> <p><a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-12.jpg"><b>Fig. 9</b></a> shows pressure measurements of medium pressure shrinker socks at circumferences one inch from the distal end. These pressures should relate to pressures exerted on those fitted with the narow, the medium, and the wide as indicated by the rectangles. These pressures met our criteria for a sock with medium pressure of 15 to 20 mmHg. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-13.jpg"><b>Fig. 10</b></a> shows pressure measurements of medium pressure shrinker socks at circumferences six inches to eight inches from the distal end. These pressures should relate to pressures exerted on those fitted with the narrow, the medium, and the wide as defined by the rectangles. These pressures were lower than our criteria when circumferences were less than our sizing guide. This was not considered to be a problem unless a lack of pressure caused slippage. Where circumferences were more than our sizing guide, the pressures of the narrow exceeded our criteria as did those of the heavy shrinker sock. As for the heavy shrinker sock, when the top circumference exceeds the Fits Circumference recommendation, the double taper is recommended to get the advantages of gradient pressure.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-12.jpg"><strong>Figure 9. MmHg of pressure exerted by medium pressure shrinker sock one inch from distal end.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-13.jpg"><strong>Figure 10. MmHg of pressure exerted by medium pressure shrinker sock six to eight inches from distal end.</strong></a><br /> <p>Evaluation forms revealed that both green top, heavy compression socks, and gray top, medium compression socks, were used for day and night wear. Four testers used two socks: heavy compression for daytime wear and medium compression for nighttime wear. Seventy percent of the testers wearing the heavy compression felt the tops stayed up adequately; 65 percent of the testers wearing the medium compression socks felt the tops stayed up adequately. Night-time was the most difficult time. To one tester who complained in detail about the roll down, we sent him a shrinker with a turned down zigzagged stitched top. He liked this top, but it was not pursued for fear the doubled top would cause greater pressure prox-imally. Some trials indicated the shrinker should come up proximally past the patella and that if it comes a little higher, it is less likely to roll.</p> <p>All but one of the testers using the heavy compression felt that the shrinker was improving the shape, decreasing the edema, and/or maintaining the limb. One tester, who felt the heavy pressure was not adequate, used both heavy and medium socks at the same time and still felt the need for greater pressure. The prosthetist noted this was a young man with a high pain level and a drive to get back on his legs. Sixty-four percent of the testers using the medium compression felt the shrinker was maintaining the limb's size and shape. Thirty-five percent of the respondents felt the pressure of the medium compression sock was not sufficient. Most of the amputees using the experimental shrinker socks were new patients who lost a leg because of vascular disease, usually diabetes. Any undue pressure over the residual limb serves as an excuse to take the shrinker off; therefore, medium pressure may help to start the process of controlling edema so that heavy pressure will eventually be tolerated as needed. Some of the shrinkers were worn over Ace® bandaging and some comments were made about using Ace® bandaging some of the time.</p> <p>Prosthetists' comments revealed that the experimental shrinkers were effective in shaping the distal end, hugging the anatomy, and giving good overall suspension. The distal end support was positive as long as the patients applied the shrinker firmly. Some residual limbs are very bulbous initially following surgery. This depends on the patient's physique, the surgical technique use, and the amount of edema. Previous experience indicates a bulbous residual limb will, in time (six to 12 weeks post-surgery), become slowly cylindrical, and a cylindrical amputation will become cone-shaped.</p> <p>Thirty percent of the wearers said they had not washed their shrinker sock which may have meant that they were wearing it continuously. Five percent did not answer the question. Of the 65 percent who did wash their shrinker, none mentioned any washing problems.</p> <p>In answer to the question, "Is the sock easy to apply", 100 percent of the testers said, "Yes." One said, "Very." In answer to the question, "Is the sock comfortable?," all but one tester replied positively. This one tester was having some orientation problems. Other comments were "Feels good," "Feels great, except at first when a little tender."</p> <h3>Conclusions</h3> <p>Evaluation forms for a new below-knee shrinker sock revealed it was comfortable, easy to put on, stayed up on most but not all wearers, gave desired shrinking and shaping in the heavy compression, and some shaping and residual limb maintenance for 65 percent of the medium compression wearers. When pressure was greater and the sock was fitted longer, proximally past the patella, roll down was less of a concern. Analysis of residual limb measurements and pressure measurements determined that both the heavy and the medium compression shrinker socks did exert greater pressure distally than proximally, and that wider circumferences than those recommended at six or more inches from the distal end could be accommodated by the double tapered sock.</p> <p>This study did not offer the opportunity to study above-knee shrinkers, but they are being custom made in order to gain knowledge of fit and support. The same fabric used in the below-knee shrinkers can be cut and sewn to make above-knee socks. To meet the needs of shrinking stumps, below-knee shrinkers can be altered with a sewing machine stitch if the sock is not to be used for walking. If the sock is to be used for weight bearing, it can be returned to be altered with a flat seam according to specified markings, or a smaller size can be fitted.</p> <h3>Acknowledgments</h3> <p>We are especially indebted to the prosthetists from the various facilities who did most of the reporting for the testers. Without their help, this report would not have been possible. We also wish to thank William B. Smith, CO, President, and Larry Pierce, Production Manager, of Knit-Rite, Inc.. Without their product, knitting knowledge, and encouragement, no sock would ever have been made.</p> <p><b>References:</b></p> <ol> <li>Beninson, Joseph, M.D., "Six Years of Pressure Gradient Therapy," <i>Angiology</i>, Volume 12, No. 1, January, 1961, pp. 38-45.</li> <li>Bauer &amp; Black, <i>Elastic Stocking Compression in the Therapy of Varicose Veins</i>, Chicago, Il., 1956, pp. 4-14.</li> <li>Chavatzas, Dimetrios, and Jamieson Crawford, "A Simple Method for Approximate Measurement of Skin Blood-Pressure," <i>The Lancet</i>, April 20, 1974, pp. 711-712.</li> <li>Clark, Gary S., M.D.; Barbara Blue, R.N.; and John B. Bearer, RPT, "Rehabilitation of the Elderly Amputee," <i>Journal of the American Geriatrics Society</i>, Volume 31, No. 7, July, 1983, pp. 439-447.</li> <li>Cohen, Havey D., Ph.D., Letter to Knit-Rite, Inc. on "Equipment Evaluation Service," November 14, 1984, p. 1.</li> <li>Hendricks, William M,, M.D. and Roger T. Swallow, B.A., "Management of Statis Leg Ulcers with Unna's Boots Versus Elastic Support Stockings," <i>Journal of the American Academy of Dermatology</i>, Volume 12, No. 1, January, 1985, pp. 90-98.</li> <li>Hera, J. Alan, M.D.; Antonio M. Sotlo, M.D.; Peter S. Kaufman, Ph.D.; and Stephen M. Weiss, Ph.D., "Cardiovascular Instrumentation," <i><i></i>Proceedings of the Working Conference on Applicability of New Technology to Biobehavioral Research</i>, March 16-19, 1982, pp. 207-217.</li> <li>Horner, J., R.N.; L.C. Loruth; and A.N. Nicolaides; "A Pressure Profile for Elastic Stockings," <i>British Medical Journal</i>, March 22, 1980, pp. 818-821.</li> <li>Husni, Elias A., M.D.; Jose O.C. Xemenes, M.D.; and Frederick G. Hamilton, M.D., "Pressure Bandaging of the Lower Extremity," <i>Journal of the American Medical Association</i>, Volume 206, No. 12, December 16, 1986, pp. 2715-2718.</li> <li>Isherwood, P.A.; J.C. Robertson; and A. Rossi, "Pressure Measurements Beneath Below-Knee Amputation Stump Bandages: Elastic Bandaging, the Puddifoot Dressing and a Pneumatic Bandaging Technique Compared," <i>British Journal of Surgery</i>, Volume 62, 1975, pp. 982-986.</li> <li>Johnson, George, Jr., M.D.; Cynthia Kupper, R.N.; David J. Farrar, Ph.D.; and Roger Swallow, "Graded Compression Stockings," <i>Archives of Surgery</i>, Volume 117, January, 1982, pp. 69-72.</li> <li>Makin, G.S.; F.B. Mayes; and A.M. Holroyd, "Studies on the Effect of 'Tubigrip' on Flow in the Deep Veins of the Calf," <i>British Journal of Surgery</i>, Volume 56, No. 5, May, 1969, pp. 369-372.</li> <li>Manella, K.J., "Comparing the Effectiveness of Elastic Bandages and Shrinker Socks for Lower Extremity Amputees," <i>Physical Therapy,</i> Volume 61, No. 3, pp. 334-337.</li> <li>Mooney, Vert, M.D.; J. Paul Harvey, M.D.; Elizabeth McBride, M.D.; and Roy Snelson, C.P.O., "Comparison of Post Operative Stump Management: Plaster Vs. Soft Dressings," <i>The Journal of Bone and Joint Surgery</i>, Volume 53-A, No. 2, March, 1971, pp. 241-248.</li> <li>Puddifoot, P.C.; P.C. Weaver; and Sheila A. Marshall, "A Method of Supportive Bandaging for Amputation Stumps," <i>British Journal of Surgery</i>, Volume 60, No. 9, September, 1973, pp. 729-731.</li> <li>Renstrom, Per, <i>The Below-Knee Amputee</i>, University of Goteborg, Sweden, 1981, p. 18.</li> <li>Sigg, K., M.D., "Compression with Pressure Bandages and Elastic Stockings for Prophylaxis and Therapy of Venous Disorders of the Leg," <i>Fortschritte Der Medizin</i>, No. 15, August 15, 1963, pp. 601-606.</li> <li>Spiro, M.; V.C. Roberts; and J.B. Richards, "Effect of Externally Applied Pressure on Femoral Vein Blood Flow," <i>British Medical Journal</i>, Volume 1, March, 1970, pp. 719-723.</li> <li>Swallow, Ramsey; and Roger Swallow, "How to Use Tester to Measure Compression Force of Support Hosiery," <i>Knitting Times</i>, November 22, 1976, p. 55.</li> <li>Van Pijkeren, Teun; Marinus Naeff, M.D.; and Him Hok Kwee, Ph.D., "A New Method for the Measurement of Normal Pressure Between Amputation Residual Limb and Socket," <i>Bulletin of Prosthetic Research</i>, Volume 17, No 1, Spring, 1980, pp. 31-34.</li> <li>Varghese, George, M.D.; Peter Hindle, M.D.; Serge Zilber, Ph.D.; Judith Perry, RPT; and John B. Redford, M.D., "Pressure Applied by Elastic Prosthetic Bandages: A Comparative Study," <i>Orthotics and Prosthetics</i>, Volume 35, No. 4, December, 1981, p. 34.</li> </ol> <b>Footnote</b> Midwest Research Institute is a professional not-for-profit corporation doing contract research for business, industry, government, individuals and groups.<br /><br /><b>Footnote</b> Available from Knit-Rite, Inc.<br /><br /><b>Joseph Zettl, CP. </b> Joseph Zettl, CP., is President of the American Artificial Limb Co., Inc., 1400 East Pike Street, Seattle, WA 98122.<br /><br /><b>Martha Field, M.S. </b> Martha Field, M.S., is Manager of Research and Development for Knit-Rite, Inc., 2020 Grand Avenue, Kansas City, MO 64141. <p style="width: 400px;"></p> Page Number(s) 20 - 32 Year 1987 Volume 11 Issue 1 Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-03.jpg Figure 4 TABLE I http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-04.jpg Figure 5 FIGURE 4 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-05.jpg Figure 6 TABLE II http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-06.jpg Figure 7 TABLE III http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 FIGURE 5 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-08.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-01.jpg Figure 9 FIGURE 6 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-09.jpg Figure 10 FIGURE 7 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-10.jpg Figure 11 FIGURE 8 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-11.jpg Figure 12 FIGURE 9 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-12.jpg Figure 13 FIGURE 10 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-13.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 Design and Testing of a Gradient Pressure Sock for Control of Edema Creator An entity primarily responsible for making the resource Martha Field, M.S. * Joseph Zettl, CP. * https://staging.drfop.org/files/original/64eb48831c842d569b969a8c4023b43a.pdf 23a3264fbd43cb19735d1394ea4628b9 https://staging.drfop.org/files/original/457d0569478cb47d506c23642463165c.jpg 45eb3dbafd54e0d668f2f3bfc95c21f2 https://staging.drfop.org/files/original/f273ddd8f2d9ddf2bcefdc00fecea5cd.jpg 32d7ead140275fb07cd1b5fb68f0d23c https://staging.drfop.org/files/original/926a3decfb9da45446674f936ec89f91.jpg a5f732da60ea27eaccc3b5f8030bb28a https://staging.drfop.org/files/original/1ed3a83ad57a832a54252e4a0737039f.jpg 74e042f3b878ccf644a029e6c7863bd2 https://staging.drfop.org/files/original/e646eb1d8492cc5ba623391e15c6cad5.jpg dcd12710088de3f157db636bb403595c https://staging.drfop.org/files/original/826147443b433df462696387b01d80a1.jpg a3dd7046d03c6312c1783e053e286e89 https://staging.drfop.org/files/original/6db35e73e1a625e17d758c9c372e668b.jpg 3d9d018b29c5258b24e6459783cdfe87 https://staging.drfop.org/files/original/2b3975ce6719b0edcd6b0152b38e1452.jpg 87afc6aa558904540e7d54714b7c124c https://staging.drfop.org/files/original/6f94b060664d6dee12584cfafd9dfb42.jpg e8c575c8db2e62e393094a9bf8f896e4 https://staging.drfop.org/files/original/6a71bd9c057c8ce272a912840c6bdcdb.jpg 27624130c2456841ffa292e8b25b333c DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_005.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 5 - 9 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_01_005.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 Georgia Warm Springs Foundation Feeder</h2> <h5>Robert L. Bennett, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Thirty years ago (March 1936) a young lady rom Crawfordsville, Ga., was fitted at the Georgia Warm Springs Foundation with what was referred to in her medical record as "an ingenious device" (<b>Fig. 1</b>). This apparatus was later called a "foot-operated feeder" because it required voluntary extension of her foot against a movable footboard on her wheelchair to bring about tilting of the seesaw cradle supporting her forearm. In this manner, she was able to feed herself. She used this device for twenty years and then returned to Warm Springs and was fitted with a far more efficient type with the imposing name "balanced forearm orthesis."<a style="text-decoration:none;">*</a> <!--Page 6--> The "ingenious device" just mentioned appears to have been the first feeder ever used at Warm Springs, and perhaps the first ever used anywhere.<a style="text-decoration:none;">*</a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "An ingenious device" supplied in 1936 to a patient at Georgia Warm Springs Foundation; also known as a "foot-operated feeder." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In June 1936 is found what appears to be the first feeder used at Warm Springs that required shoulder depression to bring the hands toward the head, and perhaps this feeder should be thought of as the true ancestor of our present-day device. As can be seen in <b>Fig. 2</b>, the 1936 device consisted of a metal yoke bolted to the lapboard of a wheelchair but free to revolve horizontally. A metal forearm cradle fastened to the yoke by a wooden block moved vertically in a seesaw fashion. This was called a "Barker feeder," since Edward H. Barker was the first patient to use the device. Over the next few years, at least three patients were fitted with this type of feeder.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Two views of the "Barker feeder" of June 1936. Perhaps the true ancestor of the present-day device, it required shoulder depression to bring the hand toward the head. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Reviewing the literature to determine the first feeder and then tracing the development of the feeder at Warm Springs has been an unexpectedly difficult and time-consuming job. It has been most difficult to separate mobile supportive devices used in the treatment of the paralyzed upper extremity from the functional seesaw devices used to assist the patient with a paralyzed biceps to flex his elbow.</p> <p>Looking back over the years, one is rather amazed to find that it took so long to develop the <!--Page 7--> present-day balanced forearm orthesis. The excuse must be that the development of truly efficient orthetic devices comes only with persistent patient demands and long usage. Extensive patient demand for this type of apparatus did not come until the mid-1940's. Records indicate that perhaps as few as 20 feeders were made at Warm Springs between 1936 and 1946. It should be remembered that prior to the occurrence of large epidemics of poliomyelitis in the early 1940's there were really very few patients who survived the acute attack of poliomyelitis with massive involvement of upper extremities. As the incidence of acute poliomyelitis increased, the medical profession learned how to keep these patients alive. Rather suddenly, in the mid-1940's, Warm Springs was faced for the first time with the problem of large numbers of patients who had such weakness in their upper extremities that they could not bring their hands toward their head.</p> <p>In May 1943 the bulky base of the "Barker feeder" was replaced by a simple rod and collar, the rod passing through a hole in the lapboard of the wheelchair and held in position by a simple collar (<b>Fig. 3</b>). Several holes were placed in <!--Page 8--> the lapboard to determine the proper position for attaching the feeder. In March 1945 the feeder was placed on a simple aluminum base (<b>Fig. 4</b>). This allowed the patient to move the feeder horizontally across the lap-board by body movements for best position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The feeder of May 1943. The base of the "Barker feeder" has been replaced by a simple rod and collar. Several holes placed in the lapboard helped to determine the proper position for attaching the feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The stand feeder of March 1945. The aluminum base permitted the patient to move the feeder horizontally across the lapboard by body movements for best position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The first real change in the design of feeders occurred in April 1946. The feeder was suspended from the upright of an overhead sling! Originally, it was called a "bird-cage feeder," simply because the trough was suspended in a yoke resembling the trapeze-like arrangement seen in many bird cages (<b>Fig. 5</b>). At this time, the Warm Springs treatment program dictated that no patient with severe upper-extremity involvement should use a feeder until late in the convalescent phase of care. Hence there was a natural transition from the use of overhead slings to protect the weakened shoulder girdle to the suspension feeder to develop functional capacity in the upper extremity. For the next ten years, there is record of 326 suspension feeders being fitted to a total of 197 patients. Only seven of this type were used after 1956, and none after 1961.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The "bird-cage feeder" of April 1946-so called because the trough was suspended in a yoke resembling the trapeze-like arrangement seen in many bird cages. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It was not until December 1949 that segmented feeder arms were used (<b>Fig. 6</b>). These arms were attached directly to the vertical tubing of the back of the wheelchair. Insofar as can be determined, hinged-spring control of the proximal link-seen in <b>Fig. 6</b>-was used in this instance only, and no further use of the mobile arms was made until October 1952.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Segmented-arm feeder used in December 1949. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The light and mobile C-clamp feeder that could be easily attached to the edge of a table, to the lapboard, or to a wheelchair arm rest was developed in the spring of 1950 (<b>Fig. 7</b>). Between 1950 and 1960, 61 were used on 45 patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. C-clamp feeder developed in May 1950. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In October 1952 the segmented-arm feeder was again used but without the spring hinge at the attachment of the proximal link to the back of the wheelchair. The proximal link was rigidly clamped to the upright (<b>Fig. 8</b>), allowing horizontal motion only. This feeder was followed in 1953 (<b>Fig. 9</b>) by one to which ball bearings had been added to the base and to the moving joints of the arms. The base could also be <!--Page 9--> tilted to assist movement of the proximal link. This was really the first of the present-day Georgia Warm Springs Foundation feeders. Between 1952 and 1964, 786 of these feeders were applied to 427 patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Segmented-arm feeder of October 1952. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Present-day Georgia Warm Springs Foundation feeder, the balanced forearm orthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In September 1953 it was found that many patients with severe upper-extremity weakness had good musculature in the lower extremities and trunk; therefore, while they needed a feeder, they did not require a wheelchair. It was at this time that feeders were fitted directly to the trunk of the patient, either attached to a corset (<b>Fig. 10</b>) or to a belt. Between 1953 and 1961, 100 such feeders were fitted to a total of 53 individual patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Two views of a patient fitted with a corset-based feeder. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>During the years 1946 through 1964, for which the record is quite detailed and complete, a total of 1,334 feeders were applied to 773 patients. Some patients had several different kinds of feeders, and so the latter number does not indicate that there were 773 different patients. In 1961 questionnaires were sent to 488 patients who had been fitted with feeders and who had returned to their homes with feeders. Two hundred nine replies were received; of this number, 139 (66.5 per cent) were still using their feeders.</p> <p>The feeder, or balanced forearm orthesis, was developed primarily for patients with paralyzed upper extremities following acute anterior poliomyelitis; however, it is being used for many neuromuscular problems that result in lack of sufficient voluntary strength to bring the hand toward the head. More recently it has been used in conjunction with externally powered orthetic devices that activate elbow, forearm, and hand.</p> <br /> Figure 1 http://www.oandplibrary.org/al/images/1966_01_005/sp66-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_01_005/sp66-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_01_005/sp66-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_01_005/sp66-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_01_005/sp66-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1966_01_005/sp66-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1966_01_005/sp66-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1966_01_005/sp66-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1966_01_005/sp66-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1966_01_005/sp66-010.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 Georgia Warm Springs Foundation Feeder Creator An entity primarily responsible for making the resource Robert L. Bennett, M.D. * https://staging.drfop.org/files/original/9e338894b1f207843da22d94280a118d.pdf 3393a872a919021256b2ab1ef2371b05 https://staging.drfop.org/files/original/4fee943f810bcedb55cf94bac3f60253.jpeg 0b6369b919b0a4c5d421fce6886e6d5e https://staging.drfop.org/files/original/6396c81100371bfe9d8ac940075631cb.jpg 023518571192ab6721498d9b4a8f7662 https://staging.drfop.org/files/original/0d2768cace046397bbf7d7040508d863.jpg 07e13ce84947e5b2f1732d2de5338794 https://staging.drfop.org/files/original/d83594653570ca96f690044f2b1d657d.jpg 8bc03b7ee87b349b287b877e8a698bc0 https://staging.drfop.org/files/original/8a3452f59a563b52f53eb6f67c8a4be4.jpg 470315d686168817996c70c6a4928ce9 https://staging.drfop.org/files/original/1f8be944e589b7eac3c9645bca1a26e8.jpg 59b8b275e0cb6ce51b166ec3ae492e31 https://staging.drfop.org/files/original/aec7299a96361a338ddc5dacbcdf4e28.jpeg cf51d6d972c19f2beaaeced91b298b2e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1977_02_004.pdf Text Any textual data included in the document <h2>The Geriatric Amputee</h2> <h5>Florence T. Leist, P.T.&nbsp;<br /><br /><a href="/files/original/4fee943f810bcedb55cf94bac3f60253.jpeg">Fig 1: Florence Leist</a></h5> <p><i>Presented at the Annual Meeting of the American Physical Therapy Association of Md., Inc., November 13, 1976.</i></p> <p>The purpose of this presentation is to challenge each of you to become an advocate for the geriatric amputee, and to evaluate his potential on factors other than his age.</p> <p>To dispel the theory of a person being too old to use a prosthesis I would like to share a couple of real situations.</p> <p>We had a dear 77-year-old man receive his prosthesis at our clinic at Deer's Head in the spring. Last summer I met his grandson, and when I asked him how his grandfather was, he replied, "oh, he's fine now that he has his new leg. He's even courting a girl friend." Then there is the 85-year-old woman who received a new prosthesis and yet another new one at the age of 87 to enable her to continue caring for and babysitting her great grandchildren.</p> <p>This afternoon I would like to talk <em>first</em> about factors to be considered in the management of the geriatric lower-limb amputee, and then present some statistics gathered from a review of the amputees who received their prostheses through the clinic at Deer's Head Center during its first two years of operation.</p> <p>The management of the amputee can be divided into three phases:</p> <ol> <li> <p>Post amputation and/or pre-prosthetic training.</p> </li> <li> <p>Prescription.</p> </li> <li> <p>Post prosthetic training.</p> </li> </ol> <p>One of the problems we had in the management of the geriatric amputee was the scarcity of information provided by the referring physician. We sometimes got little more information than that the patient had had an amputation - not even a mention of whether it was an AK or BK, or whether it was on the right or the left.</p> <p>To help overcome this situation we developed a questionnaire to develop not only the necessary basic history, but, more importantly, information such as cardiac status and the condition of the remaining lower limb. We also included the question "is he able to increase exertion 50 per cent more than is required for normal walking or wheelchair use."</p> <p>We used the reference "On energy requirements for prosthesis use of geriatric amputee" to establish that question (Peizer, E. <i>On the energy requirements for prosthesis use by geriatric amputees, in "The Geriatric Amputee,"</i> Committee on Prosthetics, Research and Development, National Academy of Sciences, 1961).</p> <h3>Depression</h3> <p>In the pre-prosthetic period there are many apsects to consider. From our first contact with the geriatric amputee we usually get a definite feeling about his general mental status. We often find that he is depressed: his self-image has been shattered; he is suddenly unable to walk, work, or even get out of the house; he is faced with a great fear of the future. "What," he asks, "is going to happen to me and my family?"</p> <p>To help him cope with these many frightening problems, the social worker, who we feel is an important member of the team, can be of value from the beginning by helping him face reality, helping solve some of his problems, and by giving him added encouragement.</p> <h3>Range of Joint Motion</h3> <p>Loss of range of motion is more rapid in the geriatric patient because of loss of tissue elasticity. Management is to institute bed positioning and range of motion exercises and encourage freedom of movement as soon as possible. Our goal to have not more than 10 deg. of flexion contracture in hip and knee. Stretching exercises must be carried out if contractures have developed, but one must remember that the older patient tolerates stretching poorly.</p> <h3>Muscle Strength</h3> <p>There is a generalized decrease in strength with age which is compounded by the effects of surgery and forced inactivity. Management is through general strengthening exercise, but the cardiac status and other systems must be considered in planning the exercise program. Usually we must accept less than what is considered as ideal strength. The goal is that the patient be able to support himself by a walkerette or crutches.</p> <p>Often times the geriatric amputee has poor balance and is fearful of falling. He has to be encouraged to try walking with crutches or walkerette and must be well guarded to prevent failing. Ideally our highest pre-prosthetic goal is independence in walking with crutches, however, as we are more concerned with safety and realize the older person does not have the agility and balance of a younger person, walking independently with a walkerette is acceptable. Our chief concern is the safety of the patient and his ability to function. We emphasize the specific stump exercises for extension and abduction of the hip for the AK and the quadriceps for the BK.</p> <h3>Shaping the Stump</h3> <p>In the older amputee generalized soft tissue atrophy is already present and stump wrapping should be monitored carefully. The patient and his family usually lack a clear understanding for the need of stump wrapping, so clear explanations and instructions should be given to insure proper shaping of the stump.</p> <h3>Length of Time Before Prescription</h3> <p>We usually find that most new amputees are presented at our Prosthetic Clinic about 2 months post amputation. Sometimes it is more than that and once in a while less. If it has been 2 months or longer, usually there has been adequate time for reduction of contractures, an increase in strength, proper shaping of the stump, and for learning to walk with assistive devices. If the time is shorter and the patient is able to handle himself on crutches or walkerette but still lacks range of motion or has not stabilized in the shrinking process, we usually go ahead and present him at clinic. The physician in charge of the clinic at DHC has at times given a provisional prescription, stating that when the contracture has been reduced or shrinkage has stabilized the prosthetist may proceed with fabrication of the prosthesis.</p> <p>The team approach is used at the clinic at DHC. The team consists of the physician in charge, the prosthetist, the physical therapist, the occupational therapist, the social worker, counselors from the Division of Vocational Rehabilitation, the patient, and his family, whenever possible.</p> <h3>Prescription for the Geriatric Amputee</h3> <p>Usually, when a patient has worn a prosthesis previously, a prescription for a duplication of the present prosthesis is made, i.e., when a person has a plug socket or a thigh corset, it is duplicated as closely as possible. For a new amputee, we try to prescribe components to meet the criteria which we developed during our evaluation.</p> <h3>Sockets</h3> <p>Quadrilateral sockets with partial suction and valve, usually fitted with a heavy cotton sock, is the design of choice unless there is extensive soft tissue atrophy, when a 5-ply woolen sock is used.</p> <h3>Suspension</h3> <p>A hip joint with pelvic band gives greater security. Suction is generally not prescribed for the geriatric patient because he does not have the muscle strength or tone to use it. At times a "Silesian bandage," or belt, is prescribed, but the patient often has difficulty with internal rotation of the prosthesis when he pulls the "bandage" tight. We recently had to change a "Silesian bandage" to hip joint and pelvic band for a woman.</p> <h3>Knee</h3> <p>Maximum stability at heel strike is necessary for the geriatric patient. The manually locked knee joint provides this stability in ambulation. It does result in gait deviations, but safety with the geriatric patient is our chief concern. It is better to have gait deviations than no gait at all. To help overcome partially the need to circumduct or vault the prosthesis is generally made 1/2 to 1-in. shorter than the contralateral leg.</p> <p>Another knee component that is prescribed sometimes is the BOCK safety knee which provides stability through friction upon weight-bearing.</p> <h3>Foot Components</h3> <p>When a locked knee is used a single-axis foot is desirable because it permits the entire plantar surface of the foot to make contact with the floor early in the stance phase. With a person who is not a vigorous walker, such as an older person is apt to be, an extra soft heel bumper is indicated.</p> <p>When a SACH foot is used with an articulated knee an extra soft heel cushion is desirable.</p> <h3>Post-Prosthetic Training</h3> <p>Post-prosthetic training for a geriatric amputee should be considerably different from that for a young vigorous person. Balance, strength, agility, and endurance will all be reduced greatly and we must proceed more slowly. Goal setting will vary greatly from individual to individual - from limited use in the home to general activities of daily living, to return to work, from walking with no assistive device, to walking with cane or canes, crutches, or walkerette.</p> <p>We must set realistic goals for the geriatric amputee. Many of these people have not been active for a long period before amputation, and they will probably not regain vigorous strength and agility. But if we can return them to the life style to which they were accustomed then I think we have reached our goal.</p> <p>As I have said several times before, we are concerned with safety. While we would like to have a perfect gait, without any assistive device, we settle for safe gait with an assistive device. But when a 75-year-old man can climb on and run a tractor on the farm, what difference does it really make if he uses a cane? Or, if a 75-year-old woman is taking care of herself, staying by herself most of the day and performing household chores, is it so awful she uses a walkerette?</p> <p>Last year we conducted a review of the patients who received a prosthesis through our clinic during the first 2 years of its existence. The purpose of this was to ascertain whether or not the clinic was meeting the needs of the patient; i.e., were we prescribing the proper kind of prosthesis for the individual? And, we felt, this would be partially determined by the use the patient made of his prosthesis. All patients had had their prosthesis for at least a year.</p> <p>We interviewed each of these 24 patients on the day of the clinic, having them complete a questionnaire. Level of amputation, age group, and cause of amputation are given in <b>Table 1</b>. Five of these questions with the result are given in <b>Table 2</b>, <b>Table 3</b>, <b>Table 4</b>, <b>Table 5</b>, and <b>Table 6</b>.</p> <strong>Table 1. Classification of Patients</strong><br /><img src="/files/original/6396c81100371bfe9d8ac940075631cb.jpg" alt="Italian Trulli" width="368" height="158" /><br /><br /><strong>Table 2. I Wear My Artificial Limb:</strong><br /><img src="/files/original/0d2768cace046397bbf7d7040508d863.jpg" br="" width="580" height="179" /><br /><strong><br />Table 3. When I Wear My Limb It Is On:</strong><br /><img src="/files/original/d83594653570ca96f690044f2b1d657d.jpg" br="" width="602" height="134" /><br /><br /><strong>Table 4. When My Limb Is On I Can:</strong><br /><img src="/files/original/8a3452f59a563b52f53eb6f67c8a4be4.jpg" br="" width="565" height="224" /><br /><br /><strong>Table 5. When I Walk I Use:</strong><br /><img src="/files/original/1f8be944e589b7eac3c9645bca1a26e8.jpg" br="" width="571" height="127" /><br /><br /><strong>Table 6. I Need Someone To Assist Me When I Walk:</strong><br /><img src="/files/original/aec7299a96361a338ddc5dacbcdf4e28.jpeg" br="" width="566" height="74" /> <p>It was apparent to us from these statistics that we evidently were meeting the needs of the patients and that the amputees over 60 years of age function about on the same level of those under 60.</p> <p><b>References:</b></p> <ol> <li>Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, <i>The management of lower-extremity amputations</i>, Prosthetic and Sensory Aids Service, Veterans Administration, TR 10-6, August 1969.</li> </ol> Page Number(s) 4 - 7 Year 1977 Volume 1 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-6.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Text Copy Edit Figure 7 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Geriatric Amputee Creator An entity primarily responsible for making the resource Florence T. Leist, P.T.  https://staging.drfop.org/files/original/730cd988b459c0470f09d2a2b1c901c0.pdf c64b39002b638752f02a6481b5256f6c https://staging.drfop.org/files/original/f5b53660057bef0aa5062375e0944618.jpg 71c691b1acd762609be7aef78e31a615 https://staging.drfop.org/files/original/507f8e598d697564a8825ef436c9831f.jpg 8c2dab42f1da4a77dd5b8083f04dce69 https://staging.drfop.org/files/original/541b427a8b6b0e194b041e8cc2c59da1.jpg 6919d95465a51c86db5c65678cb30502 https://staging.drfop.org/files/original/3d90295042f79f041d671c5d41f0392d.jpg 7d59e48c5e8c4047578f190b6e516375 https://staging.drfop.org/files/original/71925d0bb446f6b649060c3ce4462e59.jpg 9b323c95c211ec10d01e7feee755cd18 https://staging.drfop.org/files/original/3396fe9730b14b2e8657689fe74865b5.jpg 643294f08d5a592e58d3ea194294785d https://staging.drfop.org/files/original/b9a09fc152979d703b46c792aed66798.jpg a101cb269531ad4c2ddca3abe3c64fb3 https://staging.drfop.org/files/original/a310a604046c1382bc0c3548b947c299.jpg 0c5f822f77e1f2a66fd8f148fb0fb1b0 https://staging.drfop.org/files/original/2a80303457c8a42d0517fa0e01a299e9.jpg 44668a6d1b6a2b3675ba14074520a508 https://staging.drfop.org/files/original/3df94aa6ab1f93ff4d20a470503069ef.jpg f0c64be6e5bbae5c7b28834975248ee8 https://staging.drfop.org/files/original/3afb84d3903ae00d345a76156822ebc2.jpg c8495b91e25a321f39294efe21e110ad Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_03_109.pdf Text Any textual data included in the document <h2>The Hip Disarticulation Prosthesis as Developed by the O.I.M. Noord Nederland</h2> <h5>Peter Tuil&nbsp;<a style="text-decoration: none;">*</a></h5> <p>What characterizes the hip disarticulation prosthesis of the O.I.M. Noord Nederland is the use of a four-bar Otto Bock knee joint as a hip joint. O.I.M. Noord Nederland has used this variation with much success over the last five years. At first, it was questionable whether the joint would be strong enough, but this has proven not to be an issue. There have been some problems with the 3R21, but only when it is used as a knee joint. These complications have been due to extreme flexion, lamination sections that were too thick and caused the joint to tear apart during flexion, or too much external rotation.</p> <p>There are two advantages in the use of the four-bar hip joint. First, the patient walks with a lower energy expenditure because the prosthesis shortens the swing phase. In contrast to patients who have worn older style hip disarticulation prostheses (for years patients used to be fitted with a tilting-table prosthesis or later with a wooden "Canadian hip" prosthesis), the patients with the new style prosthesis walk more and have indicated that they use less energy. Second, there is hardly any strain on the cosmetic cover, so much less damage is done.</p> <p>An additional advantage of the four-bar joint is that the construction can be less critical. Besides, the whole prosthesis can be readily adjusted.</p> <h3>Description of the Fabrication Method</h3> <p>To make the plaster impression, two wooden blocks are mounted on a table or casting stand. (Editorial note: Presumably this stand is adjustable in height.)</p> <p>These wooden blocks have sloped planes so that a wedge-formed gap is created between them (<b>Fig. 1</b>). In the back, the sloped side forms a 60° angle. In the front, the sloped side is divided into two different angles (<b>Fig. 2</b>). Both blocks can rotate around their vertical axles with regard to the table to which they are attached. They can also be shifted with regard to each other in the sagittal plane by means of a spindle (worm gear mechanism). The blocks are primarily meant to provide a good fitting of the residual limb and pressure relief in the places where that is necessary.</p> <strong><a href="/files/original/f5b53660057bef0aa5062375e0944618.jpg">Figure 1</a>. Apparatus used for casting.</strong><br /><br /><strong><a href="/files/original/507f8e598d697564a8825ef436c9831f.jpg">Figure 2</a>. Side view of the wooden blocks.</strong><br /> <p>The four-bar joint is attached to the socket by means of a specially manufactured adaptor (<b>Fig. 3</b> and <b>Fig. 4</b>). The adaptor, which will later be incorporated into the socket, mimics the wedged shape of the wooden blocks (<b>Fig. 5</b>).</p> <strong><a href="/files/original/541b427a8b6b0e194b041e8cc2c59da1.jpg">Figure 3.</a> The adaptor.</strong><br /><br /><strong><a href="/files/original/3d90295042f79f041d671c5d41f0392d.jpg">Figure 4</a>. Shows how the adaptor, which will later be laminated into the socket, relates to the wedged form of the wooden blocks.</strong><br /><br /><strong><a href="/files/original/71925d0bb446f6b649060c3ce4462e59.jpg">Figure 5.</a> The apparatus forms a good plane of reference.</strong><br /> <p>Finally, the impression of the wooden table provides a good plane of reference for the plaster model (<b>Fig. 6</b>).</p> <strong><a href="/files/original/3396fe9730b14b2e8657689fe74865b5.jpg">Figure 6</a>. Position of the adaptor as related to the pelvic socket.</strong><br /> <p>This impression of the horizontal plane must remain horizontal during the construction process. During plaster modification, one should maintain unchanged the medial of the plaster model in the transverse plane, so that the impression of this edge will always indicate the line of progression of the plaster model.</p> <p>The socket is laminated in three layers. First though, a layer of Pe-Lite™ is put on the plaster model, followed by a layer of stockinette, and finally a layer of P.V.A. foil. The layer of stockinette is always applied under the first layer of foil. This will provide better suction, absorb some moisture, and the plaster model need not be as smooth.</p> <p>The first layer is laminated from flexible resin with two layers of Perlon stockinette, which is elastic in two directions. Subsequently the adaptor is located as shown in <b>Fig. 7</b>.</p> <strong><a href="/files/original/b9a09fc152979d703b46c792aed66798.jpg">Figure 7</a>. Reinforcement of the socket.</strong><br /> <p>The space between the adaptor and the plaster model is filled with "leichtspatel" (filler). The base of the plaster model must stand horizontally. The adaptor is placed approximately 4 to 5cm lateral of the groin. The maxim is to get the adaptor directly underneath the ischial tuberosity. However, this is influenced by the needs of the cosmetic cover.</p> <p>The adaptor is then covered with two layers of stockinette and a reinforcing layer of carbon fiber matting to prevent the adaptor breaking loose from the forces generated at heel strike. A strip of carbon fiber is put in the front to prevent the pelvis socket from curling inward. A reinforcing band of glass fiber is placed diagonally as shown in <b>Fig. 8</b>. Over this, two layers of stockinette are placed. First, rigid lamination resin is applied on those areas where the socket must be rigid. The rest is laminated with flexible resin. An adjustable "jig" is necessary in order to be able to turn the model around in the bench-vice quickly. The final layer is done with flexible resin and two layers of stockinette.</p> <strong><a href="/files/original/a310a604046c1382bc0c3548b947c299.jpg">Figure 8</a>. Alignment is first considered with the patient seated.</strong><br /> <p>A layer of stockinette and P. V. A. foil are put on the socket. Then, the little cap needed to finish the cosmetic cover is laminated with three or four layers of stockinette and one layer of carbon fiber. The extra time needed to form this cap will later save a lot of time during the finishing of the cosmetic cover.</p> <p>The prosthesis is completed with a four-bar knee joint (3R21), a single axis ankle joint foot, and a rotation adaptor.</p> <p>The alignment of the prosthesis is first considered in the sitting position. One must take into account the symmetry in comparison to the healthy limb (<b>Fig. 9</b> and <b>Fig. 10</b>). The definitive alignment is settled upon during stance and walking exercises (<b>Fig. 1</b>0). The adjustment of the 3R21 knee joint is very important. Mistakes in alignment can cause malfunctions of the knee joint. Many adjustments are possible with regard to rotation in the hip joint itself. The lack of facility to adjust abduction has never been a problem.</p> <strong><a href="/files/original/2a80303457c8a42d0517fa0e01a299e9.jpg">Figure 9</a>. Side view of the patient sitting and wearing the prosthesis.</strong><br /><br /><strong><a href="/files/original/3df94aa6ab1f93ff4d20a470503069ef.jpg">Figure 10</a>. The realization of definitive alignment.</strong><br /> <p>The freedom of movement when seated is considerable (<b>Figs. 11 and 12</b>).</p> <strong><a href="/files/original/3afb84d3903ae00d345a76156822ebc2.jpg">Figure 11 and 12.</a> Freedom of movement when seated.</strong><br /> <p>The cosmetic cover is shaped in the hip area, as well as in the knee area, so that less tension will be induced in the cover during flexion and when seated. Finally, a long elastic strip is glued to the inner anterior wall of the cover. This is done to protect the foam-cover.</p> <p>The construction process for a prosthesis for a hemipelvectomy is similar.</p> <em><b>*Peter Tuil </b> Peter Tuil can be contacted at Stitchting Orthopedische Instrumentmakerij, Noord-Nederland Dilgtweg 5, 9751 ND Haren (Gn), The Netherlands.<br /><br /><br /></em> Page Number(s) 109 - 113 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-10.jpg Figure 11 FIGURE 11 & 12 http://www.oandplibrary.org/cpo/images/1988_03_109/1988_03_109-11.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Hip Disarticulation Prosthesis as Developed by the O.I.M. Noord Nederland Creator An entity primarily responsible for making the resource Peter Tuil * https://staging.drfop.org/files/original/d88a16b9a8be8084709e5e3adb48845a.pdf 3bf668620dc8e9ac8dec0a9782f54663 https://staging.drfop.org/files/original/9821ea432dcfb99e529e07004a2d4b03.jpg 5d9aa8667c4ce230ed99756df8364395 https://staging.drfop.org/files/original/eb06fba52df94637c4b6d85035154ac4.jpg 9af7d40a114f591e59157a8d4bd39d7b https://staging.drfop.org/files/original/71125124f8bf550f9e1870dc7b82f83d.jpg c3f5f019e6bcd04d9fb4bfd8a7ea136b https://staging.drfop.org/files/original/c83141350daa6a9dced25ae8109cb4cb.jpg 0deaeb30af7098bb4cefd892cadccc9c https://staging.drfop.org/files/original/625a51addd8c1771d0fbfb9ff3446faf.jpg 5b7f229a85f9f81fb36df03e125eb95f https://staging.drfop.org/files/original/a65a9477cbb2256a4c408da06fd4df7c.jpg f1fb749d8eb5ae7fdb7aceb732bfd3cc https://staging.drfop.org/files/original/7a19ba2de351fc879c98037e9c7956ca.jpg 0972d0503197bd6c97a29eca33d9dfc3 https://staging.drfop.org/files/original/925e37100e40101885b0398c2f037f9d.jpg 00861f5944bcf0f34911969c8b80d7f8 https://staging.drfop.org/files/original/ae805c38cc6d026abdb67d5c360765fc.jpg 3e1feb6503597f324afdbd0f0eb66669 https://staging.drfop.org/files/original/b73662bf43c27c8c8d15f5062cc7888b.jpg 77cd871c4f3f6062588f8e31b5524165 https://staging.drfop.org/files/original/2815dcc928454d295136ea43e0f41512.jpg 2f18a1dc1f8aad3b6c99e9c30f158861 https://staging.drfop.org/files/original/bc5ce764af992800cce13e2e42da079d.jpg cb14265891e5a2032db169a588dc6af6 https://staging.drfop.org/files/original/216ecc082ecea7c002317a5eb27d1d67.jpg 021d3e3f8d4f67bcbfbc942c5e2fc0f2 https://staging.drfop.org/files/original/33d9ce6aa7d9acddadfc6e4d2e456e03.jpg 8f1a796e02e25b804a1655808e51b6fa https://staging.drfop.org/files/original/be22f04f3641e4eb9b1cef97a00dc965.jpg bd502110b239db19d048a8790d45337b https://staging.drfop.org/files/original/144ae762beee458ea85db2c14acf2563.jpg 896f7b63820817cc7194620990fddbbc https://staging.drfop.org/files/original/a3349004a023470f77a69f0db5586cf6.jpg c41f81120bd300258ce7f60145120ffe https://staging.drfop.org/files/original/3346562c362c352c74f3c5f15478deb2.jpg 7a688ef6fc33cfb6d1e84f5824c83923 https://staging.drfop.org/files/original/fc6361c99f7ba00662630eaca378f5a4.jpg de3ee67c2d6483c25e1eb10f66991303 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_004.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 4 - 43 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1961_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The History and Development of Syme's Amputation</h2> <h5>R. I. Harris <a style="text-decoration:none;">*</a><br /></h5> <p>James Syme (1799-1870), the last and greatest of the pre-Listerian surgeons (<b>Fig. 1.</b>), was renowned in his day as the most eminent surgeon in the English-speaking world. Well informed and well trained by study and travel, he developed in practice the experience, courage, sagacity, and dexterity that enabled him to obtain improved results in the surgical treatment of disease at a time when anaesthesia and antisepsis were unknown. During his occupancy of the Chair of Clinical Surgery at the University of Edinburgh (1833-1869), he developed and perfected many new surgical procedures. Time has outmoded them all save one-his disarticulation amputation through the ankle joint with preservation of the heel flap to permit weight-bearing on the end of the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. James Syme (1799-1870), Professor of Clinical Surgery, University of Edinburgh, 1833-1869. Holl's engraving from George Richmond's drawing of him "in the prime of life." Probably this was Syme's likeness at age 43 when he performed his first amputation at the ankle. From Paterson. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the days before antisepsis, the surgeon's efforts to cure his patients frequently ended in disaster. Compound fractures and operation wounds were almost invariably complicated by one or other of the "hospital diseases"<a></a>: erysipelas, septicaemia, pyaemia, hospital gangrene. The patient was fortunate if he escaped death. On rare occasions his wound might heal by "first intention" or "under a scab." Otherwise the wound became "inflamed." If it discharged "laudable pus," it might heal by "second intention," and if so the outlook was reasonably good. But if the discharge was "thin, watery, sanious, acrid," the future for the patient was ominous. Death too frequently supervened. We know now that these complications were the manifestation of virulent infections. But in 1843, when Syme wrote his first paper <i>On Amputation at the Ankle Joint<a></a>, </i>Pasteur's work on fermentation<a></a> which first revealed to us the world of microorganisms, was still more than a decade in the future (1856), and Lister, the founder of antiseptic surgery, was at age 16 finishing his preliminary education with a view toward entering University College, London. Twenty-four years were to elapse before Lister first wrote on his success in treating compound fractures with carbolic acid (1867). Till then the surgeon resigned himself, as had his predecessors from the dawn of history, to the possibility that his most skillful efforts and even the most simple of his operations would be followed too often by dangerous or even fatal reactions. Writing of this period, Volkmann<a></a> said in flowery simile:</p> <blockquote><p>The surgeon is like the husbandman, who having sown his field, waits with resignation for what the harvest may bring, and reaps it, fully conscious of his own impotence against the elemental powers, which may pour down on him rain, hurricane and hail storm.</p> </blockquote> <p>There is a vivid and moving picture of the surgery of the preanaesthetic and preanti-septic era in the story <i>Rab and His Friends.</i><a></a> The author, John Brown, was Syme's pupil and later his colleague and friend, and he admired him profoundly. In the memorial he wrote after Syme's death, he stated<a></a>:</p> <blockquote><p>He was my master-my apprentice fee bought him his first carriage; a gig, and I got the first ride in it, and he was my friend. He was I believe the greatest surgeon Scotland ever produced; and I cannot conceive of a greater clinical teacher.</p> </blockquote> <p>In the account of Ailie's operation, in <i>Rab and His Friends, </i>Syme is the surgeon, and John Brown is the house surgeon who tells the story. In spite of Syme's skill in removing Ailie's breast for cancer, she develops septicaemia and dies. The agony of her death from this frequent complication of the surgery of those days is so graphically depicted that it brings home to us with dramatic force the immense risks which beset the individual who sustained a compound fracture or was compelled to submit to surgical treatment-all the more impressive because it is told to us by a participant in the tragedy.</p> <p>In the case of open fractures, the complications were so likely to be fatal that the most radical measures were deemed necessary to forestall the spread of "putrefaction." Immediate amputation through the thigh was the standard procedure for compound fractures of the tibia and fibula, amputation at the site of election (a hand's breadth below the tibial tubercle) for caries and compound injuries of the foot <a></a>. Though the mortality from these amputations was 25 percent in the hands of the best surgeons and 50 percent in hospitals less carefully managed<a></a>, the results were better than those to be had from any other form of treatment. The result of conservative treatment was much worse. Mortality from compound fractures of the femur so treated was 80 percent<a></a>, from compound fractures of the tibia 50 percent<a></a>, and from compound dislocation of the astragalus 87 percent<a></a>. Whether patients were treated conservatively or by amputation, the mortality from compound injuries of the foot was shockingly great. Of those who survived compound dislocation of the astragalus without amputation, Syme said<a></a>:</p> <blockquote><p>. . . the foot generally remains in such a state of stiffness, weakness and sensibility to external impressions as to be rather an encumbrance than a support to the patient.</p> </blockquote> <p>For those who survived after amputation of the leg, the disability from loss of the limb also was great. In the words of Syme <a></a>:</p> <blockquote><p>So long as the only alternatives were an attempt to preserve the limb and amputation of the leg, there was a strong inducement to abstain from operating. But if the patient's safety and speedy recovery may be ensured by taking away merely that part of the limb, which in the circumstances can be of little value either to use or ornament, while at the same time a stump is produced in all respects preferable to a shattered, stiff, irritable foot, I think there should be little hesitation in resorting to amputation at the ankle joint under the circumstances in question.</p> </blockquote> <p>During a period of study in Europe (probably in 1822 in Paris, where he attended Lisfranc's course of surgical operations on human cadavers and Dupuytren's lectures and clinical demonstrations), Syme learned the technique of Chopart's amputation for removal of part of a foot damaged or diseased. He introduced the procedure in Edinburgh in 1829, and the results he obtained convinced him of its merit.</p> <p>Chopart's amputation (disarticulation at the mid-tarsal joint, long plantar flap) was seldom complicated by the hospital diseases that made amputations through the leg so dangerous, and it left the patient with a partial foot capable of weight-bearing and with a movable ankle joint above it. We now know that the success of Chopart's amputation was a demonstration of the principle that, in the presence of sepsis, disarticulation is a much safer procedure than is amputation through muscle masses and the open medullary cavities of long bones. Articular cartilage left on the end of a bone, or the subarticular cortical plate and the network of cancellous bone deep to it, serve as barriers to the spread of infection, whereas the intermuscular and interfascial planes of an amputation stump provide easy pathways for invasion by microorganisms. Syme could not know the true reason for the life-saving merit of Chopart's amputation because knowledge of bacteria and of wound infections was still in the future. His conviction of its value was founded on empirical experience.</p> <p>Syme commented upon the merits of Chopart's amputation as follows:</p> <blockquote><p>The operation of Chopart, which leaves only the astragalus and os calcis, is the most valuable of all partial amputations as it commands the largest portion of the foot requiring removal for disease or injury, and at the same time preserves a support for the patient not less useful than that which is afforded by the whole of the tarsus. Its introduction was long opposed on the ground that the extensor muscles of the ankle, acting through the tendo achillis, when no longer antagonized, would draw up the heel and point the cicatrix to the ground. I performed this operation in 1829, so far as I know for the first time in Edinburgh (Great Britain?) and have frequently done so since with the most satisfactory result, no inconvenience having been experienced from the source just mentioned, as the cut ends of the tendons on the forepart of the joint speedily acquired new attachments enabling them to counteract the extensive power.</p> </blockquote> <p>Syme's favourable impression of the merit of Chopart's disarticulation at the mid-tarsal joint led him to apply the same principle to the ankle joint when caries or compound injury involved the astragalus or calcaneus, problems for which Chopart's amputation was inadequate. He performed his first disarticulation at the ankle joint in 1842, thirteen years after his first Chopart amputation. The long delay in applying to the ankle joint the principle which was so successful at the mid-tarsal joint arose from the problem of how to make the long stump bear weight satisfactorily. Disarticulation at the ankle joint might prove as effective as Chopart's amputation in saving the patient's life, but the long stump would prove an intolerable nuisance unless the patient could walk upon it. In Chopart's amputation, walking upon the stump presented no problem since the whole of the posterior half of the sole of the foot remained intact, and upon this the patient walked almost as easily as upon a normal foot. Amputation at a higher level (a hand's breadth below the tibial tubercle) permitted weight-bearing by applying the flexed knee to the padded cleft in the upper end of a crude prosthesis. This was "amputation at the site of election," a useful operation if the patient survived, but the mortality rate was 50 percent.</p> <p>To make disarticulation at the ankle joint a functional success, some procedure was needed which would permit all the body weight to be borne upon the end of the stump in a manner similar to Chopart's stump. Other surgeons had attempted to solve this problem without success. Syme's solution was to detach from the underlying tarsal bones the whole thickness of the posterior half of the sole of the foot, disarticulate the astragalus from the mortise of the ankle joint, remove the malleoli, and then reapply the heel flap to the lower ends of the tibia and fibula. This proved to be the technique necessary for a satisfactory end-bearing stump at the level of the ankle joint for it provided a thick and bulky covering for the end of the stump composed of tissue adapted to weight-bearing.</p> <p>Syme's account of the development of his new operation is interesting<a></a>:</p> <blockquote><p>The idea of amputating at the ankle joint is not new, the operation having been performed on the Continent by different surgeons before I thought of it; and it would probably ere now have become generally adopted but for the doubt that was entertained as to the ends of the bones being sufficiently covered to afford the patient a comfortable and useful support for the limb. For my own part when I read of dissecting flaps of skin from the instep, or sides of the foot, I felt so much distrust in the protection that could thus be effected against the injurious effects of pressure on a part so exposed to it, that I had no desire to try the experiment. But it occurred to me, that by performing the operation in a different way all such objections might be obviated. This was to save a flap from the sole of the foot and the thick integuments of the heel, by making a transverse incision, and dissecting these parts from the os calcis, so that the dense structures provided by nature for supporting the weight of the body, might still be employed for the same purpose. Two trials of this operation having proved satisfactory, I communicated them to the profession, and am glad to find that not only my colleagues in the hospital here, but also practitioners in other planes have already acted upon this recommendation. The additional experience of my own practice now enables me to suggest some improvements in the mode of procedure-point out an error to be avoided [this was cutting the posterior tibial artery before division into the median and lateral plantar branches]-and verify the expectation formerly expressed as to amputation of the leg being hardly ever required.</p> </blockquote> <p>Since Syme does not say why it took him so long to evolve this successful technique, we can only speculate upon the reasons. It may be that the principle of raising a skin flap and then replacing it in a new position was sufficiently radical to make him hesitate. This is a possibility for it was known that amputations with flaps were more prone to postoperative troubles than circular amputations. Or it may be that he was so immersed in the many other new surgical procedures he introduced that time elapsed before he gave thought to disarticulation at the ankle joint. Or it may be that it required thirteen years of experience with Chopart's amputation to convince him that disarticulation was so much more safe than amputation that he would be justified in applying the principle to the ankle joint. Probably this last supposition is important. In the era of "hospital diseases" it was of immense value to know that disarticulations could with certainty be relied upon to heal without the complications which after amputations endangered life and marred the healing of the stump.</p> <p>Syme's first patient <a></a>was a 16-year-old boy who suffered from caries of the tarsal bones, almost certainly tuberculosis. Syme described the problem, the operation, and the result in his first published paper on the subject:<a></a></p> <blockquote><p>John Wood, aged 16, was admitted to the Royal Infirmary on the 8th of September, 1842, suffering from disease of the foot which had suppurated and ulcerated in consequence of a twist he had given to it in walking about twelve months before. The instep was swollen and there were two openings discharging pus. A probe entered the sinuses freely into the substance of the tarsal bones, more particularly the astragalus and os calcis.... As the disease had extended beyond the limits of Chopart's amputation it would have been necessary in accordance with ordinary practice to remove the leg below the knee, but as the ankle joint seemed sound I resolved to perform a disarticulation there. With this in view, I cut across the instep in a curved direction with the convexity towards the toes, and then across the sole of the foot so that the incisions were nearly opposite one another. The flaps thus formed were next separated from their subjacent connexions which was easily effected except at the heel where the firmness of texture caused a little difficulty. The disarticulation being readily completed, the malleolar projections were removed by means of cutting pliers.</p> </blockquote> <p>Although a small slough separated from the edge of the lower flap, in which a counter-opening had to be made for the drainage of matter, the patient recovered with little reaction and left the hospital in three months. Five months after the operation:</p> <blockquote><p>. . . the wounds were soundly healed, and any degree of pressure can be born by the stump which has a round form, well suited for the adaptation of a boot or artificial foot, and is strongly protected from external injury by its thick integument.</p> </blockquote> <p>The success of his first case led Syme to the following conclusion:</p> <blockquote><p>It thus appears that compound dislocation of the astragalus and caries of this bone and the surrounding articular surfaces are the principal cases for amputation of the leg. This amputation can usually be superseded by amputation at the ankle joint. . . . The advantages promised by amputation at the ankle joint instead of operation near the knee are: 1st, That the risk to life will be smaller: 2nd, That a more comfortable stump will be afforded and 3rd, That the limb will be more seemly and useful for progressive motion. ... On these grounds I think amputation at the ankle joint may be advantageously introduced into the practice of surgery. I regret having cut off many limbs that might have been saved by it, and shall be glad if what has been said in its favour encourages others to its performance.</p> </blockquote> <p>Between 1843 and 1846 Syme wrote four more papers on amputation at the ankle joint<a></a>,and he reprinted them with a summary in <i>Contributions to the Pathology and Practice of Surgery.</i><a></a> Therein he states:</p> <blockquote><p>I have operated in more nearly two than one dozen of cases with perfect success.</p> </blockquote> <p>Years later (1857) he wrote again to attest to the satisfactory results obtained by his amputation at the ankle joint.<a></a> He had been aroused by a review in <i>Lancet</i><a></a> of the then new (4th) edition of Fergusson's <i>System of Practical Surgery, </i>in which appeared the following sentence: "Mr. Fergusson states, in relation to removal of the foot at the ankle joint in the manner recommended by Mr. Syme; that he had formed from experience a most unfavourable impression against it." Syme wrote to the editor of <i>Lancet </i>to refute Fergusson's statement. He said:</p> <blockquote><p>Sir,</p> <p>Fifteen years ago I proposed a mode of affording relief from diseases that had been held to require amputation of the leg, by removal of the foot at the ankle-joint. This proposal was favourably received, and has long since been adopted by intelligent surgeons at home and abroad as the established procedure in cases proper for its performance. It is easily executed, and proves in the highest degree satisfactory, if done in accordance with certain principles which have been carefully explained, but is difficult and disastrous if performed incorrectly.</p> </blockquote> <p>He then included letters from three patients upon whom he had performed his amputation at the ankle joint, respectively 10, 14, and 15 years earlier. One of them was his first case. All were well-with useful, painless stumps on which they could walk without difficulty and without a prosthesis if necessary.</p> <p>Before Syme died in 1870, the problem of hospital diseases was in the process of solution as the result of the clinical studies of his son-in-law, Joseph Lister. Today, more than a century since Syme first wrote on amputation at the ankle joint, we have accumulated an immense fund of knowledge on the problem of infection in surgery, and we have at our command effective measures for its control. The technique of aseptic surgery and the rigid standards of cleanliness and hygiene in operating rooms and hospitals have to a large degree enabled us to eliminate infection from our surgical procedures. When infection does occur, we can now do more to control it with antiseptic and bacteriostatic and antibiotic agents than has ever before been possible. Today, therefore, the merit of Syme's amputation lies not chiefly in the circumstance that "the risk to life will be smaller." On the other hand, it still remains the most useful of all amputations of the lower extremity "because a more comfortable stump is provided, and the limb is more seemly and useful for support and progressive motion."</p> <p>Of historical interest in demonstrating Syme's conviction of the merit of end-bearing stumps in the lower extremity is the record of his attempt to devise, at the level of the knee, an end-bearing stump embodying the principles which had proved so successful at the ankle. Two years after his first account on amputation at the ankle joint he reported the results of his attempt on two patients to remove the lower extremity at the knee and to close the wound with a skin flap so that weight could be borne on the end of the stump.<a></a>Both patients seem to have been suffering from tuberculosis of the knee joint. In both, the femur was transected through the condyles just above the carious articular surface, and the end of the stump was covered with a long posterior flap of skin derived from the calf. Both wounds healed without complication, though they took a long time to do so.</p> <p>It seems evident from Syme's presentation of these two cases that he was concerned chiefly with devising an operation safer than amputation through the shaft of the femur and that he believed that transection through cancellous bone just above the articular surface would involve less risk from hospital diseases than would amputation at a higher level. Since he did not cover the end of the stump with skin accustomed to weight-bearing, he evidently believed that the achievement of a healed stump without sepsis and without serious risk to the life of the patient was the prime objective and that good function and even end-bearing would follow good healing.</p> <p>Twenty-one years later<a></a> he wrote again about transcondylar amputation of the femur. His interest had been renewed by Carden's report<a></a> of a method of amputating through the knee or through any part of the lower end of the femur using to cover the end of the bone a single, long, anterior flap composed of skin and subcutaneous tissue only. The muscles were divided at the level of transection of the bone and thus were excluded from the flap as was also the patella. Carden's purpose was to avoid the thin, sensitive, adherent cicatrix ("retreating muscles and obtrusive bone"), which so frequently resulted when equal flaps were used, and to cover the end of the femur with a broad cap of skin and subcutaneous tissue accustomed to bearing the weight of the body in kneeling (<b>Fig. 2.</b>). Syme warmly commended Carden's amputation, which he said could be performed with little risk to the patient and had the additional advantage<a></a> that:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Carden's operation by single flap, <i>a, </i>The line of the skin incision; <i>b, </i>closure of the wound; <i>c, </i>ankylosis of the knee in extreme flexion deformity following fractured patella; <i>d, </i>the end-bearing stump obtained by Carden's operation on the limb illustrated in <i>c. </i>From Carden.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p>. . . the stump proved eminently serviceable since the skin over the bone, instead of becoming thinner, acquired additional thickness so that patients could rest upon it just as they do after amputation at the ankle.</p> </blockquote> <p>In the same publication, Syme acknowledged that his earlier attempt to perfect the technique of transcondylar amputation had failed and that the method had fallen into disuse because the skin flap derived from the calf of the leg "proved very inconvenient." Syme, therefore, nearly achieved success in devising an end-bearing stump at the transcondylar level. He failed because his attention was focused upon the avoidance of sepsis and because he did not appreciate the importance of covering the end of the stump with skin naturally adapted to weight-bearing-a strange circumstance since he seems to have been well aware of the value of "the thick integuments of the heel" in the ankle-joint cases.</p> <h4>DEVELOPMENT OF SYME'S AMPUTATION</h4> <p>Shortly after Syme's first publication on amputation at the ankle joint,<a></a> the operation began to be adopted in England and Scotland, generally with satisfactory results. In subsequent publications Syme stressed details of technique he had found essential for success (i.e., avoidance of damage to the posterior tibial artery, separation of the heel flap by dissection close to the calcaneus, drainage of the dead space, etc.). By 1846 he had perfected the technique of the operation, and from then on he accumulated experience in the application of the procedure to various problems. But he wrote nothing more on the operation except the letter to the editor of <i>Lancet </i>in 1857.<a></a></p> <h4>BAUDENS' TIBIOTARSAL AMPUTATION</h4> <p>On the Continent, and especially in France, there was less ready acceptance of Syme's amputation, partly because a somewhat similar amputation<a></a> had been reported by Baudens (<b>Fig. 3.</b>) in 1842, a year before Syme's first publication. Described as a "tibiotarsal amputation," it involved a procedure in which the foot was removed by disarticulation at the ankle joint accompanied by removal of the malleoli and the posterior half of the inferior articular surface of the tibia by a single saw cut. The end of the stump was covered with a flap from the dorsum of the foot which included in its thickness all the structures from the skin to the tarsal bones and intertarsal ligaments (skin, subcutaneous tissue, tendons, nerves, and blood vessels). Baudens' concern was to secure good healing by a flap which would drape itself over the end of the stump as the patient lay supine in bed and when healed would provide a long stump on the end of which the patient could walk (<b>Fig. 4.</b>, <b>Fig. 5.</b>, and <b>Fig. 6.</b>). When reports of Syme's operation reached France, there was renewed appraisal of Baudens' cases, and the columns of <i>Les Annates de Therapeutique </i>for 1845-1847 contain several references to the problem. The following editorial comment<a></a> is typical:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. J. B. L. Baudens, the French military surgeon who published in 1842 the account of his tibiotarsal disarticulation. <i>Courtesy National Library of Medicine, Washington, D. C.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Baudens' tibiotarsal amputation. Appearance of the stump after removal of the foot. The malleoli have been removed with the posterior margin of the articular surface of the tibia. The long dorsal flap is held up. Left to itself, it fell naturally over the cut ends of the bones and required the minimum amount of fixation. From Baudens.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Baudens' tibiotarsal amputation. Appearance of the foot after its amputation. The denuded area on the dorsum of the foot indicates the extent of the flap and shows that it included in its thickness all the tissues from the skin to the tarsal bones and inter-tarsal ligaments. From Baudens.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Baudens' tibiotarsal amputation, <i>a, </i>End of the stump when completely healed; <i>b, </i>appearance of the stump when bearing weight; <i>c, </i>simple prosthesis fitted into a boot with a high, laced top. From Baudens.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p>Our readers already know the tibiotarsal amputation of the foot which Doctor Baudens performed several years ago on a young soldier at the Gros-Caillou Hospital. We followed the patient in this hospital and then at the Val-de-Grace to which he had been transferred and we were happy one year later to see him walk well with the aid of an ordinary dancing shoe supported by two small metallic splints. This soldier took long walks without fatigue, went upstairs and went down slowly, danced and jumped with agility. His peg leg made him an excellent support and all without even a limp. We were extremely satisfied with this result in spite of the fact that one or two other patients who had had this operation performed upon them by Doctor Baudens had succumbed from gangrene of the flaps. Doctor Baudens' patient was admitted subsequently to l'Hotel des Invalides. Soon we found him again admitted to the Infirmary of the Hotel and for several months he has continued there. His stump has become excessively painful. The cicatrix has re-opened and has ulcerated at several points. Doctor Hutin, the surgeon-in-chief, has been obliged to open two small new abscesses which had formed in the tissue of the scar and it is probable that the underlying bones are affected. The patient complains of acute suffering and he demands with earnest insistence an amputation near the knee. M. Hutin will probably be obliged to come to that. This fact raises questions which demand an explanation. Let us first remark that the indifference with which our surgeons, civil and military, have received the remarkable memoir of M. Baudens is not a proof that the operation is without value for it has been practised in Edinburgh by M. Syme half a score of times with complete success. (We say indifference for the reason that no French surgeon to this day has himself performed or even recommended M. Baudens' valuable operation.) It is true, however, that M. Syme had generally operated only upon children and that he had published only the immediate results of the operation. Now the question is what are the remote effects (of the operation) since the scar in M. Baudens' patient was not inflamed or ulcerated and did not re-open for more than a year after the operation. It is all the more important, therefore, to know the actual state of M. Syme's patients for this knowledge could decide whether in the patient at Les Invalides, the evil in the scar derives from morbid constitutional conditions as we have presumed or to inherent conditions in the form of the flaps or in the stump. We should recall that in M. Baudens' operation the top of the ankle is sawed off after the disarticulation, while M. Syme <i>preserved the ankle intact. </i>Let us say finally that until new facts come to enlighten the above questions and in spite of the very great aversion the civil and military surgeons show to adopting the tibiotarsal amputation, we persist in believing it beneficial in most cases which we have from time to time indicated. Amputation at the wrist is satisfactory; why then hesitate to operate at the same level in the inferior member? We know the reasons of those who oppose. Time and new facts will be the best judges.</p> <p>We should not terminate this article without stating that there prevails in military practice a sort of aversion for all those operations which one could perhaps call <i>de luxe </i>such as partial amputation of the foot, supramalleolar amputation, etc. For several reasons orders have been to adopt the same treatment for all cases. It is otherwise in civil hospitals. We have already discussed the diverse questions connected with these declarations.</p> </blockquote> <p>This editorial was reproduced in the Monthly Journal of Medical Science, where it came to Syme's attention.<a></a> Certain inaccuracies demanded correction, and there was the implication that perhaps Syme's results were not as good as they were said to be or that, if they were, the reason should be found so that Baudens' operation could be modified and made acceptable on its merits.</p> <p>Syme therefore wrote to the editor of the <i>Monthly Journal of Medical Science</i><a></a> to clarify the points in confusion. The gist of his reply was as follows:</p> <ol> <li>He had operated upon a considerable number of patients (more nearly two than one dozen of cases) with complete success.</li><li>Most of his patients were adults (not children as stated by the editor of <i>Les Annates de Therapeutique</i>).</li><li>In one case only did he leave the malleoli intact and that was the case of an infant five months of age with an erectile tumour of the foot.</li><li>His results were satisfactory, in evidence of which he quoted from letters received from his first three patients, each of whom stated that the stump was satisfactory and was scarcely any handicap.</li><li>His mode of performing the operation was to obtain a heel flap of sufficient length by cutting from the tip of one malleolus to the tip of the other. By this the risk of sloughing was lessened if not entirely prevented.</li></ol> <p>The fact is that there was an essential difference between Baudens' tibiotarsal amputation and Syme's amputation at the ankle joint. Both surgeons were striving to devise, for treatment of disease of the foot beyond the scope of Chopart's amputation, an operation which would replace amputation below the knee. They desired to diminish the risks to the patient's life and to leave him with a long, well-covered, unscarred stump capable of total end-bearing. Both surgeons disarticulated the foot at the ankle and removed the malleoli, with or without a thin flake from the lower end of the tibia. The essential difference lay in the nature of the flap used to cover the end of the stump. Baudens used a long flap from the dorsum of the foot because it would drape itself naturally over the end of the stump while the patient lay supine in bed. It required the minimum of fixation and permitted free drainage in the immediate postoperative period. Syme used a plantar flap in order that he might cover the end of the stump with the thick integument of the heel.</p> <p>Syme's amputation at the ankle joint proved superior to Baudens' tibiotarsal amputation even in the days before antisepsis. Today, with infection eliminated as an operative risk, Syme's operation has even more to recommend it as the best operation of the lower extremity.</p> <p>In addition to Baudens' tibiotarsal amputation and Syme's amputation at the ankle joint, several other amputations of the foot in the region of the ankle were devised in the latter half of the nineteenth century with the purpose of avoiding the grave complications of amputation through the leg and to provide an end-bearing stump. Though none of these proved to have the value of Syme's amputation, they are of historic interest.</p> <h4>ROUX'S AMPUTATION</h4> <p>Roux's amputation (1845) was a supramalleolar amputation<a></a> with a medial flap to cover the ends of the tibia and fibula (<b>Fig. 7.</b>). The tibia and fibula were divided transversely above the articular cartilage, and the medial flap included all the skin on the medial side of the foot as far forward as the talonavicular joint and as far inferior as the inner margin of the sole of the foot. The advantages claimed were that the flap had an assured blood supply from the posterior tibial artery and that a weight-bearing stump could be salvaged from a foot with a heel flap damaged too extensively to permit a formal Syme's amputation. The disadvantage proved to be the inadequacy of the flap, which was too thin to withstand the stresses of weight-bearing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Roux's supramalleolar amputation with medial flap, <i>a, </i>Medial view; <i>b, </i>lateral view. Redrawn from Jacobson.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is interesting to record that Roux came to recognize the superiority of Syme's amputation. In 1846, after performing his first disarticulation of the ankle joint by Syme's method, he said:<a></a></p> <blockquote><p>It appears to me that by this operation art modifies without changing the language of nature; in fact, the malleoli being removed, the lower extremity of the leg affords a base of support which transversely exceeds that of the os calcis.</p> </blockquote> <h4>GUYON'S AMPUTATION</h4> <p>Guyon's elliptical supramalleolar amputation with posterior flap (1868) was performed<a></a> by a single elliptical incision which encircled the heel and the front of the ankle joint (<b>Fig. 8.</b>). Only a finger's breadth of skin from the plantar surface of the foot in front of the heel was retained. A flake of the os calcis was removed at the insertion of the tendo achillis and retained with the heel flap, and the tibia and fibula were transected above the articular surface of the tibia. The heel flap, with its flake from the posterior end of the os calcis, was applied to the cut surfaces of the tibia and fibula, and the skin margins were sutured. The weakness of Guyon's amputation lay in the inadequate heel flap, which did not stand up under the stress of weight-bearing, and the small tapered end of the stump, which provided too small an area of support.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Guyon's elliptical supramalleolar amputation with posterior flap. Redrawn from Farabeuf.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>pirogoff's amputation</h4> <p>In 1854, Pirogoff (<b>Fig. 9.</b>), the greatest Russian surgeon of his day, published the account of his new operation at the ankle joint,<a></a> which he intended as an improvement upon Syme's amputation. In 1847, at the Clinic of Professor Chelius at Heidelberg, Pirogoff had seen two patients upon whom Syme's amputation had been performed, and he was impressed with the results. In 1848 and 1849 he performed Syme's amputation on four patients, all of whom died (one of pulmonary tuberculosis, one of scurvy, and two of sepsis, one of whom had gangrene of the heel flap). In a fifth case, an attempt to perform Syme's amputation failed because of gross damage to the heel flap incurred in separating it from the calcaneus. Nevertheless, Pirogoff, in his attempt to deal with compound injuries and caries of the astragalus and calcaneus by some method better than amputation below the knee, continued to use Syme's amputation at the ankle joint as well as Baudens' tibiotarsal amputation and Roux's supramalleolar amputation with a medial flap. From his experience he came to the following conclusions:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Nicolai Ivanovitch Pirogoff (1810-1881), who devised his amputation at the ankle to overcome certain features of Syme's amputation that he regarded as detrimental. From <i>Pirogoff: Collected Works, </i>Vol. 1, State Publications Medical Literature, Moscow-Leningrad, U.S.S.R., 1959. Print obtained through the courtesy of Dr. W. G. Bigelow and the Russian Ambassador to Canada, His Excellency A. A. Aroutunian. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The most difficult part of Syme's amputation is the separation of the heel bone from the skin. Only with great care can the tightly adherent skin be separated without injuring the flap or making it too thin.</li><li>In Syme's operation, the skin over the tendo achillis forms the base of the flap and is much thinner than the apex of the flap. If care is not taken, it may be cut too thin and the flap may become gangrenous.</li><li>A considerable depression remains in the heel flap of Syme's amputation after the os calcis is shelled out. It may form a pocket for the collection of pus.</li><li>In the method of Baudens, the skin over the lower surface of the os calcis is removed. In this operation the creation of a foundation for the stump is not accomplished as it is in Syme's method, where the thick skin of the sole of the heel forms a sturdy covering.</li><li>In Roux's method, the formation of the posteromedial flap is certainly easier than in Syme's method. The base is wider, and necrosis occurs less often because the posterior tibial artery is cut below its division. However, the base of the flap is thinner than the summit. The depression in the flap is just as deep as in Syme's method, and, finally, the Achilles tendon is completely cut at its attachment to the os calcis as in the two previous cases.</li></ol> <p>In order to avoid these inconveniences, Pirogoff devised a new procedure (<b>Fig. 10.</b>, <b>Fig. 11.</b>, <b>Fig. 12.</b>, and <b>Fig. 13.</b>). The skin incisions resembled those of Syme. The skin, soft tissues, and tendons were divided down to the bone, and the ankle joint was entered from in front by dividing the capsule anteriorly. The lateral ligaments were detached from the malleoli and the astragalus displaced downwards. The capsule was then opened posteriorly and the superior surface of the calcaneus exposed. A saw placed through the two vertical limbs of the plantar incision and across the superior surface of the calcaneus behind the body of the astragalus and in front of the tendo achillis divided the calcaneus obliquely from above downwards at the junction of the middle with the posterior third of that bone. The posterior third of the calcaneus and the tendo achillis retained their normal attachments and formed an integral part of the heel flap. The malleoli were divided at their base and removed level with the articular surface of the lower end of the tibia. The inferior articular surface of the tibia was not removed unless it was diseased. When the vessels had been ligated, the heel flap was turned up and secured to the margin of the anterior flap by two or three sutures.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Pirogoffs amputation. Redrawn from Pirogoff<a></a> and Elmslie.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Pirogoff's amputation. Dividing the calcaneus. From Farabeuf.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Pirogoffs amputation. Appearance of the stump after removal of the foot by disarticulation at the ankle. <i>A, </i>Tibia; B, fibula, <i>C, </i>os calcis "sawn behind <i>lig. sustentacula e" </i>Redrawn from Pirogoff.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. PirogofFs amputation. Appearance of the healed stump. Redrawn from Pirogoff.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The operation was ingenious and had certain merits. If the wound healed satisfactorily and the calcaneal fragment fused to the tibia, an end-bearing stump resulted, longer than a Syme's stump, so that no prosthesis was necessary to compensate for the shortening. The patient walked without much "dipping" (limp). Also the heel flap was firmly fixed in place by fusion of the calcaneal fragment to the tibia. But there were risks which could mar the success of the operation. If the calcaneal fragment failed to unite to the tibia, an unstable and painful stump end resulted. If the wound became infected, chronic osteomyelitis with persistently discharging sinuses was prone to establish itself in the calcaneal fragment or in the lower end of the tibia. Weight was borne ultimately upon the skin over the back of the heel, an area not as well suited to weight-bearing as is the plantar surface of the foot. For success, the calcaneus had to be free of disease and the heel flap not seriously damaged by trauma. In an age when the nature and management of infection was unknown, it was an operation technically difficult and uncertain in its results. Pirogoff's first three cases were all complicated by serious sepsis, and many months elapsed before they could walk on their stumps. Even then they still had discharging sinuses. Syme's operation was easier to perform and more certain of a good result, and these advantages still prevail.</p> <h4>SUBASTRAGALAR AMPUTATION</h4> <p>Subastragalar disarticulation was first mentioned by Velpeau in a single small paragraph in his <i>New Elements of Operative Surgery.</i><a></a> He stated that it had been proposed to him by des Lingerolles, who seems not to have been a surgeon. At the time Velpeau had not performed the operation. He merely mentioned it as a promising procedure in selected cases of disease or injury of the foot. Farabeuf<a></a> perfected the operative technique and described it with excellent engravings in his <i>Precis de Manuel Operatoire.</i><a></a> He also discussed its merits and limitations. There is also a paper by Hutchinson,<a></a> which contains a good description of the operation as well as a report upon the end result obtained in six cases. Five of his cases, operated upon by the technique described by Farabeuf, were gratifyingly successful, while the sixth, in which the flap was formed by a technique similar to that of Syme, was imperfect because the heel flap could not cover the head of the astragalus without undue tension.</p> <p>Subastragalar amputation is of value in a limited number of cases, the best technique being that described by Farabeuf.<a></a> A large internal and plantar flap extends to the outer margin of the heel and as far forward as the base of the fifth metatarsal <b>Fig. 14.</b>. The subastragalar and astragaloscaphoid joints are opened from the lateral side, and the heel is inverted until the medial side of the os calcis can be reached. The os calcis is then freed from the heel flap beginning at the medial surface and is removed with the foot. Care must be taken to avoid injury to the posterior tibial artery. The advantages over Syme's amputation, as stated by Hutchinson, are:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Subastragalar amputation of de Lingerolles and Velpeau giving large plantar flap. Redrawn from Farabeuf<a></a> . Dotted line is the plane of subastragalar disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The stump is some 2 in. longer than a Syme's stump.</li><li>It gives a broader base of support.</li><li>The elasticity due to ankle movement is of marked advantage in walking.</li><li>The pad at the end of the stump is much thicker.</li><li>The arterial supply is better and runs less risk during the operation.</li><li>The artificial foot can be better fitted to the stump.</li></ol> <p>Hutchinson states that between 1891 and 1900 Syme's amputation was performed under antiseptic surgery on 27 patients at the London Hospital. The outcome: complete failure, 3 (one died); suppuration and sloughing of flap, 12; good result, 12. Several factors other than imperfection in technique (e.g., difficulty in sterilizing the skin of the heel flap, delay in operating because of patient's "obstinacy," operation in unpromising cases) contributed to the poor results. Even with the advantages of anaesthesia and antisepsis, the results at the London Hospital were inferior to those of Syme. In his meagre accounts of long-term results, Syme makes no mention of a fatality, and the functional results were good. For best results from Syme's amputation, the cases must be selected carefully, and the operation has to be timed wisely and performed skillfully.</p> <p>In Hutchinson's paper also is an informative note, quoted from Clinton Dent,<a></a> on the amputations in the South African War. The following is a summary:</p> <blockquote><p>Syme's amputation was performed in a small number of cases, but the resulting stumps were not entirely satisfactory. Damage of the foot from trauma is perhaps not as good an indication for Syme's amputation as is tuberculosis, because of damage to the skin. Sloughing of the flap sometimes occurred. Syme's amputation depends more than any other upon very careful attention to the details of the technique.... In Syme's amputation it is really impossible to depart from the lines laid down by Syme in the fashioning of the flaps. [It will be remembered that Syme emphasized this in almost the same words in his letter to the editor of <i>Lancet </i><a></a> already quoted.] There may be merit in the subastragalar amputation. English surgeons are too limited in their methods of operating upon the foot and have a good deal to learn from their French colleagues.</p> </blockquote> <p>The variety of ankle amputations introduced in the latter half of the nineteenth century is an indication of a common purpose on the part of the surgeons of that era. They were attempting to replace the dangerous operation through the upper end of the tibia with the safer disarticulation at the ankle and at the same time to provide for the end of the stump a covering which would withstand the period of postoperative sepsis without undue damage and which could ultimately permit weight to be borne upon the end of the stump. When we recall that, in its early years, Syme's amputation was performed without the benefit of anaesthesia, it is not surprising that sometimes it was executed imperfectly. Time has proved that success in Syme's amputation is dependent upon precise adherence to a particular technique. Even in today's era of advanced surgery, it still is necessary, if we are to avoid imperfect results, to use a technique which differs in no essential detail from that used by Syme.</p> <p>In Syme's day, the chief difficulty that hampered the general acceptance of his procedure was the frequent occurrence of necrosis of the heel flap, and we can appreciate from Hutchinson's account that it was still a problem even in 1900 with benefit of antiseptic surgery. According to Dent also,<a></a> necrosis of the heel flap was a complication of Syme's amputation performed on soldiers in the South African War. The chief cause of necrosis of the heel flap was injury to the posterior tibial artery. Syme himself learned, in the hard school of experience, the necessity for preserving this vessel.<a></a> His account is as follows:</p> <blockquote><p>In describing the operation, I have said that care must be taken to avoid cutting the posterior tibial artery before it divides into the plantar branches and I may now explain more particularly the ground on which this advice is founded.</p> <p>Elizabeth Wilson, aged seven, was admitted on the 19th of February on account of disease in her left ankle. . . . The foot was much enlarged, stiff and shapeless; and two sinuses allowed a probe to pass into carious bone.</p> <p>On the 21st I proceeded to amputate at the ankle joint, but finding that anchylosis had taken place between the articular surfaces, I exposed the extremities of the tibia and fibula, and sawed them through without previously removing the foot as usual. In tying the vessels, it appeared that the posterior tibial artery had been divided before its division into the plantar branches, so that one ligature sufficed in place of two.</p> <p>The stump looked remarkably well and the result of the operation was expected to prove very favourable. It was, therefore, with much surprise, and no small disappointment, that in the course of a few days I saw the flap had sloughed through fully half its extent. Recovery was consequently delayed much beyond the ordinary period. . . .</p> <p>I attributed the sloughing in this case to the undue pressure of the bandage; and having occasion soon afterwards to perform the operation on a patient in Minto House, intentionally divided the posterior tibial before its division, in order to obtain the same facility in tying the vessel as on the last occasion. To my surprise and concern, the flap again sloughed to the same extent as in the case just related, and as great attention had been paid to the dressing of the stump, I could not refer this effect to the cause formerly supposed. But as on both occasions the artery had been cut before its division, while in all other cases it had been left entire, and as the flap, being deprived of nourishment from most of its ordinary sources, must be supplied with blood only through the successive anastomoses of small vessels, I concluded that this deviation from usual practice had led to the mischief in question, and I resolved to avoid it for the future.</p> </blockquote> <p>A further cause of poor result from Syme's amputation was damage inflicted on the skin over the heel while the flap was being separated from the calcaneus or while the tendo achillis was being detached from its insertion. Unless the plane of dissection hugged the calcaneus, and unless the dissection was performed with precision and delicacy, the skin was apt to be buttonholed. It was this problem especially that led Pirogoff to introduce his operation and Guyon to devise his elliptical supramalleolar amputation at the ankle joint. Syme's amputation, then and now, is an operation which must conform rigidly to an exact technique. If it is not performed properly when first attempted, many of its advantages will be lost irretrievably. It is interesting that the technique necessary for success is almost exactly that which Syme himself ultimately evolved. As we shall see later in the section on technique, the only addition of proven value is subperiosteal separation of the calcaneus from the heel flap. All other attempts at improvement have failed to achieve the success which follows the use of Syme's original technique.</p> <p>The 1914-1918 war, with its innumerable casualties, renewed interest in amputations. One outcome was the publication of an English translation of the small volume, <i>Artificial Limbs</i><a></a>, written by the French surgeons Broca and Ducroquet. In discussing end-bearing stumps, this monograph makes no mention of Syme's amputation. It lists only supramalleolar amputation, disarticulation at the ankle joint, subastragaloid amputation, and osteoplastic amputation through the ankle joint. An editor's footnote with respect to supramalleolar amputation states, "In England, of course, this is always called a Syme's amputation." This statement is not strictly accurate since an important detail of Syme's amputation contributory to its success is the large area of support provided for the heel pad when the lower end of the tibia is left intact or virtually so. Syme's operation is not a supramalleolar amputation; it is a slightly modified disarticulation. French surgeons, particularly Farabeuf,<a></a> were meticulous in distinguishing between disarticulations (in which group Syme's amputation was included) and amputations (e.g.,the supramalleolar operations of Roux and Guyon). It is true that Syme himself always referred to his operation as "amputation at the ankle joint," but in doing so he evidently used the term "amputation" in a general sense and not in the exact sense of Farabeuf. It is certain from Syme's description of his operations, and from the derivation of his operation from the disarticulation of Chopart, that Syme's operation was in fact disarticulation of the foot at the ankle joint with removal of the malleoli. Had Syme emphasized this as precisely as did Farabeuf, he might have prevented the innumerable supramalleolar Syme amputations which have been performed because of imperfect knowledge of Syme's technique or in the hope of obtaining an improved stump. These are the cases which have cast doubt on the value of Syme's operation, for the resulting stumps are functionally imperfect and may be complete failures.</p> <p>E. C. Elmslie, who translated and edited the English edition of Broca and Ducroquet,<a></a> formed a high opinion of Syme's amputation. In a footnote to the paragraph on low leg amputations allowing walking with end-bearing only, he says, after brief discussion of Pirogoff's amputation, subastragaloid amputation, and disarticulation at the ankle joint: "In fact, in this region there is Syme's amputation and a number of other far inferior amputations which should never be considered when a Syme amputation is possible." In 1924, in the section on amputations which he contributed to Carson's <i>Modern Operative Surgery</i><a></a> Elmslie states with reference to Syme's amputation:</p> <p>When successful it yields an excellent stump which is capable of complete end bearing. It can be fitted with a simple and cheap stump boot known as an elephant boot. Upon such a boot a patient with a Syme's amputation can often walk ten or twelve miles. In fact, Syme's amputation is so satisfactory that it may be said that all other amputations of the foot at a lower level are obsolete except amputation of the toes or parts of the toes.</p> <p>Despite the high regard in which he held Syme's amputation, Elmslie does not appear to have understood how essential for success is exact adherence to the precise details of Syme's technique. For reasons which probably were related to limbfitting problems, Elmslie felt it necessary to secure an improved Syme stump, and for that purpose he devised a modified Syme amputation which is described in his chapter on amputations in Carson's <i>Modern Operative Surgery.</i><a></a> It is the only procedure for Syme's amputation that is described and illustrated there. Syme's original technique is not mentioned. Elmslie does not state clearly why he felt it necessary to revise Syme's technique. However, he does state that the Syme stump was too long and the end too bulky. Almost certainly these represent criticisms by the limbfitters of Elmslie's day, who certainly had difficulties in designing, manufacturing, and fitting a satisfactory prosthesis for a Syme stump.</p> <h4>ELMSLIE'S MODIFIED SYME'S AMPUTATION</h4> <p>Elmslie's modified Syme's amputation<a></a> differed from the classical Syme's amputation in three essential particulars:</p> <ol> <li>The heel flap was smaller.</li><li>The dissection was carried out from the dorsal to the plantar surface.</li><li>The tibia and fibula were transected at a level well above the ankle joint.</li></ol> <p>Apparently the purpose of these changes was twofold: to provide a small, neat, tapered end to the stump and thus avoid the bulge in the prosthesis necessary to accommodate a bulbous-ended stump; and to accommodate more easily the ankle-joint mechanism by high transection of the tibia and fibula.</p> <p>Elmslie was not the first person to advocate high transection of the tibia and fibula to facilitate the introduction of an ankle joint mechanism in the artificial limb for a Syme amputation in the space between the end of the stump and the level of the ground. Henry Thompson,<a></a> at a meeting of the Pathological Society of London on April 21, 1863, shared in the presentation of seven patients with Syme's amputation and two patients with Pirogoff's amputation. As reported in <i>Lancet, </i>Thompson's remarks were as follows:</p> <blockquote><p>He [Thompson] would not enter upon the various points of comparison between Syme's amputation and that modification of it in which a portion of the os calcis is left in the flap, but would only refer to the different results which remained after the two operations [i.e., Syme and Pirogoff] as regards the kind of artificial limb which is applicable afterwards. He thought it very important for the surgeon and the mechanician to act in concert in most amputations of the lower extremity and he therefore showed also two artificial limbs to illustrate the advantage in relation to this matter which the proceeding of Syme offered over that of Pirogoff. In the former the patient enjoyed the advantage of complete ankle joint movement of the limb; while in the other, the stump being so close to the ground, there was no room for it and the best substitute that could be applied was by iron hinges outside of the limb. . . . Mr. Thompson wished to point out the necessity of taking off a sufficient slice of bone, including the two malleoli instead of merely removing the lower portion of the latter, so as to avoid extreme width and a bulbous stump which was more difficult to fit with a well made artificial limb than a stump which tapered gradually from the calf downwards. . . . Mr. Thompson said that the objection to the bulbous form of the stump did not materially apply if the common circular shoe which is laced around the lower part of the leg was worn [elephant boot], but it did to the artificial leg.</p> </blockquote> <p>In Elmslie's operation the skin incision was an ellipse (<b>Fig. 15.</b>) which commenced on the plantar surface of the foot 3/4 in. in front of the point of the heel. Therefrom it extended obliquely upward and forward over either malleolus to a point on the anterior surface of the ankle 1 in. above the joint line. The ankle joint was entered, the foot depressed, and the medial and lateral ligaments of the joint divided from within the joint. The astragalus was then dislocated from the mortise of the ankle joint by depressing the foot still farther. Doing so exposed the tendo achillis, which was then divided at its insertion. The calcaneus was then separated from the heel flap by dissection close to the bone from above downward. The tibia and fibula were transected 3/4 in. to 1 in. above the highest level of the ankle joint, and the heel flap was then closed over the ends of the tibia and fibula.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Elmslie's modified Syme's amputation. Redrawn from Elmslie.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Though Elmslie intended his modified Syme's amputation to be an improvement over Syme's original procedure, the result has not lived up to his expectations, and for three reasons: the small heel flap deprived the stump of an adequate covering of skin and subcutaneous tissue adapted to weight-bearing; the high transection of the tibia and fibula diminished the cross-sectional area of their cut surfaces and impaired their support for weight-bearing; the end of the stump was no longer bulbous but was tapered, a feature that permitted the artificial limb to slip up and down during walking. He succeeded in simplifying the limbfitters' problem, and he succeeded in making the stump neat and tidy, but in so doing he sacrificed the qualities of Syme's amputation essential for success- namely, a bulbous stump end to ensure that the grasp of the prosthesis would be secure and a wide area of bony support covered by a large, thick, heel pad adapted to weight-bearing.</p> <p>Elmslie's modified Syme's amputation thus closely resembled Guyon's elliptical supramalleolar operation with posterior flap.<a></a> It seems probable that in modifying Syme's operation Elmslie adopted Guyon's technique, for the only difference between Guyon's elliptical supramalleolar amputation and Elmslie's modified Syme's amputation was that in the former, unlike the latter, a flake from the posterior end of the calcaneus was removed along with the insertion of the tendo achillis and that later the flake was applied to the cut surface of the tibia when the heel flap was sutured into place. Elmslie's modified Syme's amputation was widely used in England (but not in Scotland) during the period following the 1914-1918 war, probably because of the confidence with which he advanced it as an improvement over Syme's technique and probably also because he made no mention of Syme's technique.<a></a> It is likely that this adoption of his modified Syme amputation in England led to the dissatisfaction with Syme's amputation expressed by Langdale-Kelham and Perkins of Queen Mary's Hospital at Roehampton.<a></a> They said ". . . this type of operation does not stand weight bearing on the average longer than eight years. ... It is to be hoped that the modified Syme's amputation will soon be as obsolete as the original Syme's." The handbook of the British Ministry of Pensions, <i>Artificial Limbs and their Relation to Amputations</i><a></a> also speaks with faint praise of Syme's amputation. In Scotland, in contrast to England, a rigid adherence to the precise details of Syme's original technique resulted in satisfactory end-bearing stumps. In Canada, for a similar reason, experience has also been satisfactory. The favorable results with Syme's amputation in Scotland and Canada as contrasted with the dissatisfaction with Syme's amputation in England is evidence that a wide area of bony support covered by a large, thick, heel pad is essential for a satisfactory Syme's stump. Syme's original operation provided these indispensable features, and consequently his stumps bore weight on the end satisfactorily and more or less indefinitely. Attempts to improve upon Syme's amputation (e.g., the modifications of Roux and of Elmslie), chiefly in the matters of making the end of the stump neat and of providing the limbmaker with more space for the ankle joint of the prosthesis, proved unsatisfactory in the long run because the area of support was too small and because the covering over the end of the stump would not stand up under long-continued end-bearing.</p> <p>Syme was blessed by good fortune as well as good sense. His sound judgment brought him to the conclusion that disarticulation at the ankle joint and removal of the malleoli would constitute a safe and effective means for the removal of a damaged or carious foot. The idea of preserving the heel flap to cover the end of the stump and to provide end-bearing could have come only from profound insight. His courage, boldness, and skill enabled him to devise a simple technique by which these things could be accomplished. It was his good fortune that the operation he planned and the technique he devised have both proved to be of continuing value. He knew nothing of the minutiae which concern us today, and he ill understood the grave complications which often discounted the surgeon's efforts. But he was far-sighted enough and bold enough to embark upon a radically new approach to an old problem, to build upon his first successes, and to eliminate such defects as were present in his first efforts (e.g., to preserve the integrity of the posterior tibial artery).</p> <h4>FUNDAMENTAL PRINCIPLES OF END-BEARING AMPUTATIONS OF THE LOWER EXTREMITY</h4> <p>The essential functions of the normal lower extremity are weight-bearing and locomotion, and amputation stumps in the lower extremity must be designed accordingly. The more perfectly they bear the body weight and transmit the forces of locomotion the more efficiently will they utilize prosthetic appliances. For purposes of weight-bearing, nothing is as satisfactory as a stump which can bear weight upon its end. Propulsion is best accomplished by a leg stump of the greatest possible residual length and with as many normally functioning nerves, muscles, and joints as can be preserved. Only two levels in the lower extremity can be adapted to provide end-bearing stumps-the lower end of the femur with a covering of prepatellar skin, and the expanded lower ends of the tibia and fibula covered by the heel pad.</p> <p>To secure an end-bearing stump in lowerextremity amputations, certain requirements must be met:</p> <ol> <li>In order to provide a broad area of support, the bone must be divided where its cross-sectional area is as great as possible.</li><li>The whole of the cut surface of the bone must be capable of bearing weight. This requirement can be achieved by a strong meshwork of cancellous bone across the whole area, or, in the case of the ankle joint, by retention of the subarticular cortical bone at the lower end of the tibia. The tubular cross-section of the shaft of the tibia at higher levels is unsuited to weight-bearing.</li><li>The skin and subcutaneous tissue covering the end of the stump must be appropriate for weight-bearing.</li><li>The weight-bearing skin must be properly centered upon the area of support and firmly attached to it.</li><li>The end of the stump must be bulbous, thus ensuring that the prosthesis will not slide off the stump or rotate upon it.</li></ol> <p>Syme's operation, properly performed, meets all these requirements. For conditions which require amputation in the vicinity of the ankle joint, it provides a stump superior to all others. But the initial operation provides the sole opportunity for securing a Syme stump satisfactory in all respects. Even minor deviations from detail are prone to result in a stump imperfect in one way or another, and such imperfections usually cannot be corrected by secondary operations. If the imperfection is not great, the stump may function reasonably well, for some time at any rate, but it may not stand up indefinitely, as has proved to be the case with Elmslie's modified Syme's amputation.</p> <p>Because preservation of the unique structure of the heel pad is essential for attaining a perfect Syme stump, it is appropriate now to describe its specialized nature. In the human heel, as in other parts of the body adapted to weight-bearing (finger tips, thenar and hypothenar eminences, ischial tuberosities, and prepatellar pads), the ability to withstand the stresses imposed by the weight of the body and by body movements derives in part from the thickness of the skin and in part from a special elastic adipose tissue beneath the skin. Of the two, the latter is the more important, for without the buffering action of this elastic adipose tissue not even a thick layer of skin can provide satisfactory protection against the stresses of weight-bearing.</p> <p>Kuhns<a></a> has reviewed our knowledge of elastic adipose tissue and has brought to our attention the detailed studies of Tietze<a></a> and Blechschmidt.<a></a> Kuhns shows that the stress-absorbing qualities of the subcutaneous layer in areas adapted to weight-bearing are due to its structure and to the elastic qualities of its connective tissues. In these areas the subcutaneous tissue consists of dense septa of elastic connective tissue which completely enclose spaces rilled with fat cells. Each such loculus is separate from its neighbour, and the fat cells within it are isolated from the surrounding loculi. In the heel pad, the fibrous septa extend from the dermis below and are attached above to the calcaneus posteriorly and to the plantar aponeurosis anteriorly. The flasklike spaces are filled with fat cells, and their walls are reinforced by oblique and spiral bands. These compartments, bounded by sheets of elastic fibrous tissue and filled with semifluid fat, act as hydraulic buffers. Under pressure they change form but not contents. When pressure is released, they resume their normal size and shape owing to the elasticity of the walls. A lateral radiograph of the heel, if not overexposed, often will reveal this fundamental structure of the subcutaneous tissue. The vertical septa of the relatively dense, elastic, connective tissue are readily seen extending upwards from the skin below to be attached above to the calcaneus posteriorly and to the plantar aponeurosis anteriorly (<b>Fig. 16.</b>, <b>Fig. 17.</b>, <b>Fig. 18.</b>, <b>Fig. 19.</b>, <b>Fig. 20.</b>, <b>Fig. 21.</b>, and <b>Fig. 22.</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Structure of the heel pad as revealed by radiograph. Top, without weight-bearing, bottom, patient standing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Structure of the heel pad, diagrammatic representation reproduced from radiographs. Top, without weight-bearing; bottom, patient standing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Anatomy of the field of Syme's amputation. Insert shows the plane of the section. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Structure of the heel pad in Syme's amputation. Coronal section enlarged from Figure 18. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Longitudinal section of foot to show structure of heel pad. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Horizontal section through heel pad to show structure. This specimen is a slice of the heel pad cut parallel to the sole of the foot and midway between the skin and the inferior surface of the calcaneus. The skin surface is on the back and either side of the heel. Insert shows plane of section. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Vertical section through heel flap, approximately 8X. <i>a, </i>Bellies of short muscles of foot; <i>b, </i>plantar aponeurosis; <i>c, </i>specialized elastic adipose tissue; <i>d, </i>skin. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is important to preserve intact this specialized subcutaneous tissue in the heel flap of a Syme stump; otherwise the weight-bearing qualities will be impaired. To do so necessitates removal of the periosteum and the plantar aponeurosis with the heel flap, since these elements form the superior attachment of the septa. If the heel flap is dissected through the layer of subcutaneous tissue (i.e., between the periosteum and the plantar aponeurosis above and the dermis below), the septa will be divided and the loculi opened, thus allowing the fat cells to leak out. In such circumstances, the distinctive structure and function of the elastic adipose tissue is lost, for then the tissue no longer consists of separate, elastic-walled spaces enclosing fat under tension. Once the elastic adipose tissue has been damaged, its stress-resistant properties cannot be restored.</p> <h4>THE TECHNIQUE OF SYME'S AMPUTATION</h4> <p>In the five papers Syme wrote between 1843 and 1846 there is no complete and formal description of the technique of his operation, and there is only one inadequate illustration (<b>Fig. 23.</b>). Scattered throughout the papers, however, are comments on various points in the procedure, and when the articles were gathered together and republished in the volume <i>Contributions to the Pathology and Practice of Surgery</i><a></a> there was included an addendum concerned chiefly with certain details of the operation, particularly the technique for separation of the heel flap from the calcaneus. Therein, after emphasizing the desirability of "preserving entire the thick integuments of the heel to form a cushion for the stump," and after ascribing the known failures either to lack of skill in removing the flap from the calcaneus or to the use of flaps of skin other than that from the heel, Syme describes his technique as follows:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. The only illustration included by Syme in any of his publications on amputation at the ankle joint. It appeared in the <i>London and Edinburgh Monthly Journal of Medical Science</i><a></a> with the following comment in the text: "The stump has the shape here represented, conical in form on the inferior surface and having for its apex, or central point of pressure, the thick integument which covered the heel." This illustration was not included when the five papers<a></a> on <i>Amputation of the Ankle Joint </i>were reproduced in <i>Contributions to the Pathology and Practice of Surgery.</i><a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p>The foot being placed at a right angle to the leg, a line drawn from the centre of one malleolus to that of the other, directly across the sole of the foot will show the proper extent of the posterior flap. The knife should be entered close up to the fibular malleolus and carried to a point to the same level on the opposite side, which will be a little below the tibial malleolus. The anterior incision should join the two points just mentioned at an angle of 45° to the sole of the foot and the long axis of the leg. In dissecting the posterior flap, the operator should place the fingers of his left hand upon the heel, while the thumb rests upon the edge of the integuments, and then cut between the nail of the thumb and the tuberosity of the os calcis so as to avoid lacerating the soft parts which he, at the same time, gently but steadily presses back until he exposes and divides the tendo achillis. The foot should be disarticulated before the malleolar projections are removed, which it is always proper to do, and which may be most easily effected by passing a knife around the exposed extremities of the bones and then sawing off a thin slice of tibia, connecting the two processes.</p> </blockquote> <p>Scattered throughout the five papers are some other details worth noting. Syme found it important to avoid division of the posterior tibial artery above its branching into the median and lateral plantar arteries; otherwise there was risk that the flap would slough. Separation of the heel flap, while not easy, could be accomplished satisfactorily by keeping close to the bone. The heel flap was not to be unduly large lest its circulation be impaired. Though Syme freed the heel flap before he dislocated the talus from the ankle joint, it was not long before surgeons were freeing the ankle joint first and dissecting the calcaneus from the heel flap downward from above, and this approach is part of our present procedure.<a></a></p> <p>Today, when the problem of infection is not paramount, the purpose of the operation is, first, to remove the foot by disarticulation at the ankle joint and without damage to the specialized structure of the heel flap; second, to remove the malleoli and trim the lower ends of the tibia and fibula so as to provide a broad support for weight-bearing; third, to fashion from the heel a flap with unimpaired blood supply and with its weight-bearing mechanism undamaged; and, last, to secure this heel flap firmly and accurately to the lower ends of the tibia and fibula. The resulting stump should have a bulbous end to facilitate maintenance of the prosthesis on the stump. To meet these requirements, the skin incisions should be so designed as to give a heel flap of generous size but not so large that its blood supply will be impaired. This shape and size may be obtained by tilting the plantar incision slightly forward. Syme advocated a smaller heel flap because he feared necrosis from impaired circulation. Today, with the risk of infection removed, the larger heel flap, if carefully separated from the calcaneus, need not suffer from impaired circulation, and when sutured in place it has the advantage of overlapping and protecting the anterior margin of the lower end of the tibia. The lower ends of the tibia and fibula are fashioned with a saw cut which removes the medial and lateral malleoli and shaves off the articular surface of the tibia. The plane of this saw cut must be parallel to the ground when the patient stands (<b>Fig. 24.</b>). That is to say, in all cases the tibia must be transected to suit the individual case and not necessarily in the same plane as the articular surface of the tibia or at right angles to the long axis of its shaft. The transection of the tibia and fibula must be as low as possible to ensure that an area of support as broad as possible is obtained. With the modern type of Syme prosthesis, the resulting long stump presents no problem in fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Proper saw line for Syme's amputation, when tibia is abnormal or deformed. The plane of section of the lower ends of tibia and fibula is not necessarily that of the inferior articular surface of the tibia but must in all cases be parallel to the ground when the patient stands erect. When for example the tibia is bowed, as represented here, the plane of section is horizontal and not at 90 degrees to the long axis of the bone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The fashioning of the heel flap and its proper attachment to the lower ends of the tibia and fibula are important steps in the operation. Preservation of the specialized fibroelastic subcutaneous tissue and the posterior tibial artery can best be assured by subperiosteal separation of the heel flap from the calcaneus. While this is a procedure somewhat more precise than that recommended by Syme (who advised that the flap be separated from the calcaneus by dissection with a sharp knife in a plane close to the bone), today with modern techniques and instruments it is easy to accomplish the desired result. The only step likely to give any difficulty is the detachment of the tendo achillis from the calcaneus, since in this situation there is no plane of cleavage. The tendon must therefore be divided carefully at its insertion close to the bone in order to avoid damage to the skin close behind it.</p> <p>Subperiosteal dissection of the calcaneus from the heel flap has one advantage not envisioned by Syme. Besides preserving the posterior tibial artery and the weight-bearing structure of the heel, it leaves a heel flap lined with periosteum, which more readily and more firmly adheres to the cut surfaces of the tibia and fibula. Henry Thompson<a></a> must have had something of this nature in mind when he advocated leaving a flake of the os calcis in the heel flap. As can be seen in radiographs (<b>Fig. 25.</b> and <b>Fig. 26.</b>), new bone sometimes forms from the periosteal lining of the heel flap, in which case there is very firm fixation of the heel flap to the tibia and fibula. In this connection, it is interesting to note an observation of Jacobson.<a></a> In discussing Syme's amputation, he describes the technique of removal of the calcaneus from the heel flap by an approach from above:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. A flake of new bone laid down in the heel flap of a Syme stump, the result of subperiosteal separation of the heel flap from the calcaneus. Firm fixation of the heel flap to the cut surfaces of the tibia and fibula is thus ensured. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. A large mass of bone laid down in the heel flap of a Syme stump. <i>A, </i>four months after operation; <i>B, </i>one year after operation. This unusually large cloud of new bone resulted from the stimulation of the periosteum by the inflammatory reaction to tuberculosis of the tarsus, the reason for the amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The foot being still more pressed (i.e., downward to dislocate the talus from the ankle joint), the upper nonarticular surface of the os calcis comes into view and then the tendo achillis. This is severed and the heel flap next dissected off the os calcis from above downwards, special care being taken to cut this flap as thick as possible, not to score or puncture it, but rather to peel it off the bone with the left thumb nail kept in front of the knife aided by touches of this.</p> <p>Thereto is appended a footnote:</p> <blockquote><p>If, in a young subject, the epiphysis comes away in the heel flap, it may remain there if the parts are healthy. <i>The same course may be followed with the periosteum if it is found loose and peels away. </i>Mr. Johnston Smith, when amputating both feet for frostbite, left the periosteum on one side; on the other no attempt was made to save it. The first stump was much larger than the other, harder and more rounded, more like that of Pirogoff's amputation.</p> </blockquote> <p>Published in 1889, this comment preceded introduction of the roentgen ray. In all respects, save the radiographic proof, it indicates clearly that subperiosteal separation of the heel flap results in more firm attachment of flap to the tibia and fibula than is the case when the periosteum is not preserved.</p> <p>When stresses come upon a heel flap not firmly attached to the cut surfaces of the tibia and fibula, it wobbles and thus loses some of its functional value. Moreover, the tendo achillis and the peroneal tendons buried therein drag the heel flap this way or that when they contract (<b>Fig. 27.</b> and <b>Fig. 28.</b>). Both of these problems can be eliminated by subperiosteal separation of the calcaneus from the heel flap, for doing so ensures firm fixation of the flap to the cut ends of the tibia and fibula.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Misplaced and unstable ("wobbly") heel flap, the result of tidying up the heel flap by removal of the stumps of the short plantar muscles and with them the plantar aponeurosis and the periosteum of the calcaneus. The result is a heel flap imperfectly fused to the end of the tibia and in bad position. Left, muscles at rest and heel pad held as nearly as possible under the tibia by elastic traction; right, contraction of peroneal muscles drags the unstable heel flap toward the lateral side of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Radiograph of the imperfect Syme stump shown in <b>Fig. 27.</b>. In addition to the unstable and misplaced heel flap, the high level of transection of the tibia and fibula limits the area available for support. In spite of these defects, the stump has functioned reasonably well for 12 years. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A heel flap which has been formed by subperiosteal dissection from off the calcaneus is clumsy and untidy in appearance. It is a deep, cup-shaped structure covered with thick skin and rendered bulky at its anterior end by the inclusion of the bellies of origin of the short plantar muscles. The instinct of every meticulous surgeon is to tidy it by removal of these bulky muscle stumps, but it is best to leave them in place. They do no harm, and any attempt to remove them may damage the specialized, weight-bearing, subcutaneous tissue by removing with them the plantar aponeurosis, from which the fibrous septa originate.</p> <p>The detailed steps (<b>Fig. 29.</b>, <b>Fig. 30.</b>, <b>Fig. 31.</b>, and <b>Fig. 32.</b>) in the operation as at present performed are as follows:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Technique of the Syme amputation. <i>A, </i>Skin incisions from the medial side; <i>B, </i>skin incisions from the lateral side; C, division of the collateral ligaments from within the joint; <i>D, </i>dislocation of the talus downward from the mortise of the ankle joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Technique of the Syme amputation, continued. The talus has been dislocated from the ankle joint. The calcaneus has been separated almost completely from the heel flap by subperiosteal dissection. The tendo achillis is about to be divided at its insertion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Technique of the Syme amputation, continued. Left, the anatomy of the field of operation after the tarsus has been removed from the heel flap; right, closure of the wound with drainage. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Technique of the Syme amputation, continued. The method of strapping the heel flap to the leg to ensure that its position in relation to the cut ends of the tibia and fibula is exactly correct and will remain so. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>Apply an air-pressure tourniquet to the thigh.</li><li>With the foot at a right angle to the tibia, make two incisions: First, from the tip of the lateral malleolus, across the sole of the foot to a point just below the tip of the medial malleolus, the cut being made through all the soft tissues directly down to the tarsal bones. At its center, this plantar incision should be curved slightly forward from the tips of the malleoli, rather than the reverse, so that the center of the flap will be elongated to facilitate covering the anterior margin of the cut surface of the tibia when the wound is closed. Second, a dorsal incision joining the upper ends of the plantar incision and running upward and forward at an angle of 45 deg. from the line of the tibia and from the plantar surface of the foot. It bisects the angle between the tibia and the foot. Through it the ankle joint is entered.</li><li>With the ankle joint open, plantar flex the foot and divide the tibial and fibular collateral ligaments of the ankle from within the joint. On the medial side, be careful to avoid the posterior tibial artery.</li><li>Dislocate the talus downward from the mortise of the ankle joint, open the posterior part of the capsule of the ankle joint from within, and expose the posterosuperior nonarticular surface of the calcaneus and the anterior surface of the tendo achillis just above its insertion.</li><li>With a periosteal elevator (Bristow raspatory), enter the subperiosteal plane on the medial and lateral sides of the calcaneus and extend this subperiosteal dissection to the inferior surface of the bone. Tilt the foot first into inversion and then into eversion and continue the subperiosteal freeing of the calcaneus on its inferior surface. Then work forward in the subperiosteal plane on the medial, lateral, and inferior surfaces of the calcaneus. Detach the origin of the long plantar ligament from the tuberosity of the calcaneus, and continue in the subperiosteal plane until the plantar skin incision is reached and the anterior end of the bone is free. Work backward in the subperiosteal plane until the whole of the calcaneus is free except at the insertion of the tendo achillis. With a knife, carefully divide the tendo achillis working downward from above. Stay close to the bone and avoid damaging the skin flap behind the tendo achillis. Remove the talus and calcaneus together with the damaged portion of the foot. If this step is accomplished successfully, the posterior tibial artery will be unharmed. Only its plantar branches will have been cut by the primary plantar incision. Do nothing to the posterior tibial nerve, which also will have been cut by the primary plantar incision.</li><li>Carefully turn the heel flap backward and upward, and free the malleoli and the lowest 1/4 in. of the tibia. Remove the malleoli and a thin slice of the lower end of the tibia by a saw cut. Be certain that the saw cut will be parallel to the ground when the patient is standing. The amount of tibia removed should be the thinnest possible shaving from its lower end, the sub-articular cortical plate being conserved if possible. In any case, be certain that the largest possible cross-sectional area of the tibia and fibula is obtained to ensure a broad area of support (<b>Fig. 33.</b>).</li><li>Remove the tourniquet and secure perfect haemastasis. Do not trim the heel flap, much as you may desire to make it tidy.</li><li>With interrupted sutures of chromic catgut #0 for the subcutaneous layer and interrupted everting mattress sutures of braided nylon for the skin margins, suture the margin of the heel flap to the margin of the anterior incision across the front of the ankle joint. Suture nothing but the subcutaneous layer and the skin. To drain the dead space, enclose across the wound a section of Penrose tubing and allow the ends to come out at either corner of the wound. The line of suture should be slightly above the anterior margin of the cut surface of the tibia so that cut ends of the bones fit into the cup of the heel flap.</li><li>In closing the wound, pay no attention to the disparity in size, shape, and thickness between the heel flap and the skin margin to which it will be sutured. Center the hollow of the heel flap beneath the cut ends of the tibia and fibula as accurately as possible, and begin the suture line in the center anteriorly and work to either end. Do nothing to the "dog ears" of skin which project at the corners of the approximated skin margins. In time they will shrink and disappear. To trim them invites impairment of circulation.</li><li>The heel flap thus sutured is attached only at its margin and is not yet fixed firmly to the cut surfaces of the tibia and fibula, and accordingly it can be moved about in relation to them. It needs to be secured and maintained in a proper position. To do so, hold the heel flap accurately centered beneath the cut surfaces of the tibia and fibula and secure it in this position by two strips of adhesive tape fastened U-shaped across the end of the stump in the anteroposterior and medio-lateral directions (<b>Fig. 32.</b>). Adhesive tape is better than pins transfixing the heel pad to the tibia, as has sometimes been advocated. Do not apply the adhesive strips too tightly.</li><li>Dress the wound with two layers of surgical pads smoothly applied and held in place by a mildly compressive bandage. Flannelette cut on the bias is ideal, although cotton-crepe bandage (without elastic) will do if not applied tightly.</li><li><i>Important.</i> Open the dressing 24 hours after the operation and every second day thereafter, and inspect the position of the heel flap in relation to the lower ends of the tibia and fibula. Adjust or renew the adhesive strips if necessary to maintain the correct position of the heel flap. If the operative dressing is left unchanged, the heel flap may unite asymmetrically. The stump must be inspected frequently in the postoperative period, and adjustments of the position of the heel flap must be made when necessary. Remove the Penrose tube about the sixth day.</li><li>Maintain a firm dressing until the wound is healed and the stitches are removed (about two weeks). Support the stump thereafter with a cotton-crepe elastic bandage until the first limb is fitted. At the end of four weeks, the patient may begin to put weight on the end of the stump. A prosthesis may be fitted at the end of two months, though it will require a new socket within a year, when shrinkage of the calf muscles is complete.</li></ol> <h3>IMPERFECTIONS WHICH IMPAIR THE FUNCTION OF THE SYME STUMP-HOW TO AVOID OR CORRECT THEM</h3> <p>Not all Syme stumps are perfect, but nearly all imperfections can be avoided by meticulous attention to the details of the operation. Too much emphasis cannot be placed upon a proper understanding of the principles of the amputation and upon its proper performance. Although some imperfections can be compensated for in the fitting of the prosthesis or in the manner of its use, and although some can be eliminated by revision operations, others cannot be overcome at all, usually because of faulty performance of the initial operation.</p> <h4>DAMAGE TO THE WEIGHT-BEARING STRUCTURE OF THE HEEL FLAP</h4> <p>A serious imperfection, which cannot be corrected by further operation, is damage to the weight-bearing structure of the heel flap. This is almost always due to the manner in which the operation is performed. Care must be taken to preserve intact the specialized subcutaneous fibroelastic tissue of the heel pad. As previously indicated, this can be accomplished most certainly by attention to two details in the operation: subperiosteal separation of the heel flap from the calcaneus and avoidance of any attempt to tidy the clumsy flap by removing the stumps of origin of the small muscles of the foot. If these steps in the operation are properly performed, the specialized subcutaneous tissue will remain intact and its function will be unimpaired. On the other hand, if the plane of the subcutaneous tissue is entered during the operation, there will be more or less impairment of its structure and function. This is the prime example of the necessity to perform Syme's amputation by a technique which adheres rigidly to the basic principles of anatomy. There is only one opportunity to fashion a Syme stump of the best quality and that is the occasion of the primary operation. If this is performed skillfully and with due regard for basic principles, it will produce a good end-bearing stump. If the basic principles are disregarded, or if the operation is performed carelessly, the weight-bearing qualities of the flap are likely to be impaired, and they cannot be restored by any subsequent operation.</p> <p>While a defective Syme stump deprives the patient of the comfort and good function he would enjoy with a perfect stump, it may still be sufficiently useful to make it worth while retaining. Reamputation at a higher level is not always inevitable.<a></a> Even an imperfect Syme stump may be more useful than a below-knee amputation. Therefore re-amputation at a higher level because of an imperfect Syme stump should be undertaken only after the most careful consideration of every aspect of the problem.</p> <p>Besides damage to the heel flap, and consequent impairment of the weight-bearing qualities of the stump, a number of other faults can impair the functional value of a Syme amputation.</p> <h4>MISPLACED HEEL FLAP</h4> <p>Care must be taken to secure the heel flap beneath the tibia in such a manner that the plantar surface of the flap is exactly beneath the center of the lower end of the tibia. To keep it there necessitates painstaking care and supervision during the immediate postoperative period. The heel flap being a large, cup-shaped structure, loosely attached to the leg, it must be secured in its proper position by adhesive strips and maintained so until healing has fixed it to the lower end of the tibia (<b>Fig. 32.</b>). If postoperative inspection is neglected, the heel flap may be pushed out of place by the dressing and may unite to the tibia displaced to one side or the other or backward. Its end-bearing capability is then impaired. Fortunately, if the specialized fibroelastic adipose tissue has not been damaged, malposition of the heel flap can be corrected by detaching it and replacing it in its proper position.</p> <h4>SLOPING SURFACE OF LOWER END OF TIBIA</h4> <p>If the cut surface of the lower end of the tibia is not parallel to the ground when the patient stands, the heel flap tends to be pushed to the high side of the slope (<b>Fig. 33.</b>) The plane of transection must therefore be parallel to the ground when the patient stands no matter what its geometric relationship to the long axis of the tibia. If there is any bowing or other deformity of the tibia, the proper plane of transection may actually be oblique to the long axis (<b>Fig. 24.</b>). The particular circumstances in the individual case must be assessed at the time of the primary operation to make certain not only that the plane of section of the lower surface of the tibia is parallel to the ground but also that the maximum area of bony support for the heel flap is secured (<b>Fig. 34.</b>). Any operation to revise an improper bearing surface must necessarily be at a higher level where the cross-sectional area for support is smaller (<b>Fig. 24.</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Oblique transection of lower end of tibia results in displacement of heel pad to high side. <i>A, </i>The stump when no weight is upon it; the heel pad is displaced medially. <i>B, </i>Radiograph of stump; tibia transected obliquely, higher on the medial than on the lateral side. <i>C, </i>The stump bearing weight; the heel pad is markedly displaced to medial side. The function of this heel flap (which already is unstable and misplaced) is impaired still more by the displacement which occurs when weight is borne upon it. This is the result of oblique section of lower end of tibia. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. The proper level for transection of the tibia and fibula in Syme's amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>"WOBBLY," OR UNSTABLE, HEEL FLAP</h4> <p>If the heel flap is loosely attached to the lower end of the tibia, it is easily displaced, and pressure while walking or standing may wipe it to one side or the other or backward. Similarly (<b>Fig. 27.</b> and <b>Fig. 28.</b>), it may be pulled out of place by the stumps of the tendons that are embedded in it, the tendo achillis and the peroneal tendons being the chief offenders. Because the thrust of weight-bearing cannot be maintained through the center of the flap, even when the prosthesis is snugly fitted, an unstable heel flap does not bear weight satisfactorily. The anterior margin of the lower end of the tibia presses through the scar of the anterior suture line, and the patient stands insecurely upon the shifting end of his stump. A flaccid, loose, heel flap occurs when the plane of separation is through the subcutaneous elastic adipose tissue. It can be prevented by subperiosteal dissection of the heel flap. The deep surface of the flap then attaches itself firmly to the cut surface of the bone, and the intact pad of weight-bearing subcutaneous tissue resists changes in shape. An unstable heel flap can be avoided only by proper operative technique. Once it exists it cannot be corrected by further operation though its shortcomings may be minimized by modifying the fit of the prosthesis.</p> <h4>NEUROMA ON POSTERIOR TIBIAL NERVE</h4> <p>In the surgery of the Syme amputation, no attempt should be made to free the posterior tibial nerve and divide it at a high level lest so doing lead to damage of the adjacent posterior tibial artery and consequent impairment of the blood supply to the heel flap. Although a neuroma inevitably develops at the cut end of the nerve, it seldom gives trouble. In the rare case in which the neuroma is sensitive, a cure can be effected by late transection of the nerve at a level well above the ankle joint but without removal of the distal segment of the nerve.</p> <h4>MARGINAL GANGRENE OF THE HEEL FLAP</h4> <p>Except in cases of peripheral vascular disease, marginal gangrene of the heel flap is nearly always due to faulty operative technique. Either the blood supply to the flap is impaired by injury to the posterior tibial artery, or the dressings are put on too tightly, or swelling occurs beneath the adhesive strips and they are not loosened soon enough. With care in operating, there is little danger of necrosis of the flap. Should necrosis occur, the stump is not necessarily ruined unless the loss of tissue is very great (<b>Fig. 35.</b>, <b>Fig. 36.</b>, and <b>Fig. 37.</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Salvage of a Syme stump in spite of marginal gangrene of the flap. This 38-year-old man suffered ischemic necrosis of the muscles of his leg as a complication of fracture of the femur when he was eight years old. He slowly developed a grossly deformed, insensitive foot with trophic ulceration. When the Syme amputation was performed, the posterior tibial artery was inadvertently divided. The result was marginal gangrene of the flap. Separation of the gangrenous margin occurred slowly over a period of eight months. During that time the flap was held in place by adhesive strapping and carefully applied dressings. Wearing an "elephant prosthesis" (<b>Fig. 36.</b>), he first walked five months after his operation. The scar is depressed at the line of suture as the result of the separation of the gangrenous margin of the heel flap. Left, appearance of stump; right, radiograph of stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. The temporary "elephant prosthesis" used on the patient shown in <b>Fig. 35.</b>. It enabled him to walk during the long period of wound-healing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. The final prosthesis provided the patient shown in <b>Fig. 35.</b>. See pages 52-75. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>VASCULAR INSUFFICIENCY IN THE HEEL FLAP</h4> <p>It has been said that the great length of a Syme stump results in vascular insufficiency manifested by a cold, blue, painful stump end, symptoms which are greatly accentuated in cold weather. There has been no such experience in Canada, where, in winter, many of the patients are exposed to very low temperatures. Experience leads to the conclusion that vascular stasis from exposure to cold is not a problem of any importance in the Syme amputation.</p> <h4>TENDER HEEL FLAP WITH CALLUSES</h4> <p>A calloused and tender heel flap is almost always due to failure to preserve the specialized fibroelastic adipose tissue. It is accentuated if the area of transection of the tibia and fibula is small or if there are projecting bone spurs. The problem can be prevented by proper fashioning of the heel flap and by division of the tibia and fibula low enough to provide a broad area of support. If bony spurs are present, they should be removed, but neither a damaged heel flap nor an inadequate area of support can be corrected by any subsequent operation.</p> <h4>IMPERFECT SKIN COVERING OF THE STUMP</h4> <p>In an occasional Syme stump the end is covered with skin ill adapted to weight-bearing. Usually in such cases the extent of the original trauma was such as to leave very little material from which to fashion an adequate heel flap. Sometimes the heel flap is scarred by wounds or infection. Some of the heel flap may have been lost by vascular damage, or the original covering of the stump may have been skin from a site other than the heel. Though little can be done to improve such stumps by further operation, modification of the prosthesis so as to distribute the weight between the end of the stump and the upper end of the socket, as in a below-knee prosthesis, offers promise of improvement. Despite the great importance of covering the end of the stump with skin and subcutaneous tissue accustomed to weight-bearing, there is reason to believe that, when the cut surfaces of the tibia and fibula are as broad as possible, the stresses of weight-bearing are distributed so widely that even ordinary skin and subcutaneous tissue can sometimes function satisfactorily (<b>Fig. 38.</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. A modified Syme amputation in which, because of an injury that completely destroyed the heel flap and the calcaneus, the transected ends of the tibia and fibula were covered with a flap from the dorsum of the foot. Photo shows stump 10 years after amputation, never any trouble; insert is a radiograph showing broad area of support, which probably accounts for the success of this stump despite lack of covering with normal heel pad. Similar to Baudens' supramalleolar amputation.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>INDICATIONS FOR SYME'S AMPUTATION</h4> <p>With a technique that ensures a satisfactory end-bearing stump, Syme's amputation is indicated for all destructive, infective, or other disabling lesions of the foot that cannot be dealt with by a transmetatarsal amputation. The skin over the heel must be intact. Syme's amputation should replace Lisfranc's and Chopart's whenever these amputations are apt to be unsatisfactory, as is often the case. The following are the principal conditions for which Syme's amputation is most frequently performed.</p> <h4>SEVERE INJURIES OF THE FOOT</h4> <p>Compound and comminuted fractures of the tarsus and metatarsus and crushing injuries of the foot are usually best treated by Syme's amputation. If damage to the skeleton of the foot is severe, it is often impossible to salvage a useful and painless foot. As soon as this circumstance becomes apparent, or if from the beginning it is obvious that much of the foot must be lost by reason of the injury or that the foot will ultimately become deformed, rigid, and painful, a Syme's amputation is indicated. It should be performed as soon as the risk of infection can be eliminated. With antibiotics available, the amputation can sometimes be performed as a primary measure. More frequently it will be wise to perform it as a secondary procedure after infection has been brought under control and the wound has healed or nearly healed. In dealing with injuries to the foot, especially war injuries, the advantages of the Syme amputation should be borne in mind so that, instead of immediate resort to a mid-tibial amputation, a two-stage operation can be planned, the primary stage being to remove the shattered and infected distal portions of the foot while preserving the heel flap, the second to effect a formal Syme amputation after the wound has healed or after infection is under adequate control.</p> <h4>INTRACTABLE INFECTIONS OF THE BONES AND JOINTS OF THE FOOT</h4> <p>Today infection is less often an indication for Syme's amputation than it was formerly. Antibiotics give us such control over infections (including tuberculosis) that amputation is seldom necessary as a life-saving measure. It still has a place in the eradication of persistent, chronic infection and in the management of a few unusual infections, such as blastomycosis. Syme's first operation was for tuberculous infection of the talus and calcaneus. It is a tribute to the operator that in a day of uncontrolled infection the result was completely successful.</p> <h4>DEFORMITIES OF THE FOOT</h4> <p>Foot deformities that cause serious disablement from rigidity and localized pressure and that are incapable of correction are indications for Syme's amputation. Although the chief cause of such deformities is previous trauma or infection, conditions such as old clubfoot with intractable deformity can also be well treated by Syme's amputation.</p> <h4>WAR INJURIES</h4> <p>Because battle wounds commonly cause gross damage to tissues, and because they must often be treated hastily, in large numbers, and usually under conditions less than ideal, the merits of Syme's amputation must be emphasized lest the soldier be deprived of its advantages. Every war injury of the foot should be regarded as a condition that might ultimately best be treated by Syme's amputation. Even in questionable cases, consideration should be given to a two-stage procedure: first, removal of the damaged parts with concomitant control of infection; second, a formal Syme amputation when healing of the first wound is well along.</p> <h4>FROSTBITE AND IMMERSION FOOT</h4> <p>Extreme cold causes thrombosis of the smaller vessels of the foot, especially of the distal portions, so that gangrene of the toes develops in severe cases. Foot damage from frostbite, if of considerable extent, is well treated by Syme's amputation. Less severe cases may recover without amputation, or escape with amputation of the toes, or with transmetatarsal amputation.</p> <h4>SELECTED CASES OF OBLITERATIVE VASCULAR DISEASE</h4> <p>Contrary to expectation, it has proved possible to deal with certain cases of Buerger's disease and of arteriosclerotic vascular disease by Syme's amputation. Buerger's disease is more often suitable for Syme's amputation than is arteriosclerotic vascular disease. The most suitable case is a young or middle-aged man suffering from obliterative disease with gangrene of the toes and neighboring parts and a favourable response to lumbar sympathetic block. In such cases, a lumbar sympathectomy, followed by Syme's amputation, will often provide a useful stump that will last for years. Dr. Gordon M. Dale<a></a>, who has had considerable experience with the Syme amputation for obliterative vascular disease (page 44), has had success in 50 percent of his cases. The Syme stump has provided much better function than would have been possible with amputation at a higher level, a matter of special importance since these patients constantly face the possible loss of the other leg at a later date for the same disease.<a></a></p> <h4>CERTAIN NEUROLOGICAL LESIONS</h4> <p>Neurological diseases occasionally produce in the foot changes which impair its usefulness and which may transform it into an encumbrance. If infection supervenes, the patient's life may be endangered.</p> <p>Neuropathic joints in the foot can develop from tabes dorsalis, syringomyelia, or Charcot-Marie-Tooth neuromyopathy. If the disability and deformity from these problems is severe, a Syme amputation is a valuable procedure. It removes the damaged joints and provides the patient with a useful end-bearing stump.</p> <p>The sensory loss which accompanies irreparable sciatic-nerve lesion or spina bifida is prone to result in trophic lesions of the skin of the sole of the foot. These skin lesions occur most frequently in the anterior portion of the foot, where the metatarsal heads press unduly upon the skin which underlies them. When ulceration of the skin develops, infection follows. It must be quickly and completely eradicated. The skin beneath the heel is less often involved because of the thickness of the heel pad. The ulcers beneath the metatarsal heads are so situated that a transmetatarsal amputation is seldom possible because the skin available is inadequate to cover the end of the foot without tension. Such cases are well treated by Syme's amputation.</p> <h4>SYME'S AMPUTATION IN CHILDREN</h4> <p>Syme's amputation can be utilized in children as successfully as in adults, especially in the treatment of destructive foot injuries and of certain congenital foot deficiencies and deformities. Indeed, if properly performed it has in children two special advantages not applicable to adults. Provided the lower epiphyseal line of the tibia is preserved intact, the growth in length of the tibia is but little diminished. Secondly, progressive growth does not project the lower ends of the bones through the skin, as happens all too frequently when amputation through the shaft of the tibia is performed in early childhood.</p> <p>The chief indications for the operation in children are trauma that results in irreparable damage to distal parts of the foot, vascular accidents that terminate in ischemic necrosis or gangrene of the toes and associated parts, and congenital deficiencies and deformities that result in a foot so imperfect as to be an encumbrance. It is of importance that the lower epiphyseal line of the tibia be undamaged and that an area of support as broad as possible be obtained. In children, accordingly, little more should be done to the bones than to remove the malleoli. The lower articular surface of the tibia is left untouched, while the calcaneus is removed from the heel flap by subperiosteal dissection.</p> <p>The Syme amputation can be performed in children as early as the second or third year, with great benefit to the patient. Even if it does nothing more than postpone a formal, mid-tibial amputation until growth has ceased, it is worth performing<a></a> since it ensures a shank of more or less normal length (<b>Fig. 39.</b> and <b>Fig. 40.</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. The Syme amputation in children. This 18-year-old boy suffered embolism or thrombosis at the bifurcation of the aorta as a complication of septicaemia at the age of seven years. Gangrene of his right toes and of the left foot occurred. A Syme amputation was performed on the left foot in May of 1948. He has had a perfectly satisfactory stump for 11 years. Left, the stump (in 1958) shows a large heel pad which moves rather loosely on the ends of the bones; right, radiograph of the stump showing that the transection was rather high. The left tibia is 2 1/8 in. shorter than the right. There is no projection of the bone ends through the end of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Lower extremities of a 70-year-old man whose Syme amputation was performed 65 years ago for deformed foot resulting from a severe injury at the age of two. Left, appearance of the stump; right, radiographs of the stump. The heel flap is large and soft, moves rather freely on the ends of the bones, and can be moved voluntarily by contraction of the tendo achillis. There is very little shortening of the tibia. Patient has led a very active life (squash-rackets champion at one time) and has had no trouble with his stump. He wears a Marks prothesis (wooden bucket closed with leather flaps over a tongue, solid ankle, and sponge-rubber foot). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is interesting to record that among Syme's earliest cases were three children,<a></a> ages respectively 11 years, 10 years, and 5 <i>months. </i>In all three a good result was obtained.</p> <h4>MALIGNANT DISEASE OF THE FOOT</h4> <p>Malignant disease of some part of the foot, for example malignant melanoma, is an occasional indication for Syme's amputation. Under appropriate circumstances, tumours of the tarsus, such as osteoclastoma, may be well treated by Syme's amputation. As already noted, one of Syme's outstanding successes was an amputation at the ankle joint performed for "an erectile tumour of the foot" (probably a haemangioma). In general, it may be said that any tumour of the foot which can be completely removed without sacrificing any of the principles of the amputation should be regarded as a problem suitable for treatment by Syme's amputation.</p> <h3>RESULTS AND CONCLUSIONS</h3> <p>It is difficult to discuss the results of Syme's amputation because success or failure is so much dependent upon the manner in which the operation has been performed. No matter how many Syme's stumps may be examined to ascertain the end results, the conclusions will be misleading unless the technique of the operation is known for each case. If the basic principles have been observed, and if the operation has been performed properly, the result is an assured success. If any of the fundamental principles have been disregarded, the result may be unsatisfactory, and it may not be possible to improve it. The four basic principles are simple and clear-cut: 1. to remove the damaged foot by disarticulation at the ankle joint; 2. in doing so to preserve the heel flap with its blood supply and weight-bearing qualities unimpaired; 3. to remove the malleoli and the articular cartilage on the lower end of the tibia leaving a surface of support as broad as possible; and 4. to secure the heel flap to the ends of the tibia and fibula in the best position for weight-bearing. When these principles have been followed and the operation has been performed properly, the result almost invariably is a satisfactory end-bearing stump (<b>Fig. 41.</b> and <b>Fig. 42.</b>). But the less perfect the operation the less perfect the result. If some of the principles have been imperfectly applied or some of the details of the operation neglected, the result will not be an ideal Syme's stump, though it may serve the patient's needs with reasonable satisfaction for some period of time. If the principles have been completely neglected and the operation performed without regard to the precise details of technique, the resulting stump will be unsatisfactory and beyond improvement by any subsequent operation limited to the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. A good functional Syme stump. The heel flap is large and firmly fixed to the lower end of the tibia in good position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Radiograph of the Syme stump shown in <b>Fig. 41.</b>. The area of support is as broad as possible. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Where, in the past, tradition has given rise to a somewhat blind but devoted adherence to Syme's perfected technique, the result has usually been a firm conviction that Syme's amputation is a good amputation. Where attempts have been made to improve upon the operation, usually in an attempt to simplify the limbmaker's problem or to provide a smaller and neater stump, the results have been indifferent or poor, and the operation has been condemned on inadequate grounds. This paper is the first since Syme's day to explore the reasons for the success of Syme's amputation in his hands and in the hands of those who followed him and for the failure of otherwise able surgeons to achieve equal success when they neglected or modified Syme's technique. The first merit which Syme claimed for his new procedure was "that the risk to life will be smaller." That indeed was the case in his day, when it spared the patient the dangerous amputation at the upper end of the tibia. Today this argument in favour of Syme's operation is no longer valid, since we now know the nature of infection and have solved the problem of its control. Though the environment of surgery has changed fundamentally from the preantiseptic era of Syme to the aseptic, bacteriostatic, and antibiotic era of today, his amputation at the ankle joint still has the other merits he claimed for it-"a more comfortable stump, more seemly and useful for support and progressive motion." When circumstances permit it to be performed, Syme's amputation provides indeed the most useful of all amputation stumps of the lower extremity.</p> <p>The history of Syme's amputation during the years since Syme first performed it shows that it has been used widely throughout Europe and North America with variable results. Syme's early cases had the good fortune to escape the complications due to sepsis, such as marred Pirogoff's early experience with the operation. Syme built on the experience he gained in his early successes and gradually perfected a technique which gave a good stump. In Syme's papers on the subject there is no record of a failure or a death, a circumstance extraordinary in view of the sepsis which to some degree complicated every surgical procedure of that day and also in view of the fact that many of his amputations were undertaken for tuberculous caries of the ankle joint or subastragalar joint. The explanation may lie in the fact that in Syme's day operations in the home and in small private hospitals were much less likely to be complicated by "hospital diseases" than were those performed in public hospitals. From 1829 to 1833, all of Syme's operations were performed in the private hospital he established in Minto House. Even after his appointment to the Chair of Clinical Surgery in the University of Edinburgh in 1833, he continued for another 15 years to act as the consulting and operating surgeon of Minto House Hospital and Dispensary, though wards in the Edinburgh Royal Infirmary were assigned to his official position. Syme was well aware that hospital diseases were in some way related to the overcrowding and filth that were universal in public hospitals of that day. The Minto Surgical Hospital, which he founded and controlled, was much less troubled with these complications because he was able there to avoid overcrowding, to ensure adequate ventilation and sanitation, and to segregate ailing patients from those in good health. In discussing compound dislocation of the astragalus, for example, he makes the following reference<a></a> to this aspect of the surgery of his day:</p> <blockquote><p>Compound dislocation of the astragalus with or without that curious displacement of the astragalus, which results from falling with great force on the heel, was formerly held to require amputation of the leg. The authority of Sir A. Cooper's experience encouraged attempts to preserve the limb in such cases; and in private practice both forms of injury are now frequently conducted to a successful issue, though in general through a protracted period of recovery. But it must be admitted that many lives have been lost, especially in hospitals, from trying to retain the limb. In the Royal Infirmary I find that of thirteen patients who had suffered compound dislocation of the ankle, and were not subjected to amputation, only two recovered.</p> </blockquote> <p>When Syme assumed charge of wards in the Edinburgh Royal Infirmary, he bent all his energy toward improving sanitation by providing adequate space between beds, by better ventilation, and by more cleanliness. An interesting outcome of this activity was his insistence that the Governors establish a separate hospital for the treatment of burns. The story is well told by Simpson and Wallace.<a></a> Syme's purpose was not so much to improve the treatment of burns as to remove the unfortunate burn victims, with their offensive wounds and filthy dressings, from his surgical wards to avoid contamination of his operative cases. Pirogoff's experience with his first four cases of Syme's amputation, all of whom died (of scurvy, tuberculosis, and sepsis), must surely be an indication that the surgical wards of Russian hospitals provided an environment much less favourable to surgical operations than did Syme's private hospital at Minto House or his surgical wards at the Edinburgh Royal Infirmary.</p> <p>It is said of Syme that he never wasted a drop of blood, never wasted a drop of ink, and never wasted a word. His publications on the subject of his amputation at the ankle joint were limited to the five papers<a></a> finally gathered together in <i>Contributions to the Pathology and Practice of Surgery</i><a></a> and to his letter to the editor of <i>Lancet.</i><a></a> Having developed a new operation and perfected it to his satisfaction, he published the account of its value. He indicated how the complications and imperfections could be avoided and then left it to stand on its own merit. It must be said also that in Edinburgh his operation has always been held in high repute and that his technique for the procedure has been taught without change to successive generations of students. From the present survey it seems clear that when Syme's operation is condemned because of a poor stump it is almost always because of some obvious failure to follow Syme's technique. As time goes on, more and more evidence accumulates to demonstrate that Syme's operation, properly performed, will provide a good stump. Imperfections are almost invariably the result of failure to follow strictly the details of technique.<a></a> </p> <p>It is strange that over the years there has been such imperfect appreciation of the principles of Syme's amputation. In Syme's own day, Guyon, Roux, and Pirogoff modified Syme's procedure in the hope that they might avoid certain complications. After the 1914- 1918 war, Elmslie introduced his modification, which he confidently believed to be an improvement upon Syme's original technique. Even during the 1939-1945 war, and in subsequent years, the basic principles of Syme's operation were imperfectly understood. <b>Fig. 43.</b> and <b>Fig. 44.</b>, taken from standard texts of that era,<a></a> advocate such a high transection of the tibia and fibula that the result would certainly be an imperfect stump. None of these changes in Syme's procedure has improved the results.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Drawings from Kirk<a></a> showing misconception of the principle of Syme's amputation as late as the year 1942. The indicated level of division of the tibia and fibula is too high; description of Syme's amputation as a "supramalleolar amputation" is incorrect; the skin incision shown is that of Elmslie's modification of Syme's operation, not that used by Syme himself. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Drawing of Syme's amputation showing division of tibia and fibula at a level much too high for a satisfactory stump. From Vasconcelos.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Such misunderstandings must be due to several factors. For one thing, Syme himself wrote about his amputation at the ankle joint in a limited way only, in a style always terse and often obscure, and he published nothing on the subject after 1846. In his publications there is only one inadequate illustration (<b>Fig. 23.</b>). For another, in Syme's day the matter of prime importance was to remove the patient's damaged or infected foot with minimum risk to life. That accomplished, perfection of the stump and fit of the prosthesis were secondary considerations, important but not vital. When infection disappeared as a major problem, the new mastery of surgery, derived from anaesthesia and antisepsis (later asepsis), led surgeons to think that their new freedom in operating should make it possible to refine the procedure and thus to produce a more tidy, more elegant, and more useful stump. Besides this, the demands of the limbmakers led them to believe that high transection of the tibia and fibula would ensure that the patient could more readily be fitted with a satisfactory prosthesis. Whereas in the preanaesthetic and preantiseptic days, the emphasis in operating was upon speed, dexterity, and the control of haemorrhage, in the new freedom of painless and aseptic surgery there was a widespread impulse to devise more sophisticated operations. While the functional value of Syme's amputation derived chiefly from the resulting weight-bearing properties, the stump seemed bulky, clumsy, and unsightly to the new generation of surgeons. Their success in other fields of operative procedure naturally led them to the opinion that Syme's amputation, already good, could be made still better by refining the details of the technique, and the entry into the picture of highly skilled limbfitters encouraged a belief in the necessity for certain modifications to facilitate limb-fitting.</p> <p>Today, fortunately, the perfection of a new type of Syme prosthesis (page 52) has eliminated the ankle-joint problem and minimized the bulbous appearance of the perfect Syme stump. Seldom in the history of surgery has it been necessary to adhere rigidly to the technique of an operation developed and perfected in preantiseptic days. Yet such is the case with Syme's amputation. The simple technique devised by Syme to spare his patients the risks of amputation at the site of election and to give them an end-bearing stump still provides the best end-bearing stump of the lower extremity.</p> <p>Finally, and in summary, the conclusions to be drawn from this examination of the history and development of Syme's operation are as follows:</p> <ol> <li>The stump resulting from a Syme operation has great merit. It bears all the weight of the body on its end and withstands the stresses of locomotion without difficulty and for an unlimited time. It is the most satisfactory amputation of the lower extremity and should be utilized whenever circumstances permit.</li><li>A satisfactory Syme stump can be assured if the principles underlying the operation are understood and if the technique of the operation is followed strictly.</li><li>Deviation from the basic principles or from the details of the technique of the operation will impair the perfection of the stump, and imperfections thus incurred cannot be corrected by subsequent operation.Though imperfect, a Syme stump may still be useful, but sometimes it is ruined irreparably.</li><li>All surgeons who have occasion to deal with trauma or disease of the foot which may require amputation should be familiar with the merits of Syme's amputation and should be prepared to utilize it when the occasion arises. They must be familiar with the principles of the procedure, and they must perform the operation with meticulous adherence to the technique which has proven successful. Interestingly enough, that is the technique which Syme himself perfected.</li></ol> <p>This account of the history and development of Syme's amputation cannot end better than with Syme's own summary of the operative problem, which has been quoted earlier:</p> <blockquote><p>THE AMPUTATION IS EASILY EXECUTED AND PROVES IN THE HIGHEST DEGREE SATISFACTORY IF DONE IN ACCORDANCE WITH CERTAIN PRINCIPLES WHICH HAVE BEEN CAREFULLY EXPLAINED, BUT IS DIFFICULT AND DISASTROUS IF PERFORMED INCORRECTLY.</p> </blockquote> <h3>ACKNOWLEDGMENTS</h3> <p>My thanks are due to many colleagues who have permitted me to see their patients and to reproduce in this paper their photographs and radiographs. Dr. Robert Salter, of the Hospital for Sick Children, Toronto, brought in the patient illustrated in <b>Fig. 37.</b>. Dr. Donald E. Starr, of Vancouver, sent me the photographs and radiograph shown in <b>Fig. 38.</b>. Miss Patterson and her staff at the Library of the Academy of Medicine, Toronto, have rendered me invaluable service in securing from the most distant sources journals of a hundred years ago. Without their assistance, it would have been impossible to compile these historical notes. I am indebted also to the Librarian of the Royal College of Surgeons of Edinburgh for much assistance. I am particularly indebted to Miss Alexandra Birinkova for the translation of Pirogoff's paper,<a></a> to Mrs. Hannah Parnas for the translation of Volkmann's address,<a></a> and to Beatrice Harris for the translation of relevant material from the publications of Baudens,<a></a> Farabeuf,<a></a> and Velpeau,<a></a> and from <i>Les Annates des Therapeutique.</i><a></a> My secretary, Miss Florence Spencer, has spent untold hours of unstinted labour in preparing the manuscript from my notes. I am deeply grateful to her for her devoted work on my behalf.</p> <p>Both the editor and the publisher of the British Edition of the <i>Journal of Bone and Joint Surgery </i>have kindly permitted me to utilize certain illustrations which appeared in a previous publication of mine on Syme's amputation.<a></a>. Their courtesy has enabled me to use material not available elsewhere.</p> <p>-R.I</p> <p><b>References:</b></p> <ol> <li><i>Artificial limbs and their relation to amputations,</i> British Ministry of Pensions, His Majesty's Stationery Office, London, 1939. P. 55.</li> <li>Baudens, J. B. L., <i>Nouvelle methode des amputations,</i> Premiere Memoire, <i>Amputation Tibio-tarsienne, </i>Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</li> <li>Blechschmidt, E., <i>Die Architektur des Fersenpolsters,</i> Morphol. Jahrb., 72:20-68 (1933).</li> <li>Broca, A., and C. Ducroquet, <i>Artificial Limbs,</i> Military Medical Manuals, English ed., Sir Alfred Keogh and R. C. Elmslie, eds., 1918. Pp. 77 and 78.</li> <li>Brown, Dennis, personal communication, 1955.</li> <li>Brown, John, <i>Horae subsecivae, </i>new ed. in 3 vols., Adam and Charles Black, London, 1897. Second series, p. 363. See also Everymans Library, <i>Rob and his friends and other papers, </i>by John Brown, J. M. Dent and Sons, London, 1906.</li> <li>Brown, John, <i>Horae subsecivae, </i>new ed. in 3 vols., Adam and Charles Black, London, 1897. First series, p. 360.</li> <li>Carden, H. D., <i>On amputation by single flap, </i>Brit. Med. J., 1:416 (1864).</li> <li>Dale, G. M., personal communication, 1960.</li> <li>Dent, Clinton T., <i>Surgical notes from the military hospitals of South Africa, </i>Brit. Med. J., 1:1313 (1900).</li> <li>Elmslie, R. C, in Carson's <i>Modern operative surgery, </i>1st ed., Cassel &amp; Co., London, 1924. Vol. 1, section on amputations, p. 132.</li> <li>Farabeuf, L. H., <i>Precis de manuel operatoire (ligatures, amputations), </i>G. Masson, Editeur, Paris, 1881. P. 473.</li> <li>Fergusson, <i>System of practical surgery, </i>4th ed., review in Lancet, Vol. II, p. 394 (1857).</li> <li>Godlee, Sir Rickman, <i>Life of Lord Lister, </i>3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</li> <li>Guyon, F., <i>Gazette des hopitaux, </i>p. 514 (1868), quoted from Farabeuf, <i>Precis de manuel operatoire (ligatures, amputations) </i>G. Masson, Editeur, Paris, 1881. P. 543.</li> <li>Hancock, Henry, <i>On operative surgery of the foot and ankle joint </i>(1873).</li> <li>Harris, R. I., <i>Syme's amputation, </i>J. Bone &amp; Joint Surg., 38B:614 (1956).</li> <li>Hutchinson, J., Jr., <i>On the substitution (when practicable) of subastragalar for Syme's amputation, </i>Brit. Med. J., 2:1169 (1900).</li> <li>Jacobson, W. H. A., <i>The operations of surgery, </i>First American ed., Blakiston, Philadelphia, 1889. Pp. 939-943.</li> <li>Kirk, N. T., <i>Amputations, </i>W. F. Prior Co., Inc., Hagerstown, Md., 1942.</li> <li>Kuhns, J. G., <i>Changes in elastic adipose tissue, </i>J. Bone &amp; Joint Surg., 31A:541 (1949).</li> <li>Kuhns, J., and P. D. Wilson, <i>Major amputations-analysis and study of end results in 428 cases, </i>Arch. Surg., 16:887 (1928).</li> <li>Langdale-Kelham, R. D., and G. Perkins, <i>Amputations and artificial limbs, </i>Oxford, London, 1942. P. 3.</li> <li>LeMesurier, A. B., personal communication, 1952.</li> <li>Paterson, R., <i>Memorials of the life of James Syme,</i> Edmonston and Douglas, Edinburgh, 1874.</li> <li>Pirogoff, N. L, <i>Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, </i>J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,<a></a> <i>Precis de manuel operatoire (ligatures, amputations), </i>G. Masson, Editeur, Paris, 1881. P. 527.</li> <li>Roux, J., <i>Annales de Therapeutique, </i>Paris, 1846, quoted from Farabeuf, <i>Precis de manuel operatoire (ligatures, amputations), </i>G. Masson, Editeur, Paris, 1881. Pp. 500-515.</li> <li>Shellswell, J. H., <i>Svme's amputation, </i>Lancet, Vol. II, p. 1296(1954).</li> <li>Simpson, D. C, and A. B. Wallace, <i>Edinburgh's first burn hospital, </i>J. Roy. Col. Surg. Edinburgh, 2:134 (1956).</li> <li>Syme, J., <i>On amputation at the ankle joint, </i>London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</li> <li>Syme, J., <i>Amputation at the ankle joint, </i>London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVIII, April 1843, p. 274.</li> <li>Syme, J., <i>Amputation at the ankle joint, </i>London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</li> <li>Syme, J., <i>Amputation at the ankle joint, </i>London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</li> <li>Syme, J., <i>On amputation at the knee, </i>Monthly Journal of Medical Science, Vol. 5, No. LIII, p. 337, 1845.</li> <li>Syme, J., <i>Amputation at the ankle, </i>Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</li> <li>Syme, J., <i>Contributions to the pathology and practice of surgery, </i>Murray &amp; Gibb., Edinburgh, 1848. Pp. 114-147.</li> <li>Syme, J., <i>Mr. Syme on amputation at the ankle joint,</i> Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (1857).</li> <li>Syme, J., <i>On amputation at the knee, </i>Edinburgh Medical Journal, Vol. XI, p. 871 (1866).</li> <li>Thompson, Henry, Reported in the account of the meeting of the Pathological Society of London for April 21, 1863, and published in Lancet, Vol. I, p. 525 (1863).</li> <li>Tietze, A., <i>Uber den Architektonischen Aufbau des Bindegewebes in der Menschlichen Fussohle, </i>Beitrage zur Klin. Chir., No. 123, p. 493 (1921).</li> <li>Valery-Radot, R., <i>Life of Pasteur, </i>Doubleday, Page &amp; Co., New York, 1919. Chapter IV.</li> <li>Vasconcelos, E., <i>Modern methods of amputation,</i> Department of War Medicine, The Philosophical Library, New York, 1945.</li> <li>Velpeau, A. A. L. M., <i>New elements of operative surgerv, </i>First American Ed., Samuel and William Wood, New York, 1847. P. 595.</li> <li>Volkmann, Richard, <i>Sammlung klinischer Vortrage,</i> Vol. III, #221, (Surg. 70), p. 1878, Die Moderne Chirurgie (1882).</li> <li>Warren, R., I. Thayer, H. Achenbach, and L. Kendall, <i>The Syme amputation in peripheral vascular disease, </i>Surgery, Vol. 37, p. 156 (1955).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Harris, R. I., Syme's amputation, J. Bone &amp;Joint Surg., 38B:614 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Velpeau, A. A. L. M., New elements of operative surgerv, First American Ed., Samuel and William Wood, New York, 1847. P. 595.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Volkmann, Richard, Sammlung klinischer Vortrage, Vol. III, #221, (Surg. 70), p. 1878, Die Moderne Chirurgie (1882).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Pirogoff, N. L, Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,12 Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 527.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Vasconcelos, E., Modern methods of amputation, Department of War Medicine, The Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Kirk, N. T., Amputations, W. F. Prior Co., Inc., Hagerstown, Md., 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Kirk, N. T., Amputations, W. F. Prior Co., Inc., Hagerstown, Md., 1942.</td></tr><tr><td class="clsTextSmall"><b> 42.</b> </td><td class="clsTextSmall">Vasconcelos, E., Modern methods of amputation, Department of War Medicine, The Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Kuhns, J., and P. D. Wilson, Major amputations-analysis and study of end results in 428 cases, Arch. Surg., 16:887 (1928).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Syme, J., Mr. Syme on amputation at the ankle joint, Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (1857).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr><tr><td class="clsTextSmall"><b> 31.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVIII, April 1843, p. 274.</td></tr><tr><td class="clsTextSmall"><b> 32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 33.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</td></tr><tr><td class="clsTextSmall"><b> 35.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle, Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Simpson, D. C, and A. B. Wallace, Edinburgh's first burn hospital, J. Roy. Col. Surg. Edinburgh, 2:134 (1956).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 33.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Brown, Dennis, personal communication, 1955.</td></tr><tr><td class="clsTextSmall"><b> 24.</b> </td><td class="clsTextSmall">LeMesurier, A. B., personal communication, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Warren, R., I. Thayer, H. Achenbach, and L. Kendall, The Syme amputation in peripheral vascular disease, Surgery, Vol. 37, p. 156 (1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Dale, G. M., personal communication, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Shellswell, J. H., Svme's amputation, Lancet, Vol. II, p. 1296(1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Jacobson, W. H. A., The operations of surgery, First American ed., Blakiston, Philadelphia, 1889. Pp. 939-943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Thompson, Henry, Reported in the account of the meeting of the Pathological Society of London for April 21, 1863, and published in Lancet, Vol. I, p. 525 (1863).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Jacobson, W. H. A., The operations of surgery, First American ed., Blakiston, Philadelphia, 1889. Pp. 939-943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr><tr><td class="clsTextSmall"><b> 31.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVIII, April 1843, p. 274.</td></tr><tr><td class="clsTextSmall"><b> 32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 33.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</td></tr><tr><td class="clsTextSmall"><b> 35.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle, Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Blechschmidt, E., Die Architektur des Fersenpolsters, Morphol. Jahrb., 72:20-68 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Tietze, A., Uber den Architektonischen Aufbau des Bindegewebes in der Menschlichen Fussohle, Beitrage zur Klin. Chir., No. 123, p. 493 (1921).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Kuhns, J. G., Changes in elastic adipose tissue, J. Bone &amp;Joint Surg., 31A:541 (1949).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Artificial limbs and their relation to amputations, British Ministry of Pensions, His Majesty's Stationery Office, London, 1939. P. 55.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Langdale-Kelham, R. D., and G. Perkins, Amputations and artificial limbs, Oxford, London, 1942. P. 3.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Broca, A., and C. Ducroquet, Artificial Limbs, Military Medical Manuals, English ed., Sir Alfred Keogh and R. C. Elmslie, eds., 1918. Pp. 77 and 78.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Guyon, F., Gazette des hopitaux, p. 514 (1868), quoted from Farabeuf, Precis de manuel operatoire (ligatures, amputations) G. Masson, Editeur, Paris, 1881. P. 543.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Thompson, Henry, Reported in the account of the meeting of the Pathological Society of London for April 21, 1863, and published in Lancet, Vol. I, p. 525 (1863).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Broca, A., and C. Ducroquet, Artificial Limbs, Military Medical Manuals, English ed., Sir Alfred Keogh and R. C. Elmslie, eds., 1918. Pp. 77 and 78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Broca, A., and C. Ducroquet, Artificial Limbs, Military Medical Manuals, English ed., Sir Alfred Keogh and R. C. Elmslie, eds., 1918. Pp. 77 and 78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Dent, Clinton T., Surgical notes from the military hospitals of South Africa, Brit. Med. J., 1:1313 (1900).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Syme, J., Mr. Syme on amputation at the ankle joint, Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (1857).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Dent, Clinton T., Surgical notes from the military hospitals of South Africa, Brit. Med. J., 1:1313 (1900).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Hutchinson, J., Jr., On the substitution (when practicable) of subastragalar for Syme's amputation, Brit. Med. J., 2:1169 (1900).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Velpeau, A. A. L. M., New elements of operative surgerv, First American Ed., Samuel and William Wood, New York, 1847. P. 595.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Pirogoff, N. L, Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,12 Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 527.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Pirogoff, N. L, Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,12 Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 527.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Pirogoff, N. L, Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,12 Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 527.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Pirogoff, N. L, Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,12 Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 527.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Guyon, F., Gazette des hopitaux, p. 514 (1868), quoted from Farabeuf, Precis de manuel operatoire (ligatures, amputations) G. Masson, Editeur, Paris, 1881. P. 543.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Hancock, Henry, On operative surgery of the foot and ankle joint (1873).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Jacobson, W. H. A., The operations of surgery, First American ed., Blakiston, Philadelphia, 1889. Pp. 939-943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Jacobson, W. H. A., The operations of surgery, First American ed., Blakiston, Philadelphia, 1889. Pp. 939-943.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Roux, J., Annales de Therapeutique, Paris, 1846, quoted from Farabeuf, Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. Pp. 500-515.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle, Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Syme, J., Mr. Syme on amputation at the ankle joint, Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (1857).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Carden, H. D., On amputation by single flap, Brit. Med. J., 1:416 (1864).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the knee, Edinburgh Medical Journal, Vol. XI, p. 871 (1866).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Carden, H. D., On amputation by single flap, Brit. Med. J., 1:416 (1864).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the knee, Edinburgh Medical Journal, Vol. XI, p. 871 (1866).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the knee, Monthly Journal of Medical Science, Vol. 5, No. LIII, p. 337, 1845.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Fergusson, System of practical surgery, 4th ed., review in Lancet, Vol. II, p. 394 (1857).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Syme, J., Mr. Syme on amputation at the ankle joint, Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (1857).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVIII, April 1843, p. 274.</td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle, Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr><tr><td class="clsTextSmall"><b> 37.</b> </td><td class="clsTextSmall">Syme, J., Mr. Syme on amputation at the ankle joint, Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (1857).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Godlee, Sir Rickman, Life of Lord Lister, 3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Godlee, Sir Rickman, Life of Lord Lister, 3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Godlee, Sir Rickman, Life of Lord Lister, 3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr><tr><td class="clsTextSmall"><b> 31.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVIII, April 1843, p. 274.</td></tr><tr><td class="clsTextSmall"><b> 32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 33.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</td></tr><tr><td class="clsTextSmall"><b> 35.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle, Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Brown, John, Horae subsecivae, new ed. in 3 vols., Adam and Charles Black, London, 1897. First series, p. 360.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Brown, John, Horae subsecivae, new ed. in 3 vols., Adam and Charles Black, London, 1897. Second series, p. 363. See also Everymans Library, Rob and his friends and other papers, by John Brown, J. M. Dent and Sons, London, 1906.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Godlee, Sir Rickman, Life of Lord Lister, 3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</td></tr><tr><td class="clsTextSmall"><b> 44.</b> </td><td class="clsTextSmall">Volkmann, Richard, Sammlung klinischer Vortrage, Vol. III, #221, (Surg. 70), p. 1878, Die Moderne Chirurgie (1882).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Valery-Radot, R., Life of Pasteur, Doubleday, Page &amp;Co., New York, 1919. Chapter IV.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Godlee, Sir Rickman, Life of Lord Lister, 3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Paterson, R., Memorials of the life of James Syme, Edmonston and Douglas, Edinburgh, 1874.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>R. I. Harris </b></td></tr><tr><td class="clsTextSmall">M.C., M.B., F.R.C.S. Can., F.R.C.S. Eng. (Hon.), F.R.A.C.S. (Hon.), F.R.C.S. Edin. (Hon.), Lecturer in Surgery, University of Toronto, Toronto, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1961_01_004/a001.jpg Figure 2 http://www.oandplibrary.org/al/images/1961_01_004/a002.jpg Figure 3 http://www.oandplibrary.org/al/images/1961_01_004/a003.jpg Figure 4 http://www.oandplibrary.org/al/images/1961_01_004/a004.jpg Figure 5 http://www.oandplibrary.org/al/images/1961_01_004/a005.jpg Figure 6 http://www.oandplibrary.org/al/images/1961_01_004/a006.jpg Figure 7 http://www.oandplibrary.org/al/images/1961_01_004/a007.jpg Figure 8 http://www.oandplibrary.org/al/images/1961_01_004/a008.jpg Figure 9 http://www.oandplibrary.org/al/images/1961_01_004/a009.jpg Figure 10 http://www.oandplibrary.org/al/images/1961_01_004/a010.jpg Figure 11 http://www.oandplibrary.org/al/images/1961_01_004/a011.jpg Figure 12 http://www.oandplibrary.org/al/images/1961_01_004/a012.jpg Figure 13 http://www.oandplibrary.org/al/images/1961_01_004/a013.jpg Figure 14 http://www.oandplibrary.org/al/images/1961_01_004/a014.jpg Figure 15 http://www.oandplibrary.org/al/images/1961_01_004/a015.jpg Figure 16 http://www.oandplibrary.org/al/images/1961_01_004/a016.jpg Figure 17 http://www.oandplibrary.org/al/images/1961_01_004/a017.jpg Figure 18 http://www.oandplibrary.org/al/images/1961_01_004/a018.jpg Figure 19 http://www.oandplibrary.org/al/images/1961_01_004/a019.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The History and Development of Syme's Amputation Creator An entity primarily responsible for making the resource R. I. Harris * https://staging.drfop.org/files/original/b21f639d8362d0faf7871fcd6b206981.pdf 00160730564941a88e1227cce0fc4cd6 https://staging.drfop.org/files/original/ae5fbb09b20594328d67143767a4b196.jpg 1f7187fd9cd02bd85bbacdc01a7d59b1 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_02_050.pdf Year 1963 Volume 7 Issue 2 Page Number(s) 50 - 52 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_02_050.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_02_050.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 Limb-Deficient Child, a Review</h2> <h5>Charles H. Frantz, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p><i>The Limb-Deficient Child</i> is important as the first comprehensive summary of modern techniques in the relatively new field of child prosthetics. For until recent years, the consensus was that prosthetic fitting could wait "until the child is older"-an opinion based on the generally unsatisfactory attempts to care for the child amputee as if he were simply a small adult. The presentation made in <i>The Limb-Deficient Child</i> is based on the experience of the Child Amputee Prosthetics Project of the University of California at Los Angeles. The Project was started in 1955 and is supported by grants from the United States Department of Health, Education, and Welfare. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. <i>The Limb-Deficient Child</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Dr. Milo B. Brooks, who is the Medical Director of the Project, various members of the Project staff, and other persons closely associated with the Project are the contributors to <i>The Limb-Deficient Child</i>. The nine chapters of the book cover the role of the medical director, orthopedic considerations, psychosocial problems, preprosthetic evaluations, preprosthetic therapy, child prosthesis design and fitting, training, training the upper-extremity amputee, and lower-extremity training. There are numerous illustrations, the appendix contains various evaluation charts developed at the Child Amputee Prosthetics Project, and there is an index.</p> <p>Chapter I, "The Role of the Medical Director," describes the type of information desired from the referring physician and parents, stressing social information concerning the family organization, the child's general physical condition, and the type of amputation presented. A number of charts depict the normal development of children, with heights and weights for given ages. There is some discussion of the growth and development of limb-deficient children, the problems of limb dominance, and psychological adjustment. The etiology of congenital limb deficiencies is briefly discussed, and statistics are presented on cases studied at the Project. The thalidomide syndrome is briefly mentioned.</p> <p>Chapter II, "Orthopedic Considerations," discusses the relative importance of orthopedic management, the utilization of plas-ter-of-Paris cast techniques for correction, the use of braces, indications for surgical interference, the problem of scars, and the functional range of joints. Although very brief, the discussion on long bones, osteotomies, the problem of terminal overgrowth of long bones, neuromata, and the judgment and timing of surgical conversion of deficient extremities to more conventional types of stumps will be of interest to the orthopedist.</p> <p>This reviewer, however, is not in agreement with the attempt made in the discussion of the development of limbs to assign dermatome relationships to the limb buds.</p> <p>In general, this reviewer agrees with the brief classification of limb deficiencies, although it is incomplete from an anatomical standpoint. Perhaps future modifications may be in order to produce a more universal nomenclature, understandable to all who are interested in the limb-deficient child. The classification is followed by the prosthetics management of the terminal transverse deficiencies from wrist disarticulation (acheiria) up to amelia or shoulder disarticulation.</p> <p>Chapter III, "The Psychosocial Problems," gives a realistic discussion of parental guilt feelings and parental cooperation and emotional stability. There is discussion of the role of the physician in attempting to produce an environment of cooperation by the parents, an environment that is essential for success in treating the child amputee. The problems confronting the prosthetics team during the child's preadolescent and adolescent years are discussed, and the role of the social worker is clearly defined. This is an important chapter in the book.</p> <p>Chapter IV, "Preprosthetic Evaluations," discusses in detail the roles of the occupational therapist and the physical therapist. Reference is made to <i>The First Five Years of Life</i>, by Arnold Gesell and others, and it is highly desirable that therapists be well acquainted with this work. Chapter IV briefly describes the progress of motor kinesthetic development from the infant to the toddler. Techniques for determining the range of motion and the functional needs of the child are analyzed carefully. The chapter discusses the self-care needs of the child and relates them to the type of prosthesis indicated.</p> <p>In Chapter V, "Preprosthetic Therapy," the principles of joint motion, the correction of contractures, techniques of bandaging for shrinkage, the proper use of crutches, and skin care are elucidated and beautifully illustrated by photography.</p> <p>Chapter VI, "Child Prosthesis Design and Fitting," presents the important consideration of the growth of the child as contrasted to the adult. Materials for prostheses, such as plaster and polyester and epoxy resins, are discussed. The choice of terminal devices appropriate to the age and size of the child is clearly stated and well illustrated. Techniques for harnessing are demonstrated by photography. In addition, there are shown nonstandard types of prostheses for fitting upper-extremity phocomelic children. Unusual methods for operating elbow locks, by the phocomelic limb, buried in the humeral section of the prosthesis, are given special attention. The problems of upper-extremity amelia, both unilateral and bilateral, are discussed and shown in photographs, including cable systems and the various methods of hook-ups for the transmission of power. The problem of fitting a multihandicapped child is covered, together with some of the frustrating problems of finding power for terminal-device operation that is adequate in terms of the amount of energy expended. Stages of fitting lower-extremity amelic children from a small stationary bucket up to two prostheses are shown.</p> <p>In Chapter VII, "The Training Period," the training of the limb-deficient child is stressed, and rightly so. The child must know what the prosthesis will do for him. The chapter also emphasizes that one cannot go beyond the child's capabilities or his kinesthetic development for his years. One must not expect too much too soon in the avenues of function. There is a practical and well-illustrated discussion of clothing needs and modifications for ease of application. Illustrations also show how to reduce friction from the system through proper alignment of the cable-control assembly. Techniques to be employed by the unilateral and the bilateral amputee in applying and removing the prosthesis are excellently illustrated. The lower extremities are dealt with briefly with respect to the fitting of the socket, proper application-especially the fitting of a suction socket-and the problems involved with a patellar-tendon-bearing prosthesis and bilateral lower-extremity prostheses.</p> <p>Chapter VIII, "Training the Upper-Extremity Amputee," is well illustrated and goes into considerable detail. The environmental situation is discussed, and the necessary equipment is illustrated. In this reviewer's mind, there is some question about the discussion of training infants, because it is debatable whether one actually trains an infant or simply exposes him to experience in motor fields. There is discussion of the desirability of the presence of parents during training periods. Techniques for activating the components in stages by the young child are clearly presented, and action photographs show the functional capabilities of youngsters of various ages, both unilateral and bilateral types. Activities (aids to daily living) are well documented and very practical. This chapter should be especially interesting to occupational therapists.</p> <p>Chapter IX, "Training the Lower-Extremity Amputee," is much shorter than the preceding chapter. It gives a brief description of the progress of a youngster from infancy to an erect standing posture. Three phases of training are discussed with respect to the lower-extremity amputee. Comfort, fit, and skin tolerance are important during the first phase, with frequent inspection of the skin and prosthesis alignment. Independent ambulation is achieved during the second phase. During the third phase, faster ambulation, stair climbing, and walking up and down ramps and over uneven ground are mastered. This training is clearly illustrated by excellent photographs.</p> <p>Judging by its title, one would expect <i>The Limb-Deficient Child</i> to be a textbook on all facets of the child amputee. It is not such a text. It is a well-written presentation of the experiences of the Child Amputee Prosthetics Project of the University of California at Los Angeles. The problems of the limb-deficient child are much more far-reaching than this volume indicates.</p> <p>But the book is important as the first of its kind and should serve as a reference for physical and occupational therapists and for pros-thetists. It is a clear and very adequately illustrated narrative, with excellent photographs of children in action during their training periods, and photographs of prostheses. Harnessing patterns and cable operations are clearly depicted. There is much material here that should be of great assistance to therapists and prosthetists, particularly those who have broad experience with adult amputees. For with this text they can translate their past experience into the area of child amputees, especially those with congenitally malformed limbs.</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>Charles H. Frantz, M.D. </b></td></tr><tr><td class="clsTextSmall">Medical Co-Director, Area Child Amputee Program, Michigan Crippled Children Commission; Chairman, Subcommittee on Child Prosthetics Problems, CPRD, NAS-NRC, Washington, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_02_050/1963-Autumn-59.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 Limb-Deficient Child, a Review Creator An entity primarily responsible for making the resource Charles H. Frantz, M.D. * https://staging.drfop.org/files/original/704be8285e9e81b00a548f4079273dd0.pdf 8d139ddf679c176348350d328a543afd https://staging.drfop.org/files/original/49cf18e648ecc82d654ec1eff2291631.jpg c1cfed36a05f0a2fc50153fd5c760913 https://staging.drfop.org/files/original/75674097e4e35c77fdec5a976ff86d62.jpg 9f31ccdf0294986d2aea9d550887f50f https://staging.drfop.org/files/original/6e8abc5344c8c89a34bb7bb7e58e2657.jpg 6093fff8491a17af6fc0bb951f2df011 https://staging.drfop.org/files/original/37d0211a1c3964d660b5475199ef272d.jpg e15ab0ecdc3c30f04f9a0f88d1e7f911 https://staging.drfop.org/files/original/074ff2c61033b2276ba9ba6b32d533dc.jpg 18833eb4185b3218e31d0f5a35889396 https://staging.drfop.org/files/original/25f6feb898b3105da3d22efedaad8b5f.jpg 14cd923437e363674f1305376f929c93 https://staging.drfop.org/files/original/98c6f90be1d6a610b1532fee234863eb.jpg 77448c6435f7e839884d481f8bb7c0bc https://staging.drfop.org/files/original/bf8014ecf9aef0436238851fa1474e8e.jpg a485adc4c47126a56ef395422b794cc0 https://staging.drfop.org/files/original/a3f8fed82c099bfaf63d22effee25dc9.jpg 3aafbd4368cc3968a6ed5d0bf3d576af https://staging.drfop.org/files/original/63989f61bdf02ae37100a3e5d28a3065.jpg 3b2ff7b083f358ef57a6a637a5333dc6 https://staging.drfop.org/files/original/6a514f0e2ba1bfd9ba93437672e576c3.jpg 17049ac032017d5b129e9629dd56a9f4 https://staging.drfop.org/files/original/dd2a27378293b40a365d988be7038823.jpg 487fe803ef2ffdf12201d3e066227729 https://staging.drfop.org/files/original/79421da1d5927a2f575339efaaae587a.jpg 7727b475ea61106ccba34b7e0a8fea80 https://staging.drfop.org/files/original/85780afcefa210b16b3180eb1a8a32c7.jpg 0929c4e5349737a970d707389cc7e591 https://staging.drfop.org/files/original/80b1690efe4254fee0a6b928f0221b73.jpg b35fcbb513359778fadce4c9655b88ac https://staging.drfop.org/files/original/a7b48775e41332452941b1805803de4f.jpg 2d1f4f535f9b9df473d2a83b9a61d6db https://staging.drfop.org/files/original/354cad5e63e3f2ee432a2a43b8af480f.jpg f54280fbcdcd946cade07b9a0e67cf76 https://staging.drfop.org/files/original/8932dd244d2f177f348642bab3474157.jpg a9162486c8f3c0b05d8e402bb14cb9cc https://staging.drfop.org/files/original/172fcac01d1f6b60da95c9da079d9b0c.jpg 29f465e6e6425c776b16326e64e5ec8a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_01_004.pdf Year 1955 Volume 2 Issue 1 Page Number(s) 4 - 34 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_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 Lower-Extremity Clinical Study-Its Background and Objectives</h2> <h5>VerneT. Inman, M.D., Ph.D., <a style="text-decoration:none;">*</a><br />Howard D. Eberhart, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p> If it may be postulated correctly that the most satisfactory artificial leg is the one which most nearly simulates the static and dynamic behavior of the natural limb it replaces, the successful practice of lower-extremity prosthetics poses a twofold requirement. The first is an intimate and detailed knowledge of the characteristics of the normal leg in all common activities, and the second is the ability to reproduce as nearly as possible, by a combination of design and fit of the substitute limb, the kinetic and kinematic features essential to normal locomotion. In the Artificial Limb Program, principal responsibility for fundamental studies in normal and amputee gait and in lower-extremity prosthetics has, since 1945, resided in the Prosthetic Devices Research Project at the University of California, Berkeley Campus. </p> <p> But the problems facing the leg amputee are not wholly prosthetic. Many, indeed, are clearly medical. For the amputee, being no longer the whole normal individual, manifests gross structural and physiological changes to be dealt with successfully only by the physician. </p> <p> The Lower-Extremity Clinical Study being conducted jointly by the Department of Engineering, University of California, Berkeley, and the University of California Medical School, San Francisco, and in cooperation with the U. S. Naval Hospital, Oakland, has as its chief objectives the analysis of medical problems inherent in the amputated state and the application of fundamental knowledge to practical problems in the management of lower-extremity amputees. Current techniques and practices in the fitting of leg amputees still are so varied from place to place and from prosthetist to prosthetist that some orderly means has been wanting for establishing what is, everything considered, the best prosthetics practice in the lower extremity. Designed to close the gap between basic work in the laboratory and work in the field, the Clinical Study is an outgrowth of the fundamental research in locomotion conducted earlier by the Berkeley Project. </p> <h3>The Background </h3> <p> For a number of years during World War II a group at the University had been conducting research in the field of biomechanics and had published data relating to the behavior of the upper extremity. In the autumn of 1945, therefore, the University was approached by a representative of Northrop Aircraft, Inc., a company which at that time was already engaged in prosthetics research<a></a> under contract with the then Committee on Artificial Limbs of the National Academy of Sciences- National Research Council. It was requested that the University group undertake an investigation aimed at providing information that could be utilized in the design and construction of lower-extremity prostheses. </p> <p>The suggestion having been taken under advisement, the entire Committee on Artificial Limbs met at the University shortly thereafter to consider the proposal and to evolve details of contractual arrangement. Out of this meeting came two basic observations. One was that, inasmuch as the financial support for the work was to come from public funds, any information derived from the contract would have to be shared with all other contractors participating in the Artificial Limb Program as well as with the general public. The other was that, in the opinion of the conferees, between five and seven years of study would be required before sufficient detailed and quantitative information could be accumulated to effect substantial improvement in lower-extremity prostheses.<a></a> At the outset, the University group insisted that it be kept free of the task of developing prosthetic devices-that it simply be permitted to investigate normal human locomotion and to furnish the collected data for others to use. The original concept of the scope of the project-as a program of basic research in human locomotion-has been adhered to up to the present time, the only deviations having involved development of experimental devices<a></a> needed to assist in the locomotion studies. </p> <p> The early years, then, were spent in working out techniques suitable for recording objectively the motions and the forces involved in the gait of man.<a></a> Of course, the investigators took advantage of all the previous work in this field, not only that done by other contractors<a></a> participating in the Artificial Limb Program but also that contained in material, particularly that of Elftman<a></a> published in the United States and in foreign countries over a period of many years. By 1947, enough data had been accumulated to publish a comprehensive report<a></a> on the walking pattern of normals and of leg amputees.<a style="text-decoration:none;">*</a> </p> <p> Attempts to translate the results of basic research into criteria for the improvement of prosthetic devices led to the second phase of the project, that is, to developmental research, an area that involves engineering and prosthetics technology. During the last few years, this phase of the project has been conducted on a relatively small scale. As devices were prepared for trials by amputees, the problem of fit and alignment had to be attacked, and hence fundamental studies were undertaken in this area in order to establish a set of basic principles and techniques.<a></a> Because fitting and alignment contribute most to the comfort and therefore to the success of any artificial leg, the validation of these principles and techniques formed the basis for embarking on the third phase of the project, the Lower-Extremity Clinical Study, an activity that provides a laboratory where medical and prosthetic problems can be handled under controlled conditions. It offers an opportunity to see how individual solutions may be obtained by applying a set of general principles based on biomechanical considerations. Until recently, the study group has been concentrating on the problems of the above-knee amputee because that case appeared to offer neither the most difficult nor simplest set of circumstances. </p> <h4> The Locomotion Studies </h4> <h5> <i>Muscle Physiology</i> </h5> <p> When the Prosthetic Devices Research Project first was organized, man was viewed as a machine, the object being to measure the displacements, accelerations, and forces required in human locomotion.<a></a> But man is more than a single machine. He is powered by a complicated system of many internal engines served by muscles. Accordingly, the study was broadened to include the field of muscle physiology.<a></a> Investigation of the behavior of the musculature during normal locomotion (<b>Fig. 1</b>) revealed the basic action of the various muscles involved<a></a> It was shown that in locomotion each muscle acts when it is near its rest length but that it acts for a very short period of time in each walking cycle.<a></a> This action makes the contraction essentially isometric and limits the activity of each muscle fiber to a few twitches. Under these conditions the muscle works with minimal energy and maximum tension, which helps to explain why a person can walk considerable distances without tiring. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical electromyographic summary curves, in this case for the hamstring group. Ten subjects. Cadence: 95 steps per minute, level walking. Data from UC studies 102. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Upon working out the speed of contraction, it was found that, if muscles are halved, their contractile velocities likewise are halved (<b>Fig. 2</b>). Utilizing a profile electromyographic recording (electromyogram rectified and dampened to give a relatively smooth line), and taking the maximum amplitude in a given cycle as 100 percent, the average durations with an amplitude greater than 75, 50, or 25 percent are approximately 0.04, 0.1, and 0.2 second, respectively.<a></a> Since it seems probable that the profile electromyographic amplitude largely indicates relative numbers of active motor units, it would appear that most of the units participating in this phasic action are active during bursts of 0.1 to 0.2 second only. According to Weddell<a></a>, at a repetition rate of 20 per second or less most motor units would fire in each cycle one to four times only. In such a case, any temporal summation taking place at neuromuscular junctions would not be effective fully, and the action of a motor unit, at least in a normal phasic pattern like locomotion, would not have the character of a sustained tetanus. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Relation between the maximum speed with which a muscle can contract and the weight with which it is loaded. When the length of the muscle is halved, its speed of contraction is also halved. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> As a result of these investigations, in 1947 the group at Berkeley, noting the earlier work of Blix<a></a>, was first to call attention to the length-tension relationships existing in human muscles<a></a> and thus laid the basis for the decision to use certain muscles for the cineplastic technique.<a></a> The characteristics of the length-tension diagram have since proved to be of fundamental importance in devising prosthetic aids for upper-extremity amputees.<a></a> The cineplastic muscle tunnel, comprising a skin-lined tube placed through the distal end of a muscle, permits an amputee to utilize effectively his own muscle forces for activating an artificial arm or hand. But in order to operate a cineplastic prosthesis efficiently, it is necessary that the muscle be near its rest length, so that it can generate a force sufficiently large and so that it can shorten enough to carry out necessary movements.<a></a> Appearing in publications as early as 1949, the work conducted at the University of California has been recognized by Buchthal<a></a> of the University of Copenhagen as the best so far done on normal human muscle dynamics. </p> <h5> <i>Energy Requirements</i> </h5> <p> In another study, an investigation was made of the dissipation of energy (<b>Fig. 3</b>) in human locomotion.<a></a> Results showed that approximately 50 percent of the energy consumed in walking is used simply in bouncing up and down, that is, in vaulting over one leg and then the other. The other half is used in the oscillations of the legs. It is therefore apparent that, if the amputee is not to be subjected to unduly large energy demands, he must have a smooth pathway of displacement of the center of gravity of the body.<a></a> Any deviation from the smooth, natural locus of the center of gravity means excessive dissipation of energy and consequent degradation into heat.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 3. Typical moment-angle diagram for the leg of a normal subject during level walking. From Bressler [sic] and Berry (14). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Contrary to much popular belief, man not only pushes his way through space. He also <i>pulls </i>his way.<a></a> Indeed, deceleration of the swinging leg, not push-off from the other toe, provides the greater part of the energy for locomotion, the proportion attributable to deceleration of the swinging leg being about 4, that attributable to push-off only 3. Energy is absorbed by the knee to decelerate the leg and foot during the swing phase, but not all of the energy so absorbed is lost.<a></a> A considerable portion is stored and returned to the system in the later part of the swing phase to impart continued forward acceleration at the time when most of the body's potential energy is lost.<a></a> Thus locomotion is due not only to the push of the member in support but also to the pull of the deceleration in the swinging knee. </p> <p> Because the above-knee amputee has no calf group, and therefore cannot contribute the equivalent of this force at push-off, it was suggested that some conservation of energy might be effected in a prosthetic device without an ankle joint.<a></a> That this was a correct deduction has since been demonstrated (<b>Fig. 4</b>) in the Stewart-Vickers leg,<a></a> in which the ankle is locked at toe-off until 20 deg. of knee flexion has occurred.<a></a> It has the highest net output and the lowest total input of all legs tried to date (<b>Fig. 5</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 4. Cadence changes observed in above-knee amputees asked to walk at "normal" speed first with a conventional limb and then with the Stewart-Vickers (locked ankle) prosthesis 114. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Energy characteristics of the normal ankle compared with those of the conventional leg and the Stewart-Vickers leg. Top, total input, total output, and net output of both ankles per stride. Bottom, input and output of each ankle per step. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Amputee Pain </h4> <p> Intimate contact with amputees led to the early investigation of pain as related to the amputee patient.<a></a> In 1946 a team of interviewers set out to question amputees in various hospitals, particularly in the Veterans Administration Hospitals and in the Naval Hospital then at Mare Island. Over a period of a year and a half, detailed histories were obtained from 80 patients. As a result of this review, further funds were provided by ACAL to establish a Pain Clinic at the University of California, primarily to evaluate pain as found in the amputee. Established in August 1949, the clinic functioned until January 1953. </p> <p> In June 1952, an analysis of 218 amputees was reported.<a></a> In this study, which constitutes one of the largest series on record, the type and frequency of pain in the amputee were explored. Because it was thought that perhaps deficiencies in stump circulation might contribute to the pain experienced by the amputee, circulatory studies were undertaken. Concurrently, innervation of the deeper tissues was studied.<a></a> Sections of tissue were taken from periosteum, muscle, and skin, and the nerve supply to these tissues was demonstrated by a methylene blue technique. </p> <p> One of the most intriguing aspects of this investigation was the work with normal individuals in whom irritative lesions purposely were produced in the deeper tissues.<a></a> With the authors, some 75 medical students, and three laboratory assistants serving as subjects, 0.5 to 1.0 cc. of 6-percent saline solution was injected systematically into the paravertebral muscles at each intervertebral level from the atlanto-occipital area to the lower sacrum. Five subjects were used in the testing of each injection site, a total of 140 individual observations being made. Although the distribution of pain approximated a segmental plan, it also overlapped considerably and differed in location from the conventional dermatomes. It was found that, in any irritation of deep somatic tissues, pain did not restrict itself to the area of injection but tended to radiate distally into the extremities. Injection of 6-percent saline into any given interspinous level produced in the normal a characteristic pain distribution that was remarkably constant from subject to subject. The distribution of pain referral from deep structures in the normal suggested similar investigations in the amputee. To elicit the sensation of the phantom limb, it was necessary to inject the salt solution into the appropriate interspace. In the normal, radiation of pain into the lower limb was most marked when the interspinous tissue between L4 and L5 was affected, and in the above-knee amputee the L4-L5 interspace also gave the best response. The immediate reactions of amputees resembled those reported by normals-a rapid onset of pain close to the site of injection and then, in the case of L4-L5 injection, radiation into the buttocks and the posterolateral aspect of the thigh. In nearly all instances there occurred a rapid "filling" of the absent areas of the phantom limb, the subjects usually evidencing surprise at the sudden totality of a phantom limb even though the new portions were seldom, if ever, immediately painful. </p> <p> Severe pain was a frequent feature in the portion of the phantom present before injection. After injection the pain often spread into the newly "filled in" portion of the phantom limb. Transient pain following injection occurred in phantom limbs regardless of the existence of preinjection pain. But in many cases involving pre-existing phantom pain, a secondary decrease in the amount of pain followed the injection, in some but not in all instances the decrease being preceded by a transitory accentuation of the pre-existing pain. Occasionally, the decrease reached the point where no pain was felt, so that the amputee experienced the first complete relief in many months. </p> <p> The decrease in pain is even more remarkable when one considers that it is brought about by the application of a noxious stimulus to a tissue remote from the phantom itself. For example, in an above-knee amputee who had undergone amputation two months before the investigation, there was a phantom sensation of the "foot" only, the phantom being very painful with the sensation of severe constriction of the great "toe" (<b>Fig. 6</b>). When saline was injected into the L4-L5 interspace, much of the intervening phantom limb was filled in almost immediately, the anterior aspect of the "leg" becoming the most prominent part. Soon after the phantom was "completed," the preexisting pain in the "foot" increased in intensity and area. This state continued for five or six minutes, whereupon the pain began to decrease and continued to do so until, in another five minutes, it had disappeared completely. Numbness, but not pain, remained in the "foot" only. In some instances even phantom awareness disappeared after saline injection. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Effect of interspinous injection of saline on the painful phantom limb of one subject. A, Phantom before injection. B, Radiation of sensation induced by injection of 6-percent sodium chloride solution. C, Residual sensation following injection. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In general, the saline injections had greater effects on phantom limbs than on real ones, a peculiar susceptibility best illustrated by the effects of mid-line injections. An accurately placed mid-line injection in a normal subject produces very little radiation, the severe pain being confined to a rather small area in the immediate vicinity of the injection. In the case of the amputee, however, such minimal radiation in the trunk is accompanied by profound effects on the phantom extremity. Every conceivable change in phantom form and phantom pain can result from interspinous injection of an irritating hypertonic saline solution, the changes probably stemming from the sudden increase in the sensory inflow at the particular segmental level. </p> <p> Out of these observations came, then, one method of treating phantom pain, for when a small amount of hypertonic saline was injected into the appropriate segmental interspinous ligament, the phantom experience was changed and pain occasionally was relieved. This finding led to the use of hypertonic saline for the treatment of various painful conditions. Although permanent cures resulting from such techniques are not numerous, the method may prove to be a valuable addition to the modern medicine chest, which is by no means rich in effective pain palliatives.<a></a> </p> <p> It deserves to be noted that, in seeking the origin of the phantom experience, one must look not only for direct involvement of the nerves of major nerve trunks. The entire segment of the extremity must be investigated for any irritative skeletal lesions arising from the joints, the muscles, or the connective tissues of the stump or from portions proximal to the stump. </p> <h3> Evolution of Basic Data </h3> <p> From the basic studies now has come much information of value in prosthetics. As early as 1947 it was determined<a></a> that in normal walking the leg rotates in space internally and externally about 15 deg. on the average (<b>Fig. 7</b>). That this horizontal rotation of the extremity might be of some importance in human locomotion has since been known as the "Berkeley fetish," and as far as is known no one has yet taken cognizance of the fact in any successful limb design. In 1950 it was suggested<a></a> that it would be of considerable value if deceleration at the end of the swing phase could be incorporated through some sort of variable-cadence knee joint. This has been done in at least one device, the U.S. Navy above-knee leg,<a></a> now available commercially (see <i>Digest, </i>this issue, page 65). Several others currently are under development. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 7. Typical relative rotations of the pelvis, femur, and tibia in normal, level walking. Data from UC studies </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> At the same time it was suggested that, inasmuch as the above-knee amputee can obtain no forward propulsion by contraction of the calf group, the ankle joint is of little use- that, indeed, if an ankle joint with rubber bumpers is used, energy is lost by hysteresis of the bumpers. As already mentioned, the improved performance of the Stewart-Vickers leg, in which the ankle is locked at toe-off up to 20 deg. of knee flexion, proves the validity of the original observation. Similarly, it was pointed out that, because of the interrelationship between the ankle-foot function and the knee-joint function, greater stability would be required of the knee joint were the articulated ankle to be abandoned. </p> <p> In 1953, Saunders, Inman, and Eberhart<a></a>, summing up the results of all the basic studies, pointed out that there is an interrelationship between all displacement patterns of all segments of the lower extremity, that there are six major determinants in locomotion, that modification of one results in modification of the others, and that any changes in the knee or ankle, either in normal or in amputee, are necessarily accompanied by compensatory changes in the remaining joints. Basically, locomotion is the translation of the center of gravity through space along a pathway requiring the least expenditure of energy (<b>Fig. 8</b>). The six major determinants of the pathway are pelvic rotation, pelvic tilt, knee flexion, knee extension, knee and ankle interaction, and lateral displacement of the pelvis. Serial observations of irregularities in these determinants provide insight into individual variation and a dynamic assessment of pathological gait, which may be viewed as an attempt to preserve the lowest possible energy consumption by exaggerating motions at unaffected levels. Compensation is reasonably effective with the loss of one determinant, that at the knee being the most costly. Loss of two determinants makes effective compensation impossible, the cost of locomotion in terms of energy then being increased threefold, with an inevitable drain upon the body economy. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The sum of the effects of the six determinants of gait. The pathway of the center of gravity is a smooth curve in both horizontal and vertical planes. From Saunders, Inman, and Eberhart<a></a>, by permission of The Journal of Bone and Joint Surgery. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> With regard to the surgery of amputation, the studies in muscle physiology suggested that considerable improvement might be effected in lower-extremity prosthetics were muscles fixed in the distal end of the stump so that they could not retract.<a></a> As previously pointed out, retraction of these muscles means shortening, and shortening means an inability to develop natural tensions. More recently the studies have suggested that, in order to retain normal weight-bearing through the shaft of the femur, more attention should be paid to the possibility of end-bearing rather than to the more conventional method of weight transmission through the ischial seat. All of these ideas, derived from the results of the early studies on locomotion, were offered to the limb industry by the University group in the hope that designers or manufacturers would incorporate the recommended features into new prostheses. </p> <h3> The Clinical Study </h3> <p> In the spring of 1953, after years of basic study, the question arose as to what might be done toward applying to the amputee problem some of the knowledge gained. After several months of discussion, the UC Prosthetic Devices Research Project accepted a proposal to institute the so-called "Clinical Study," the principal objective being to draw upon the pool of fundamental knowledge, to attempt to apply it toward the solution of practical problems, and to see whether or not there would emerge certain definite devices or methods which could be passed on to the artificial-limb industry and to prosthetists. Last year, then, the clinical program was established, and currently it is the center of attention. </p> <p> To organize such a clinical study obviously required a limbshop and examining rooms. Through the kindness of the Navy, space was afforded at the Navy Prosthetics Research Laboratory at the U.S. Naval Hospital at Oakland, California. There the setup includes a small limbshop where prosthetics work is done, a medical examination room, fitting and training rooms, an evaluation and photography room, and conference rooms, the entire operation being conducted in cooperation with the limb industry. Through the Industry Advisory Committee, amputees are selected on the basis of referral by limbshops, by physicians, by rehabilitation agencies, by the Veterans Administration, and by direct personal contact. After preliminary screening by the Clinical Study Group, an individual is selected only with the approval of the Industry Advisory Committee, and all of the work is done with the knowledge, assistance, and cooperation of the artificial limb industry. </p> <p> Because it is concerned primarily with research, the Clinical Study is not a commercial operation, and consequently production is not high and is not supposed to be. Thus far only 16 subjects have entered the clinic. Of these, 10 are unilateral above-knee amputees ranging in age from the teens to the seventies, two are bilateral above-knee cases, one is a bilateral above-knee/below-knee case, two are hip-disarticulation cases, and one is a unilateral below-knee case. Five are in the follow-up stage, six in the postfitting adjustment stage, three in the fitting stage, and two in the pre-prescription stage. All save one have been complicated cases, presenting difficult problems that nobody else wished to tackle. From particular cases such as these have come practical answers for other difficult cases. </p> <p> A thorough and complete study-from the medical, biomechanical, and prosthetic points of view-is made of each case, and individual problems are diagnosed and corrected. To find the best possible solution in any particular case requires a knowledge of what attempts have been unsuccessful and why they failed, for sometimes a great deal more is learned by determining why one proposed solution failed than by determining why another was successful. </p> <h4> The Clinic Team </h4> <p> The clinic team consists of an orthopedic surgeon, a prosthetist, a physical therapist or amputee instructor, and sometimes an engineer<a></a>. This group makes the initial evaluation and provides a prescription<a></a> based on complete data including a medical history, an analysis of existing condition of the stump and of the rest of the body, and an evaluation of the old prosthesis. The prescription is reviewed by the Clinic Study Panel, including several orthopedic surgeons, a psychiatrist, a prosthetist from industry, and an engineer familiar with prosthetic problems. Once the prescribed device is fitted, the results are viewed by the Panel, and the reasons for success or failure are documented fully so that the case may serve as an example for future reference. No experimental devices are used in the clinic program. Only those devices available commercially are fitted to the subjects. </p> <h4> Industry Participation </h4> <p> Active participation by individual members of the artificial-limb industry has not yet started, but plans are now being made for such activity in the immediate future. That part of the program will involve working with prosthetists, screened by the industry, who will visit the clinic for a period of orientation. They will follow cases through the clinic study and then be assigned a shop case on a cooperative basis. The clinic team will act initially as a review committee in preparing the prescription, but the individual prosthetist will fill the prescription in his own shop. After fitting, the amputee and the prosthetist will return to the clinic for evaluation. This procedure provides a twofold check. It evaluates the prosthetist's degree of efficiency and tests the validity of the clinic's method of prescription. </p> <h4> Prosthetic Problems </h4> <h5> <i>Crotch Pressure</i> </h5> <p> Because enough time has now elapsed to be sure that more than temporary success has been achieved, some general ideas can be discussed with a fair degree of confidence. The most common complaint heard by the group relates to crotch pressure. In every instance, however, the condition has been eliminated. Correcting for excessive crotch pressure involves two things-the right socket shape and correct alignment (page 35). Proper socket shape is ensured by providing for ischial-gluteal bearing (which prevents sinking into the socket), by controlling the anteroposterior dimension, and by raising the height of the socket brim. </p> <h5> <i>Localized Socket Pressure</i> </h5> <p> The next most common complaint relates to edema. Rarely has there been a case of the suction socket where edema could be traced to high negative pressure alone. Excessive crowding or tightness invariably were contributing factors. Edema may result principally from a high rate of pressure change at any point along the length of the stump. Because emphasis has been placed on socket shape near the top brim, not enough attention has been given to good fit throughout the length of the stump. Any constrictions or ridges, including those formed by muscle groups, cause pressure changes that interfere with venous return. The inside finish of the socket also may be a factor. In one instance, for example, a severe case of edema was alleviated by providing the socket with a smooth, high-gloss finish. </p> <h5> <i>Socket Brim</i> </h5> <p> Skin irritation around the socket brim also is a source of annoyance and discomfort. Accordingly, dermatologists are cooperating in the program. They examine amputees having skin problems and outline procedures for therapy, including the taking of biopsies of the skin. Pigmentation is evaluated to determine whether or not it is due to capillary hemorrhage caused by decreased suction or whether it is merely a pigmentation that often occurs in areas of friction. Out of this study should come a routine test and a new modality of skin care for the leg amputee. </p> <p> Again, the condition can be eliminated by controlling the shape and height of the anterior and lateral brim above the ischial seat. Medial width also is a controlling factor because it determines the total amount of pressure exerted by the front of the socket to maintain stability on the posterior weight-bearing surface. And, as in the case of edema, the inside finish is important in preventing skin damage. Sitting discomfort, a complaint often heard, usually is relieved by using a flat back, by not having the inside edge of the seat too sharp, and by ensuring that any channel for gluteal relief is not too large. </p> <h5> <i>Alignment</i> </h5> <p> Alignment is a continuing problem, and the development of guiding principles is most important. Although general principles are comparatively simple to state, to understand them fully and to apply them to individual cases is difficult. One of the objectives of the clinical program is to apply to typical problem cases the alignment principles developed through fundamental research and to develop examples showing how these principles can be applied, why they work, and the end-results that can be obtained. Naturally, the best results are obtained when the stump is so oriented as to take full advantage of the remaining hip musculature. There is a growing body of information relating to a number of common problems-problems associated with changing from a pelvic belt to a suction-socket leg; problems concerning the very muscular stump with prominent hamstrings or with some particularly firm muscle or muscle groups isolated in the stump; problems of the short and the long above-knee stump; problems caused by the flabby stump; and problems of inside finish. </p> <h4> Medical Problems </h4> <p> Often the problems of the amputee, both in the lower extremity and in the upper, stem not from an ill-fitting prosthesis. More often the problems can more properly be termed medical. Accordingly, the Clinical Study includes investigation of those aspects of amputee rehabilitation related to physiological changes associated with loss of limb. </p> <h5> <i>Pain</i>-<i>Phantom and Real</i> </h5> <p> As pointed out long ago<a></a>, loss of the normal limb so often is followed by the appearance of some form of phantom limb that, when a patient does not acknowledge one, it is suspected that he is withholding information or that the phantom has been repressed. Statistics show that the phantom is a normal phenomenon in the sense that most amputees have it. It is pathological, however, in the sense that the amputee perceives something that actually does not exist. </p> <p> In general, awareness is a matter of degree and, to some extent, a matter of verbal conventions. Some amputees say that the phantom has the same unobtrusive quality as does the material counterpart, that it appears only when called upon. Sometimes the amputee has difficulty in remembering that the phantom is unreal and that it does not serve in the capacities of its living predecessor. The normal person is not particularly aware of his limbs unless his attention is drawn to them in some way. Except under the impact of a sudden stimulus, or when a special effort is made, preferably together with a movement, our awareness is potential and shadowy in nature. With the eyes closed, and with the limb at complete rest, awareness is, in fact, not too far removed from mere imagination. To make certain that the limb exists, we move it, look at it, or rub some part of it. The amputee cannot conduct such an empirical test. </p> <p> Sometimes the patient can sense his lost limb as acutely as he can the remaining real one, and he often can imagine that he can "move" the phantom. More often, however, the phantom draws attention to itself by some "abnormal" sensation which makes the amputee more aware of it than he is of his real limb. Fortunately, only a small percentage of all phantoms habitually are painful. Some typical ones are shown in (<b>Fig. 9</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The phantom limb, a phenomenon of almost universal occurrence among amputees. A, Phantom toes and ankle, reported more frequently than are other phantom parts of the amputated lower extremity. B, Mild "tingling," characteristic of the painless phantom, is often described in terms of "crawling ants." C, The "telescoping" phantom, in which the foot, over a period of time, gradually approaches the stump and finally disappears within it. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Frequently the "foot" seems to shorten and approach the end of the stump. The patient illustrated in Figure <i>9C </i>experienced "telescoping" of the phantom, a phenomenon which, contrary to the observations of most other writers on the subject, was found infrequently in the Berkeley series. It is true that relatively undifferentiated parts like the calf and the forearm commonly are not felt. Some phantoms of distal parts are, from their onset, situated at the normal distance from the trunk. Others always seem to be located closer to the stump than normal. A few patients experience a gradual shrinkage of intermediate phantom parts, as has occurred over a period of years in the subject illustrated in (<b>Fig. 10</b>). In this case, all that remains of the shrunken ghost are the "toes," and these have come to lie not in empty space, as is the rule, but inside the stump. Not infrequently a phantom which has shortened may, on application of a prosthesis, lengthen and actually become identified with the artificial limb. Thus, in one instance, a young above-knee amputee felt as though the shortened "foot" were appended to the stump. When he wore his prosthesis, however, the phantom foot felt as though it were in the position corresponding to that of the artificial foot. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. A rare and peculiar form of phantom experience. Here the two "toes" seem to reside within the stump itself. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Awareness of the missing member may or may not be described as basically unpleasant, but it is subject to intermittent unpleasant sensations-itching, tingling, or pain (<b>Fig. 11</b>). As pointed out by Livingston <i>, </i><a></a> the pattern of the painless phantom bears no resemblance to the areas of distribution of the major peripheral nerves. Thus the partial nature of the phantom cannot be ascribed to the affection of certain nerve lesions in the stump. Rather, the pattern of the phantom seems to relate to the most mobile parts and to those serving the highest degree of sensory function. But a substantial number of amputees experience, at one time or another, some sort of painful phantom of varying duration (<b>Table 1</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The painful phantom, of fairly common occurrence among amputees at one time or another. Only some 30 percent experience no phantom pain at any time. Probably about 10 percent face persistent and sometimes incapacitating pain. A, Among the similes used to describe a phantom pain is "as if my toes are being crushed by a hammer." B, Pain experienced at the site of an injury leading to amputation, such as a fracture, often persists as a part of the phantom pattern. C, The "hot wire" sensation and involuntary cramping of phantom toes are among the other frequent manifestations. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><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> How many amputees have pain? Taking into consideration the inadequacies of follow-up information, the subjective character of the pain experience, and the semantic difficulties beclouding the term "pain," a conservative estimate would be that 80 percent of all amputees are substantially free of pain and are either being trained for useful work or else are already actually so engaged. It is likely that, of the remaining group, possibly half are faced with severe intermittent or persistent pain. Because of persistent, incapacitating pain, approximately 10 percent of all amputees never get into a limbshop, never get out of the doctor's office. They become narcotic addicts and often commit suicide. Where pain enters the phantom syndrome, it may assume large clinical importance. If it is excruciating and persists for long periods, it may take a devastating toll of the whole personality and physical well-being. </p> <p> In describing severe pain, we all use a vocabulary taken from common objects known to produce injury. Lesser pains are described in terms of cutaneous and deep sensations. Thus we speak of "pressure," of "pins and needles," of "sharp" pains and "dull" aches, of "stabbing" and "shooting" pains. It seems unlikely that man at his present stage of evolution ever will devise a specific terminology for pain because he has no special organ for observing his discomforts. No matter how introspective a person may be, his account of pain always is phrased in imagery taken from other fields of experience. Nothing could be more real than these sensations, but we say "as if" to give them intelligible expression. The vocabulary is metaphorical. </p> <p> It is not surprising, therefore, to find amputees using language akin to that of the torture chamber when they try to do justice to their agonies. They hardly go further than anyone else in telling about physical sufferin. Nor do they hallucinate when they talk about "ropes" and "vises," for they remain aware of the imaginary character of these similies. It is possible, however, that, as the tearing and squeezing sensations are felt in a part of the body known to be missing, the suffering is heightened and the imagery made more vivid by the ghostly character of the phantom. </p> <p> It has been argued that phantom sensations are hallucinations because they entail a belief in the reality of an absent object, or that they are illusions because irritations of the stump are being misinterpreted, or that they are normal sensations because the cerebral representation of the once-present member still is intact. Some workers have correlated the type of sensation with the "level" of its origin in the nervous system, painful sensations being ascribed to pathological conditions of the cut nerve end in the stump or to mental aberrations. But classifications of either the amputee's descriptions or of the presumptive causes bringing about the sensations have thus far been unsatisfactory. The various frames of reference used in the statistical survey at Berkeley do, in fact, overlap. Duration and frequency of pain have some influence on the complaint of severity. Tingling and burning seem to be more superficial and, however annoying, more tolerable than do tearing, stabbing, cramping, squeezing, and crushing. It should be understood, however, that there are degrees of each of these and that, as such, intensities may, to a point, be compared with each other. </p> <p> It is obvious that a patient's account of his painful feeling is colored by his personality. The way a person describes such experiences depends not only on the abnormal processes causing them but also on his imagination, his previous experience, his learning, his cultural inheritance, and his vocabulary. But any view which discounts the abnormal physiological processes and credits only their "mental" interpretation is probably in error. The complexity of the nervous system and its integration into one functioning whole does not favor the idea that there is one chief recipient and executive who sorts out the messages from the various parts of the body and, in the case of pain, edits them as writhings and groans or as sentences made up of more or less colorful language. It seems improbable that there is simply one stimulus arising somewhere in the organism and that the ego reacts to this stimulus in a more or less stoic way. A so-called "neurotic" or "imaginative" disposition is likely to pervade the most "bodily" of processes, while a steadfast person is apt to have a stomach and blood vessels no more stable than his emotional display. </p> <p> Regardless of individual personalities, however, there is a certain uniformity in the complaints of pain-stricken amputees. Although the matter has not been explored from the point of view of psychophysiological typing, it appears that pain phenomena cannot be predicted either from the age of the patient or from the age of his phantom. By the same token, racial or cultural background and physical or mental make-up cannot be used to predict pain phenomena. Nor have the local pathological factors before, during, and after amputation-the factors that might be held responsible for the appearance of pain-been elicited. </p> <p> Aside from the problem of the painful phantom is that relating to painful stumps (<b>Fig. 12</b>). Amputees may have spontaneous stump pain. Or they may have so-called "trigger points," certain areas which, on slight pressure, tend to produce a flash of pain persisting for various intervals of time. Patients have complained of circumscribed areas of pain in the stump even though palpation revealed no corresponding point of tenderness. These two conditions usually are found together. Nodularities in the stump often are palpable, as indeed they are, on a minor scale, in other subcutaneous parts of the body. Some of these are tender, some are not; some are and some are not connected with phantom pain. In fact, separate places in the same stump may represent exclusive triggers-one for stump pain, the other for phantom pain. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Types of stump pain. About a third of the clinical reports of pain refer to discomfort in the stump rather than in a phantom part. Stumps may be painful to the touch (A) or spontaneously (B). Frequently present are "trigger points," pressure upon which gives rise to pain over a larger area, either in the stump or in a phantom or both (C). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> But the conditions prevailing at the end of the stump, including such nodules as the famous "amputation neuroma," do not provide a basis for intelligent speculation. The mere fact that stimulation of a presumptive neuroma often produces pain in the phantom is no proof for the theory that the "cause" of this pain lies solely in the periphery. In order to be disabused of such a notion, one has only to look at certain cases of known diseases of the central nervous system or at. complete transections of the spinal cord. In the latter, the brain receives no communications from the stump. In cases of painful diseases of the central nervous system, stimulation of the normal peripheral tissues having their nervous connections with the diseased part of the central nervous system often produces an abnormal sensation, including pain. This phenomena always is referred to the periphery. Nobody sounds convincing when he says that he feels pain in the brain or spinal cord. The central nervous system has no conscious sensory representation of itself. The mere description of a painful sensation does not permit detection of its origin. The origin has to be deduced from circumstantial evidence which, in the case of amputees, is lacking. Even where sensations are "triggered off" from the periphery, they can be completed only by participation of the central nervous system, and disturbances may occur anywhere along the line. </p> <p> We are confronted with the anomaly that stimulation of a certain trigger point within the stump arouses not a distant, painful phantom but one incorporated in the flesh of its own trigger. The specificity of this trigger further is illustrated by the fact that, on the opposite side of the same stump, there may be another tender spot, stimulation of which sets up increased local stump pain. </p> <h5> <i>Circulatory Problems</i> </h5> <p> Investigation of circulation in the amputee reveals that the stump acts as though it were poikilothermic, that is, it has no ability to change its temperature. Rather, the temperature of the stump matches that of the surroundings, as occurs in a cold-blooded animal. </p> <p> Studies concerning the relationship of the vascular system to pain in amputees have been conducted along three general lines. First has been evaluation of the status of the circulatory system in amputation stumps, both in patients suffering from phantom or stump pain and in amputees free of pain. The second has involved clinical and laboratory studies of selected nonamputee patients suffering from pain syndromes possibly related in pathophysiology to phantom pain. And finally tests have been conducted with various sympatholytic drugs and blocking procedures, first with respect to their effects on phantom-limb pain and related pain syndromes and second in regard to their effects on the circulation of blood in stumps and in painful limbs. </p> <p> Studied in detail were 43 amputees, 31 without known vascular disease (Group A) and 12 suffering from vascular disease either as the underlying cause of amputation or as a concomitant to the amputation (Group B). Pain in the stump or phantom limb was an important problem for 15 of the patients in Group A and for 8 of those in Group B. The remainder described varying degrees of phantom awareness but denied that pain existed or, if it did exist, that it was disturbing. </p> <p> One method of investigation was simple clinical examination. In that survey, stumps appearing to have an adequate blood supply were found, when exposed to air at room temperature, to be almost uniformly cold to the touch as compared with the opposite extremities. In oscillometric tests, the pulse of arterial blood into the stump was found to be significantly smaller than that into the normal limb (<b>Fig. 13</b>). In skin tests with histamine, the appearance of normal flares and wheals indicated that local denervation could not account for the failure of the skin to warm during generalized body warming. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Pulsations recorded during generalized vasodilatation in a below-knee amputee. Oscillometric records show a smaller amplitude of pulsation in the blood vessels supplying the stump (A) than in those supplying the sound limb (B). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> (<b>Fig. 14</b> and <b>Fig. 15</b>) indicate graphically the results of surface-temperature measurements on the normal extremities and on the stumps of two amputees. <a></a> Skin temperature was measured after initial exposure of the body to cool air in a room with controlled atmosphere, the subject being exposed until finger and toe temperatures were stabilized. Recordings were made by means of thermocouples taped to the skin of the stump and to the contralateral extremities at multiple points along the length of the limb, the thermocouples being applied symmetrically so that points equidistant from the trunk could be compared. All such measurements were made with the subject in a basal state and exposed to room air between 17deg and 21deg C, conditions leading uniformly to constriction of the cutaneous vessels of the extremities in normal subjects. Under such circumstances, a temperature gradient exists between the proximal and distal portions of a normal arm or leg, so that the surface temperature of a finger or toe is several degrees lower than the temperature at points near the trunk. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Surface temperatures in the upper extremities of a below-elbow amputee during cooling and subsequent warming and vasodilatation. Above, time-temperature relations. Below, length-temperature relations. Points along the extremities indicate the locations of thermocouples. Relative humidity constant at 65 percent. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Surface temperatures in the lower extremities of an above-knee amputee during cooling and subsequent warming and vasodilatation. Above, time-temperature relations. Below, length-temperature relations. Points along the extremities indicate the locations of thermocouples. Relative humidity constant at 74 percent. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Temperatures then were recorded during maximal vasodilatation induced by oral administration of whiskey and wrapping the trunk in an electric blanket. After vasodilatation, the gradient is abolished or reversed in the normal limb, finger and toe temperatures rising to 30deg C or higher. </p> <p> At the end of the initial cooling period, when subjects had been exposed to cool room air for periods of from 30 to 150 minutes, the surface temperature at the distal end of the stump almost invariably was cooler than was the skin at a symmetrical point on the corresponding intact limb. Analysis of the temperature gradients found after cooling showed further that, in at least a third of the Group A amputees and in half of the Group B amputees, the stumps were cooler than were the opposite extremities, not merely at the distal ends but for distances of from 20 to 55 cm. from the ends. </p> <p> In one instance a patient was put in a room at 18deg C with nothing across his body except a towel. Over a period of two hours the body temperature was lowered to a point just above that at which shivering occurred. The temperature of the toe in the normal extremity dropped to a low level. When the patient suddenly was given 2 ounces of whiskey and warm water and had an electric blanket placed across his chest, the temperature of the normal extremity rose rapidly. But the temperature of the stump remained constant during the entire procedure, a phenomenon characteristic of all amputation stumps. </p> <p> A total of 40 amputees (28 Group A, 12 Group B) were subjected to one or more vasodilatation tests, and the responses of 45 stumps were observed. Of these, nearly two thirds failed to warm significantly at a time when the skin temperature of the normal extremities had risen to 30deg C as a result of indirect or "reflex" vasodilatation. Only occasionally did stumps show evidence of significant vasodilatation. It occurred with higher frequency in those patients with underlying or concomitant vascular disease than in amputees of Group A. Thus, of 11 stumps in which the temperature rose to the same level as the corresponding point on the contralateral limb, or even to levels reflecting "ceiling" blood flow for skin, only six were among the 32 stumps of Group A patients, and five were among the 13 stumps of Group B patients. In brief, a smaller proportion of stumps showed vasodilatation in Group A patients (one fifth) than in Group B patients (two fifths). </p> <p> In the majority of trials, experiments with other methods of inducing vascular relaxation were equally ineffective in causing a rise in stump temperature. In a total of eight intravenous injections of vasodilator drugs, the temperature of the stump increasedonlyslightly on two occasions (2.5deg C or less). A rise in temperature was effected once with Priscoline (2-benzylimidazoline hydrochloride) and once with tetraethylammonium chloride. Injections of prccaine in the region of the lumbar sympathetic ganglia produced a significant warming of the stump in one of two cases only. No correlation was found between the degree of phantom or stump pain experienced by these patients and the extent to which slump temperature fell during the initial period of exposure or the extent of stump warming during generalized vasodilatation. Amputees rarely complained of stump or phantom pain during these experiments, even though they were subjected to extremes of temperature requiring rapid vasomotor adjustments. </p> <p> The ease with which stumps become cool on exposure to a cold environment can be attributed to two factors. First, surface-volume relationships in stumps favor cooling. Second, less blood passes through the stump than through comparable portions of the intact limb because, in the stump, distal tissues are absent. Apparently the shunts between the arterial and the venous side, which permit an increased volume of blood to flow through the extremity, are located distal to the wrist joint and to the ankle joint. In amputations at or above the wrist or ankle, therefore, flow of blood to the extremity is impaired. Normally, body heat is lost chiefly through radiation from hands, head, and feet. When the body is deprived of one of these radiating "fins," the remaining stump cannot be warmed. Neither can excess heat be radiated away, and for that reason an amputee often finds intolerable an environmental temperature that is quite acceptable to the normal. The amputee is distressed in a heated room, while the normal subject suffers no discomfort. Since the radiating mechanism is lost with amputation of an extremity, and since the only other means of cooling is through evaporation of sweat, the amputee is more likely to be troubled with problems of perspiration. </p> <h5> <i>Skeletal Changes</i> </h5> <p> In addition to problems of pain and changes in circulation, the amputee sometimes is troubled by decalcification of the stump and adjacent portions of the pelvis, a change that occurs when the body weight no longer is borne along the axis of the major articulations but along the prosthetic weight line (page 36). Because in an osteoporotic extremity the covering of the bone is more sensitive than is that in the normal, a decalcified bone often becomes exceedingly tender and develops spontaneous pain. </p> <p> An interesting fact is that the joint itself, in (<b>Fig. 16</b>) the hip joint, begins to show early degenerative changes because it no longer transmits weight. In future studies it should be possible to evaluate more closely what changes are to be expected in the proximal articulations of an amputation stump, and more particularly in the joint cartilage covering the articulations, as a result of elimination of normal weighi-bearing through thesearticulations. Obviously, the only way la preveni osteoporosis and increased sensitivity is to resort to some type of end-bearing. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16 Roentgenogram of an above-knee amputee, showing skeletal changes that occur when the hip and the remainder of the leg on the amputated side are deprived of the normal stimulation of weight-bearing </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In the younger leg amputee, moreover, especially in growing children, other bony deformities develop (<b>Fig. 17</b>). Instead of the normal curvature of the neck of the femur, there develops a valgus deformity as is seen in polio and in dislocated hips. And finally, of course, because of loss of the mass of the limb, one must expect to find scoliosis and other abnormalities in the spine (<b>Fig. 18</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Complicating deformities in juvenile amputees. When amputation is necessitated in childhood, defects often occur in the subsequent growth of related bony structures. Here, for example, the pelvis is smaller, and the pelvic-femoral angle larger, on the amputated side than on the sound side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Scoliosis, a postural defect often a sequel to amputation of the lower extremity. Loss of the weight of the amputated limb leads to habitual compensatory positioning of other body elements and thus complicates rehabilitation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3> Summary </h3> <p> In summary, it may be said that, first, amputation produces changes in musculature, not only the familiar contractures and atrophy <i>{50,88) </i>but other changes as well. If a muscle is cut in half, its ability to shorten is decreased. A mid-thigh amputation decreases the effective normal range of motion of the hamstring group. If the hamstring group is cut in half, the velocity of contraction is halved, and an amputee thus afflicted cannot therefore perform certain functions with any degree of facility. </p> <p> The mechanism of normal level walking requires the expenditure and distribution of considerable energy, for which the body depends largely upon the leg musculature. Thus, the handicap resulting from loss of any part of the leg is due not only to the loss of support but also to the loss of power available from the muscles. The skeletal structure of a normal limb can more or less easily be simulated in a prosthesis, but such a device has little value without simultaneous provision for the necessary power. Accordingly, an understanding of the energy characteristics of normal level walking is important in considering the design criteria for artificial legs. Judging from the results of the energy studies at Berkeley, at a given pace an above-knee amputee uses two and a half to three times as much energy as does the normal. The adverse effect of this overexertion is only further complicated by the fact that heat production is increased at a time when the radiating mechanism has been impaired. In the manufacture of any lower-extremity prosthesis, then, an important consideration, is to design the substitute limb for maximum energy conservation. </p> <p> Medical problems are common to all amputees. Some of them, for example those related to circulation, cannot be solved, but proper surgical procedures help to preserve the musculature and skeletal structures of adjacent joints. Moreover, many things can be done to relieve pain, both spontaneous phantom pain and the tender trigger points occurring in stumps. All amputees suffer some discomfort at one time or another. They are bothered by skin changes occurring over the bony prominences, by edema at the distal end of the stump, and by attritional lesions occurring in the folds of the groin (<b>Fig. 19</b>). A minor skin lesion can disable a leg amputee completely, especially when it means staying off the leg or going on crutches. Increased perspiration and poor ventilation of the stump in the prosthesis may close the sweat glands and make the skin susceptible to fungal diseases, and contact dermatitis may result if the patient is allergic to certain materials used in the manufacture of the prosthesis. Such problems must be solved by socket fit, by alignment, or by other procedures. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Problems of fit. Among them are irritation and swelling in the crotch area, edema at the stump end, and tenderness at pressure points. Because such problems are more or less readily corrected by proper fit and alignment, they are less medical than prosthetic, although chronic skin irritation may need the attention of a dermatologist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> From the Clinical Study have come valid recommendations concerning fit, alignment, and functional characteristics. As already noted, some horizontal rotation (between 9 and 15 deg.) is desirable in an artificial leg. Further, increased stability in the knee joint increases the leg amputee's sense of security. Some conservation of energy can be effected by eliminating the articulated ankle joint. And finally, the matter of appearance deserves consideration. In this regard, attention must be given to the color, contour, and texture of the artificial leg. </p> <p> In the last analysis, the problem of the leg amputee is more than that of providing him with a prosthetic device. He has many medical problems, including pain, abnormalities in circulation, heat intolerance, and skeletal and muscular changes. The prosthetic device itself raises other problems-conservation of energy, proper alignment, comfort, and cosmetic appearance. The Lower-Extremity Clinical Study is concerned with the solution of all these problems. The manner in which solutions are sought is shown in (<b>Fig. 20</b>), where the central area represents the pool of fundamental knowledge accumulated over a period of nine years. As the amputee moves around the circle, each problem is studied and solved before he is allowed to move into the next phase of processing. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Functional organization of theLower-Extremity Clinical Study:. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> To date, pain and skin irritation have been the predominant problems, and study groups are being organized to investigate these areas in detail. Study groups also have been organized to investigate skeletal and muscular changes. At each step in the process, the panel itself often is faced with difficult problems. For example, the question of evaluation always is present, and it is not easy to determine whether or not the amputee actually has benefited from the time and effort devoted to his case. But as each difficulty is solved, the information derived is placed at the disposal of all those concerned, not only those within the Clinic Study Group but also all others whose interests lie in the field of amputee management. Seminars are held weekly to ensure that the information is brought to the attention of all interested persons. Eventually, all of the problem-solving data stemming from the investigations will appear in educational publications and will be available to members of the artificial-limb industry. </p> <p> Finally, it may be said that the University group has no intentions of producing prosthetic devices and, indeed, makes excursions into that field only when it is necessary to develop experimental models pertinent to the study. </p> <p> The only function is to produce sound ideas that can be used by the artificial-limb industry in the manufactuie and fitting of improved prostheses. The study must, however, continue to be active until the basic scientific information can be translated into useful guides for the professions involved in the rehabilitation of the amputee. </p> <h3> Acknowledgments </h3> <p> For the illustrations appearing in this article, the authors are indebted to two people in particular. 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Johnson, The works of that famous chirurgion, Ambrose Parey, translated out of the Latine and compared with the French, Richard Cotes and Willi: Du-gard, London, 1649. </li> <li>Polissar, M. J., Concentration and potential pattern within the membrane and its relation lo penetration of ions and lo time constants of electrolonus and accommodation, Fed. Proc, 11:124 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. I. A physiochemical model of contractile mechanism, Am. J. Physiol., 168:766 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. II. Analysis of other mechano-chemical properties of muscle, Am. J. Physiol., 168:782 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. III. Interpretation of thermal behavior of stimulated muscle, Am. J. Physiol.. 168:793 (1952). </li> <li>Polissar, M. J., Physical chemistry of contractile process in muscle. IV. Estimates of size of contractile unit, Am. J. Physiol., 168:805 (1952). </li> <li>Radcliffe, C. W., Flexion stiffness of prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, May 1949. </li> <li>Radcliffe, C. W., Information useful in the design of damping mechanisms for artificial knee joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950. </li> <li>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. </li> <li>Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 23ff. </li> <li>Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Humanlimbs andtheirsubstitutes, McGraw-Hill, New York, 1954. Especially pp. 686-688. </li> <li>Ralston, H. J., Muscle dynamics, Surgical Forum (1951), American College of Surgeons, Clinical Congress, W. B. Saunders, Philadelphia, 1952. p. 418.</li> <li>Ralston, H J., Isometric tension in the intact human quadriceps, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 692. </li> <li>Ralston, H. J., Mechanics o] voluntary muscle, Am. J Phys. Med., 32:166 (1953). </li> <li>Ralston, H. J., J R Close, V T. Inman, and B. Feinstein, Dynamical and electrical features of human isolated voluntary muscle in isometric and isotonic contraction, Fed. Proc, 7:97 (1948). </li> <li>Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110. </li> <li>Ralston, H J., B. Feinstein, and V. T. Inman Rate of atrophy in muscles immobilized at different lengths, Fed. Proc, 11:127 (1952). </li> <li>Ralston, H. J., V. T. Inman, B. Feinstein, and B. Libet, Human electromyogram, Am. J. Physiol., 163:743 (1950). </li> <li>Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947). </li> <li>Ralston, H. J., B. Libet, and E. W. Wright, Jr., Effect of stretch on action potential of voluntary muscle, Am. J. Physiol., 173:449 (1953). </li> <li>Ralston, H. J., and B. Libet, The question of tonus in skeletal muscle, Am. J. Phys. Med., 32:85 (1953). </li> <li>Ralston, H. J., M. J. Polissar, V. T. Inman, J. R. Close, and B. Feinstein, Dynamic features of human isolated voluntary muscle in isometric and, free contractions, J, Appl Physiol., 1:526 (1949). </li> <li>Ralston, H. J., E. W. Wright, Jr., B. Feinstein, and V. T. Inman, Effect of stretch upon action potential of voluntary muscle, Am. J. Physiol., 159:586 (1949). </li> <li>Ryker, N. J., Jr , Glass walkway studies of normal subjects during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 20, January 1952. </li> <li>Ryker, N. J., and S. H. Bartholomew, Determination of acceleration by use of accelerometers, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </li> <li>Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </li> <li>Schiller, F., Pain-controlled and uncontrolled, Science, 118:755 (1953). </li> <li>Spittler, A. W., and I. E. Rosen, Cineplaslic muscle motors for prostheses of arm amputees, J. Bone and; Joint Surg , 33A:601 (1951). 100. Strait, L. A., V. T. Inman, and H. J. Ralston, </li> <li> Sample illustrations of physical principles selected from physiology and medicine, Am. J. Physics, 15:375 (1947). </li> <li>Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York. 1954. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Preliminary Report [to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, September 1947. </li> <li>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. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Supplementary Report 2, The forces and moments in the leg during level walking, revised August 10, 1948. </li> <li>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. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Biceps cineplasty and prosthesis for below-elbow amputations, April 1950. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952. </li> <li>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, 2nd ed., August 1953. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, The pattern of muscular activity in the lower extremity during wilking, September 1953. </li> <li>Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </li> <li>Wagner, Edmond M., and John G. Catranis, New developments in lower-exlremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. p. 482. </li> <li>Wagner and Catranis, op. cit., p. 511. </li> <li>Weddell, G., B. Feinstein, and R. E. Pattle, Electrical activity of voluntary muscle in man under normal and pathological conditions, Brain, 67:178 (1944). </li> <li>Wohlfart, G., B. Feinstein, and J. Fex, Uber die Bieziehung zwischen electromyographischen und anatomischen Befunden in normalen Muskeln und bei neuromuskularen Erkrankungen, Arch. f. Psychiat. u. Ztschr. Neurol., 191:478 (1954). </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Brown, E., and N. Foreman, Studies of skin temperature and of indirect vasodilatation in amputation stumps, Am. J. Med., 10:112 (1951). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Livingston, Kenneth E., The phantom limb syndrome: a discussion of the role of major peripheral nerve neuromas, J. Neurosurg., 2:251 (1945). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>66.</b> </td><td class="clsTextSmall">Mitchell, S. Weir, Phantom limbs, Lippincott's Mag. Pop. Lit. So, 8:563 (1871). </td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Pare, A., from T. Johnson, The works of that famous chirurgion, Ambrose Parey, translated out of the Latine and compared with the French, Richard Cotes and Willi: Du-gard, London, 1649. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The principles of prosthetic prescription, Chapter 6 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">Bechtol, Charles 0., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>88.</b> </td><td class="clsTextSmall">Ralston, H J., B. Feinstein, and V. T. Inman Rate of atrophy in muscles immobilized at different lengths, Fed. Proc, 11:127 (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>97.</b> </td><td class="clsTextSmall">Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>68.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Shakedown lest of the Navy above-knee prosthesis, May 1951. </td></tr><tr><td class="clsTextSmall"><b>112.</b> </td><td class="clsTextSmall">Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Information useful in the design of damping mechanisms for artificial knee joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, 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>59.</b> </td><td class="clsTextSmall">Levens, A. S., V. T. Inman, and J. A. Blosser, Transverse rotation of the segments of the lower extremity in locomotion, J. Bone and; Joint Surg., 30A:859 (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>98.</b> </td><td class="clsTextSmall">Schiller, F., Pain-controlled and uncontrolled, Science, 118:755 (1953). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone and; Joint Surg!, 36A:981 (1954) </td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Inman, V. T., Innervation of the extremities, 3rd Biennial Western Conference on Anesthesiology, The California Society of Anesthesiologists and the Northwestern Society of Anesthesiologists, Los Angeles, 1953. p. 22. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>109.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Livingston, Kenneth E., The phantom limb syndrome: a discussion of the role of major peripheral nerve neuromas, J. Neurosurg., 2:251 (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>114.</b> </td><td class="clsTextSmall">Wagner and Catranis, op. cit., p. 511. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Contini, Renato, Prosthetics research and the engineering profession, Artificial Limbs, 1(3):47 (September 1954). p. 58. </td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953. </td></tr><tr><td class="clsTextSmall"><b>112.</b> </td><td class="clsTextSmall">Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>78.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Flexion stiffness of prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, May 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>48.</b> </td><td class="clsTextSmall">Felkel, E. O., Determination of accelerations of the human leg during locomotion, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Winter 1951. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">'Bartholomew, S. H., Determination of knee moments during the swing phase of walking and physical constants of the human shank, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, January 1952. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Supplementary Report 2, The forces and moments in the leg during level walking, revised August 10, 1948. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Inman, V. T., Theoretical requirements of a lower-extremity prosthesis, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, December 22, 1950. </td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Saunders, J. B. deC. M., Verne T. Inman, and Howard D. Eberhart, The major determinants in normal and pathological gait, J. Bone and; Joint Surg., 35A(3):543 (1953) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Herbert Elftman, and Verne T. Inman, The locomtor [sic] mechanism of the amputee, Chapter 16 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Elftman, H., The basic pattern of human locomotion, Ann. N. Y. Acad. Sci., 51:1207 (1951). </td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Elftman, Herbert, The functional structure of the lower limb, Chapter 14 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>13.</b> </td><td class="clsTextSmall">Bresler, B., Use of energy methods for evaluation of prostheses, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bressler [sic], B., and F. R. Berry, Energy characteristics of normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, April 1950. </td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (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>17.</b> </td><td class="clsTextSmall">Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Blaschke, Alfred C, and Craig L. Taylor, The mechanical design of muscle-operated arm prostheses, J. Franklin Inst., 266:435 (1953). </td></tr><tr><td class="clsTextSmall"><b>101.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York. 1954. </td></tr><tr><td class="clsTextSmall"><b>107.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Biceps cineplasty and prosthesis for below-elbow amputations, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The cineplaslic method in upper-extremity amputations, J. Bone and; Joint Surg., 30A:359 (1948). </td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. 4.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Blaschke, A. C, and C. L.Taylor, Biomechanical considerations in cineplasty, University of California (Los Angeles), Department of Engineering, Special Technical Report 18, 1951. </td></tr><tr><td class="clsTextSmall"><b>99.</b> </td><td class="clsTextSmall">Spittler, A. W., and I. E. Rosen, Cineplaslic muscle motors for prostheses of arm amputees, J. Bone and; Joint Surg , 33A:601 (1951). 100. Strait, L. A., V. T. Inman, and H. J. Ralston, </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>57.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Libet, Benjamin, H. J. Ralston, and Bertram Feinstein, The effect of stretch on action potential in muscle, Biol. Bull., 101:194 (1951). </td></tr><tr><td class="clsTextSmall"><b> 64.</b> </td><td class="clsTextSmall">Libet, B., and E. W. Wright, Jr., Facilitation at neuromuscular functions by stretch of muscle, Fed. Proc, 11:94 (1952). </td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Ralston, H. J., Muscle dynamics, Surgical Forum (1951), American College of Surgeons, Clinical Congress, W. B. Saunders, Philadelphia, 1952. p. 418.</td></tr><tr><td class="clsTextSmall"><b>84.</b> </td><td class="clsTextSmall">Ralston, H J., Isometric tension in the intact human quadriceps, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 692. </td></tr><tr><td class="clsTextSmall"><b>85.</b> </td><td class="clsTextSmall">Ralston, H. J., Mechanics o] voluntary muscle, Am. J Phys. Med., 32:166 (1953). </td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">Ralston, H. J., J R Close, V T. Inman, and B. Feinstein, Dynamical and electrical features of human isolated voluntary muscle in isometric and isotonic contraction, Fed. Proc, 7:97 (1948). </td></tr><tr><td class="clsTextSmall"><b>87.</b> </td><td class="clsTextSmall">Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110. </td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947). </td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">Ralston, H. J., B. Libet, and E. W. Wright, Jr., Effect of stretch on action potential of voluntary muscle, Am. J. Physiol., 173:449 (1953). </td></tr><tr><td class="clsTextSmall"><b>93.</b> </td><td class="clsTextSmall">Ralston, H. J., M. J. Polissar, V. T. Inman, J. R. Close, and B. Feinstein, Dynamic features of human isolated voluntary muscle in isometric and, free contractions, J, Appl Physiol., 1:526 (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>11.</b> </td><td class="clsTextSmall">Blix, Magnus, Die Lange und die Spannung des Muskels, Scandinav. Arch. f. Physiol., 6:150 (1894). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>115.</b> </td><td class="clsTextSmall">Weddell, G., B. Feinstein, and R. E. Pattle, Electrical activity of voluntary muscle in man under normal and pathological conditions, Brain, 67:178 (1944). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Inman, V. T., B. Feinstein, and H. J. Ralston, Some observations on electromyography, Am. J. Physiol., 155:445 (1948). </td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Inman, Verne T., H. J. Ralston, J. B. deC. M. Saunders, Bertram Feinstein, and Elwood W. Wright, Jr., Relation of human electromyogram lo muscular tension, University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1951. </td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Inman, V. T., H. J. Ralston, J. B. deC. M. Saunders, B. Feinstein, and E. W. Wright, Jr., Relation of human electromyogram lo muscular tension, Electroencephalog. and; Clin. Neuro-physiol., 4:187 (1952). </td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Libet, B., and B. Feinstein, Analysis of changes in electromyogram (EMG) with changing muscle length, Am. J. Physiol., 167:805 (1951). </td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Libet, Benjamin, and Bertram Feinstein, Human electromyogram, Surg. Forum, W. B. Saunders Co., Philadelphia, 1952. p. 415. </td></tr><tr><td class="clsTextSmall"><b>89.</b> </td><td class="clsTextSmall">Ralston, H. J., V. T. Inman, B. Feinstein, and B. Libet, Human electromyogram, Am. J. Physiol., 163:743 (1950). </td></tr><tr><td class="clsTextSmall"><b> 116.</b> </td><td class="clsTextSmall">Wohlfart, G., B. Feinstein, and J. Fex, Uber die Bieziehung zwischen electromyographischen und anatomischen Befunden in normalen Muskeln und bei neuromuskularen Erkrankungen, Arch. f. Psychiat. u. Ztschr. Neurol., 191:478 (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>60.</b> </td><td class="clsTextSmall">Libet, B., Neuromuscular facilitation by stretch, and the duration of muscular activation in locomotion, Proc. 19th Internat. Physiol. Cong., Montreal, 1953. p. 563. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Blaschke, A. C, General energy considerations and determination of muscle forces in the mechanics of human bodies, University of California (Los Angeles), Department of Engineering [Contractor's Memorandum Report No. 9 to the Advisory Committee on Artificial Limbs, National Research Council], September 1950.</td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and; Joint Surg., 29:607 (1947). </td></tr><tr><td class="clsTextSmall"><b>111.</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 pattern of muscular activity in the lower extremity during wilking, September 1953. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">Polissar, M. J., Concentration and potential pattern within the membrane and its relation lo penetration of ions and lo time constants of electrolonus and accommodation, Fed. Proc, 11:124 (1952). </td></tr><tr><td class="clsTextSmall"><b>74.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. I. A physiochemical model of contractile mechanism, Am. J. Physiol., 168:766 (1952). </td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. II. Analysis of other mechano-chemical properties of muscle, Am. J. Physiol., 168:782 (1952). </td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. III. Interpretation of thermal behavior of stimulated muscle, Am. J. Physiol.. 168:793 (1952). </td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">Polissar, M. J., Physical chemistry of contractile process in muscle. IV. Estimates of size of contractile unit, Am. J. Physiol., 168:805 (1952). </td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">Ralston, H. J., and B. Libet, The question of tonus in skeletal muscle, Am. J. Phys. Med., 32:85 (1953). </td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall"> Sample illustrations of physical principles selected from physiology and medicine, Am. J. Physics, 15:375 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">'Bartholomew, S. H., Determination of knee moments during the swing phase of walking and physical constants of the human shank, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, January 1952. </td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Berry, F. R., Jr., Angle variation patterns of normal hip, knee and ankle in different operations, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 21, February 1952. </td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Bressler [sic], B., and F. R. Berry, Energy characteristics of normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, April 1950. </td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bresler, B,, and F. R. Berry, Energy and power in the leg during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, May 1951. </td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Close, J. R., and V. T. Inman, The action of the ankle joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1952. </td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Close, J. R., and V T. Inman, The action of the subtalar joint, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 24, May 1953. </td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Cunningham, D. M., Components oj floor reactions during walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950. </td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Felkel, E. O., Determination of acceleration from displacement-time data, University of California (Berkeley), Prosthetic Devices Research Project, [Report to] the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 16, September 1951. </td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Felkel, E. O., Determination of accelerations of the human leg during locomotion, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Winter 1951. </td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Ryker, N. J., and S. H. Bartholomew, Determination of acceleration by use of accelerometers, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, September 1951. </td></tr><tr><td class="clsTextSmall"><b>105.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Supplementary Report 2, The forces and moments in the leg during level walking, revised August 10, 1948. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>103.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Preliminary Report [to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, September 1947. </td></tr><tr><td class="clsTextSmall"><b>104.</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>106.</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>108.</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 fitting and alignment of the suction socket prosthesis, March 1952. </td></tr><tr><td class="clsTextSmall"><b>110.</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, 2nd ed., 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>Footnote</b></td></tr><tr><td class="clsTextSmall">The 1947 report contains an extensive bibliography of earlier work, mostly German, on the mechanism of human locomotion and on related matters. It is available, either in photostat form or on microfilm, from the U. S. Armed Forces Medical Library, 7th Street and Independence Ave., S. W., 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Elftman, H., A cinematic study of the distribution of pressure in the human fool, Anat. Rec, 69:481 (1934). </td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Elftman, H, The measurement of the external force in walking, Science, 88:152 (1938). </td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Elftman, H., The rotation of the body in walking, Arbeitsphysiol., 10:219 (1938). </td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Elftman, H., The force exerted by the ground in walking, Arbeitsphysiol., 10:485 (1938). </td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Elftman, H., Forces and energy changes in the leg during walking, Am. J. Physiol., 125:339 (1939). </td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Elftman, H., The function of muscles in locomotion, Am. J. Physiol., 125:357 (1939). </td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Elftman, H., The function of the arms in walking, Human Biol., 11:529 (1939). </td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Elftman, Herbert, The work done by muscles in running, Am. J. Physiol , 129:672 (1940). </td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Elftman, H., The action of muscles in the body, Biol. Symposia, 3:191 (1941).</td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Elftman, H., Experimental studies on the dynamics of human walking, Trans. N. Y. Acad. Sci., 11:1 (1943). </td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Elftman, H., The bipedal walking of the chimpanzee, J. Mammalogy, 25:67 (1944). </td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Elftman, H., The carrying angle of the human arm as a secondary sex character, Anat. Rec, 91:49 (1945). </td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Elftman, H., The orientation of the joints of the lower extremity, Bull. Hosp. Joint Diseases, VI-.139 (1945). </td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Elftman, H., Torsion of the lower extremity, Am. J. Phys. Anthropol., N.S. 3:255 (1945). </td></tr><tr><td class="clsTextSmall"><b> 42.</b> </td><td class="clsTextSmall">Elftman, Herbert, and John T. Manter, The axis of the human foot, Science, 80:484 (1934). </td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Elftman, Herbert, and John Manter, Chimpanzee and human feel in bipedal walking, Am. J. Phys. Anthropol., 20:69 (1935). </td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Elftman, H., and J. T. Manter, The evolution of the human fool, with especial reference to the joints, J. Anat., 70:56 (1935). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Adel Precision Products Corp., Burbank, Calif.,Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council, The development of a hydraulically operated artificial leg for above knee amputations, 1947. </td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall"> Bradley, C. A, and Son, Inc., and Catranis, Inc., Syracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and foot position; toe pick up and foot providing lateral, plantar and dorsal flexion, July 1947. </td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">Goodyear Tire and; Rubber Company, Akron, Ohio, Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a foot prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947. </td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Hosmer Corp., A. J., Santa Monica, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Hydraulic weight bearing knee lock for knee dis-articidation amputations; work arms for wrist disarticulations, below and above elbow amputations; work tools and devices for vocational rehabilitation; hydraulic control to actuate hooks and hands used on work arms; improved design hook, 1947. </td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">National Research and Manufacturing Company, San Diego, Calif., Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, 1947. </td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston, III., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arms, arm harnesses, hands, and hooks; mechanical testing of artificial legs, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Eberhart, Howard D., The objectives of the lower extremity prosthetics program, Artificial Limbs, May 1954. p. 4. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Eberhart, H. D., and V. T. Inman, An evaluation of experimental procedures used in a fundamental study of human locomotion, Ann. N. Y. Acad. Sci., 51:1213 (1951). </td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>80.</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>81.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 23ff. </td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Humanlimbs andtheirsubstitutes, McGraw-Hill, New York, 1954. Especially pp. 686-688. </td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Ryker, N. J., Jr , Glass walkway studies of normal subjects during normal level walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 20, January 1952. </td></tr><tr><td class="clsTextSmall"><b>102.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr><tr><td class="clsTextSmall"><b> 112.</b> </td><td class="clsTextSmall">Wagner, Edmpnd M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 8. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>113.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis, New developments in lower-exlremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. p. 482. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report [to the] Committee on Artificial Limbs, National Research Council (Contract VAm-21223), A report on prosthesis development, 1947. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Howard D. Eberhart, M.S. </b></td></tr><tr><td class="clsTextSmall">Professor of Civil Engineering, University of California, Berkeley; member, Advisory Committee on Artificial Limbs, National Research Council, and of the Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>VerneT. Inman, M.D., Ph.D., </b></td></tr><tr><td class="clsTextSmall">Professor of Orthopedic Surgery, School of Medicine, University of California, San Francisco; Professional Associate, Advisory Committee on Artificial Limbs, National Research Council; member, Technical Committee on Prosthetics, ACAL, NRC. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-12.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_01_004/table01.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_01_004/1955-JanuaryOCRBatchc-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 The Lower-Extremity Clinical Study-Its Background and Objectives Creator An entity primarily responsible for making the resource VerneT. Inman, M.D., Ph.D., * Howard D. Eberhart, M.S. * 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/e38c9d5be738df236a12e73aa11a7478.pdf 63744e2c2435c2b8aa6be87baa775d5b https://staging.drfop.org/files/original/56b68415d28babc42822184b94ea133f.jpg c1d1ab1268f7d844c5e4adb9f18570b1 https://staging.drfop.org/files/original/468c9f40dadb34370263e2258781e772.jpg 066f09438b83937ce9374ec73d152011 https://staging.drfop.org/files/original/f6b7d160b8278d855a477b3e2ea5c2cb.jpg f93f5d0c017f506a7192b341323b7b69 https://staging.drfop.org/files/original/bf1c26f96bb42345b531ec1166264189.jpg 9fd52199760b1396b088edc497712c32 https://staging.drfop.org/files/original/96c04506d1db97cbfd92fea9a88f48b2.jpg cd55c79d19ab9841de50523ab1e0419a https://staging.drfop.org/files/original/01a220eb783cc84d9ce7dad16b20bdf9.jpg bd31c2caa285cf8fd77da049a48cf137 https://staging.drfop.org/files/original/49d84cfc8f81b98ee25f6ed516a68603.jpg 348aae2a8ee726a6780827ea3caa5d52 https://staging.drfop.org/files/original/f04bf788ae7667d4ba0783d1f063dbeb.jpg fddd1ca9fcc7c38b79f776f973540e84 https://staging.drfop.org/files/original/d15fb9bfe71401e0c9e78eee923227ae.jpg de5d7ef764071728608ace84183afd4a https://staging.drfop.org/files/original/73879f8eef1bcebd75a39d4efb07bbe5.jpg 0c17a23c627102a5b74bfa203bc0affd https://staging.drfop.org/files/original/faf957c4e45f636ead6709d159155cbb.jpg 6a41e41b6042f89654f9aa13b55cff12 https://staging.drfop.org/files/original/e7adf4c708c388d05f78818bc47b73bc.jpg 0224ffefe34ab3baefa64141bd79eaef DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_037.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 37 - 48 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/1969_01_037.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_037.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 Mechanical Properties of Bone</h2> <h5>F. Gaynor Evans. Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Bone is the material with which the orthopaedic surgeon deals. Consequently, some knowledge of its mechanical properties is of importance for an understanding of the mechanism and management of fractures, as well as the design of prosthetic or orthotic appliances and protective gear, <i>e.g., </i>crash helmets. The behavior of a body under a load or force is a function not only of the form and structure of the body, but also of the mechanical properties of the material composing the body. For example, a steel beam will support a higher load before breaking and will behave differently under loading than will an oak beam of exactly the same shape and dimensions because of differences in the mechanical properties and structure of steel and of wood.</p> <p>The mechanical properties of bone are determined by the same methods used in studying similar properties of metals, woods, and other structural materials. These methods are based on certain fundamental principles of mechanics, a knowledge of which is essential for understanding the terminology employed.</p> <p><i>Mechanics, </i>the science dealing with the effect of forces upon the form or the motion of bodies, has two subdivisions- statics and dynamics. <i>Statics </i>is the study of bodies at rest or in equilibrium as a result of the forces acting upon them. <i>Dynamics </i>is the study of moving bodies. The mechanical properties of materials are usually studied under static conditions, <i>i.e., </i>under a slowly applied force or load, because the behavior of the test specimen can be more easily analyzed when the load is slowly applied.</p> <p>A <i>force </i>is anything which tends to change the state of a body with respect to its motion or the relative position of the molecules composing the body. More simply stated, a force is a push or a pull. There are three primary kinds of forces: (1) <i>compressive </i>or pushing together forces, (2) <i>tensile </i>or pulling apart forces, and (3) <i>shearing, </i>or forces which make one part of the body slide with respect to an adjacent part (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Types of pure force-stress and strain. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a force is applied to a body, it produces stress and strain within the body. <i>Stress </i>(<b>Fig. 1</b>) is the ratio between the force and the area upon which it acts, <i>i.e., </i>force per unit area. Stress is generally computed in terms of pounds per square inch (psi) or kilograms per square millimeter (ksm). Recently, some investigators of the strength characteristics of bone and other biological materials have been recording stress values in terms of kiloponds, dynes, or newtons per unit area, instead of pounds or kilograms because pounds and kilograms are units of mass as well as units of force. There will be no misunderstanding, however, if one specifies that stress values are in terms of <i>pounds force or kilograms force per unit area. </i>Stress is often used synono-mously with strength, but the term has little value unless the kind of strength, <i>i.e., </i>tensile, compressive, etc., is indicated. All strength values in the following discussion are in terms of <i>pounds force per square inch.</i></p> <p><i>Strain </i>is a change in the linear dimensions of a body as the result of the application of a force (<b>Fig. 1</b>). Since there are no standard units of measurement for strain, it can be recorded as percentage, inches/inch, centimeters/centimeter, etc. Strain can be seen if it is sufficiently large, <i>e.g., </i>as in stretching of a rubber band, but stress, which is only the ratio between force and area, is always invisible. The kind of stress and strain in a body is the same as the kind of force producing it.</p> <p>When stress is plotted against strain, a <i>stress-strain curve </i>is obtained (<b>Fig. 2</b>). From a tangent drawn to the straightest part of the stress-strain curve the <i>modulus of elasticity </i>of the material, or the ratio between unit stress and unit strain, can be computed. The modulus of elasticity is a measure of the <i>stiffness </i>of a material, not its elasticity as one might assume from the name. <i>Elasticity </i>is the property of a material that allows it to return to its original dimensions after the removal of a force or load. The <i>energy </i>the specimen absorbs to failure can be determined by measuring the area below the stress-strain curve.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Stress-strain curves for a dry- and a wet-tested specimen of compact bone from the posterior quadrant of the proximal third of the femoral shaft of a 70-year-old white man who died from pulmonary tuberculosis. The stress values are in pounds force per square inch <a></a>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The method of choice in determining the tensile or compressive strength of a material is to make a test specimen of a standardized size and shape and test it under a pure tensile or a pure compressive force. Under these conditions the cross-sectional area of the specimen is known, or can be easily computed, and only one force—tension or compression—is involved. Furthermore, the force is uniformly distributed over the cross-sectional area of the specimen. Consequently, the ultimate tensile or compressive strength of the material can be easily calculated from the formula <i>S </i>= <i>P/A, </i>in which S is stress, P is force or load, and A is the cross-sectional area of the specimen (<b>Fig. 1</b>).</p> <p>If the specimen is tested like a simple beam (i.e., supported at the ends and loaded midway between the supports) and bending occurs, tensile, compressive, and shearing forces are all involved. Tensile forces develop on the convex side of the bent specimen while compressive forces occur on the opposite (concave) side (<b>Fig. 3</b>). Both types of forces are maximum at the surface and decrease inwardly to zero at the neutral plane or axis. There are also shearing forces which, like the tensile and compressive forces, are not uniformly distributed over the cross section of the specimen. Under bending conditions, the force responsible for failure as well as its magnitude is more difficult to determine. The bending forces in the neck of the femur, as a result of the load applied to the head of the bone (<b>Fig. 4</b>), have been determined by Zarek <a></a> , an engineer who is currently working in biomechanics. For further discussion of forces in bending, see Harris' <i>Strength of Materials</i>. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Distribution of tensile and compressive forces in a body tested like a simple beam <a></a>. L = length or span between supports; N. A. = neutral axis or plane; P = force or load. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Stress distribution in the neck of the femur.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The speed at which a force is applied to a specimen influences the values obtained for some of its mechanical properties. Mc-Elhaney and Byars <a></a> found that the ultimate compressive strength and the modulus of elasticity of fresh and embalmed femoral cortical bone from cattle and man increased with higher strain rates of loading while the energy-absorbing capacity and the strain at failure decreased. The effect of high strain rates of loading on specimens of beef bone, cut and tested in different directions, has recently been investigated by Bird et al. <a></a></p> <p>Embalming also affects the mechanical properties of bone, at least those of compact bone. Thus, the mean ultimate tensile strength (in the long axis of the specimen and of the intact bone) is greater at the 0.01 significance level in embalmed wet- and dry-tested tibial specimens than in similarly tested unembalmed specimens <a></a>. Furthermore, embalmed, wet-tested tibial specimens have a higher mean tensile strain, a greater mean single shearing strength (perpendicular to the long axis of the specimen) and are harder (Rockwell No.) than similarly tested embalmed specimens <a></a>. However, the latter type of specimens has a higher mean modulus of elasticity. An analysis of variance showed that the increase in the hardness of the embalmed specimens was significant at the 0.01 level. As far as I am aware, there are no similar studies concerning the effect of embalming on the mechanical properties of spongy bone.</p> <p>Two types or forms of bones are found in the foot-irregularly shaped bones (the tarsals) and miniature long bones (the metatarsals and the phalanges). The tarsal bones are essentially shells of compact bones filled with spongy bone, fat, marrow substance, blood, etc. The actual amount of osseous material in bones, such as the tarsals and the bodies of vertebrae, is not very great. According to Policard and Roche <a></a> the talus and the calcaneus are about 80 per cent nonosseous tissue. The percentage of bone in the bodies of 92 human lumbar vertebrae studied by Bromley <i>et al. </i><a></a> varied from a maximum of approximately 24 per cent to a minimum of 15.5 per cent in males and from 21 per cent to 12 per cent in females at 5 and 70 years of age, respectively. As far as I am aware, there are no studies on the mechanical properties of spongy bone from the foot. Therefore, examination of such properties will be based on data obtained from the human femur.</p> <p>Two types of specimens were used-a rectangular bar (the standard specimen) 0.79 cm. x 0.79 cm. x 2.5 cm. and a cube 0.79 cm. on a side. The specimens were obtained from the head, neck, greater trochanter, and condyles of the femur with the long axis of the standard specimens oriented in different directions.</p> <p>The specimens were tested under direct compression in a Riehle 5000-lb. capacity testing machine, equipped with an automatic stress-strain recorder and calibrated to an accuracy of ±0.5 per cent. The low range scale of the machine (0-200 lbs.) was used with the load registered on the dial of the machine in units of 0.5 lbs. The specimens were loaded at a speed of 0.45 in. per min.</p> <p>All specimens were tested wet to more nearly approximate the condition in the living foot. Drying of compact bone increases its ultimate tensile strength (in the long axis of the specimen), its modulus of elasticity, and its hardness (Rockwell No.) but decreases its single shearing strength (perpendicular to the long axis of the specimen) and its tensile strain.<a></a> Similar studies have not, to my knowledge, been made on spongy bone.</p> <p>The ultimate compressive stress (strength) and strain, the modulus of elasticity, and the energy absorbed to failure were computed from stress-strain curves for wet-tested specimens. The density of air-dried specimens was determined with a strontium 90 densitometer developed by Evans, Coolbaugh, and Lebow <i><a></a>. </i>Dry specimens were used to avoid the effects of moisture that might be trapped within the interstices of the specimens. A total of 69 rectangular (standard) specimens and of 15 cubic specimens from 1 adult, white female, 3 adult, Negro males, and 6 adult, white males were tested. All specimens were kept in saline solution until tested. A minimum of 20 load-deformation readings were taken for each specimen during the test period.</p> <p>The results of the study showed that the mean compressive stress (strength) of the cubic specimens was greater than that of the rectangular (standard) specimens from the same region (<b>Fig. 5</b>). This phenomenon is characteristic of practically all materials. In cubic specimens high frictional forces developed between the ends of the specimen and the testing machine to resist the tendency of the specimen to be squeezed out of the machine. Furthermore, the upper part of the cube tends to be impacted into the lower part. Both of these factors contribute to higher values for compressive stress and modulus of elasticity in cubic than in specimens which are longer than wide. Because of these factors, it is felt that the values obtained from the rectangular (standard) specimens more accurately represent the true mechanical properties of spongy bone.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Mean and range of variation in some mechanical properties of spongy bone from different regions of the femur. Compressive stress values in pounds force per square inch. Gt. troch. = greater trochanter; Lat. = lateral; Med. = medial; Cond. = condyle. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the living body, most of the bones are subjected to bending action as a result of gravity, muscular activity during movement, and blows. Consequently, the bones are subjected to a combination of tension, compression, and shearing rather than to a single pure force. The question then arises as to why the strength of bone is usually determined by testing the specimens under a pure force. The answer to this question, on mechanical grounds, has already been given. There are, however, other valid reasons for testing the strength of bone under pure tension or compression.</p> <p>Experimental studies with strain sensitive lacquers on bones within the living body as well as outside of it demonstrate that certain types of linear fractures of the skull, the pelvis, and the long bones all arise from failure of the bone from tensile stresses and strains produced in it by bending <a></a>. The determination of the tensile strength of bone under pure tension thus has direct application to the mechanics of fractures of those types. Clinical experience also indicates that tensile forces are important in the production of many types of fractures.</p> <p>Compression fractures are quite common in the bodies of the vertebrae, especially those in the lumbar region, and in the calcaneus, the most frequently fractured of the tarsal bones <i><a></a> . </i>Compression fractures of the talus also occur. There is, consequently, a sound practical reason for investigating the compressive strength of the tarsal bones, especially the calcaneus and the talus although, to my knowledge, it has not been done. The rationale for determining the strength of spongy bone from the femoral head and condyles under direct compression is that these regions of the bone are normally subjected to compression forces in the erect posture <i><a></a> . </i>Specimens from other regions were similarly tested for comparative purposes.</p> <p>When the results of the tests were compared according to the region of the bone from which the specimens were obtained, without regard to the direction of loading, several differences were found. The rectangular (standard) specimens from the neck had the highest and those from the greater trochanter the lowest mean compressive stress. Among the cubic specimens the highest and the lowest mean compressive stresses were found in specimens from the head and the medial condyle, respectively.</p> <p>Regional variation was also found in the modulus of elasticity (stiffness) of the specimens (<b>Fig. 5</b>). The mean stiffness of the rectangular specimens exceeded that of the cubic specimens from the same region except for the specimens from the head. The rectangular specimens from the neck and the medial condyle, respectively, had the highest and the lowest mean modulus. The maximum and the minimum stiffness means of the cubic specimens were found in those from the head and the medial condyle, respectively.</p> <p>Comparison of the mean compressive strain, mean energy absorbed to failure, and mean density of the rectangular and cubic specimens from different parts of the femur also reveals interesting differences (<b>Fig. 6</b>). The cubic specimens showed somewhat more variation in the mean compressive strain than did the rectangular ones, the strain being greatest in the specimens from the head and least in those from the medial condyle. Little difference was found in the mean compressive strain of the rectangular specimens, those from the head having a slightly greater strain than those from the condyles. The cubic and the rectangular specimens from the head had the highest while those from the medial condyle had the lowest mean energy absorbed to failure. However, the former specimens showed more regional difference than did the latter. The mean density for both types of specimens was greatest in those from the head and least in the ones from the lateral condyle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Mean and range of variation of some mechanical properties of spongy bone from various regions of the femur. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A statistical analysis of the above data from the rectangular (standard) specimens revealed the following significant differences between the means. The mean compressive stress of the strongest specimens (from the neck) was greater, at the 0.02 significance level, than that of the weakest specimens (from the greater trochanter). The difference between the mean compressive strain of the specimens from the head, which had the highest, and that of specimens from the medial condyle, which had the lowest, was significant at the 0.01 level.</p> <p>The mean energy absorbed by the specimens from the head was significantly greater, at the 0.02 level, than that absorbed by specimens from the medial condyle. The differences between the means for the other mechanical properties of the rectangular specimens were not statistically significant. The number of cubic specimens tested was not sufficiently large for statistical analysis.</p> <p>Comparison of the maximum compressive stress and modulus of elasticity (<b>Fig. 7</b>) of the rectangular and cubic specimens according to the direction of loading showed that spongy bone is an anisotropic material, i.e., a material that is not equally strong in all directions. The rectangular specimens loaded in the direction of the long axis of the neck of the femur showed the highest, while those loaded in the anterior-posterior direction showed the lowest mean compressive stress. Among the cubic specimens, the highest mean compressive stress was found in specimens loaded in a lateral-medial direction and the lowest in specimens loaded in a superior-inferior direction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Mean and range of variation in some mechanical properties of femoral spongy bone according to the direction of loading. Stress values in pounds force per square inch. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rectangular specimens loaded in a lateral-medial direction had the highest mean modulus of elasticity and those loaded in the anterior-posterior direction the lowest. The cubic specimens loaded in a lateral-medial direction had the highest mean modulus of elasticity while the lowest was found in the specimens loaded in a superior-inferior direction.</p> <p>Considerable variation was also found in the energy absorbed to failure, the compressive strain at failure, and the density of the specimens when evaluated with respect to different directions of loading (<b>Fig. 8</b>). The rectangular specimens loaded in a lateral-medial direction had the highest mean energy-absorbing capacity whereas those located in an anterior-posterior direction had the lowest. The highest mean energy-absorbing capacity among the cubic specimens was found in those loaded in a lateral-medial direction and the lowest in the specimens loaded in a superior-inferior direction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Mean and range of variation in some mechanical properties of femoral spongy bone according to the direction of loading. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rectangular specimens loaded in a lateral-medial direction had the highest average compressive strain and those loaded in the direction of the long axis of the neck had the least. The compressive strain of the cubic specimens loaded in a lateral-medial direction far exceeded that of all other specimens. The lowest compressive strain among cubic specimens was found in those loaded in the superior-inferior direction.</p> <p>Surprising differences were found in the density of specimens cut in different directions. The density of rectangular and cubic specimens cut in the lateral-medial direction was the same but greater than that of any other specimens. The rectangular specimens cut in the superior-inferior and in the anterior-posterior direction were the least dense. Cubic specimens were the least dense when cut in the superior-inferior direction. These differences in density of the specimens suggest directional variation in the orientation and abundance of trabeculae in various parts of the femur.</p> <p>A statistical analysis of the means for the various mechanical properties with respect to the direction of loading revealed the following significant differences. The variation between the energy absorbed by rectangular specimens, loaded in the lateral-medial direction, was significantly greater at the 0.01 level than that of the specimens subjected to anterior-posterior and to superior-inferior loading. The difference between the maximum compressive strain (found in lateral-medial loading) and the minimum strain (found in specimens loaded in the direction of the long axis of the neck) was significant at approximately the 0.04 level. No other significant differences were found between the means for the other mechanical properties when analyzed with respect to the direction in which the specimens were cut and loaded.</p> <p>Although spongy bone is much weaker than compact bone (<b>Fig. 9</b>), its foam-like structure makes it a good energy-absorbing material, as demonstrated experimentally more than a century ago by Dr. Physick <a></a> and more recently suggested by Evans, Pedersen, and Lissner <i><a></a> . </i>The presence of fat, marrow substance, and blood in the interstices of spongy bone in the living condition enhances its energy-absorbing capacity by making it act like a quasi-hydrostatic system. The capacity of bone to absorb energy is one of its important mechanical properties as far as fracture mechanics is concerned because, as pointed out by Lissner and Evans, <a></a> all physical injuries arise from the absorption of energy. Most fractures are produced by impacts or blows and thus involve energy absorption.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Mean and range of variation in strength of various bones according to type (compact or spongy) and. direction of loading <a></a>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another mechanical property of bone to be considered is its fatigue life. This is especially important in relation to march, stress, or fatigue fractures which are most common in the metatarsal bones although they have also been reported in other bones. These fractures are thought to be the result of repetitive loading such as occurs during marching, hence the name "march" fracture.</p> <p>The only investigation known to me on the fatigue life of intact bones is one we made several years ago <i><a></a> . </i>In this study the strength of intact human metatarsal bones was determined by loading them to failure in a Sonntag Flexure Fatigue machine equipped with an automatic counter (which recorded the number of cycles to failure) and shutoff. The chief advantage in using this type of fatigue machine is that it has an inertia force-compensator spring which absorbs or eliminates all unknown inertia forces. Consequently, the force in the specimen being tested, regardless of its rigidity, is equal to the known force produced by the oscillator assembly.</p> <p>Forty-one bones were tested with a force of 15 lbs. (the maximum that could be applied with our machine), 3 bones with 12 lbs., and 8 bones with 10 lbs. Only the second through fifth metatarsals were tested because the first one was too large for the fatigue machine. The influence of moisture upon the fatigue life of the specimens was investigated in 10 bones by allowing water to drip on them during a test. The bones were not degreased and all were tested at room temperature. None of the bones exhibited any known pathologic condition. In order to hold the bone in the fatigue machine during a test, the ends were embedded in Selectron 5026 plastic. The number of repetitions to failure was automatically recorded and the machine shut off as soon as the specimen broke. A cycle means the bone is bent once up and once down.</p> <p>Comparison of the results obtained for the wet- and the dry-tested specimens showed that drying tended to decrease the fatigue life of the bones (<b>Table 1</b>). The probable explanation is that drying increased the modulus of elasticity of the bone and hence the specimens were stiffer. The number of repetitions to failure, with a 15-lb. force, varied from 1,000 to 10,297,000 for the dry specimens and from 150,000 to 13,908,000 for the wet specimens. Metatarsals 2 and 3 showed the greatest fatigue life when tested wet. No consistent relations were found between the fatigue life of the bones and their size or age of the individuals from whom they were obtained. The type of fracture produced experimentally (<b>Fig. 10</b>) was similar to some reported <a></a> in the clinic literature (<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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Experimentally produced fatigue fracture of an intact human metatarsal bone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. A clinical fatigue fracture of a metatarsal bone.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is interesting to speculate how long an individual must walk before the metatarsals would be subjected to the same number of repetitions at which failure occurred in our experiments. If it were assumed that an individual walked at the army pace of 120 steps per min., walking 50 min., resting 10 min., one would have to walk continuously for almost a month before the second metatarsal would be subjected to the number of repetitions at which the failure occurred in the present study. During each cycle of loading, the bone was bent up and down in a vertical plane. The fracture was probably a tensile failure initiated on the side which, at the instance of failure, was the convex or tensile side.</p> <p><b>References:</b></p> <ol> <li>Bird, F., H. Becker, J. Healer, and M. Messer, <i>Experimental determination of the mechanical properties of bone</i>, Aerospace Med., 39:1:44-48, 1968.</li> <li>Bromley, R. G., N. L. Docku, J. S. Arnold, and W. S. S. Jee, <i>Quantitative histological study of human lumbar vertebrae</i>, J. Geront., 21: 537-543, October 1966.</li> <li>Evans, F. G., <i>Stress and strain in bones, their relation to fractures and osteogenesis</i>, Charles C Thomas, Springfield, Ill., 1957.</li> <li>Evans, F. G., <i>Significant differences in the tensile strength of adult human compact bone</i>, in H. J. J. Blackwood, Proceedings of the first European bone and tooth symposium, pp. 319-331, Pergamon Press, Oxford, 1964.</li> <li>Evans, F. G., <i>Relazioni tra alcune proprieta meccaniche e struttura istologica dell'osso compatto umano</i>, Arch. Putti, in press.</li> <li>Evans, F. G., <i>Relation of the physical properties of bone to fractures</i>, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 18:110-121, 1961.</li> <li>Evans, F. G., and M. Lebow, <i>Regional differences in some of the physical properties of the human femur</i>, J. Appl. Physiol., 3:9:563-572, March 1951.</li> <li>Evans, F. G., and M. Lebow, <i>The strength of human compact bone as revealed by engineering technics</i>, Amer. J. Surg., 83:3:326-331, 1952.</li> <li>Evans, F. G., C. C. Coolbaugh, and M. Lebow, <i>An apparatus for determining bone density by means of radioactive strontium (Sr90)</i>, Science, 114:2955:182-185, 1951.</li> <li>Evans, F. G., H. E. Pedersen, and H. R. Lissner, <i>The role of tensile stress in the mechanism of femoral fractures</i>, J. Bone Joint Surg., 33A: 485-501, 1951.</li> <li>Harris, C. O., <i>Strength of materials</i>, American Technical Society, Chicago, 1963.</li> <li>Key, J. A., and H. E. Conwell, <i>The management of fractures, dislocations, and sprains</i>, C. V. Mosby, St. Louis. 1951.</li> <li>Koch, J. C, <i>The laws of bone architecture</i>, Amer. J. Anat., 21:177-298, March 1917.</li> <li>Kraus, G. R., and J. R. Thompson, <i>March fracture: An analysis of 200 cases</i>, J. Roent. Radium Therapy, 52:281-290, 1944.</li> <li>Lease, G. O'D., and F. G. Evans, <i>Strength of human metatarsal bones under repetitive loading</i>, J. Appl. Physiol., 14:1:49-51, 1959.</li> <li>Lissner, H. R., and F. G. Evans, <i>Engineering aspects of fractures</i>, Clin. Orthop., 8:310-322, 1956.</li> <li>McElhaney, J. H., and E. F. Byars, <i>Dynamic response of biological materials</i>, Amer. Soc. Mech. Eng., 65-WA/HUF-9, December 1965.</li> <li>Policard, A., and J. Roche, <i>La formation de la substance osseuse</i>. Essai de coordination des donnees histologiques et biochimiques. Ann. Physiol. Physicochim. Biol., 13:645-703, 1937.</li> <li>Wistar, C, <i>A system of anatomy</i>, Ed. 4, Carey, Lea and Carey, Philadelphia, 1827.</li> <li>Zarek, J. M., <i>Biomechanics: Its application to surgery</i>, Chap. 6 in L. Gillis, Modem trends in surgical materials, Butterworth and Co. Ltd., London, 1958, pp. 106-123.</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>14.</b> </td><td class="clsTextSmall">Kraus, G. R., and J. R. Thompson, March fracture: An analysis of 200 cases, J. Roent. Radium Therapy, 52:281-290, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Kraus, G. R., and J. R. Thompson, March fracture: An analysis of 200 cases, J. Roent. Radium Therapy, 52:281-290, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Lease, G. O'D., and F. G. Evans, Strength of human metatarsal bones under repetitive loading, J. Appl. Physiol., 14:1:49-51, 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Evans, F. G., Relation of the physical properties of bone to fractures, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 18:110-121, 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>16.</b> </td><td class="clsTextSmall">Lissner, H. R., and F. G. Evans, Engineering aspects of fractures, Clin. Orthop., 8:310-322, 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">Evans, F. G., H. E. Pedersen, and H. R. Lissner, The role of tensile stress in the mechanism of femoral fractures, J. Bone Joint Surg., 33A: 485-501, 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Wistar, C, A system of anatomy, Ed. 4, Carey, Lea and Carey, Philadelphia, 1827.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Koch, J. C, The laws of bone architecture, Amer. J. Anat., 21:177-298, March 1917.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Key, J. A., and H. E. Conwell, The management of fractures, dislocations, and sprains, C. V. Mosby, St. Louis. 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Evans, F. G., Stress and strain in bones, their relation to fractures and osteogenesis, Charles C Thomas, Springfield, Ill., 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>9.</b> </td><td class="clsTextSmall">Evans, F. G., C. C. Coolbaugh, and M. Lebow, An apparatus for determining bone density by means of radioactive strontium (Sr90), Science, 114:2955:182-185, 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>7.</b> </td><td class="clsTextSmall">Evans, F. G., and M. Lebow, Regional differences in some of the physical properties of the human femur, J. Appl. Physiol., 3:9:563-572, March 1951.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Evans, F. G., and M. Lebow, The strength of human compact bone as revealed by engineering technics, Amer. J. Surg., 83:3:326-331, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bromley, R. G., N. L. Docku, J. S. Arnold, and W. S. S. Jee, Quantitative histological study of human lumbar vertebrae, J. Geront., 21: 537-543, October 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Policard, A., and J. Roche, La formation de la substance osseuse. Essai de coordination des donnees histologiques et biochimiques. Ann. Physiol. Physicochim. Biol., 13:645-703, 1937.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Evans, F. G., Relazioni tra alcune proprieta meccaniche e struttura istologica dell'osso compatto umano, Arch. Putti, in press.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Evans, F. G., Significant differences in the tensile strength of adult human compact bone, in H. J. J. Blackwood, Proceedings of the first European bone and tooth symposium, pp. 319-331, Pergamon Press, Oxford, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bird, F., H. Becker, J. Healer, and M. Messer, Experimental determination of the mechanical properties of bone, Aerospace Med., 39:1:44-48, 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">McElhaney, J. H., and E. F. Byars, Dynamic response of biological materials, Amer. Soc. Mech. Eng., 65-WA/HUF-9, December 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Zarek, J. M., Biomechanics: Its application to surgery, Chap. 6 in L. Gillis, Modem trends in surgical materials, Butterworth and Co. Ltd., London, 1958, pp. 106-123.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Evans, F. G., Relation of the physical properties of bone to fractures, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 18:110-121, 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>11.</b> </td><td class="clsTextSmall">Harris, C. O., Strength of materials, American Technical Society, Chicago, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Zarek, J. M., Biomechanics: Its application to surgery, Chap. 6 in L. Gillis, Modem trends in surgical materials, Butterworth and Co. Ltd., London, 1958, pp. 106-123.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Evans, F. G., and M. Lebow, Regional differences in some of the physical properties of the human femur, J. Appl. Physiol., 3:9:563-572, March 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>F. Gaynor Evans. Ph.D. </b></td></tr><tr><td class="clsTextSmall">Department of Anatomy and Highway Safety Research Institute, The University of Michigan, Ann Arbor, Mich. 48104.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_037/spring69-33.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_037/spring69-34.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_037/spring69-35.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_037/spring69-36.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_037/spring69-37.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_037/spring69-38.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_037/spring69-39.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_037/spring69-40.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_01_037/spring69-41.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_01_037/spring69-42.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_01_037/spring69-43.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_01_037/spring69-44.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 Mechanical Properties of Bone Creator An entity primarily responsible for making the resource F. Gaynor Evans. Ph.D. * https://staging.drfop.org/files/original/88bef5d62a14398fc3a18bca7131f8d8.pdf 86d59bbde4b62c325ee0ebad480c4e5f https://staging.drfop.org/files/original/a84e8ce4eb14a01f0ef2b2853a788184.jpg 0a6c5befd14aa80990442ce44b52ab3b https://staging.drfop.org/files/original/086c58dc00817fa00adcb9085b4887ee.jpg 3c6699b65e4f90cf65ce688efeef8135 https://staging.drfop.org/files/original/9b7bcc17ba2e80fbdba893a929d85938.jpg 9ed6bb7ee61966d89d7987f935e7b034 https://staging.drfop.org/files/original/16080d78a84c16864ec113cd9ecacdf5.jpg b392c89f1756f04fe19a3ad6250113e2 https://staging.drfop.org/files/original/29997ac6960eedc1a118bddad0b95f7c.jpg 6c9a31a9af5ba3831ccdbeb8f4936c57 https://staging.drfop.org/files/original/5786b706e7e673ea58f74136b2873bd9.jpg 0cd440682c88a020c34584737b244d7d https://staging.drfop.org/files/original/9619f95ba15af83f199f79659e870183.jpg b4c873ee734251f9760a68756ee81e23 https://staging.drfop.org/files/original/98848e3c786b553e83ab938453172bb8.jpg 0c8c38b091e2db04fca212e6d969202b https://staging.drfop.org/files/original/156b8585b39aa6c343505e1dbb2319eb.jpg 473d661cc1700725a11f2a0801e2f0b4 https://staging.drfop.org/files/original/180831d52019c33f425c4abef213436c.jpg cb53f48a3e0b0aadd418c3f302efb8c8 https://staging.drfop.org/files/original/00d9d63023a6fe1b224f4e65f8f427d8.jpg d19eb70180882f9be9283cfe7c9fad7c https://staging.drfop.org/files/original/92cc21d0b179a43c17c8e2601b36face.jpg ef09bcbd71c9a5ab1946affdd2d3a1fb https://staging.drfop.org/files/original/84ed9b79ed6c37a2442937152385a670.jpg 96cc057c0c3752fe06400aaef020bf31 https://staging.drfop.org/files/original/02800ee7d2bcaf59054a58fa1a76f5f9.jpg bcd50bad74ee70aedc0c9fdd43ae2b78 https://staging.drfop.org/files/original/e83e8ff373a7a2161bce8c4e4b469c59.jpg e0815425b9120a70904cb54f6db154c4 https://staging.drfop.org/files/original/13e717b3a2917a1f960b337b564c1a2c.jpg 95b5a4e637a9579f4f7f1262bd8f9f93 https://staging.drfop.org/files/original/c7761c10dee8f20eb5989c636532dd48.jpg 16a76ccbb32f47d32cc0636dfe8b849c https://staging.drfop.org/files/original/de8c25414b9f0dc535a4ece8c2a3bc3c.jpg e42c82f4b353b2d82db9be8e58647298 https://staging.drfop.org/files/original/aae1935446e932da0d197817ff316667.jpg cdfce01bb2a2f3d62f09803a4399a4cd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_004.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 4 - 25 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_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>The Munster-Type Below-Elbow Socket, a Fabrication Technique</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br />Kevin A. Cody, M.A. <a style="text-decoration:none;">*</a><br />George Hartmann, C.P.O. <a style="text-decoration:none;">*</a><br />Dominick E. Casella <a style="text-decoration:none;">*</a><br /></h5> <p>The introduction of the Munster technique into the United States in 1958 generated considerable interest in the prosthetics profession, particularly for the management of amputees with short and very short below-elbow stumps. However, in spite of the enthusiasm for this technique, its application has met with varying success in this country. The dearth of precise instructional material has undoubtedly contributed to the lack of consistent results. Each prosthetist has improvised from the limited information available, sometimes successfully, sometimes unsuccessfully.</p> <p>The purpose of this article and the manual upon which it is based<a></a> is to present a detailed description of the Munster technique based upon the procedures utilized in the successful fittings performed in the New York University evaluations of 1963-1964.<a></a> But there can be no substitute for formal instruction and demonstration in the technique. This point is stressed because at least one critical procedure in the fabrication technique, that of cast taking, is quite difficult to learn by the written word and pictures alone.</p> <p>The procedures presented do not conform in every respect to those promulgated by the developers, Drs. Oskar Hepp and G. G. Kuhn.<a></a> However, it is believed they are a close approximation. For this reason the technique is referred to as the "Munster-type" fabrication technique. In choosing this title, it is intended to give appropriate credit to Drs. Hepp and Kuhn for the original development of the technique, without implying identity with their procedures.</p> <p>Short below-elbow stumps have always presented fitting problems for the obvious reasons of small attachment area, poor leverage, and a decreased range of useful motion. Split sockets and step-up hinges have commonly been used to provide a full range of elbow flexion (135 deg.) to amputees having very short below-elbow stumps. However, this system is characterized by several features which tend to reduce its over-all acceptability. Step-up hinges decrease the lifting power available to the amputee, increase the bulk of the prosthesis at the elbow and proximal forearm, and historically have lacked durability. (<b>Fig. 1</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Anterior-oblique and posterior-oblique views of the Munster-type prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>During the middle 1950's, Drs. Hepp and Kuhn of Munster, Germany, formulated a new approach to the prosthetic management of short upper-extremity stumps. They developed a technique for fabricating sockets for below-elbow and above-elbow amputations which provides a more intimate encapsulation of short slumps.<a></a> </p> <h3>Evaluation of Munster Fabrication Technique</h3> <p>New York University Adult Prosthetic Studies became interested in the Munster technique for amputees having short and very short be-low-elbow stumps, following the favorable experiences reported by amputee clinics in fitting preflexed arms (that is, arms bent to provide a certain amount of preflexion) to children.<a></a> Under the auspices of the Subcommittee on Evaluation of the Committee on Prosthetics Research and Development, New York University conducted an evaluation of what was considered the Munster technique in applications to adult amputees.<a></a> The general characteristics of the below-elbow sockets fabricated in this study were:</p> <ol> <li>The forearm was set in a position of initial flexion (average 35 deg.) in relation to the humerus. Because of the reduced range of useful motion, the socket was flexed to position the terminal device in the most generally useful area.</li><li>The anterior trim line extended to the level of the antecubital fold, with a channel provided for the biceps tendon to avoid interference between socket and biceps tendon during flexion.</li><li>The posterior aspect of the socket enclosed the olecranon, taking advantage of this bony prominence to provide attachment and stability to the socket. The trim line was just above the level of the epicondyles.</li></ol> <p>Because of the high anterior and posterior walls of the sockets, the range of motion for the average amputee was limited to approximately 70 deg. (from 35 deg. to 105 deg. flexion). The limited range of motion characteristic of Munster-type sockets bears emphasis (<b>Fig. 2</b> and <b>Fig. 3</b>). In current practice, the acceptable checkout standard for maximum elbow flexion with the prosthesis is that it should be within 10 deg. of stump flexion without the prosthesis. This standard is not applicable to the Munster-type prosthesis. Nevertheless, the decreased range of motion available has been found acceptable by unilateral amputees who typically use their prostheses as assistive devices and perform very few activities at the extremes of the flexion-extension range.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Maximum extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Maximum flexion, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The results of the New York University study of Munster-type fittings cited earlier indicated that:</p> <ol> <li>Amputees reacted positively to the comfort and security of the socket.</li><li>The decrease in flexion range had no appreciable effect on the prosthetic functions of unilateral amputees. However, for bilateral subjects, modification of the anterior trim line and the provision of a wrist-flexion device were necessary for the performance of tasks close to the body.</li><li>Lifting and holding forces available to the amputee were generally superior.</li></ol> <p>(<b>Fig. 4</b> and <b>Fig. 5</b>)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. "Live lift"-resisting vertical downward force while maintaining the elbow flexed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. "Axial load"-resisting vertical downward force with the elbow extended. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Following the favorable results obtained in fitting adult amputees, New York University Child Prosthetic Studies initiated a study of the applicability of these procedures to children with very short, short, and long below-elbow deficiencies. As of March 1965, ten successfully fitted children ranging in age from 20 months to 10 years had worn their prostheses for periods ranging from 4 to 14 months.</p> <p>Although the study of the children's fittings had not been completed at this writing, the indications are that fabrication procedures for adults, as described in this article, would be equally applicable to children.</p> <h3>Prescription Considerations</h3> <p><i>A priori, </i>this method of socket fabrication would appear to be of greatest potential benefit to amputees with stumps of the short and very short types. These are patients who, under current practice, would typically be fitted with metal elbow hinges-step-up, polycentric, or, at the longer limits of the range, single-pivot or flexible hinges. Prime beneficiaries might be amputees who normally would be fitted with split sockets and step-up hinges because of the inherent disadvantages in this type of fitting.</p> <p>In general, this hypothesis has been verified by fitting experience to date. In the NYU evaluations approximately 90 per cent of the stumps fitted fell into the short and very short below-elbow categories. Specifically, nine adults (including one bilateral amputee) with stump lengths ranging from l-1/2 in. to 5-1/2 in. (18 to 52 per cent) and eight children with stumps 2 in. to 3 in. long (25 to 40 per cent) were successfully fitted with Munster-type prostheses.</p> <p>The precise limits of applicability of the Munster-type prosthesis (that is, the minimum and maximum stump lengths) must be determined individually for each patient. However, based upon a somewhat limited investigation of these considerations, the following guidelines are offered:</p> <p><i>Minimum length: </i>Very short stumps virtually disappear at 90 deg. of elbow flexion. Hence, the maximum prosthetic flexion angle obtainable with stumps in this category is limited accordingly. The shortest stump fitted at NYU was 1-1/2 in. (18 per cent) in length. The maximum flexion angle obtained (with prosthesis) was 80 deg.</p> <p>Thus, fitting of Munster-type sockets to stumps as short as 1-1/2 in. depends upon the acceptability of a very limited amount of elbow flexion (usually less than 90 deg.).</p> <p><i>Maximum length: </i>With regard to maximum stump length, two limiting factors must be considered:</p> <ol> <li>Depending on the extent of the anatomical deficiency, stumps of mid-length and longer usually have some degree of residual pronation-supination which may be harnessed in a conventional below-elbow socket with flexible hinges. This active pronation-supination of the prosthesis is eliminated with the Munster-type fitting. The question to be decided is whether other advantages of the Munster-type prosthesis adequately compensate for the loss of rotation in a given case.</li><li>The configuration of the Munster-type socket (proximal opening at an angle to the socket) presents progressively increasing difficulty in donning and doffing the prosthesis as stump length increases. Absolute stump length rather than proportion of sound side remaining appears to be the prime determinant. The difficulties can be reduced by socket modifications, such as a looser fit or lowered trim line. Such modifications, however, progressively reduce control and retention of the prosthesis.</li></ol> <p>NYU has fitted several adult and juvenile amputees whose stumps fell into the long classification; that is, 55 per cent of sound side or longer. One adult at the borderline of the long classification (5-1/2 in.-56 per cent) and a child well within this category (4 in.-66 per cent) were not affected by the considerations mentioned above. In both cases residual pronation and supination were minimal, and no difficulty was experienced in putting on and taking off the prosthesis.</p> <p>However, an adult with a 7-in. stump (66 per cent) required considerable modifications to the proximal brim before the prosthesis could be delivered successfully. The anterior trim line was reduced approximately 1/2 in. below the cubital fold to facilitate passage of the stump. The subject had about 55 per cent of residual stump rotation; but, since this rotation had not been utilized in the previous prosthesis, no deprivation was imposed by the Munster-type arm.</p> <p>One child with a 6-in. (92 per cent) stump was also successfully fitted with two different modifications of the Munster-type prosthesis. In the initial prosthesis, the posterior trim line was reduced to just above the olecranon for manageable donning and doffing. In a second fitting, the standard trim lines were maintained, but the socket was made somewhat looser than usual. Both modifications produced sockets with slightly reduced but still very acceptable retention.</p> <p>Thus, the Munster-type prostheses can apparently be fitted without difficulty to stumps up to the limit of the short below-elbow classification (55 per cent). The fitting of longer stumps involves consideration on an individual basis of the factors discussed.</p> <h3>Bilateral Fittings</h3> <p>The question of fitting Munster-type prostheses bilaterally is not fully resolved. Two problems are inherent in such fittings:</p> <ol> <li>The difficulty in donning two closely fitting prostheses without assistance.</li><li>The limitation imposed by restricted elbow flexion, particularly on the dominant side.</li></ol> <p>NYU has had no experience in fitting children bilaterally but has successfully fitted one bilateral adult amputee (4-in. and 5-1/2-in. stumps). The inherent problems were resolved by:</p> <ol> <li>Fitting the sockets less snugly than usual to facilitate donning.</li><li>Lowering the anterior trim line and providing a wrist-flexion unit on the dominant side for activities close to the body.</li></ol> <p>It is probable that selected juvenile bilateral amputees might be successfully fitted with similar modifications.</p> <h3>Procedures</h3> <h4>Stump Eexamination and Measurements</h4> <p>Materials required for stump examination and measurements are:</p> <ul> <li>Measuring tape</li> <li>Ruler</li> <li>Goniometer</li> <li>Measurement form (<b>Fig. 6</b>)</li> </ul> <p>A thorough stump examination is an important prerequisite to any prosthetic fitting procedure. In the Munster-type fitting, a stump examination is even more critical than usual because of the intimate socket encapsulation of the stump. Skin irritations, painful scars, abrasions, and sensitive areas must be identified so that necessary socket reliefs maybe anticipated and provided.</p> <p>Consistent with sound prosthetics practice, it is advisable to follow the conventional measurement procedures described in the<i>Manual of Upper Extremity Prosthetics</i><a></a> so that a comprehensive record will be available for future reference. The appropriate below-elbow measurements are recorded on the modified Upper-Extremity Measurement Chart shown as <b>Fig. 6</b>. However, it should be noted that, since the plaster-wrap casts are used as check sockets in this technique and stump molds made from the wrap casts are not corrected to measurements, the only measure essential for fabrication is the length of the normal forearm to wrist and thumb tip.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Measurement form. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It should also be noted that stump and sound forearm lengths are pleasured from the olecranon rather than from the epicondvles, since the olecranon is more convenient to use as a reference point on the cast and socket. These measurements are described below.</p> <p><i>Stump length: </i>The stump length is measured from the posterior aspect of the olecranon (<b>Fig. 7</b>). If distal redundant tissue is present, the measurement should include the redundancy.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Measuring stump length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Forearm length: </i>With the patient's sound forearm flexed at approximately 90 deg., and held midway between pronation and supination, measurements are made from the proximal aspect of the olecranon to the distal aspect of the ulnar styloid, and from the olecranon to a point on the ulnar border of the hand which corresponds to the thumb tip (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Measuring forearm length. A, Measuring from the proximal aspect of the olecranon to the distal aspect of the ulnar styloid; B, measuring from the olecranon to a point on the ulnar border of the hand which corresponds to the thumb tip. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Wrap Cast</h4> <p>Materials required to take the wrap cast are:</p> <ul> <li>Cotton stockinette (appropriate size for stump)</li> <li>Dacron tape for temporary harness</li> <li>Yates clamps</li> <li>Indelible marking pencil</li> <li>Three rolls of plaster-of-Paris bandage (6 or 8 cm. elastic-type preferred)</li> <li>Pail of water</li> </ul> <p>A snug, form-fitting cotton stockinette is placed over the stump to insulate the skin and hair from plaster. The assistance of the amputee or a temporary figure-eight harness may be used to keep the stockinette free from wrinkles. The harness method is generally preferable for children.</p> <p>Application of the proper molding grip is essential to the success of the wrap cast and hence to the final outcome of the fitting. It is important, therefore, that the prosthetist practice this procedure on each amputee prior to the application of the cast. He will thus become familiar with the individual characteristics of each amputee's stump, and the possibility of erroneous molding once the stump is wrapped will consequently be reduced. Furthermore, the amputee will know what to expect during the casting procedure and be better able to cooperate.</p> <p>It is important to note that the prosthetist will be able to apply the molding grip more conveniently when his arms and those of the amputee are at the same level. It is suggested, therefore, that child amputees sit on a table or stand on a raised platform.</p> <p>In this article, the specific steps to be followed are described for a right below-elbow amputee (the hand positions are reversed for a left amputee). Because of the fundamental importance of the correct molding grip, this aspect of the fabrication procedure is illustrated with both photographs and drawings.</p> <p>With the amputee's stump flexed to 90 deg., the index and middle fingers of the pros-thetist's right hand are placed on the anterior surface of the stump. The prosthetist's right wrist should be in a neutral or slightly extended position. The two fingers should rest on either side of the biceps tendon and along the anterior surface of the slump. Moderate pressure is exerted (to the point of firm resistance) simultaneously into the cubital fold and downward on the anterior surface of the stump, but am concentration of pressure distally is avoided (<b>Fig. 9</b> and <b>Fig. 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Practicing the molding grip. The prosthetist exerts moderate pressure on either side of the biceps tendon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Another view of the prosthetist exerting pressure on either side of the biceps tendon, simultaneously into the cubital fold and downward on the anterior surface of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The dorsal aspect of the proximal ulna is distinctly wedge-shaped. The prosthetist's left hand is shaped so that the thenar and hypo-thenar eminences form a channel into which this wedge will fit (<b>Fig. 11</b>). The grooved hand is then positioned against the underside of the stump to provide stability and support without distortion. The metacarpal joints of the prosthetist's left hand should be located just below the amputee's olecranon (<b>Fig. 12</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Practicing the molding grip. A, The wedge-shaped ulna as viewed from the rear; B, channel formed in the prosthetist's hand; C, the ulna fitted into the channel. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Practicing the molding grip; positioning the grooved left hand of the prosthetist against the underside of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The index, middle, and ring fingers of the prosthetist's left hand are cupped and positioned on the distal posterior surface of the humerus just above the level of the epicondyles (<b>Fig. 13</b>). Gentle downward pressure is applied with the pads of the fingers. Care must be taken to avoid pressure between the palm of the hand and the olecranon. Thus relief is automatically provided for the olecranon. The little finger and the thumb may be curled to make contact with the medial and lateral epicondyles, respectively. However, these digits should <i>not </i>exert any pressure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Practicing the molding grip; gentle downward pressure being applied by the pads of the index. middle, and ring fingers of the prosthetist's left hand. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In view of the intimate fit which characterizes the Munster-type socket, tender areas and bony prominences such as the olecranon and the epicondyles must be clearly defined for the provision of the necessary reliefs. While the stump is flexed at 90 deg., these areas are marked with an indelible pencil so that thev may be easilv identified on the wrap cast (<b>Fig. 14</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Marking tender areas and bony prominences </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A preliminary trim line is marked on the cast sock by drawing a line posteriorly connecting two points 1 in. superior to the medial and the lateral epicondyle, respectively; and the line is continued anteriorly so that it passes through a point 1/2 in. above the mid-cubital space (<b>Fig. 15</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Marking the preliminary trim line on the cast sock. A, A line is drawn posteriorly connecting two points 1 in. superior to the medial and the lateral condyles; B, the line is continued to pass anteriorly 1/2 in. above the mid-cubital space. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The critical relationship between the stump and the Munster-type socket cannot be overemphasized. Every effort should be made, therefore, to obtain a properly fitting cast. To this end, it is recommended that at least two, and preferably three, casts be taken so that the prosthetist and the patient together may choose the best of the series. Elastic or non-elastic plaster-of-Paris bandages may be used, but the elastic is preferable since it results in a more accurate configuration.</p> <p>While the stump is flexed at 90 deg. and the humerus is held midway between internal and external rotation, the wrap is commenced with two circular turns above the elbow joint (over the olecranon and the cubital fold). Only very slight tension should be applied to the plaster-of-Paris bandage (either elastic or nonelastic) in the process (<b>Fig. 16</b><i>A</i>). The wrapping proceeds to the distal end of the stump in a figure-eight or a spiral pattern (<b>Fig. 16</b><i>B). </i>The wrap is continued at least 1/4 in. above the reference marks made earlier.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Wrapping the stump. A, The wrap is begun with two circular turns around the elbow joint-over the olecranon and the cubital fold; B, the distal end of the stump is included in either a figure-eight or a spiral pattern; C, the wrap is continued at least 34 in. above the reference marks made earlier. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the wrapping has been completed, the molding grip practiced earlier is applied (<b>Fig. 17</b>). Finger pressure should be sufficient to displace all loose tissue (to the point where firm resistance is reached). Pressure is maintained until the plaster has set.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Application of the molding grip to the wrap cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the plaster has hardened, the proximal end of the wrap cast is reinforced with several turns of nonelastic plaster-of-Paris bandage in order to minimize distortion. Then the stockinette is pulled down over the cast (<b>Fig. 18</b><i>A</i>). As the cast is gently worked off the stump, upward pressure is applied to the arm to increase skin tension at the proximal end of the cast in order to break the vacuum seal (<b>Fig. 18</b><i>B</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Removal of wrap cast. A, Pulling the stockinette down over the cast; B, applying upward pressure on the arm as the cast is gently worked off the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The stockinette is removed from the cast, and the indelible markings which have been transferred from the stockinette to the inner wall of the cast are accentuated (<b>Fig. 19</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Accentuating the indelible markings transferred from the stockinette to the inner wall of the cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These procedures should be repeated until a minimum of two, and preferably three, casts have been taken.</p> <h4>The Check Socket</h4> <p>Materials required to prepare the check socket are:</p> <ul> <li>Knife</li> <li>Scissors</li> <li>Fresh plaster</li> <li>Water</li> </ul> <p>All of the wrap casts taken should be prepared in accordance with the procedures described below and used as check sockets. The one agreed upon by both the prosthetist and the patient as providing the most comfortable fit and the greatest range of motion and maximum security is selected for use in the preparation of the positive plaster model.</p> <p>A hole is cut in the cast, just large enough to allow the passage of a stump pulling sock and as close to the distal end as possible so that shortening of the cast is minimized (<b>Fig. 20</b><i>A</i>). The final trim lines for every socket must be determined individually for each amputee. However, as an initial step, the proximal end of the cast is trimmed to the level of the reference line made earlier (<b>Fig. 20</b><i>B</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Trimming the cast. A, The hole cut in the distal end should be just large enough to permit passage of a stump pulling sock; B, trimming the proximal end at the level of the reference line made earlier. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast is then moistened, and the inside of the cast is smoothed with fresh plaster to remove all gauze marks, except in the area of the epicondyles and the olecranon (<b>Fig. 21</b>). <i>No </i>plaster should be added in these critical areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Smoothing the inside of the cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Fitting The Check Socket</h4> <p>Materials required for fitting the check socket are:</p> <ul> <li>Cotton stockinette (stump pulling sock)</li> <li>Indelible marking pencil</li> </ul> <p>A length of stockinette is placed on the amputee's stump, and the distal end of the stockinette is drawn through the hole in the check socket. The stump is pulled into the socket, care being taken that all flesh is drawn inside the cast (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Pulling the stump into the check socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the check socket on the amputee, the usual tests are made for adequacy of fit, comfort, and range of motion by having the amputee exert force against resistance in elbow flexion, extension, and rotation (<b>Fig. 23</b>). Although the stump cannot rotate the socket, there may be some undesirable rotation of the stump within the socket. If the fit of the check socket is not satisfactory, the socket should be rejected.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Determining the adequacy of the fit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the check socket causes any pain or discomfort, the appropriate area should be marked on the outside of the socket so that relief can be provided (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Marking an area which requires relief. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The same procedures are repeated with the other check sockets and the best socket is selected for use in completion of the prosthesis.</p> <h4>Establishing The Range of Motion in Check Sockets</h4> <p>The maximum forearm flexion and extension positions attainable with the Munster-type prosthesis will be significantly less than those achieved in conventional prostheses. Experience has shown that the maximum flexion range for the typical short below-elbow stump fitted with a Munster-type socket is approximately 70 deg. (from 35 deg. initial flexion to 105 deg. maximum flexion).<a></a> A range of motion of this magnitude is not always achievable but should be the initial goal of the fitting.</p> <p>The principal factors limiting the range of motion are:</p> <ol> <li>Restriction in the maximum flexion angle obtained attributable to one or more of the following conditions: <ul> <li>Insufficient relief for the olecranon</li> <li>Too small a channel for the biceps tendon</li> <li>Too high an anterior wall</li> </ul> </li><li>Restriction in extension attributable to too high a posterior trim line.</li></ol> <p>However, it must be emphasized that lowered trim lines or loose fit will adversely affect the retention of the socket on the stump. Hence, the initial trim lines need to be closely maintained in order to provide maximum socket retention. They should be reduced only when absolutely necessary to provide greater comfort or increased range of motion, or both.</p> <p>Materials required in establishing the range of motion are:</p> <ul> <li>Indelible pencil</li> <li>Scissors or knife</li> <li>Goniometer</li> <li>Ruler</li> </ul> <p>A line is drawn on the lateral side of the check socket coincident with its long axis (from the lateral epicondyle to the mid-distal end) to serve as a guide in measuring flexion and extension (<b>Fig. 25</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Drawing a line on the check socket coincident with its long axis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The center of the goniometer is placed on the lateral epicondyle. The lower arm of the goniometer is placed on the long axis line, and the upper arm of the goniometer is lined up with the acromion (<b>Fig. 26</b>). Maximum flexion and extension angles are measured from these points of reference.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Placement of goniometer to measure maximum flexion and extension angles </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If motion is restricted, the specific cause for the restriction should be determined and corrective action should be taken (<b>Fig. 27</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Trimming the check socket to provide increased range of motion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the amputee cannot achieve the proposed 35 deg. of initial flexion in the check socket, the discrepancy is compensated for in the alignment of the forearm shell. Therefore, while the stump is maintained in an actively extended position, a second line is drawn on the check socket at an angle of 35 deg. between the humerus and the stump (<b>Fig. 28</b>). This line will serve as a guide in aligning the forearm shell.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Drawing a second line at a 35-deg. angle between the humerus and the stump to serve as a guide in aligning the forearm shell. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The adequacy of the proposed initial flexion angle is tested by placing a ruler along the <i>35 </i>deg. line drawn on the check socket (<b>Fig. 29</b>). The ruler is placed to correspond to the intended length of the finished prosthesis; that is, the olecranon-to-thumb-tip measurement recorded on the Upper-Extremity Measurement Form (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Placing a ruler along the 35-deg. line to test the adequacy of the proposed angle of initial flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee should flex and extend this improvised forearm composed of the check socket and the ruler (<b>Fig. 30</b>). Maximum flexion should be about 105 deg., except for very-short stumps, where it probably may not exceed 90 deg. Because of the inherent limitation of motion associated with the Munster-type prosthesis, the usual test of having the amputee bring his terminal device to his mouth is not applicable. The goal is to provide the maximum flexion angle possible compatible with a cosmetically acceptable initial flexion position and socket retention.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Checking the flexion and extension of the improvised forearm composed of check socket and ruler. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the maximum flexion angle obtained with 35 deg. of initial flexion is not acceptable, the angle of the ruler is adjusted to provide greater initial flexion. Initial flexion angles to a maximum of 45 deg. have been used, but at the expense of decreased cosmesis (<b>Fig. 31</b>). If less than 35 deg. of initial flexion is desired for cosmetic or other reasons, the angle is decreased accordingly. Such reduction also decreases the maximum flexion angle obtainable. The selected angle of initial flexion is indicated on the check socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Alternative angles of initial flexion: 30 deg., increased extension, decreased flexion; 40 deg., increased flexion, decreased extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Preparation of the Positive Model</h4> <p>Materials required for the preparation of the positive model are:</p> <ul> <li>Plaster-of-Paris bandage</li> <li>Talcum powder</li> <li>Hollow pipe (approximately 12 in. in length and 1/2 in. in diameter)</li> <li>Awl</li> <li>Two roundhead screws</li> <li>Fresh plaster</li> <li>Water</li> <li>Sanding screen</li> <li>Indelible marking pencil</li> <li>Vaseline or other parting agent</li> </ul> <p>The distal end of the check socket is closed with plaster-of-Paris bandage or with masking tape (<b>Fig. 32</b>) and a small extension (approximately 1 in.) is constructed at the proximal end of the check socket (<b>Fig. 33</b>), again with plaster-of-Paris bandage or with masking tape. This extension will provide the prosthetist with a margin of safety in smoothing the positive stump model without disturbing the desired trim line.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Closing the distal end of the check socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Construction of extension at proximal end of the check socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the inner surface of the check socket has been sprinkled with talcum powder, the check socket is filled with liquid plaster of Paris (<b>Fig. 34</b>). Before the plaster hardens, a hollow pipe is inserted into the plaster. A recess approximately 1 in. to 1-1/2 in. deep is made in the plaster at the proximal end of the mold. A small hole, approximately 1/4in. in diameter, should be drilled in the pipe toward the bottom of the recess to facilitate vacuum lamination.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Check socket filled with liquid plaster of Paris and a hollow pipe inserted into the plaster. The small hole drilled in the pipe will facilitate vacuum lamination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the positive model has hardened, the check socket is punctured with an awl at the proximal and distal ends of the forearm-extension reference line (<b>Fig. 35</b>). The punctures should penetrate into the positive stump model. An indelible pencil is inserted into the holes to mark the positive model.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Puncturing the check socket with an awl in order to mark on the positive model the proximal and distal ends of the forearm extension reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The plaster wrap (check socket) is removed, and major irregularities, for example, superfluous plaster, are trimmed from the positive model (<b>Fig. 36</b>). All reference marks should be accentuated on the positive model.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Trimming irregularities from the positive stump model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The junction between the positive model of the stump and the mold extension is faired with liquid plaster of Paris to provide a smoothly curved radius (<b>Fig. 37</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Fairing the juncture between the positive model and the mold extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The olecranon area on the positive stump model is built up approximately 1/16 in. with liquid plaster of Paris (<b>Fig. 38</b>). This build-up will provide additional relief for this bony prominence.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Building up the olecranon area on the positive model to provide relief for this bony prominence. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The distal end of the positive stump model is built approximately 1/2 in. with liquid plaster of Paris. This build-up will increase the length of the socket slightly and provide space for the hole through which the stump sock is pulled (<b>Fig. 39</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Building up the distal end of the positive model to increase the length of the socket slightly and to provide space for the hole through which the stump sock is pulled. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The positive model is sanded smooth, and roundhead screws are inserted into the two reference holes made on the lateral side of the model. These screws will produce projections on the laminated socket through which a line will be drawn to align the forearm extension cone.</p> <h4>Lamination</h4> <p>Materials required for lamination are:</p> <ul> <li>Drill with 1/8-in. bit</li> <li>PVA sheets</li> <li>Dacron blanketing</li> <li>Nylon stockinette</li> <li>Polyester resin</li> <li>Promoter</li> <li>Masking tape</li> <li>Vacuum pump</li> <li>Wrist unit</li> <li>Manila paper</li> </ul> <p>The socket and forearm shell are laminated in accordance with standard procedures.<a></a> Vacuum lamination<a></a> is recommended to provide a truer reproduction of the model.</p> <p>Holes 1/8 in. in diameter, are drilled through the undercut areas at the proximal end of the positive model in order to draw the PVA bag into those areas during vacuum lamination (<b>Fig. 40</b>). The holes should exit in the vicinity of the previously mentioned hole in the pipe.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Drilling 1/8-in. holes through undercut areas at proximal end of the positive model to draw in PVA bag during vacuum lamination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the stump model has been lubricated, the inner PVA bag, dacron blanketing (for a smoother inner surface), the nylon stockinette, and the outer PVA bag are applied in the usual manner<a></a>, under a vacuum pressure of 12 in. of mercury (<b>Fig. 41</b>). (This is equivalent to 5.9 psi.)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Inner PVA bag, dacron blanketing, nylon stockinette, and outer PVA bag ready for lamination on lubricated stump model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Polyester resin is applied in the standard manner.<a></a> Special attention should be paid to working the resin into the undercut areas (<b>Fig. 42</b>). The layup is oven-cured as usual.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Working resin into undercut areas. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the socket has cured, an opening is cut in the extreme distal end of the socket (<b>Fig. 43</b>). The hole should be of sufficient diameter to allow the passage of the stump pulling sock.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Cutting an opening in the distal end of the socket to allow passage of the stump pulling sock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A reference line is drawn on the outer wall of the socket by connecting the two screwhead projections. A forearm extension cone is applied in the usual manner, with the long axis of the cone coincident with the reference line (<b>Fig. 44</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Forearm extension cone aligned with reference line established by screwheads on socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The lamination procedure for the forearm is the same as for the socket, except that dacron blanketing is not used (<b>Fig. 45</b>). The forearm extension may be laminated as a separate section or directly over the socket, using a wax melt-out. Both procedures work satisfactorily. After the forearm laminate has been cured, the prosthesis is cut along the proximal socket brim and the mold is broken out.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Forearm extension laminated over socket and cone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Fitting of the Prosthesis</h4> <p>A 1-in. hole is drilled through the medial wall of the forearm shell close to the distal end of the inner socket to permit passage of the stump pulling sock. The edges of the hole are polished with a grinding cone (<b>Fig. 46</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Polishing the edges of the hole tor the stump pulling sock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Wearing a length of stockinette (approximately 8 to 10 in.) as a stump sock, the amputee inserts his stump into the socket and pulls the distal end of the sock through the hole (<b>Fig. 47</b>). The application of tension on the stump sock facilitates the complete insertion of the stump into the socket. The sock is left on the stump and the end of the sock is tucked into the forearm shell.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Application of tension on the stump sock facilitates the complete insertion of the stump into the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is checked for the adequacy of its fit. Reliefs are provided and trim lines are modified (<b>Fig. 48</b>) where necessary for comfort and range of motion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Checking the adequacy of socket fit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Harnessing</h4> <p>Three different harness arrangements have been used successfully at New York University with the Munster-type sockets.</p> <p>Initially, the arms were fitted with a conventional figure-eight harness with triceps pad, flexible hinges, and inverted Y-strap. However, the intimate stump encapsulation, flexion attitude, and high trim lines of the Munster sockets provide excellent retention and security, and in most cases obviate the need for suspensory apparatus to maintain the socket on the stump. Without harness, the majority of subjects in the Xew York University stud}' with adult amputees were able to resist high axial loads (in the order of 50 lb.) with negligible socket displacement. In the fitting of child amputees, the same results obtained with axial loads up to one-third of body weight. Hence, the two simplified axilla-loop harness systems which will be described have proved adequate for most patients.</p> <p>The conventional harness is fabricated according to standard prosthetics practice.<a></a> However, because of the integral security of the socket, the size of the triceps pad may be reduced.</p> <p>In the New York University fittings a triangular triceps pad constructed of light-gauge aluminum covered with leather was used exclusively (<b>Fig. 49</b>). The general pattern of the templates used as a guide in shaping this pad is shown in <b>Fig. 50</b>. The exact size of the template for each subject is determined as follows:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. View of conventional harness showing triceps pad fabricated of light-gauge aluminum covered with leather. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Pattern of template for triceps pad (not actual size). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The width is equal to one-half the circumference of the arm measured just above the epicondyles.</li><li>The length is three-quarters of the width.</li></ol> <p>There is no significant functional difference in the two simplified axilla-loop harness systems. In one system the reaction point is located at the proximal socket, while in the other it is located over the triceps. The choice between the two systems depends upon the amputees' preferences regarding the position of their control cables.</p> <p>To locate the reaction point on the proximal socket, a standard housing crossbar assembly is riveted to the <i>midline </i>of the posterior wall of the socket approximately 1/2 to 3/4 in. distal to the proximal brim (<b>Fig. 51</b>). The crossbar portion of the loop is directed upward.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Simplified axilla-loop harness with reaction point on proximal socket. Upper, standard housing crossbar assembly riveted to the midline of the posterior wall of the socket. Lower, harness completed with an axilla-loop arrangement. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The distal retainer base plate is located on the lateral side of the forearm in the usual manner so that it produces as direct a line of pull as possible between the crossbar and the terminal device.</p> <p>The cable-housing assembly is attached in the usual manner. The cable should be maintained as short as possible without interfering with function in order to reduce the incidence of the cable rubbing on the flesh or clothing.</p> <p>The harness is completed with an axilla-loop arrangement (<b>Fig. 51</b>). An additional suspensory strap (that is, a front-support strap) or flexible hinges are not needed.</p> <p>The simplified axilla-loop system is appropriate for most patients. But some patients will object to the low position of the control cable, which may interfere with the sleeves of shirts or blouses. To meet such objection, the reaction point may be located on a small leather triceps pad (3 in. x 3 in.)(<b>Fig. 52</b>). A small strap, preferably Velcro, is sewn across the middle of the posterior surface of the triceps pad to provide a means of securing the pad to the arm. A standard housing crossbar assembly is attached over the strap and centered on the triceps pad. The distal retainer base plate is placed on the forearm in the same manner as described in the previous system. The cable housing assembly is attached in the usual manner. The harness is complete with an axilla-loop arrangement. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. Reaction point on small triceps pad. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Checkout Procedures</h4> <p>Standard below-elbow checkout procedures<a></a> are applied to the Munster-type prosthesis and the usual requirements should be met except for the following:</p> <ol> <li>Since prosthetic forearm rotation is eliminated, the pronation-supination measure is not applicable.</li><li>Since a decreased flexion range is an integral feature of the socket, the checkout standard of a 10-deg. loss of flexion with prosthesis does not apply. Maximum flexion for most amputees will range between 100 deg. and 115 deg., which may be approximately 30 deg. less than stump flexion with the prosthesis off.</li><li>Because of the decreased elbow flexion, the requirement for opening of the terminal device at the mouth may not apply. However, full opening of the terminal device should be available at maximum flexion of the elbow.</li></ol> <p>In following the checkout procedures, particular attention should be paid to the unique features of these sockets; namely, the critical importance of the fit of the socket around the epicondyles and olecranon and the built-in suspension of the sockets. The application of compression and torque forces (particularly a vertical downward force at the terminal device with the elbow flexed at 90 deg.) should indicate the presence of any pressure areas around the elbow. Additionally the axial-load test<a></a> -application of a vertical downward force at the terminal device with the elbow fully extended-should reveal any deficiencies in the suspension feature of the sockets.</p> <p>It must be recognized, however, that, because of the close fit of the socket over the epicondyles and olecranon, some adults will not be able to tolerate the accepted axial-load standard of 50 lb. (or, for children, one-third of the body weight). Special caution to avoid injury to the amputee should be taken when applying the axial-load force. Failure to meet the 50-lb. standard should not in itself be sufficient cause to reject the prosthesis.</p> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</li> <li>Hepp, O., and G. G. Kuhn, Upper Extremity Prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</li> <li>New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The "Muenster" type fabrication technique for below-elbow prostheses, June 1964.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, preflexed arm study, November 1960.</li> <li>New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the "Muenster-type" below-elbow prosthesis, April 1965.</li> <li>University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</li> <li>University of California (Los Angeles), School of Medicine, Department of Surgery (Orthopedics), Prosthetics Education Program, How to use vacuum technique in plastic lamination over models of irregular shapes, January 1, 1962.</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">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (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>6.</b> </td><td class="clsTextSmall">University of California (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>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed , 1958.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">University of California (Los Angeles), School of Medicine, Department of Surgery (Orthopedics), Prosthetics Education Program, How to use vacuum technique in plastic lamination over models of irregular shapes, January 1, 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (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>7.</b> </td><td class="clsTextSmall">University of California (Los Angeles), School of Medicine, Department of Surgery (Orthopedics), Prosthetics Education Program, How to use vacuum technique in plastic lamination over models of irregular shapes, January 1, 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (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>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (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>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, preflexed arm study, November 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hepp, O., and G. G. Kuhn, Upper Extremity Prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Hepp, O., and G. G. Kuhn, Upper Extremity Prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Fishman, Sidney, and Hector W. Kay, The Munster-type below-elbow socket, an evaluation, Artificial Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Muenster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the 'Muenster-type' below-elbow prosthesis, April 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Dominick E. Casella </b></td></tr><tr><td class="clsTextSmall">Research Administrative Assistant, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>George Hartmann, C.P.O. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Kevin A. Cody, M.A. </b></td></tr><tr><td class="clsTextSmall">Associate Research Scientist, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, New York University, 317 East 34th Street, New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Avenue, N. W., Washington, D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_02_004/autum65-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_02_004/autum65-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_02_004/autum65-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_02_004/autum65-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_02_004/autum65-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_02_004/autum65-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_02_004/autum65-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_02_004/autum65-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_02_004/autum65-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_02_004/autum65-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1965_02_004/autum65-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1965_02_004/autum65-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1965_02_004/autum65-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1965_02_004/autum65-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1965_02_004/autum65-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1965_02_004/autum65-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1965_02_004/autum65-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1965_02_004/autum65-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1965_02_004/autum65-19.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 The Munster-Type Below-Elbow Socket, a Fabrication Technique Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * Kevin A. Cody, M.A. * George Hartmann, C.P.O. * Dominick E. Casella * https://staging.drfop.org/files/original/ff93388a2b326482cd23ab1fe7b0530f.pdf 56f90f8e21d338b8b528570d124e7f89 https://staging.drfop.org/files/original/dcdfac18ac5ac3022676315508cf5d48.jpg dbee38bac224a96a2c011cb17d7d6a9f https://staging.drfop.org/files/original/e19ee311b0e20a0019bbf64b23a2defd.jpg 709d5e732087fd5a57d43b48a0652c1c https://staging.drfop.org/files/original/ff5fb16a3b6eb4327a31bb1992c94add.jpg 634c592b76ea73a55e13cf93c72ae7ca https://staging.drfop.org/files/original/dd03140d20e3ea247047a03394d6be8f.jpg 9801ffc457b82c0e5e04953cb4376b90 https://staging.drfop.org/files/original/1c887547c6cbac99872483f954e8b43a.jpg 056339fc83108b1608ab7864990f343f https://staging.drfop.org/files/original/8c92a0c6606452d4426b8a44d4f4bff6.jpg 3f5ae3451b2192b7ea3f4231b3f169e8 https://staging.drfop.org/files/original/32fdad7b172199d9b720f189835bc3c9.jpg 9710e54f4022a14c41497f00812a7a4c https://staging.drfop.org/files/original/aa48e315ac77e0e2136d3931d68f5e2e.jpg f8768c064188a404312b028d7fff4829 https://staging.drfop.org/files/original/b5bef2c3795da5096649620616ab5554.jpg 7bf997809b8206a66916590c0d7b404b https://staging.drfop.org/files/original/b19587d2238d7d8b888d85da0d64eef4.jpg aeafbf39f3d3f61b596eddca5ba9ffaf https://staging.drfop.org/files/original/c1ce590718115f39e52684aee441de8f.jpg d5ae4663e0a01f258e869afed35cbd4a https://staging.drfop.org/files/original/c7a6dde19f351a434ecf52aabd0334d3.jpg 65cdb5dd9ad39d3da6951490f7ee16f8 https://staging.drfop.org/files/original/cf1809077913f566b86fa7e5199c3c20.jpg 4530478b27ca832a157266ebe524bb10 https://staging.drfop.org/files/original/37824783f3fe6a952766ec00f7dd01d9.jpg b11bbffa4e419db31441af1f803b4640 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_02_004.pdf Year 1964 Volume 8 Issue 2 Page Number(s) 4 - 14 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_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>The Münster-Type Below-Elbow Socket, an Evaluation.</h2> <h5>Sidney Fishman, Ph. D. <a style="text-decoration:none;">*</a><br />Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p> Short stumps have always presented fitting problems in both upper- and lower-extremity amputation sites for the obvious reasons of small attachment area and a lack of useful range of motion. In an attempt to alleviate these problems for upper-extremity amputees, Drs. O. Hepp and G. G. Kuhn<a></a> of Münster, Germany, developed fitting techniques for the below-elbow and the above-elbow amputee, respectively, that provide a more intimate encapsulation of short stumps. </p> <p> For the below-elbow amputee, the general characteristics of this technique (<b>Fig. 1</b>) are: </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Münster-Type fitting for below-elbow ampute. A, Lateral view ondicating the preflexion angle; B, anterior view indicating high trim line; C, posterior view indicating olecraron fit and the small tricep pad. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The elbow is set in a preflexed position (average 35 deg.). Because of the reduced range of useful motion, the socket is flexed so as to position the terminal device in the most generally useful area.</li><li>A channel is provided at the antecubital space for the biceps tendon to avoid interference between socket and biceps tendon during flexion.</li><li>The posterior aspect of the socket is fitted high around the olecranon, taking advantage of this bony prominence to provide attachment and stability to the socket.</li></ol> <p>For the above-elbow amputee, the characteristics of the technique are: </p> <ol> <li>The socket is fitted high on the acromian, utilizing this bony structure to retain the socket in position and provide stability. </li><li>The axillary section of the socket conforms closely around the tendons of the pectoralis major and latis-simus dorsi muscles to enable the patient to exert the force of these major muscles in moving his prosthesis.</li></ol> <p> In an earlier study<a></a>, amputee clinics reported a favorable experience in fitting preflexed arms (that is, arms bent to provide a certain amount of preflexion) to children with short and very short below-elbow stumps. Since the Hepp-Kuhn technique seemed to represent an improvement in fittings of the preflexed type, New York University initiated a preliminary investigation of the procedure for adult amputees of this type. This study took place in the early part of 1961 and was limited to two short-below-elbow subjects. This exploratory study yielded generally positive outcomes in terms of function and comfort. One short-above-elbow amputee was also fitted with encouraging results. </p> <p> The present evaluation is an extension of the initial study with major emphasis given to below-elbow fittings. Concurrently, further exploration of the above-elbow fitting technique was undertaken and is continuing, although not reported in this article. </p> <p> For lack of a better term, the fitting procedures employed in this study are referred to as the "Münster-type" techniques. It should be emphasized that no claim is made that the techniques are identical to those followed by Drs. Hepp and Kuhn. New York University personnel witnessed a demonstration of the techniques given by Dr. Kuhn in 1960 and had available the cited reference. However, none of the New York University fittings were either directly or indirectly supervised or checked by the developers. </p> <p> Both logic and prior experience suggest that the greatest benefit from the Münster-type below-elbow fitting technique may accrue to subjects with short and very short below-elbow amputations in that the step-up hinges and split sockets characteristic of typical United States fittings for these categories could be eliminated. Historically, step-up hinges have lacked durability. Moreover, a price is paid for the step-up characteristic by a corresponding decrease in lifting power. Contrariwise, it is apparent that the range of elbow flexion is reduced by the Münster-type fitting. This reduction may or may not be significant in terms of amputee function (<b>Fig. 2</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Comparison of split socket and Münster-type fitting of very short below-elbow case. A, Very short below-elbow stump-3-1/4 in.; B, split socket with step-up hinge provides 140 deg. of elbow flexion; C, Münster-type fitting permits less elbow flexion but enables the amputee to carry considerably greater weight with flexed prosthesis unsupported by harness. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Sample</h3> <p> The sample in this study consisted of eight adult below-elbow amputee subjects (including one bilateral amputee) whose stumps were relatively short-from 3-1/4 in. to 5-1/2<i> </i>in. measured from the medial epicondyle to the end of the stump. The physical characteristics of the sample and a description of their previously worn prostheses are given in <b>Table 1</b> and <b>Table 2</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Methodology</h3> <p> The Münster-type techniques for fitting below-elbow prostheses, as understood by New York University personnel, were followed in fabricating experimental arms for the eight subjects in the sample. In one case (WP), however, the anterior trim line (channel for biceps tendon) was reduced in order to provide this bilateral amputee with a greater range of elbow flexion. All prostheses incorporated triceps pads, leather hinges, and figure-eight harnesses. Six of the eight subjects (OB, PL, TM, WP, ES, and PW) were fitted with polyester porous sockets fabricated in accordance with the technique developed at the Army Medical Biomechanical Research Laboratory (formerly the Army Prosthetics Research Laboratory)<a></a>. The other two subjects (DC and QS) were fitted with nonporous plastic sockets. </p> <p> The evaluation consisted essentially of a "before" and "after" comparison of status. The prosthetic status of all subjects in this study was assessed prior to their fitting with the Münster-type prosthesis in order to obtain a basis for later comparison. At one month and at six months after delivery of the experimental prosthesis, the prosthetic status of the subjects was reevaluated and comparisons between the conventional and experimental prostheses were drawn. </p> <p> The stumps of all subjects were examined prior to the experimental fitting in order to identify their condition (scars, irritations, discolorations, etc.). This examination was repeated at the specified intervals to see what effect, if any, the experimental socket had had on the physical condition of the stump. </p> <p> Two self-administering rating scales completed by all subjects elicited their opinions regarding prosthetic comfort, function, and cosmesis. A questionnaire was administered prior to the experimental fitting to assess the amputees' opinions regarding their conventional prostheses. A comparative questionnaire was administered in the post-fitting evaluations to compare the experimental and the conventional prosthesis in the factors previously rated. </p> <p> A prosthetic-usefulness schedule<a></a> was applied to the six subjects who had previously worn a functional prosthesis to investigate their opinions concerning the relative value and comparative ease of performance of the conventional and experimental prostheses in the areas of work, home tasks, social life, dressing, and eating. </p> <p> Three evaluation procedures were administered to the six subjects who had previously worn functional prostheses, as follows: </p> <ol> <li>The angles of preflexion and maximum flexion were measured on both conventional and experimental prostheses, as well as the amount of vertical downward force the amputees could resist with their elbows flexed at 90 deg. (live lift) and fully extended (axial load). </li><li>The accuracy of positioning control exhibited by the amputees was measured with both conventional and experimental prostheses. Scoring of performance on the positioning control test<a></a> was in terms of accuracy and speed</li><li>The amputees' ability to perform a series of 12 bimanual practical activities was rated on a seven-point scale. For each activity, six factors were rated independently but simultaneously by two experienced examiners. This evaluation was administered initially to the amputees with their conventional prostheses and then repeated with the experimental prostheses at the one-month and at the six-month post-fitting evaluations.</li></ol> <h3>Results</h3> <h4>Stump Examinations</h4> <p>In all cases a period of two to three weeks was required for the subjects to become adjusted to the more intimate fit of the Münster-type socket. During this initial wear period, the usual complaint was of an irritation in the medial epicondylar area, which was corroborated by visual examination. However, after this adjustment period, the experimental socket had no observed or reported effects on the amputation stump, although amputees were generally aware of increased pressure on the olecranon when the forearm was flexed. </p> <h4>Amputee Reactions</h4> <p> Comparative reactions to the conventional and experimental prostheses were obtained from the eight subjects in the sample. The factors investigated and the amputees' ratings are presented 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> It is clear from (<b>Table 3</b>) that, with few exceptions, the amputees reacted very favorably to the Münster-type prosthesis. Sixty per cent of the responses were favorable toward the experimental item while only five per cent were unfavorable. The two factors which brought forth negative reactions were comfort (two subjects) and adjustments (two subjects). These negative reactions reflect difficulties experienced by these two amputees in adjusting to the intimate fit of the Münster-type socket. However, all seven subjects in the sample who had previously worn rigid hinges of one type or another cited the elimination of these hinges as a definite contribution to comfort. </p> <p>No differences in reactions which could be attributed to socket porosity, or lack of it, were noted. The fact that the wear period for most of the subjects was confined to the winter months may explain this lack of difference. </p> <p>The data on effort and control are of particular interest. All subjects in the sample reported improvement in these factors as a result of wearing the experimental prosthesis. Further questioning revealed that the amputees' opinions regarding improved prosthetic control with less expenditure of effort appeared directly attributable to the more intimate fit of the Münster-type socket. This reaction was commonly expressed by such statements as: "The prosthesis feels a part of me" and "I feel right-handed again." Several subjects reported that the Münster-type sockets did not tend to slip off their stumps under load, as was the case with their conventional sockets. One subject cited the more secure fitting of the Münster-type socket to be particularly advantageous in performing overhead activities because his stump did not slip out of the socket when he performed a pulling motion with the prosthesis. </p> <p>The reactions of the two subjects (ES and PL) who had previously worn nonfunctional prostheses (for 15 and 20 years, respectively) are noteworthy. Neither became especially skillful prosthesis users in the course of the study, but both did come to use their terminal devices for grasp, which they had not previously done. Their highly positive responses to the experimental item and the fact that it changed their prosthetic status from that of nonusers to users after so long a period were considered quite unusual. Since both patients were fitted with porous laminate sockets, the role of the Münster-type fitting is not completely "pure" but, at least, must be regarded as contributory. </p> <p>Of the six subjects who had previously worn functional devices, five were able to perform the same number of activities with the experimental prostheses as with the conventional, while one subject reported increased prosthetic function with the Münster-type prosthesis (for example, he was able to carry a coat on his flexed forearm and was able to use his prosthesis in steering a car). However, all six amputees indicated that activities were easier to perform with the experimental prosthesis because the close-fitting socket afforded better control and the elimination of the rigid hinges provided greater freedom. </p> <p>In no case was there any evidence that the decreased range of motion with the experimental prostheses caused an appreciable decrease in prosthetic function. Since unilateral amputees routinely use their prostheses as assistive devices, there are few activities that are performed prosthetically at the extreme ends of the flexion-extension range. Bilateral subjects, however, are dependent on their prostheses for all upper-extremity functions and therefore require a greater range of motion. To provide the bilateral subject in our sample with an increased range of elbow flexion on his dominant side (40 deg. to 120 deg.), the anterior trim line was lowered. In addition, a wrist-flexion unit was provided to facilitate the performance of tasks close to his body. </p> <h4>Functional Evaluation</h4> <h5><i>Biomechanical Data</i></h5> <p> The Münster technique provides an intimate encapsulation of the amputated stump which results in a decreased range of motion. Forearm rotation is virtually eliminated, and the elbow flexion-extension range is significantly reduced. However, this type of fitting frequently increases the amputees' ability to resist moments about the elbow and to sustain axial loads. </p> <p> A comparison of the flexion ranges of the conventional and experimental prostheses is presented in (<b>Table 4</b>).</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> The preflexion angle of the Münster-type socket ranged from 20 deg. to 45 deg., with an average of 35 deg. The exact preflexion angle was planned for each subject contingent on such factors as stump length, natural elbow motion, and amputee preference. Maximum flexion of the experimental sockets ranged from 85 deg. to 120 deg. with an average of 105 deg. </p> <p> <b>Table 5</b> compares the maximum holding forces that amputees (the six who had previously worn functional prostheses) were able to maintain with both prostheses. "Live lift" refers to the amount of vertical downward force (applied at the terminal device) that an amputee can resist while maintaining his elbow at 90 deg. (<b>Fig. 3</b>). To allow for different forearm lengths, the data are expressed in foot-pounds. "Axial load" refers to the amount of vertical downward force applied at the terminal device that an amputee was able to resist with his elbow in an extended position. A complaint of pain or one-inch slippage of the socket on the stump was taken as the maximum tolerable load (<b>Fig. 4</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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. live-lift test </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. axial-load test </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In all cases the amputees were able to resist a greater force in the live-lift test with their Münster-tvpe prostheses than with their conventional prostheses. For three subjects (DC, WP, and PW) the differences were very significant. In subject DCs case, this difference can be readily understood since he had previously worn a split socket and step-up hinge with an inherent mechanical disadvantage. For subjects WP and PW (prior single-pivot and flexible-hinge wearers, respectively), it is speculated that their improved lifting power was directly related to the more intimate fit of the experimental sockets. However, it is not clear why the same ratio of improvement did not obtain for the other subjects. </p> <p> Four of the six subjects were able to resist a greater axial load with the Mtinster-type prostheses than with their conventional prostheses. The maximum axial load on the experimental prosthesis for the other two subjects was limited by stump pain, particularly in the epicondylar area. </p> <h5> <i>Positioning Control Test</i> </h5> <p> The positioning control test investigated the amputees' ability to control their prostheses; that is, to bring the terminal device to a desired location in space with measured speed and accuracy. Specifically, it tested the skill of the amputees in striking designated targets in the vertical (on the wall) and horizontal (on a table) planes. Three different sequences were applied in the vertical plane and two in the horizontal. Accuracy was measured by the distance of a mark (made by a pencil held in the terminal device) from the target. Superior prosthetic performance therefore is indicated by the lower scores and performance times. <b>Table 6</b> and <b>Table 7</b> present the data for the three vertical and two horizontal sequences of the positioning control tests, respectivelv. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Analysis of the data of the positioning control test reveals minimal differences between the conventional and the experimental prostheses. In the vertical sequences, these differences favored the experimental prostheses slightly, with regard to accuracy, but the reverse is true regarding speed. In the horizontal sequences the experimental prostheses were slightly favored in both accuracy and speed. However, none of the differences proved statistically significant. </p> <h5> <i>Practical Activities Test</i> </h5> <p> Comparative performance data were obtained on five subjects in the sample. Two of the remaining three subjects were not tested because they had no prior experience with a functional prosthesis. The third subject (WP) had previously worn English-made components (terminal devices, wrist units) which it was not possible to duplicate in his experimental prosthesis. Since these different terminal devices would have introduced an extraneous variable into the experimental situation, the data from this subject are not included here. </p> <p> Performance data were obtained on a 12-item practical activities test. The activities were: using a pencil sharpener, tying a necktie, tying a shoelace, carrying several packages, filing a fingernail, hammering a nail, opening a jar, putting on a glove, using a can opener, using a paper clip, using a telephone and taking a message, and removing bills from a wallet. Six factors, each rated on a seven-point scale, were considered for each test activity. The factors were: position of the prosthesis for use, grasp of the object (secure or insecure), position of object for use (efficient or inefficient), maintenance of position of object during use (efficient or inefficient), appearance of performance (natural or unnatural), adequacy of general performance (efficient or inefficient). The average scores for each subject in these six factors are presented in (<b>Table 8</b>), with the higher scores reflecting better performance. The average performance times for each subject are shown in (<b>Table 9</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The data from (<b>Table 8</b>) indicate that there were apparently no significant differences in performance between the Münster-type and conventional prostheses, and the time comparisons in (<b>Table 9</b>) present no clearcut patterns. Two implications of these findings are of interest. First, the obvious and measurable decrease in range of forearm flexion imposed by the Münster-type fitting has no discernible effect on the bimanual performance of unilateral amputees. Second, the highly favorable reactions of subjects to the function and control aspects of the experimental arm were not corroborated by the performance-test data. This apparent lack of agreement may derive from two factors, either singly or in combination: some subtle but important differences in performance did exist but were not detectable by the observational testing procedures applied, or the more intimate and perhaps better fit of the experimental prosthesis (as compared to the conventional) created a "halo" effect which positively affected opinions concerning other aspects of the prosthesis. That is to say, since the prosthesis felt better, it must necessarily perform better. </p> <h3>Applicability of the Technique</h3> <p> Since it was hypothesized that the experimental item might have prime applicability to amputees whose stumps fell into the very short or short categories, attention was focused in the study on the fitting of such subjects. However, it was also of interest to investigate the range of stump lengths (or types) for which the Münster-type fitting might be suitable. </p> <p> In the New York University sample the shortest stump fitted was 3-1/4 in. To investigate the possibility of fitting stumps <i>shorter </i>than this, a cast and check socket were made for a bilateral amputee with a 2-1/2 in. below-elbow stump on one side (currently wearing a stump-actuated elbow lock) and an above-elbow stump on the other side. Since the below-elbow stump virtually disappeared at 90 deg. of flexion, it was thought that this was the absolute maximum flexion angle that might be obtained. This limitation was not considered acceptable for the dominant prosthesis of a bilateral amputee. It was also considered that this stump length was very near the lower limit for acceptable fitting, even for a unilateral amputee. </p> <p> With respect to maximum stump length, two limiting factors are observed: </p> <ol> <li>Stumps of mid-length and longer usually have some amount of pronation-supination which can be harnessed in a conventional below-elbow socket (with flexible hinges), but not in the Münster-type socket. </li><li>The configuration of the Münster-type socket (proximal opening at a sharp angle to the shaft) presents progressively increasing difficulty to donning and doffing as stump length increases (<b>Fig. 5</b>).</li></ol> <p> In the New York University series, in which the longest stumps fitted were <i>5-1/2 </i>in. (two subjects), neither of the above considerations was significant in either case. It is estimated, however, that the slumps of these two subjects were approaching the upper length limit to which the Münster-type socket could be applied without sacrifice of residual pronation-supination, or modification of the proximal socket to facilitate donning and doffing. </p> <p> Subject to further study, therefore, it appears that the Münster-type socket can be applied to the range of below-elbow-stump types for which rigid hinges (step-up, multiple action, and single-pivot) are typically prescribed at present. Some consideration probably should be given to the development of a prosthesis that will permit stump-actuated pronation and supination of the terminal device, yet retain the stability afforded by the Münster-type socket. </p> <h3> Summary and Conclusions</h3> <p> The applicability of Münster-type fittings was investigated by New York University. The sample for this study consisted of eight subjects with below-elbow amputations ranging from 3-1/4 in. to 5-1/2 in. (34 to 52 per cent). The results of the evaluative procedures, which included interview techniques and performance testing, indicated the following: </p> <ol> <li>A brief "breaking-in" period was required by all subjects to adjust to the more intimate fit of the Münster-type socket. After this initial period of adjustment, the experimental sockets had no observable or reported effects on the amputation stumps except a slight increase in pressure on the olecranon during lifting activities. The use of soft (Silastic) inserts over the epicondyles and olecranon to ameliorate these factors is under investigation at New York University.</li><li>The subjective opinions of all subjects were heavily in favor of the Münster-type prostheses.</li><li>The decrease in flexion range had no appreciable effect on prosthetic function for the unilateral amputees. For bilateral subjects, modification of the anterior trim line and provision of a wrist-flexion device may be necessary for performance of tasks close to the body. </li><li>The lifting and holding forces demonstrated by the amputees were generally better with the Münster-type prostheses.</li><li>The data from the positioning control and practical activities testing were inconclusive.</li></ol> <p> The evidence suggests, therefore, that the Münster-type prostheses are functionally advantageous with considerable cosmetic and comfort appeal for amputees with very short to medium below-elbow stumps. </p> <h3>Recommendations</h3> <p> Based on the results of this study, it is recommended that: </p> <ol> <li>The Münster fabrication technique be accepted as a satisfactory means of fitting below-elbow amputees. Prime applications would be for patients with unilateral losses whose stump lengths were classified in the short and very short categories.</li><li>Upon completion of the detailed fabrication manual now being prepared by New York University, the Münster below-elbow fabrication technique be introduced into the curricula of the Prosthetics Education Programs.</li></ol> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. View of Münster-type socket showing sharp angle of the proximal opening in relation to shaft. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Hepp, O., and G. G. Kuhn, <i>Upper extremity prostheses</i>, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces, and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</li> <li>Hill, James T., and Fred Leonard, <i>Porous plastic laminates for upper-extremity prostheses</i>, Artificial Limbs, Spring 1963, pp. 17-30.</li> <li>New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, <i>The "Münster" type fabrication technique for below-elbow prostheses</i>, June 1964.</li> <li>New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, <i>Preflexed arm study</i>, November 1960. </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>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Münster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Münster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hill, James T., and Fred Leonard, Porous plastic laminates for upper-extremity prostheses, Artificial Limbs, Spring 1963, pp. 17-30.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">New York University, Child Prosthetic Studies, Research Division, College of Engineering, Final report, Preflexed arm study, November 1960. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Hepp, O., and G. G. Kuhn, Upper extremity prostheses, Proceedings of the Second International Prosthetics Course, Copenhagen, Denmark, July 30 to August 8, 1959, Committee on Prosthetics, Braces, and Technical Aids, International Society for the Welfare of Cripples, Copenhagen, Denmark, 1960, pp. 133-181.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 Project Director, Orthotics and Prosthetics, New York University, 252 Seventh Ave., New York, N.Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Sidney Fishman, Ph. D. </b></td></tr><tr><td class="clsTextSmall">Project Director, Orthotics and Prosthetics, New York University, 252 Seventh Ave., New York, N.Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-01.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-02.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-03.jpg Figure 6 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-04.jpg Figure 7 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-05.jpg Figure 8 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-3.jpg Figure 9 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-4.jpg Figure 10 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-06.jpg Figure 11 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-07.jpg Figure 12 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-08.jpg Figure 13 http://www.oandplibrary.org/al/images/1964_02_004/Aut64-table-09.jpg Figure 14 http://www.oandplibrary.org/al/images/1964_02_004/1964-Autumn-5.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 Münster-Type Below-Elbow Socket, an Evaluation. Creator An entity primarily responsible for making the resource Sidney Fishman, Ph. D. * Hector W. Kay, M.Ed. * https://staging.drfop.org/files/original/a9f10fd556c1a92dcd99130f4c4c7fb4.pdf 471c56da3d5a2d6cbb3f53fef609568e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_02_002.pdf Text Any textual data included in the document <h2>The Nature of Contractures</h2> <h5>Justin Alexander, Ph.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>When orthotic devices are supplied to a patient, it is generally in the hope that function can be enhanced. If this expectation is to be realized, joint mobility or range of motion should be within normal limits. Unfortunately, there are many patients where a significant deficit in freedom of movement occurs. It is essential to realize that the causative factor for such limitation is varied, so that one may develop a reasonable treatment approach.</p> <p>Impedence to free motion can result from injury or malfunction of the skin overlying a joint, muscles or tendons surrounding or crossing joints, the joint capsule, or the joint surfaces. In many instances joint disturbances can be avoided by timely intervention such as correct positioning; active, assistive or passive exercises; or stretching and joint mobilization. Unfortunately, even when meticulous care is provided, limitations of movement can occur. Once tightness has been allowed to develop, it becomes more difficult and painful to restore normal function. A variety of mechanical devices designed to minimize the danger of developing contractures, or to overcome them, have been described in the literature. Surgical intervention may be attempted in carefully selected instances as well.</p> <p>A common sequela to prolonged inactivity is loss of flexibility due to shortening of muscle fibers and connective tissue. In an otherwise healthy individual this does not cause a serious problem and one can expect that with resumption of normal activity, muscles will regain length and flexibility. If, however, a limb is immobilized because of injury or disease, tissue repair involves replacement of muscle fibers with scar tissue which consist of collagen. Early, persistent, and careful physical therapy usually produces satisfactory restoration of movement.</p> <p>Delay in starting therapy or placing the responsibility for performing a prescribed regimen completely on the patient or family member, without assurance that the program is understood and that it will be performed, is prone to produce serious impedance to normal mobility. It is important to note that when a distal joint is immobilized, the more proximal joints are not utilized as much as under ordinary conditions and secondary joint limitation may develop. Some common examples are the concommitant tightness of hip flexors and knee flexors, or the limitation seen in the shoulder and elbow of the patient who has sustained a Colles fracture of the wrist.</p> <p>Immobilizing a part in a resting position does not necessarily produce limitation of movement, provided there is physiological rest.<a></a> On the other hand, if a part is immobilized and there is active muscle contraction to prevent the muscle from being elongated or the joint moved, muscle tightness can be invariably expected. When a person expects that motion might be painful, such as during the acute phase of Rheumatoid Arthritis or during severe and prolonged periods of ischemia, a "protective spasm" can be anticipated and frequently results in "irreversible contracture." The term "irreversible" must be used tentatively, since, if given enough time, the contracture may be relieved through ordinary activity.<a></a> In most instances, therapy cannot be provided or justified for the long period required to ameliorate the situation. In several instances, we have observed changes occuring over two years or longer following initial insult.</p> <p>Extravasation of fluid into tissue surrounding the joint, which may be observed following repeated trauma. This could be a result of stretching which is performed too enthusiastically, or after episodes of bleeding in an individual with hemophilia. It will invariably result in deposition of collagen and may continue to permit calcification of the capsule. This could end in heterotopic bone formation.</p> <p>Heterotopic ossification presents a difficult problem to manage. While there have been some reports of spontaneous remission over time, others have reported recurrence after surgical excision.</p> <p>Repeated insults to the integrity of the joint itself can lead to complete blockage of the joint, either as ankylosis of the capsule or due to fusion of the joint surfaces. Depending on which joint is involved, total or partial joint replacements have been very successful in restoring function and almost completely eliminating pain.</p> <p>The management of the patient with contractures is complicated and if it is to be successful, close collaboration between physician, therapist, orthotist, and the patient and family is imperative. In the presence of contracture, the application of an orthotic device can be wrought with danger. If too much tension is applied in order to gain motion when the patient is walking, protective spasms may counteract any stretching effect. It is also possible that excessive pressure can result in a fracture, especially if the patient has ben inactive for some time and if osteoporosis is present. The chances of successfully reducing joint limitations are increased when physical therapy and orthotic devices are combined in a comprehensive treatment program.</p> <p><b>References:</b></p> <ol> <li>Harris, R. and Copp, E.P., "Immobilization of the Knee Joint in Rheumatoid Arthritis," <i>Ann. Rheum. Dis.</i>, 21:353, 1962.</li> <li>Partridge, R.E.H. and Duthie, J. Jr., "Controlled Trial of the Effect of Complete Immobilization of the Joints in Rheumatoid Arthritis," <i>Ann. Rheum. Dis.</i>, 22:91, 1963.</li> <li>Alexander, J., "Irreversible Contractures: An Impediment to Prosthetic Rehabilitation" <i>Newsletter Prosthetics and Orthotics Clinic</i>, 4:3, 1, 1980.</li> </ol> <div style="width: 400px;"><em><b>*Justin Alexander, Ph.D. </b> Justin Alexander, Ph.D., is with the Albert Einstein College of Medicine, Yeshiva University, 1300 Morris Park Avenue, Bldg. 'J,' Room 2N4, Bronx, New York 10461.</em><br /><br /><br /></div> Page Number(s) 2 - 3 Year 1985 Volume 9 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Nature of Contractures Creator An entity primarily responsible for making the resource Justin Alexander, Ph.D. * https://staging.drfop.org/files/original/cb540e7ef43f29b8f2a54281780f08ca.pdf db1f8f57d64f091532e8e80aa08d9455 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1980_02_001.pdf Text Any textual data included in the document <h2>The Nature of Orthotics Practice</h2> <h5>Sidney Fishman, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />Joan E. Edelstein, M.A.&nbsp;<a style="text-decoration: none;">*</a><br />Lynn Michaelson, B.S.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>How typical is YOUR orthotics practice? How extensively are plastic orthoses being utilized? How many KAFO wearers utilize a knee lock, and what kind? Examining the experience of a larger number of certified orthotists regarding these and other prescription issues is a logical way to gain perspective on contemporary orthotics management. Some time ago New York University Post-Graduate Medical School conducted a pilot survey of approximately sixty orthotists who were attending several short-term courses. While the sample was small and drawn largely from the Eastern seaboard, the completed questionnaires revealed a number of interesting trends regarding patient population, orthotic designs, and materials.</p> <p>Among the most important of the preliminary findings is the overwhelming predominance of lower limb orthotics (LLO) practice over spinal (SO) and upper limb (ULO) activities by a ratio of 5 to 1 to 1; the continued preference, although small, for metal rather than plastic materials, especially for LLO's. Lastly, middle aged adults with upper motor neuron disorders (stroke, etc.) constituted the largest single type of patients requiring services.</p> <h3>Population</h3> <p>Although orthotists reported that they treated substantial numbers of patients in all age brackets, about 55 % of the individuals fitted were between 18 and 60 years of age. Of the remaining 45% , the proportion of children below 18 years exceeded that of older adults (over 60) by a third.</p> <p>Patients presented a wide variety of disorders. Among LLO wearers, more than half had upper motor neuropathies; approximately 30 percent had skeletal disorders, and the remaining 20 percent had lower motor neuron diseases. In contrast, the greatest number of ULO's were worn by persons with lower motor neuron lesions (42%), while the remaining individuals wearing ULO's experienced upper motor neuron and skeletal disorders in nearly equal numbers.</p> <h3>Materials</h3> <p>The great majority (80%) of orthotists responding used both metals and plastics in their LLO practice, however 10 percent stated that plastics constituted the primary or sole material in all LLO's they made, while the remaining 10 percent used metals only. Overall, the ratio of usage of aluminum to plastic to steel was 5 to 4 to 1.</p> <h3>Lower Limb Orthotic Designs</h3> <p>Among the lower limb devices fabricated, 63 percent were AFO's while 37 percent were HKAFO's, KAFO's, and KO's. Forty-six percent were unilateral AFO's and 25 percent were KAFO's applied unilaterally; 17 percent of the LLO were AFO's fitted bilaterally.</p> <p>The solid stirrup was by far the most commonly used method of shoe attachment (42%), followed in turn by the split stirrup (20%), plastic shoe insert (18%), calipers (15%), and miscellaneous attachments (5%). About half of the LLO's prescribed permitted free or nearly free ankle motion of which 17 percent permitted free motion, and 37 percent utilized some form of motion assist, usually a coiled or wire spring. Approximately one-third of the ankle components limited motion in some way with 27 percent of such appliances utilizing stops, and 10 percent consisting of solid ankles. Such diverse components as dual action assists and double axis joints accounted for 11 percent of the orthotic ankles.</p> <p>In relation to specific AFO designs utilized, the most frequently identified were patellar tendon bearing, Denis Browne, posterior leaf spring (both Rancho polyethylene and TIRR polypropylene), VAPC shoe clasp and the NYU insert.</p> <p>As regards orthoses encompassing the knee and/or the hip, a single axis joint with drop lock, (with or without spring loading) accounted for nearly 70 percent of knee controls provided. Cam and plunger locks were very seldom used and only 13 percent of the orthoses had free knee joints, including single axis as well as offset and polycentric types. Regarding hip joints, the number of free single and double axis joints far exceeded that of any locking hip joints.</p> <p>Approximately half of the orthotists reported making fracture LLO's of one type or another. A third had fabricated both AK and BK fracture orthoses, while nearly 10 percent had made only BK fracture orthoses and 5 percent had fabricated AK designs exclusively.</p> <p>As for other specific KO and KAFO designs, orthotists constructed knee cages and trilateral Legg-Perthe's orthoses most commonly.</p> <h3>Upper Limb Orthoses</h3> <p>While as indicated, the survey focussed on LLO practice, several interesting facts concerning ULO management also emerged. The most frequently prescribed ULO was the opponens orthosis (70%), while 19 percent were provided with prehension orthoses with about 21 percent of this number being fitted bilaterally. External power was employed in only 3 percent of the fittings reported.</p> <p>Although these preliminary data indicate some interesting patterns there is no doubt that it is not possible, at the present time, to present a satisfactory overview of the nature of orthotics practice, with any degree of confidence. This fact presents particular problems for the educational institutions who are obliged to teach students those procedures and techniques which are most widely utilized by the practitioners. The same lack of information causes severe difficulties for potential researchers in relation to their ability to identify and undertake valuable and meaningful projects. Consequently there is a crying need for more comprehensive and reliable information than is presently available. We therefore propose to obtain such data from as many certified orthotics facilities in the country as possible. A revised questionnaire has been prepared which attempts to obtain the most important, precise information regarding lower limb orthotics practice.</p> <p>We request that each certified facility complete the questionnaire on pp. 8-10. It should take no more than 15-20 minutes. Return the completed form to Prosthetics and Orthotics, NYU Post-Graduate Medical School, 317 East 34th St., New York, NY 10016, by Sept. 15, 1980. Obviously only one questionnaire for each facility should be submitted, since any duplicate returns would tend to unbalance the information gathered. Lastly, in order to identify regional differences and to permit the possibility of follow-up contacts, we ask that each return be identified. In order to avoid any possible intrusion on confidential business statistics please note that all of the requested information is only in percentages of total practice.</p> <p>Following the necessary period of time to accumulate, tabulate and analyze the data, a report summarizing the results of the study will be published in a forthcoming issue of the Newsletter. At a later time similar surveys relating to spinal and upper limb practice will be undertaken.</p> <em><b>*Lynn Michaelson, B.S. </b> New York University Post-Graduate Medical School<br /><br /><b>*Joan E. Edelstein, M.A. </b> New York University Post-Graduate Medical School<br /><br /><b>*Sidney Fishman, Ph.D. </b> New York University Post-Graduate Medical School</em><br /> <div style="width: 400px;"></div> Page Number(s) 1 - 2 Year 1980 Volume 4 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Nature of Orthotics Practice Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D. * Joan E. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_01_015.pdf Text Any textual data included in the document <h2>The Neurophysiological Ankle-Foot Orthosis</h2> <h5>Cyndi Ford, P.T.&nbsp;<a style="text-decoration: none;">*</a><br />Robert C. Grotz, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Joanne Klope Shamp, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Since the late 1960's when Yates<a></a> and Lehneis<a></a> wrote the first articles pertaining to the use of plastics, orthotic practice has been revolutionized by the design possibilities afforded by total contact devices. However, prescription of lower extremity orthoses for neuro-logically involved patients has traditionally depended solely upon biomechanical principles even as neurophysiological approaches to treatment gained recognition and acceptance. Neur-odevelopmental Techniques (NDT) were developed as a theory of Karl and Berta Bobath and evolved to "a sensorimotor approach to control motor output and in doing so change sensory input."<a></a> Handling techniques which counteract patterns of abnormal tonic reflex activity reduce spasticity and allow facilitation (activation) of normal postural reactions through stimulation of key points of control, which include points on the foot and ankle. Recent advances incorporating neurophysiological principles of inhibition and facilitation into the design of ankle-foot orthoses make possible tone-reducing devices with specific areas of pressure or contact to inhibit abnormal hypertonicity.</p> <p>Eberle, Jeffries, and Zachazewski<a></a> recently reported success with an inhibitive AFO, a concept that was not feasible with metal orthotics. Their report stated that "the technique of fabrication used for the construction of a molded polypropylene AFO allows for all of the tone-inhibiting characteristics of casting ... to be built into the AFO."</p> <p>Although tone-reducing AFO inhibit abnormal hypertonicity in the affected lower extremity, the disadvantages inherent in traditional AFO persist. Limited ankle dorsi-flexion and plantar flexion, create a negative influence upon independent knee and hip function. Floor reaction forces intended to prevent the typical hemiplegic knee recurvatum during stance phase also contribute to increased effort and decreased smoothness in gait. Tonic foot reflexes elicited by contact on the plantar surface of the foot as a means to facilitate normal movement are disregarded.</p> <p>In an effort to address these gait concerns, an orthosis was designed based upon the neurode-velopmental concepts as described by Bobath<a></a> and Utley<a></a>, and the foot reflexes as described by Duncan and Mott<a></a> with the following considerations in mind:</p> <ol> <li> <p>A design configuration intended to utilize both biomechanical principles to limit calcaneal varus and neurophysiological principles (of facilitation and inhibition) to obtain dynamic ankle dorsiflexion and plantar flexion.</p> </li> <li> <p>Selection of a material with adequate flexibility, durability, and shape retention under conditions of continual deformation during ambulation.</p> </li> <li> <p>Ease of donning for the one-handed patient.</p> </li> </ol> <h3>Design Rationale</h3> <p>The Neurophysiological Ankle-Foot Orthosis (NP-AFO) is a custom polypropylene device, vacuum-formed over a plaster model of the patient's affected lower extremity (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-01.jpg"><b>Fig. 1</b></a>). Within the total contact design are incorporated the following forces:</p> <ol> <li> <p>A three-point pressure system to biomechanically control calcaneal varus (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-02.jpg"><b>Fig. 2</b></a>).</p> </li> <li> <p>A biomechanical force medial to the achilles tendon to counterbalance and prevent excessive pronation and rotation of the orthosis in the shoe (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-03.jpg"><b>Fig. 3</b></a>).</p> </li> <li> <p>A neurophysiological force on the medial aspect of the calcaneus, extending to the plantar surface of the longitudinal arch without creating pressure under the navicular itself (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-03.jpg"><b>Fig. 3</b></a>). This facilitates straight plane dorsiflexion.</p> </li> <li> <p>A neurophysiological force on the lateral aspect of the plantar surface of the foot (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-04.jpg"><b>Fig. 4</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-05.jpg"><b>Fig. 5</b></a>) to facilitate the eversion reflex (peroneals) and recruit more proximal controls (vastus lateralis and gluteus medius) for knee and hip stability as discussed by Duncan<a></a>. The amount of dorsiflexion assist may be graded by adjusting the width of the segment joining the heel-cup and the metatarsal arch (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-05.jpg"><b>Fig. 5</b></a>).</p> </li> <li> <p>A neurophysiological force to inhibit the toe grasp reflex (toe flexors and gastroc-nemius-soleus) by unweighting of the metatarsal heads through use of a metatarsal arch (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-06.jpg"><b>Fig. 6</b></a>).</p> </li> <li>Biomechanical function through flexibility of the foot and ankle due to the trimlines and configuration of the plastic NP-AFO (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-07.jpg"><b>Fig. 7</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-08.jpg"><b>Fig. 8</b></a>).</li> </ol> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-07.jpg">Figure 7.</a> Medial view, left foot<br /></strong><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-08.jpg">Figure 8.</a> Lateral view, left foot</strong><br /> <h3>Prescription Rationale</h3> <p>The NP-AFO is designed for use in the treatment of the patient with a central nervous system disorder, such as a cerebral vascular accident or closed head injury. Assessment should include analysis of the individual's tone or spasticity, range of motion, and the availability of follow-up by members of the clinic team familiar with a neurophysiological approach to care. Spasticity has been classified as minimal, moderate, or severe in terms of function of the foot and ankle during gait.<a></a> Minimal spasticity allows the patient to land on a stable calcaneus without excessive supination of the forefoot and then shift the body weight over the heads of the metatarsals, although during swing phase the foot assumes a varus or supinated posture. Moderate spasticity causes the calcaneus to assume a position of varus with excessive supination at initial contact; however, during midstance some pronation occurs and the body weight can again be transferred normally across the forefoot. Severe spasticity is characterized by the foot and ankle being held rigidly in a position of equinovarus throughout stance so that the body weight remains on the lateral aspect of the forefoot with little or no weightbearing through the heel or medial metatarsal heads. This varus position persists throughout swing phase also.</p> <p>Patients exhibiting minimal or moderate spasticity are excellent candidates for the NP-AFO. Patients with severe spasticity are candidates only if their tone can be modified through handling techniques and/or inhibitive casting. The use of toe separators (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-09.jpg"><b>Fig. 9</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-10.jpg"><b>Fig. 10</b></a>, and<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-11.jpg"> <b>Fig. 11</b></a>) as an adjunct treatment is also effective in patients with a separate toe grasp reflex to inhibit excess tone and reduce pain.<a></a> In order for the NP-AFO to function appropriately, the patient must have at least 15 degrees of passive dorsiflexion with the knee in flexion.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-09.jpg">Figure 9.</a> Toe separators fabricated from Plastazote® with a Moleskin® cover and toe extension.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-10.jpg">Figure 10.</a> Toe separators in place under the toes</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-11.jpg">Figure 11.</a> Superior view showing tabs to hold in place under sock.</strong><br /> <p>Follow-up by a clinic team familiar with the device is important to monitor the continued fit and function. With most AFO the major concern may be skin breakdown. However, with the NP-AFO the change in fit due to edema, weight loss, or tone variations may require modifications to maintain the critical areas of contact.</p> <p>Contraindications for this device are severe spasticity which cannot be modified through inhibitive casting or handling techniques, and early excessive pronation or calcaneal valgus with the foot pronated at initial contact of stance.</p> <h3>Clinical Experience</h3> <p>The NP-AFO has been prescribed for 35 patients with the following diagnoses: 29 Cerebral Vascular Accidents (CVA), 4 Closed Head Injuries (CHI), 1 Cauda Equina Injury, and 1 undiagnosed Demyelinating Disease. Although three patients were lost to follow-up, the NP-AFO has continued to be worn by the remaining 32 with overwhelming acceptance which seems to be attributed to the comfort and function of the device. Of the four patients converted from traditionally designed orthoses (2 metal, 2 plastic AFO), three have improved gait patterns and prefer the NP-AFO to their previous device. The fourth has rejected orthotic care due to refusal to adapt footwear from inappropriate styles with 2 1/2" heels. Four patients became independent ambulators without the use of any orthotic device.</p> <h3>Fabrication</h3> <p>Polypropylene was chosen as the thermoplastic currently exhibiting the best conformance to the desired qualities, when used in the fabrication process described.</p> <h3>Casting Procedure</h3> <p>The casting technique is similar to that described in <i>Lower Limb Orthotics, A Manual</i><a></a> and is a procedure commonly used by certified orthotists. The cast must be taken in a position of maximal dorsiflexion, preferably 20 degrees. The calcaneus, midfoot, and forefoot should be in a neutral position. It has been our experience that tone-reducing handling activi-. ties performed by a physical therapist just prior to casting will help assure an optimal position. These activities include forefoot, midfoot, and hindfoot mobilizations as taught by Jan Utley.<a></a></p> <p>The cast is removed upon hardening and filled with plaster to create a positive model for use in vacuum-forming of the orthosis. The positive model is now ready for modifications to create the necessary biomechanical and neurophysiological forces.</p> <h3>Modification Of The Positive Model</h3> <p>As the key to function of the orthosis is selective inhibitive and facultative forces, accurate cast modification is essential. Plaster removal is performed in the following areas to a depth of 0.5 to 1 cm. depending upon the compressibility of the patient's extremity. These modifications must be sufficient to provide a very firm force to the skin as designated.</p> <ol> <li> <p>Medial and lateral to the achilles tendon using a Scarpa's knife to deeply groove the modification (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-12.jpg"><b>Fig. 12</b></a>).</p> </li> <li> <p>Medial aspect of the calcaneus extending to the plantar surface of the longitudinal arch <em>without</em> creating pressure under the navicular itself that would stimulate mid and forefoot supination (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-13.jpg"><b>Fig. 13</b></a>).</p> </li> <li> <p>Along the lateral plantar surface of the mid- and forefoot, excluding the base and head of the fifth metatarsal (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-14.jpg"><b>Fig. 14</b></a>).</p> </li> <li> <p>Create a metatarsal arch 6mm. proximal of the metatarsal heads for the inhibitive function of unweighting the metatarsal heads and thereby reduce tone (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-06.jpg"><b>Fig. 6</b></a>).</p> </li> <li> <p>Smooth entire cast.</p> </li> </ol> <p>If an accurate negative cast and positive model were created, no further modifications are necessary.</p> <h3>Vacuum-Forming Process</h3> <p>Leather, nylon, or rope cording is applied to the cast (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-15.jpg"><b>Fig. 15</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-16.jpg"><b>Fig. 16</b></a>, and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-17.jpg"><b>Fig. 17</b></a>) to create strengthening corrugations in the orthosis after molding.</p> <p>A separating agent or material is used between the positive model and the hot plastic to create adequate vacuum and to leave a smooth inner surface. For our drape-forming process one layer of perlon with one layer of ladies' nylon knee-high stockings are applied and smoothed with talc. Stress-relieved 3/16" polypropylene is then drape-formed under vacuum to the positive model and allowed to cool for 24 hours.</p> <h3>Trimlines</h3> <p>The orthosis is removed from the positive model using a cast cutter and is sanded to finish according to the following trimlines:</p> <ol> <li> <p>Overall height of the orthosis is equal to the distance from the plantar surface of the calcaneus to the flare of the achilles tendon as it meets the gastrocnemius-soleus group, multiplied by 2. An average overall length for a 175cm. (5'9") adult is 25.5cm. (10").</p> </li> <li> <p>Length of the plantar extension is terminated 6mm. proximal to the metatarsal heads for comfort.</p> </li> <li> <p>The lateral trimlines (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-18.jpg"><b>Fig. 18</b></a>) come as far anterior as possible and still allow passage of the leg into the orthosis. The posterior trimline (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-18.jpg"><b>Fig. 18</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-19.jpg"><b>Fig. 19</b></a>) approaches the lateral margin of the achilles tendon, but may require modification to prevent a bowstring effect by the heel counter of the shoe against the NP-AFO.</p> <p>Note that flexibility is enhanced by the narrowing anteriorly and posteriorly as the lateral side meets the heelcup.</p> </li> <li> <p>The achilles tendon is left exposed to the point of flare with the gastronemius-soleus (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-19.jpg"><b>Fig. 19</b></a>).</p> </li> <li> <p>The medial margin is trimmed so as to provide the appropriate forces and yet avoid contact on the medial malleolus and under the navicular. The open area provides for lack of resistance to dorsiflexion and plantar flexion (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-20.jpg"><b>Fig. 20</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-21.jpg"><b>Fig. 21</b></a>).</p> The plantar extension (<a href="http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-21.jpg"><b>Fig. 21</b></a>) may be varied in width depending upon the size of the patient and flexibility desired, but as it serves only to join the metatarsal arch to the heelcup, it should remain as flexible as possible. The distal aspect, including the metatarsal pad, should span the distance between the shaft of the first metatarsal and the extreme lateral margin of the foot to allow maximum facilitation of the eversion reflex.</li> </ol> <p>A full 1/8" Plastazote® liner is glued to the inner surface of the orthosis, with the exception of the areas contained by the patient's shoe to allow ease of donning the same size shoe previously worn by the patient. A Velcro® strap of 2" width is applied to the proximal anterior calf. A lace-tied or Velcro®-closed shoe is recommended to maintain the critical fit of the NP-AFO.</p> <h3>Discussion</h3> <p>The movement allowed by the NP-AFO encourages dynamic control of the entire lower extremity. When sitting, normal weight-bearing attitude can occur with the foot remaining in full contact with the floor throughout a full range of knee flexion. Analysis of the normal movements of the ankle during elevation from a chair has revealed to us that the ankle begins in dorsiflexion and continues to dorsiflex during the initial phase of the elevation before plantar flexing to a relatively neutral position. Devices which eliminate this normal range of dorsiflexion necessarily require a patient to work over an abnormal base and make difficult active weight-bearing during elevation. The ability to assume a normal weight-bearing surface in a position of power as allowed by the NP-AFO encourages weight-bearing on the affected extremity throughout all activities of daily living.</p> <p>Further, dynamic control of the pelvis and knees are encouraged during ambulation by eliminating floor reaction forces inherent in other AFO. Without these abnormal forces, the patient experiences the normal movement of the pelvis and knee over the foot, allowing development of a propulsive toe-off with the NP-AFO.</p> <p>Progressing from use of the NP-AFO to being independent of assistive devices is more feasible, as the patient has the opportunity to gain control of muscles through the normal range of movement.</p> <h3>Summary</h3> <p>The adequacy of traditional AFO to provide a safe, functional gait pattern is irrefutable. However, experience with patients who sustained a CVA five to fifteen years ago and received a traditional metal or plastic AFO reveals they now present problems related to overuse of the sound side: the pathomechanics resulting from a rigid ankle and/or increasing hypertonicity from abnormal weightbearing patterns. As more patients have increased lifespans following a CVA, treatments and orthotic care which assure prolonged quality of life become increasingly important. Neurophysiological treatment attempts to do this through emphasis upon normal movement patterns and integration of the affected and unaffected sides.</p> <p>The NP-AFO is a biomechanically and neurophysiologically effective ankle-foot orthosis that is appropriate for creating a functional gait in the patient with a central nervous system disorder. The design allows for independent motion at the ankle, knee, and hip joints in a lightweight and cosmetic custom-made orthosis. The NP-AFO joins the inhibitive cast and other neurophysiological armamentarium in new approaches to the rehabilitation of the spastic or hypertonic patient.<br /><br /><em><b>*Joanne Klope Shamp, C.P.O. </b>Joanne Klope Shamp, C.P.O., is with the Shamp Pros-thetic-Orthotic Center in Norton, Ohio.<br /><br /><b>*Robert C. Grotz, M.D. </b>Robert C. Grotz, M.D., is Medical Director for Edwin Shaw Hospital in Akron, Ohio<br /></em></p> <p><em><b>*Cyndi Ford, P.T. </b>Cyndi Ford, P.T., is with the Edwin Shaw Hospital in Akron, Ohio.</em></p> <h3>Additional Reading</h3> <ol> <li> <p>Bobath, B. "The Application of Physiological Principles to Stroke Rehabilitation—A Special Report," <i>The Practitioner</i>, December, 1979, Vol. 223, 793-4.</p> </li> <li> <p>Ibid, "The Treatment of Neuromuscular Disorders by Improving Patterns of Coordination," <i>Psychotherapy</i>.</p> </li> <li> <p>Bobath, B. and Bobath, K., "The Importance of Memory Traces of Motor Efferent Discharges for Learning Skilled Movement," <i>Developmental Medicine and Child Neurology</i>, 1974, p. 16, pp. 837-8.</p> </li> <li> <p>Cherry, D.B., "Review of Physical Therapy Alternatives for Reducing Muscle Contracture," <i>Physical Therapy</i>, Volume 60, Number 7, p. 877, July, 1980.</p> </li> <li> <p>Effgen, S., "Integration of the Plantar Grasp Reflex as an Indicator of Ambulation Potential in Developmentally Disabled Infants," <i>Physical Therapy</i>, Volume 62, Number 4, pp. 433-35, April, 1982.</p> </li> <li> <p>Freedman and Herman, "Inhibition of EMG Activity in Human Triceps Surae Muscles During Sinusoidal Rotation of the Foot," <i>Journal of Neurology, Neurosurgery and Psychiatry</i>, 1975:38, pp. 336-45.</p> </li> <li> <p>Knutsson, E. et al., "Different Types of Disturbed Motor Control in the Gait of Hemiparetic Patients," <i>Brain</i>, 1979:102, p. 405.</p> </li> <li> <p>Lehmann, J.F., "Biomechanics of Ankle-Foot Orthoses: Prescription and Design," <i>Archives of Physical Medicine and Rehabilitation</i>, Volume 60, May, 1979, p. 200.</p> </li> <li> <p>Ibid, "Plastic Ankle-Foot Orthoses: Evaluation of Function", <i>Archives of Physical Medicine and Rehabilitation</i>, p. 402.</p> </li> <li> <p>Ibid, "A Biomechanical Evaluation of Knee Stability in Below-Knee Braces," <i>Archives of Physical Medicine and Rehabilitation</i>, p. 688, December, 1970.</p> </li> <li> <p>Manfredi, Sacco and Sideri, "The Tonic Ambulatory Foot Response," <i>Brain</i>, 1975: 98, pp. 167-80.</p> </li> <li> <p>Perry, et al., "Determinates of Muscle Action in Hemiparetic Lower Extremity," <i>Clinical Orthopaedics and Related Research</i>: p. 131, March-April, 1978.</p> </li> <li> <p>Walters, R.L., "The Enigma of 'Carry Over'," <i>International Rehabilitation Medicine</i>, 1984:6, pp. 9-12.</p> </li> <li> <p>Watemabe, I. and Obubo, J., "The Role of Plantar Mechanoreceptor in Equilibrium Control," <i>Ann-NY-ACAD-Science</i>, 1981: 374, pp. 855-64.</p> </li> <li> <p>Weiz, S., "Studies in Equilibrium Reaction," <i>Journal of Nervous and Mental Disorders</i>: 88, 1938, p. 150.</p> </li> </ol> <p><b>References:</b></p> <ol> <li>Yates, G., "A Method for Provision of Lightweight Aesthetic Orthopaedic Appliances," <i>Orthopaedics</i>: Oxford, 1:2, pp 153-162, 1968.</li> <li>Lehneis, H.R., "New Concepts in Lower Extremity Orthotics," <i>Medical Clinics of North America</i>, 53:3:3, pp. 585-592, 1969.</li> <li>Bobath, K., "The Problem of Spasticity in the Treatment of Patients With Lesions of the Upper Motor Neurone," The Western Cerebral Palsy Centre, London, England.</li> <li>Eberle, E.D.; Jeffries, M.; and Zachazewski, J.E., "Effect of Tone-Inhibiting Casts and Orthoses on Gait: A Case Report," <i>Physical Therapy</i>, 62:4 pp. 453-455, 1982.</li> <li>Bobath, B. and Bobath, K., <i>Motor Development in Different Types of Cerebral Palsy</i>, Heinman, London, 1975.</li> <li>Utley, J., NDT Adult Hemiplegia and Closed Head Injury Certification Course, Columbus, Ohio, July, 1982.</li> <li>Duncan, W. and Mott, D., "Foot Reflexes and the Use of the Inhibitive Cast," <i>Foot and Ankle</i>, p. 145, 1983.</li> <li>Duncan, W., "Tonic Reflexes of the Foot," <i>Journal of Bone and Joint Surgery</i>, July, 1960.</li> <li>Sarno, J.E. and Lehneis, H.R., "Below-Knee Orthoses: A System for Prescription," <i>Archives of Physical Medicine and Rehabilitation</i>, Vol. 54, p. 548, December, 1975.</li> <li>Rehabilitation Engineering Center, Moss Rehabilitation Hospital. <i>Lower Limb Orthotics: A Manual</i>, First Edition, Philadelphia, 1978.</li> </ol> Page Number(s) 15 - 23 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-14.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-15.jpg Figure 16 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-16.jpg Figure 17 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-17.jpg Figure 18 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-18.jpg Figure 19 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-19.jpg Figure 20 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-20.jpg Figure 21 http://www.oandplibrary.org/cpo/images/1986_01_015/1986_01_015-21.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 Neurophysiological Ankle-Foot Orthosis Creator An entity primarily responsible for making the resource Cyndi Ford, P.T. * Robert C. Grotz, M.D. * Joanne Klope Shamp, C.P.O. * https://staging.drfop.org/files/original/cc46ad414ca9f0d932c9c1bd427dabc4.pdf 497441a68e5f2a4eef555521963106c4 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_010.pdf Text Any textual data included in the document <h2>The New Revolution</h2> <h5>Timothy B. Staats M.A., C.P.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The recent development and proliferation of advanced and precision fitting techniques in prosthetics have caused many prosthetists to reevaluate those principles which were held sacred for the past twenty years. In the last three years in particular, both below-knee and above-knee prosthetics have undergone tremendous changes.</p> <p>Many progressive practitioners recognize that the term "Patellar Tendon Bearing (PTB)" is no longer considered descriptive of a well designed below-knee socket and use the term only in a historical sense. The term Total Surface Bearing better describes what has superseded PTB philosophy.</p> <p>In above-knee prosthetics, a greater revolution is in the offing. Now the CATCAM (Contour-Adducted-Trochanteric-Controlled Alignment Method) socket is shaking the underpinnings of the Quadrilateral above-knee socket design. For those of us who are "dyed-in-blue-and-gold-UCLA-Quad-socket" prosthetists, it is both difficult and exciting to see the development and confusion a rival design causes throughout the profession. I am sure that thirty years ago the "wood-socket-plug-fit" prosthetists shared a similar feeling when the quadrilateral socket and later the introduction of plastics caused their world to turn upside down.</p> <p>The point is that change and improvement are inevitable. You can fight it and it will flow over you like a river, or you can go with the flow and learn to adapt to new techniques. I have been asked repeatedly what I think about the use of multiple check socket fittings, CATCAM, alginated check sockets, and the Flex-Foot. The list goes on and on. American prosthetists in particular must understand that we are in the midst of a full blown revolution and the results of this revolution will set the path we follow for the next couple of decades. Rather than question what is right or wrong without really having proof of either, I have chosen a path as the director of a prosthetics education program of "pouring fuel on the fire." What better time or place for controversy than at UCLA, where the first school was started over thirty years ago.</p> <p>Is all this extra precision and care really necessary to accurately fit an artificial limb? The answer is quite simple, and if you are an amputee the question is repulsive. If superior techniques that can improve the quality of the care provided to amputees are available but are not used, it is nothing less than criminal.</p> <p>There are those who would question: how much of a good thing is enough? That is a question that the patient must answer and the prosthetist must decide based on knowledge and education. The fact that many of the newer techniques and fitting regimes demand more time and effort than methods which have been in use for twenty years is entirely a separate issue. While it may not be possible to provide these services for the reimbursements, which are now received from payment sources, this does not mean that the techniques do not work or are wrong. It only means that the third party payers are ignorant of changes which have occurred in our profession and must be introduced to the benefits of new procedures.</p> <p>This same principle applies to prescribing physicians. It is totally fair to say that a physician who took his prosthetics-orthotics training over five years ago is now out of date. The same is true for practitioners who have not upgraded their practices through educational opportunities during this period.</p> <p>It is always uncomfortable when you begin to wonder whether you are doing the best you can for your patient. It is even more uncomfortable when you know you are not. We should never be satisfied with our work and never doubt that a better job can be done. With such a philosophical upheaval running rampant through our profession, the time for learning is now. Are you satisfied with application of outdated techniques, or are you willing to enter a new era of prosthetic and orthotic practice? The choice is yours.</p> <em><b>*Timothy B. Staats M.A., C.P. </b> Timothy Staats, M.A., CP., is Adjunct Assistant Professor and Director of the Prosthetics &amp;Orthotics Education Program at UCLA, Rehabilitation Center, 1000 Veteran Avenue, Rm 22-41, Los Angeles, CA 90024.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 10 - 11 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The New Revolution Creator An entity primarily responsible for making the resource Timothy B. Staats M.A., C.P. * https://staging.drfop.org/files/original/2dea17a3a5a3c752d1ee37559bbaa825.pdf 7a4435086ff3850c01c2ef893fa48eac https://staging.drfop.org/files/original/43d8a129940cb8511733726caf27bf79.jpg 5b81f8134177bd4ec394e1f9f2c7aa76 https://staging.drfop.org/files/original/39e08fec5517e38ce66dbeac92235181.jpg 69fe78cabce5d19c388bd5c6790f61fa https://staging.drfop.org/files/original/3a2aea30bf763bcff465c69a91b543c6.jpg 50d23a5eff289ab00376b2787b04b7a4 https://staging.drfop.org/files/original/a8157ca13387fd20c5b413875668ef69.jpg 0ae08cbaf0551506dc3f01cef5e2c987 https://staging.drfop.org/files/original/0b36336724f1ed95ee0fdecea4e24704.jpg 72776be8ad19dce1b202d29195559889 https://staging.drfop.org/files/original/9f72cc18e382ab675a87069c72e62cd2.jpg b62295fcb70277ba0a60bef4591a702f https://staging.drfop.org/files/original/58911f3f64dd71a25a20575b8272b859.jpg b996ee7ff9c38a927feb2bb4ca0678f1 https://staging.drfop.org/files/original/900709fd561acd10c0f47effcf1360ef.jpg b85e77771aac862aba66ec7c33585be5 https://staging.drfop.org/files/original/073bad9839c0df598f8e71002a2f42be.gif 4535091be1c2df849d6a024ab57da422 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_047.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 47 - 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/1955_02_047.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_047.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Noticeability of the Cosmetic Glove</h2> <h5>Tamara Dembo, Ph.D. <a style="text-decoration:none;">*</a><br />Esther Tane Baskin, M.A. <a style="text-decoration:none;">*</a><br /></h5> <p>Ahand prosthesis can be useful in more than one way. It can be helpful in dealing with objects, and it can be helpful in interpersonal relations. The latter aspect is the one with which we are here concerned. The usefulness of a prosthesis in human relations is termed "social usefulness." To a wearer who considers his hand amputation a private matter, for example, and to one who does not wish to be recognized as an amputee, a prosthesis is socially useful if it cannot be recognized as an artificial device. Moreover, the amputee may be concerned that another person looking at the prosthesis should feel comfortable. In such a case, that prosthesis is most useful which does not repulse or embarrass another person but is "good to look at."<a style="text-decoration:none;">*</a></p> <p>In 1949 a cosmetic glove, produced at the Army Prosthetics Research Laboratory, was sent for testing to the Research Division of the College of Engineering, New York University. Investigation of the cosmetic glove led to formulation of the problem of the social usefulness of prosthetic devices in general. The methods developed during the study of the glove are, furthermore, generally applicable to the investigation of the social usefulness of other prostheses. This article deals only with the problem of the noticeability of the cosmetic glove. The question of its appearance, <i>i.e., </i>the desirable and undesirable characteristics of the sight of the cosmetic hand, is not discussed.</p> <h3>Experiments and Results</h3> <p>On cursory examination, the experimental prosthesis looked like a normal hand, but on closer scrutiny it could easily be recognized as a cosmetic device. Further, it did not match the normal hand of the particular wearer, although it was, at that time, the best match among several available cosmetic gloves (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>, and <b>Fig. 4</b>). Moreover, the glove simply was filled with vinyl foam, and the hand was thus nonfunctional except insofar as the amputee might wedge light objects between the springy fingers.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Winthrop Sullivan wearing the cosmetic glove on his left (to the reader's right). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Mr. Sullivan'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. 3. Brennan C. Wood wearing the cosmetic glove on his right (to the reader's left). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Mr. Wood's hands. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The problem was to determine whether such a glove is realistic enough not to be noticed as a prosthesis, or, rather, how frequently the wearer of such a glove goes unrecognized as an amputee. Four different experiments were conducted.</p> <h4>Experiment I</h4> <p>In the first experiment, 30 separate tests were performed. Each required a wearer,<a style="text-decoration:none;">*</a> an experimenter, an observer, and a stranger. The stranger was the "subject" because his reaction, <i>i.e., </i>whether he did or did not recognize the cosmetic hand as a prosthesis, was of prime importance. The wearer went, as a cus tomer, to various stores and shops in New York City and engaged salemen (subjects) in conversation. In each instance, he put his arms on the counter and, to make sure that the cosmetic glove was in sight of the salesman, gestured, pointed, scratched his hand or face, indicated size or shape of objects, held a newspaper, smoked, soiled the cosmetic hand and wiped it off, or supported objects <i>(e.g., </i>held a wallet against his body with the artificial hand), all the while acting in a leisurely manner in order to prolong the contact, usually for from five to twenty minutes. Experimenter and observer entered the store with the wearer but as a separate party. While the wearer talked to the subject, experimenter and observer stood aside as if engaged in conversation, the observer pretending to listen to the experimenter but actually taking notes on the behavior of the wearer and the salesman. The latter, of course, did not know that he was the "subject" of a psychological experiment.</p> <p>When the wearer left the store, the experimenter approached the salesman and asked some questions about the man who had just left. The observer continued to stand aside and recorded the discussion (interview) between the experimenter and the subject. An example of an interview follows:</p> <blockquote><p><i>Experimenter: </i>Did you notice anythingabout the man who was just in here? <br /> <i>Salesman: </i>In what respect? <i>Experimenter: </i>Well, did you notice anything unusualabout him? <br /> <i>Salesman: </i>About his hand. <br /> <i>Experimenter: </i>What was there about it you noticed?<br /> <i>Salesman: </i>There was no action in it. <br /> <i>Experimenter: </i>When did you notice it? <br /> <i>Salesman: </i>When he had his hand at his side. When helighted a cigarette. He held his hand like this[shows stiff position].<br /> <i>Experimenter: </i>Do you think it could have been an artificial hand? <br /> <i>Salesman: </i>No, it was not an artificial hand. It was his hand. He held it close to his side. Maybe he had no action in the shoulder. He did not use that hand. Used one hand at mirror. Held it. Just turned it.</p> </blockquote> <p>After being informed that the hand was a prosthesis, the salesman said he had not recognized it as such.</p> <h4>Experiment II</h4> <p>In the second experiment, three or four people (college students and their friends) were asked to take part as subjects of a psychological group experiment on "impressions of personality." On their arrival, the subjects found the wearer, who was introduced as one of the group members. Everyone was asked to sit around a table and to wait for another group member supposedly delayed and, in the meantime, to get acquainted with each other. The wearer, holding his hands in plain view on the table, conversed with the group members. After about 10 minutes he left the room, ostensibly to make a phone call. Then each member of the group was asked to accompany an experimenter to another room, where the participant was asked to give his impression about the person who went to make the phone call. If, during the interview, it became clear to the experimenter that the subject had not noticed the hand, the subject was given another opportunity to observe the wearer, and then a second interview took place. Sometimes the procedure was repeated a third time. In all, 29 subjects were used.</p> <p>An example of an interview performed in Experiment II follows:</p> <blockquote><p><i>Experimenter: </i>As you know, we are studying quick impressions of personality. Mr. X is part of the experiment. Could you give your first impressions of him? What struck you about him, mainly?<br /> <i>Subject: </i>He seemed intelligent, friendly, sociable. It seemed as though he could talk on other than his major field of interest.<br /> <i>Experimenter: </i>How would you describe him physically?<br /> <i>Subject: </i>Physical impressions are a pretty personal matter, I think. Would say he was more positive than negative, from the point of view of attractiveness. Genial.<br /> <i>Experimenter: </i>Could you give the outstanding characteristics of his face?<br /> <i>Subject: </i>He had a fairly easy smile, seemingly accompanying a sense of humor and a desire to please.<br /> <i>Experimenter: </i>Could you describe his hands?<br /> <i>Subject: </i>Yes, I noticed his hands. I usually do notice hands.<br /> <i>Experimenter: </i>Could I interrupt to ask why you always notice hands?<br /> <i>Subject: </i>I just always have. It dates from the fact that when I was young I thought I couldn't be beautiful, but I could have nice hands and fingernails, so I always notice other people's. I guess I can visualize the hands of every friend I have ever had. I think his were in between, no particular character.<br /> <i>Experimenter: </i>Anything else?<br /> <i>Subject: </i>He had nice hair, a little wavy. A kind of flushed face, more healthy than not.<br /> <i>Experimenter: </i>Were there any gestures on Mr. X's part that you remember?<br /> <i>Subject: </i>No. He had his hands out on the table most of the time, but I don't remember his gestures particularly.</p> </blockquote> <p>The subject who stated that she usually notices hands did not notice the cosmetic hand or any signs of difference about the hand. The experimenter and the subject returned to the group. After about ten minutes more the wearer left, and the second interview took place:</p> <blockquote><p> <i>Experimenter: </i>Now can you give some further impressions of Mr. X?<br /> <i>Subject: </i>I noticed his eyes more this time, a little different than most people's but difficult to describe, noticeable. I noticed his nose tips up a little, like Sonja Henie's. I noticed his hands more because you called them to my attention, but I don't think these physical impressions mean too much.<br /> <i>Experimenter: </i>Was there anything outstanding about his hands?<br /> <i>Subject: </i>His nails were not particularly graceful, they were a little short, but clean looking. I confirmed the fact that his hair was curly and his face ruddy. He seemed very well balanced, not neurotic, in that he seemed willing to go along on other people's fun. He certainly didn't show any compulsion to take the spotlight or to resent it when somebody else took it.<br /> <i>Experimenter: </i>We'll all go back together again, and then<br /> there will be a third interview. I want you to notice his hands again particularly, and in detail. Notice the movement or lack of it. The subject was interviewed again after she saw the wearer for the third time:<br /> <i>Subject: </i>I did notice his hands, the shape, and the rather short fingernails. They looked clean and healthy, but I like tapering fingernails.</p> </blockquote> <p>Even during the third period of contact with the wearer, the subject did not notice any difference between the wearer's two hands, although she was able to describe them. The results of Experiments I and II are given in (<b>Table 1</b>).</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>Of 30 subjects in Experiment I, 24 (80%) did not recognize the cosmetic hand as a prosthesis. In fact, they did not even notice any difference between the two hands of the wearer.<a style="text-decoration:none;">*</a> The remaining 6 subjects (20%) commented that the arm or hand was in some way injured, but they too did not notice that the hand was artificial.<a style="text-decoration:none;">*</a> Thus, in an everyday situation of a salesman dealing with a customer, <i>not one </i>salesman in Experiment I noticed the cosmetic glove <i>as a prosthesis.</i></p> <p>The question arises as to why the prosthesis was not noticed by the salesmen. One could ask whether the unnoticeability may not be accounted for by the "fact" that the busy New York salesman does not have enough time to pay attention to the appearance of his customers. This, however, was not borne out by the data. When asked to describe the customer (the wearer), the salesman was well able to describe how the wearer looked, what he did, and what he said. Yet the saleman had not noticed the cosmetic glove.</p> <p>In Experiment II, 29 subjects took part.<a style="text-decoration:none;">*</a>Within the framework of "description of personality," 23 (80%) did not notice any difference between the two hands, 3 (10%) noticed that one hand looked different from the other but did not recognize it to be an artificial hand, and 3 (10%) noticed that it was a prosthesis.</p> <p>That the cosmetic hand was not recognized by any of the salesmen as a prosthesis and rarely as such by the students and their friends, one may argue, is due to the "fact" that people do not pay attention to the properties of another person's hands. To test this "hypothesis," Experiment III was carried out.</p> <h4>Experiment III</h4> <p>In Experiment III, with a setup essentially the same as in Experiment II, the wearer used a hook instead of the cosmetic hand. Here, 11 out of 12 people (92%) noticed that the amputee was wearing a prosthesis. It appears, then, that the cosmetic hand goes unnoticed not because people are negligent in their observations but rather because it does not deviate sufficiently from the appearance of the natural hand. The hook, however, which deviates radically in appearance the normal is noticed readily (<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 /> <h4>Experiment IV</h4> <p>In the first three experiments, untrained observers were used. The question arose as to whether different results would be obtained in experiments with people especially trained to notice bodily characteristics. One could expect that art students, for example, would be especially apt to notice the cosmetic hand. Accordingly, in Experiment IV, six art students participated as subjects, all members of a drawing class for which the wearer served as a model. Six to eight feet separated the wearer from the students. They were told that, after having made the drawing, they would be asked how the model impressed them as a person.</p> <p>During the first part of the experiment, the wearer posed with his cosmetic left hand supporting his chin (<b>Fig. 5</b>). Ten minutes were allotted for the drawing. Then the wearer left, and the art students were questioned individually, the interviews being conducted in terms of what impression the art student had of the model's personality. Results showed that not one of the six art students was aware that he had been drawing an artificial hand, although some reference was made to the difference between the two hands, or it was felt that the hand somehow did not fit the person.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Mr. Sullivan as sketched by an art student. The hand held to the face is the cosmetic one. While drawing this picture, the art student did not notice a difference between the two hands (Experiment IV, Part 1). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The second part of the experiment offered even greater opportunity for direct comparison of the two hands. Here, the subjects were told that the model (wearer) would return for a second pose and that later the subjects would be asked "how his <i>hands </i>expressed personality." During the second drawing period, the wearer sat with his two hands covering his face (<b>Fig. 6</b>). But even under these conditions, only two of the six subjects noticed that one of the hands was artificial. The remaining four did not realize that they were drawing a cosmetic hand.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Second drawing of Mr. Sullivan by the same art student who drew the picture shown in Figure 5. The notation listing the differences between the two hands is that made by the student at the time of the drawing (Experiment IV, Part 2). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To illustrate how, in spite of differences noticed between the two hands in Experiment IV, it did not occur to the subjects that one hand was artificial, excerpts from two interviews conducted after the second drawing (<b>Fig. 7</b>) follow:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Drawing made by an art student during Experiment IV, Part 2. The left hand (on the reader's right) is the cosmetic one. The student saw the hands as different owing to the occupation he ascribed to the wearer. He thought the wearer was a violinist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p><i>Experimenter: </i>What gives now?<br /> <i>Subject: </i>Interesting things, real interesting. Makes a difference when you know you're supposed to look at hands. About his hands, there is a basic difference in his two hands. The right hand is more used, I would say [left hand is the cosmetic one]. There are several interesting things about them. First of all, the fingernails were fairly short. Gives me an idea that he may play a stringed instrument. The button of his cuff was open, couldn't tell if broken off. I thought of a violinist who would open his cuff so he could handle it. I think he is right handed because that would be the bow hand, and all the movement would have opened the cuff. I don't think this particularly jibes with the feeling that the hand that would do the fingering would be the most wrinkled, worn hand. For this was not the case. Yet had the feeling that he does do something special that involves t h specialized use of one of his hands.<br /> <i>Experimenter: </i>Why do you think this?<br /> <i>Subject: </i>Well, there is a basic difference in structure. 1 couldn't see the right hand before when he was posing [subject refers to <b>Fig. 5</b>], I drew the right hand first. It was thinner. I felt there was more structure visible, it was more wrinkled, I could think of some special occupation. Another interesting thing, the watch was worn inside the wrist on the right hand, which made me think it indicates a little about the personality.</p> </blockquote> <p>Another interview in Experiment IV went as follows:</p> <blockquote><p><i>Experimenter: </i>And what did the hands express?<br /> <i>Subject: </i>Well, it looked to me as if [the hands express] the character of a person in very serious thought.Some trouble, wrestling with some problem, rather unhappy.<br /> <i>Experimenter: </i>Was this because of the hands, or the pose, or both? <i>Subject: </i>Both together. The hands were very tense and tight, not relaxed. Indicated that there was a conflict. <br /> <i>Experimenter: </i>This was the physical appearance?<br /> <i>Subject: </i>Yes, the tense position of the hand and fingers, the fingers close together and tight, not relaxed and easy. They show what's inside the person. He unconsciously clenched his fist and you noticed something.</p> </blockquote> <h3>Discussion</h3> <p>In the first experiment in which the cosmetic glove was worn, not once was the cosmetic hand recognized as a prosthesis. In Experiment II, the glove was seen as a prosthesis by only three (10%) of the subjects. In both experiments, a difference between the two hands was noticed only rarely. In Experiment III, the hook was recognized as a prosthesis in all cases save one. If one wishes to "explain" the unnoticeability of the cosmetic hand during relatively short contacts, one may say that the appearance of the cosmetic hand is similar enough to that of the normal to remain unnoticed. We know, however, that the differences between the glove and the normal hand are pronounced enough to be seen by almost anyone. What, then, are the conditions under which the <i>similarity, </i>rather than the <i>dissimilarity, </i>is decisive? To understand what is involved requires a brief discussion of a few general problems of visual perception.</p> <p>It is a well known fact that objects on which we focus are seen much more clearly than are those seen within the area of our peripheral vision. Distinguished from these two areas in the visual field should be two others, namely, "area of concern" and "area of mere presence." An object is in the "area of concern" if we inspect it, that is, if we concern ourselves with it. If, however, we perceive an object "as just being there," if it is not being examined by us and we do not concern ourselves with it, it is in the "area of mere presence."</p> <p>The area of presence and the area of concern of a visual field do not necessarily coincide with the central (focal) and peripheral parts of the field of vision. Each of the areas, that of concern or that of mere presence, can be either central or peripheral. We can, for example, stare at an object, focus on it, and yet not be concerned with it but with something going on elsewhere in our field of vision. Such is the case, for example, when one is looking at an object but wishes to watch another person unobtrusively. Here, the object focused upon is central and at the same time is in the area of mere presence. The person being watched is in the peripheral field of vision but at the same time is in the area of concern. Centrality and peripherality thus are distinguished by whether we do or do not look at an object directly, areas of presence or concern by whether or not we attend to (examine) the object.<a style="text-decoration:none;">*</a></p> <p>Often there is a tendency on the part of an observer to make the area of concern coincide with the center of his field of vision, while objects that do not concern him are shifted to the periphery. The separation of the field of vision into central and peripheral areas is, however, essentially different from the separation into areas of concern and of mere presence. With regard to the noticeability of the cosmetic hand, the most important fact is that objects in the area of concern differ in appearance from those in the area of presence. Some differences in details perceived when two objects are in the area of concern are not perceived when two objects are in the area of mere presence. Thus, two objects in the area of concern may look different, whereas the same two objects may look alike when in the area of mere presence.</p> <p>In meeting people, we usually do not concern ourselves with their hands, <i>i.e., </i>hands are in the area of mere presence. Because the observer perceives fewer details in this area, hands which on examination look different can appear alike to the stranger and thus may not provoke attention during casual contacts. This would account for the infrequency with which the cosmetic hand was recognized in Experiments I and II. Since looking directly at or focusing on an object does not necessarily mean that the object is examined, glancing and looking at the hands directly, as did some of our subjects, failed to result in observation of significant differences.</p> <p>When something unusual happens, the hands shift from the area of mere presence to that of concern or, to put it in another way, the observer changes the position of the hand from the area of mere presence to that of concern. If, for instance, the subject expects the wearer to use a given hand, and if this hand is not used as expected, or if the action is interrupted (Experiment I), the observer becomes concerned with the hand, examines it, and becomes aware of its deviation from an ordinary hand. Again, if examination of the hands is suggested to a subject, the area in which they are seen becomes one of concern. Moreover, if the subject is told that the hand is artificial, an incentive is provided to examine it. In this case, too, the hand is perceived in the area of concern.</p> <p>The physical properties of the cosmetic hand are such that, on examination, they are seen not to match those of an ordinary hand. Yet the handlike prosthesis is sufficiently similar to a normal hand that, in the area of mere presence, it may be seen as an ordinary hand. A hook, however, differs to such an extent in physical properties that, even in the area of mere presence, it can hardly be mistaken for a hand. This accounts for the results of Experiment III, in which the hook was noticed by all but one subject.</p> <p>In comparatively few instances (Experiments I and II), the cosmetic hand was seen as "different" from the other hand but was not recognized as artificial. The existence of cases in which differences are recognized, but in which the hand is not recognized as a prosthesis, may be due to the fact that, as a rule, people are not aware that a realistic hand prosthesis exists. Were that fact commonly known, the 20 percent who noticed the hand as "injured" in the first experiment, and the 10 percent who noticed it as "different" in the second experiment, might have seen it as a prosthesis. But knowledge of the existence of such a prosthesis would not affect the proportion of those who saw <i>no </i>difference (80 percent in both the first and second experiments). Since they did not notice any difference, these subjects would not even begin to concern themselves with the hand. As long as the hands match in the area of presence, knowledge that artificial hands exist would not in itself lead to an examination of hands.</p> <h3>Future Work</h3> <p>Briefly stated, the results show that strangers in everyday contacts with the wearer rarely notice a difference between the two hands. Yet noticeability is only one aspect of the larger problem of social usefulness of the cosmetic hand. Recognition of the cosmetic hand as a prosthesis is bound to occur in repeated contacts with the wearer. Furthermore, friends and relatives know that a wearer is an amputee. When the hand is recognized as artificial, a new problem arises. The appearance of the hand in the area of concern becomes important. Preliminary investigations indicate that, when the cosmetic glove is recognized as such, its appearance evokes in some people very unpleasant feelings. The study of the appearance of the cosmetic glove thus is necessary in order to determine the emotional impact relative to that of other prostheses and to ascertain which properties of the hand provoke negative feelings.</p> <p>Some people perceive a cosmetic hand as having a yellowish greenish shade. This circumstance might evoke toward the prosthesis feelings as toward a dead hand. Such feelings might be alleviated if the color of the cosmetic hand approached more closely that of an ordinary hand (page 57). It might even be shown that, to appear as real as possible, the cosmetic hand should have a definitely less yellowish tinge than does an ordinary hand. For such determinations, the subjects chosen should have strong negative feelings toward the hand available now, and observations should be made when the hand is worn.</p> <p>In conclusion, it should be stressed again that the problem of noticeability is only one aspect of the larger problem of the social usefulness of prostheses. Further studies are required to uncover those psychological properties of the observer which have to be taken into account in order to develop not only "functionally" but also "socially" (or rather "socio psychologically") useful prostheses.</p> <br /> Figure 1 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-34.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-35.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-36.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-37.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_02_047/table01.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_02_047/table02.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-40.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-41.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_02_047/1955-MayOCRBatch-42.gif 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 Noticeability of the Cosmetic Glove Creator An entity primarily responsible for making the resource Tamara Dembo, Ph.D. * Esther Tane Baskin, M.A. * 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/10c1e9153313406ba4f5bb6316536cb0.pdf f021c880f280590c0b2349861906bbcb https://staging.drfop.org/files/original/dc11864cea6523c87bf2d8df4550c001.jpg 13279d0e9cb832a37dc538a352203e0b https://staging.drfop.org/files/original/2002e46ffabbd7a8026db85c3669de1f.jpg 74ffcd886b527321c2f9d37afc60ab20 https://staging.drfop.org/files/original/9dc4487b2acddd05e4f0f442510b35b9.jpg d5f724d51a1e6ba2b8a1d03c305f1774 https://staging.drfop.org/files/original/3a68d5d8a5f6b3952661c4bbd46eefa7.jpg 89904eeb58e41489800af4cb2a49a63e https://staging.drfop.org/files/original/77c9d3c2d4a941dc2c53cdf6f0a49971.jpg fc10f1203fdabd37b416196d917e1a9b https://staging.drfop.org/files/original/1ba9f329202448af3fa4efbfd9070888.jpg 2f146206c850edfddfda674098294ccb https://staging.drfop.org/files/original/35727e9c9abf2b58afcb30a82a68b630.jpg 6e3ea0d5ebea2f60d1d2cf5edb70215a https://staging.drfop.org/files/original/7880f6b348c16563637e568b84221d13.jpg 1b1a6610e78623175fbdc6336c343ba5 https://staging.drfop.org/files/original/bda95fea38a30663bb14a54fdd0bf252.jpg 003b6c53652ab72a46888a097359d477 https://staging.drfop.org/files/original/1c9248ec6e5c79bd34a6b0e521ddc916.jpg d08a866941e3cec5031a61f6feb966fa https://staging.drfop.org/files/original/c604af9b9225d4ffc11d1b6d9f2b0fdf.jpg db1f4c9447ff9977f7a3c7a7cbc0d8ac https://staging.drfop.org/files/original/d289c21c42aa9f609743bcb0fe52e10a.jpg 5cee6ff75cd02de689a5b21010742089 https://staging.drfop.org/files/original/ee73aa307cf4e9cc566ca1852eb9efa2.jpg 386ce91b1d4443ce1250cd660c0715ab https://staging.drfop.org/files/original/4a3d7f3112ca91a59eaf1ff5a9a5a204.jpg ee3ea0c538854c55e5170f52570aba84 https://staging.drfop.org/files/original/b830cc45412e5424f35cc65c231b8d5b.jpg 0fcd7e975fb49b493c0e6d7c0191bc84 https://staging.drfop.org/files/original/b2e854fc9a5e33325ed8ec746dda8ae0.jpg 2f339c44ea64b52504a784b6443b4a77 https://staging.drfop.org/files/original/6de37e945a0e41d8484dc77c16bc3cd6.jpg 04bdad71e4b68a0386a544b9b4121882 https://staging.drfop.org/files/original/febbd73f2648976234d696c9b757b7ae.jpg d7658aff6e0000e75444773e217cde8e https://staging.drfop.org/files/original/d5b7a908de158673aff7c895d77eba42.jpg fe328b7b8ee047f1d66414ae1226bf7e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_013.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 13 - 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/1969_02_013.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_02_013.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 Transparent Socket Fabrication Procedure</h2> <h5>Thomas Grille <a style="text-decoration:none;">*</a><br />Ronald Lipskin <a style="text-decoration:none;">*</a><br />Richard Hanak <br /></h5> <p>It has been recognized for a long time that a transparent socket that could be made to fit the stump would be a useful tool in studying the relationship between the amputation stump and the socket of a prosthesis. Early attempts by a number of investigators to devise sockets of acrylics such as Plexiglas and Lucite were abandoned because of the difficulty encountered in controlling the contours and because of the inordinate amount of time required for fabrication of a single socket.</p> <p>In 1966, the New York University Prosthetics and Orthotics group undertook a comprehensive study to develop a practical method of fabricating a transparent socket using newer materials and fabrication techniques.</p> <p>The criteria for the selection of the transparent material to be utilized for the socket were that it be water-clear with good transparency, have adequate strength and fracture resistance, and be non-toxic. The method of fabrication was to be reasonably simple and was not to require an excessive amount of actual working time or sophisticated equipment; the materials and equipment were to be readily available.</p> <p>Two basic approaches were explored: vacuum forming and casting.<a style="text-decoration:none;">*</a> Transparent polycarbonate sheet material was used in the attempts to make a socket using the vacuum forming method. Below-knee sockets were made by this method, but it was necessary to form the socket in two parts and to bond them together, a procedure which was time-consuming and which required extreme care if accuracy was to be obtained.</p> <p>Both epoxy and polyester resins were tried for casting transparent sockets. Satisfactory results could be obtained with epoxy resins, but excellent results were obtained consistently with polyester casting resins when RTV silicone rubber was used on the outer surface of a male plaster slush mold and the casting surfaces were covered with polyvinyl chloride film. This article describes the procedures, in a step-by-step fashion, for fabrication of a transparent socket using polyester casting resins.</p> <h4>Silicone Male Mold</h4> <p>A conventional hard socket is supported on a wood attachment block during the fabrication of the silicone rubber male mold. <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>1. Using approximately five layers of plaster bandage, the proximal trim line of the conventional socket is built up to the level that existed prior to trimming (about 1 in. above the proximal end of the socket with the interior surface made reasonably flat). After the plaster bandage has hardened, any rough interior areas are sanded smooth, and any plaster that interferes with the interior contour is removed.</p> <p>2. To facilitate separation of the silicone shell from the hard socket, the interior surface of the hard socket is sprayed with Dow Corning Silastic RTV Mold Release. <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>3. In order to retain the liquid silicone rubber in the hard socket, masking tape is used to form a V2-in.-wide rim around the proximal edge of the plaster-bandage buildup.</p> <p>4. Dow Corning Silastic D RTV Silicone Rubber is mixed with 5% by weight of Silastic D RTV thinner. One-half to one lb of silicone is used for BK sockets and 1-1/2 to 2 lb are used for AK sockets, depending upon socket size.</p> <p>5. Stannous octoate catalyst is added in a ratio of 100 drops or 2.2 gm to 1 lb of silicone rubber. This provides a 10-min working and a 1-hr curing time, which is the optimum for this procedure. The working time can be changed by varying the amount of catalyst. (Although this catalyst recommendation differs from the product-use instructions, its use is suggested because it has been found to be more convenient.) If stannous octoate is not available, a proportion of one part of standard catalyst to five parts of silicone rubber is used. <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>6. The mixture is poured into the hard socket, then the socket is rotated by hand so that the entire inner surface is covered. After this has been accomplished, the socket is rotated only in one direction to insure an even distribution of the mixture to a uniform thickness of approximately % in. The rotation (in one direction) is continued until the mixture is set (10-15 min); the mixture is then allowed to cure at room temperature for 45 min. <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>A uniform wall thickness of approximately 1/8 in. is important in order to provide adequate shock absorption during break-out and to avoid the formation of an undersized socket. <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>7. The silicone-rubber shell is pulled away from the medial wall, and a slit is made down the medial side of the socket. The slit will simplify the removal of the completed male mold by permitting the hard socket to be spread open. The slit is started 1/2 in. below the proximal brim and ended 2 in. short of the distal edge. (A wooden tongue blade and a clamp can be used to keep the silicone shell away from the medial wall while cutting the socket.) <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>8. The male mold will be fabricated with a hollow core in order to simplify breaking it out of the transparent socket. With the silicone shell in the hard socket, a plaster slush mold is poured to a 3/4-in. thickness, except at the distal end, where the thickness should be approximately 1-1/2 in. The plaster is allowed to set. <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>9. A pipe drilled with a few vacuum holes is inserted as a mandrel into the slush mold, and secured at its distal end with additional plaster. The middle section of the mold is filled with paper, and plaster is added at the proximal end of the mold to secure the mandrel. The plaster is allowed to set. <b>Fig. 10</b> - <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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>10. To separate the completed male mold from the hard socket, the plaster-bandage buildup is removed, the socket is opened along the slit, and the socket is slipped off. <b>Fig. 12</b> - <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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>11. To permit the application of vacuum to the undercut areas, 1/8-in. holes are punched through the silicone shell and 1/8-in. holes are drilled through the underlying plaster. The holes must be cut through to the void space in the male mold. <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 /> <h4>Female Mold</h4> <p>12. An alignment pin is used to insure correct alignment of the distal ends of the male and female molds during casting of the transparent socket. A hole 1/2 in. in diameter is punched in the silicone shell, and one 1/2 in. in diameter and 3/4 in. deep is drilled into the distal aspect of the male mold. An alignment pin, cut 1/2<i> </i>in. in diameter by 3 in. long of nonferrous metal rod. is inserted into the distal hole. <b>Fig. 16</b> - <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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>13. In order to provide a 1/4-in. wall thickness for the transparent socket, a 1/4-in. Dacron felt sleeve, a 1/8-in. Dacron felt sleeve, and a cotton stockinette sleeve are prepared, all to fit over the male mold. Compression eventually will reduce the thickness of the sleeves to the desired 1/4 in. Holes 1/2 in. in diameter are cut in the ends of the sleeves to permit clearance of the alignment pin. The two felt sleeves are pulled over the male mold and trimmed even with the proximal edge of the mold. <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><i>AK Sockets Only</i></p> <p>To reinforce the proximal-lateral wall, a 5-in. x 7-in. strip of 1/8-in. felt is attached to the outer sleeve with Barge cement (<i>a</i>).</p> <p>Because of limited space between the male and female molds for AK sockets, a means for pouring the polyester resin into the completed female mold must be provided by creating a lip, or inlet, at its proximal anterior brim (<i>b</i>). A triangular piece of 1/4-in. felt is rolled to form a funnel and fastened with Barge cement to the anterior brim of the outer sleeve so that the top of the funnel is even with the top surface of the mold. (The funnel is not needed in the below-knee socket fabrication, because in that case there is adequate space between the male and female molds.)</p> <p>14. To facilitate alignment of the male and female molds, and to insure a uniform wall thickness of the transparent socket, the felt is cut away in the region above the posterior socket trim line as illustrated. The female mold will be contoured so that a proximal surface of this mold will contact the corresponding surface of the male mold. <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><i>BK Sockets Only</i></p> <p>The felt layers are cut out in the region above the popliteal trim line. The cutout should not cross the popliteal trim line. <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><i>AK Sockets Only</i></p> <p>The Dacron layers are trimmed in the flat areas above the posterior and medial brims, leaving approximately 1 in. of uncut material above the socket trim lines. <b>Fig. 21</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>15. The stockinette sleeve is now pulled over the felt on the male mold and tied to the mandrel. <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 /> <p>16. To provide for the transparent socket pedestal, a piece of 1/32-in.-thick plastic sheet is wrapped around the distal end of the male mold, over the sleeve, beginning at the point where the male mold starts to slope in and extending to the distal end of the alignment pin. The vertical seam and horizontal juncture line are sealed with tape. <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 /> <p>17. Plaster is poured into the cylindrical cavity formed by the plastic sheet, leaving 1/2<i> </i>in. of the alignment pin exposed above the plaster level. The plaster is allowed to set, and the plastic sheet is removed. <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>18. An inflated balloon is inverted over the lay-up and pushed downward as the air is slowly released. The distal end of the balloon is tied off around the alignment pin, and the proximal end around the mandrel. The balloon is then covered with a coat of silicone spray. <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>19. To fabricate the female mold, 4-in. plaster bandage is wrapped around the balloon-covered male mold, starting at the distal end and overlapping each previous wrap by approximately 3 in. until a 4- to 6-layer thickness is achieved. Care is taken to avoid using excessive tension while applying the plaster bandage so as to prevent compression of the felt and reduction of the wall thickness of the transparent socket. In addition, the undercuts (<i>e.g., </i>the patellar region in BK sockets) are minimized or reduced by bridging the bandage in that area. <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>To provide a good receptacle for the exposed length of the alignment pin, it is covered with additional plaster, and the plaster is allowed to set. <b>Fig. 28</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>20. The balloon and stockinette are trimmed off to expose the proximal end of the mold. <b>Fig. 29</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>21. Using a combination square or a strip of metal bent to 90 deg as a guide, orientation lines are drawn on the proximal ends of the molds to provide references for their realignment. Two lines on each of the four sides are sufficient. <b>Fig. 30</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>22. The molds are separated, and the felt and stockinette lay-up is removed from the inside of the female mold.</p> <p>23. The plaster pedestal is broken out of the female mold, and the balloon and the alignment pin are removed without breaking the pin's receptacle.</p> <p>24. At this point, a slit is made in the female mold to simplify its removal from the transparent socket after casting. Starting 1 in. below the proximal rim on the medial side, a cut is made vertically along three-quarters of the socket length. The cut is covered with two vertical layers of plaster bandage on the exterior surface. The interior surface is smoothed where necessary. <b>Fig. 31</b> - <b>Fig. 32</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>25. To complete the mold, 1/16-in.-dia vacuum holes are drilled in the undercut area of the female mold to insure the correct surface contour on the transparent socket. <b>Fig. 33</b> - <b>Fig. 34</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>Alignment Of The Molds And Casting</h4> <p>26. The outer surface of the female mold is covered with a 1/4-in. felt sleeve. A PVA bag is pulled over this sleeve, and both covers are trimmed even with the proximal edge. A vacuum tube is attached to the distal end of the PVA bag and secured with plastic tape.</p> <p>27. A heavy coating of Vaseline petroleum jelly is applied to the inside surface of the female mold. <b>Fig. 35</b> - <b>Fig. 36</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>28. The end of a second PVA bag is fastened to the alignment pin with a rubber band and then both are inserted (glossy side in) into the alignment pin receptacle in the female mold. The interior PVA bag is lapped over the exterior PVA bag and sealed with pressure-sensitive tape. At least 4-in. overlaps must be provided because this PVA bag will later be fastened to the male mold mandrel. <b>Fig. 37</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>29. Vacuum is applied and the wrinkles are smoothed out on the interior PVA bag. This lining provides the smooth exterior surface of the transparent socket. <b>Fig. 38</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>30. A PVA sheet (glossy side out) is pulled over the male mold and fastened to the mandrel with plastic tape. The sheet is reinforced around the alignment pin with plastic tape, and a 1/2-in. hole is cut through the tape and the PVA bag for the alignment pin. Vacuum is applied and the wrinkles in the PVA sheet are smoothed out. <b>Fig. 39</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>AK Sockets Only</i></p> <p>The valve body may be placed before or after casting. If placement is done before casting, the valve body is filled with beeswax and glued with Barge cement to the PVA sheet on the male mold in the appropriate location. The valve body must be so located that it will not subsequently contact the wall of the female mold during the casting procedure. <b>Fig. 40</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>31. The female mold is placed in a bench vise or other supporting device, with the proximal end up and proximal edges horizontal. The male mold is oriented in the female mold by means of the alignment pin and placed all the way down on the pin. <b>Fig. 41</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>BK Sockets Only</i></p> <p>The posterior surfaces of the molds are butted in the region superior to the popliteal trim lines, and the orientation marks are aligned. The molds are taped together securely to maintain the alignment.</p> <p><i>AK Sockets Only</i></p> <p>The surfaces superior to the posterior and medial brims are butted and the orientation marks aligned. The molds are secured with tape. <b>Fig. 42</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>32. One to 1-1/2 qt of polyester casting resin for below-knee or 2 to 3 qt for above-knee sockets (depending on the size) are combined with the catalyst, with constant stirring. The manufacturer's instructions are followed regarding the amount of catalyst required to obtain a "slow setting time." Ideally, the resin should have a 1/2-hr gel time, which is adequate time for pouring. The resin is poured slowly and continuously while the female mold is simultaneously tapped to prevent any air bubbles being entrapped in the casting. <b>Fig. 43</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>33. After the resin has set to a soft gel (about 30 min), the tape around the PVA bags is removed, and the outer PVA bag and Dacron sleeve are removed. The male mold PVA bag is punctured around the pipe, and the female mold PVA bag is pulled secure and tied to the mandrel. <b>Fig. 44</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>34. After the resin has set to a firm gel (about 1 hr after pouring), the plaster strips are peeled off the slit in the female mold. The female mold is then removed by spreading the slit open, with care being taken not to tear the PVA bag on the transparent socket. The resin is allowed to cure for an additional hour at room temperature. <b>Fig. 45</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>35. The vacuum equipment is removed. The transparent socket (on the male mold) is heated in the oven at 165 deg F for 4 hours. The oven is turned off, and the socket is left until the oven cools to 125 deg F. This heat-treating helps to eliminate any internal stresses that may have developed during the curing phase. <b>Fig. 46</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>Finishing The Socket</h4> <p>36. The PVA bags are cut along the proximal edge of the male mold. To protect the transparent socket surfaces from scarring, the PVA bags are left in place. The plaster slush mold is carefully chiseled away, and the mandrel and silicone shell are removed. <b>Fig. 47</b> - <b>Fig. 48</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>37. The socket is cut down to the proximal trim lines, using a band saw and electric sander. The rough edges are smoothed by hand-rubbing with fine-grade sandpaper. The transparency can be restored to these edges by applying a surface coating of resin to the area, covering with a PVA sheet, and allowing to cure.</p> <p>38. Any flashing on the interior surface around the alignment pin is removed, and the bottom of the hole is sealed with tape. The hole is filled with resin and allowed to cure.</p> <p><i>AK Sockets Only</i></p> <p>If the valve body was placed before the casting, a hole saw of the same size as the valve body diameter is now used to bore through to the valve body. To improve the boring angle, the distal corner of the socket pedestal is sawed and ground down. <b>Fig. 49</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>If the valve body has not yet been placed, the anteromedial corner of the socket pedestal is sawed and ground off to provide a flat surface. Then, using a hole saw of the same size as the valve body diameter, a hole is bored through the socket wall. The valve body is carefully secured in place with either polyester resin or epoxy cement so that the inner surface of the valve body is flush with the inner surface of the socket. <b>Fig. 50</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>39. Before the socket is attached to an adjustable leg, the pedestal base is sanded flat and to the proper alignment angulation, using a disk sander. <b>Fig. 51</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>BK Sockets Only</i></p> <p>Suspension-strap retainers are attached to the below-knee socket with #8-32 flat-head machine screws. The holes may be countersunk by using an inside countersink tool. <b>Fig. 52</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>40. The socket attachment plate is fastened to the transparent socket by drilling and tapping eight holes in the pedestal base and securing with flat-head machine screws. <b>Fig. 53</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>41. The PVA bags are removed, and the completed transparent socket is polished with silicone spray and a soft cloth. (This spray is also a good lubricant to facilitate donning the socket.) <b>Fig. 54</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>Completed above-knee socket mounted on an adjustable leg. <b>Fig. 55</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>Completed below-knee socket.</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">R. Lipskin and T. Grille, The Development of the NYU Transparent Socket Fabrication Technique, November 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Ronald Lipskin </b></td></tr><tr><td class="clsTextSmall">Present address: Prosthetics Center, Bioengi-neering Research Service, 252 Seventh Ave., New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Thomas Grille </b></td></tr><tr><td class="clsTextSmall">Now with Key Mfg. Co., Brooklyn, N. Y. 11207.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-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 The NYU Transparent Socket Fabrication Procedure Creator An entity primarily responsible for making the resource Thomas Grille * Ronald Lipskin * Richard Hanak  https://staging.drfop.org/files/original/3f041b7c947e529153fa28232c237ff9.pdf d1f852ea47d629b46c047b9ae3e541ec https://staging.drfop.org/files/original/730b7c386610ac5066f7d34810d6e1cb.jpg 5d4cfcb9a11c6bdca221c13237a938da https://staging.drfop.org/files/original/7833aeed5e0f5b304177a2c2f4041545.jpg 8933a2daac139a455663a0839530e760 https://staging.drfop.org/files/original/3b3ef544eebe463014069b1f9f559617.jpg 49669d1ea09bc77fd63e098e093c5229 https://staging.drfop.org/files/original/1f0783dbf17ee81abcf3918ec110bc1a.jpg 3e6547ec9784789f1cd9426bc2316851 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_169.pdf Text Any textual data included in the document <h2>The O.K.C. Above-Knee Running System</h2> <h5>John Sabolich, B.S., C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>For many years, above-knee amputees have been trying to run step over step rather than using the hop and skip running gait typified by Terry Fox in his run across Canada. This type of locomotion is still biomechanically defined as walking since it still contains a double support phase when both feet are touching the ground simultaneously. True running has no period of double support.</p> <p>One reason that above-knee amputees have had to run in this manner is that the lower shank does not accelerate forward fast enough for true running due to inertia. While the thigh segment quickly flexes about the hip, the foot tends to stay in place, causing the knee to flex beyond a desirable position and resulting in what is commonly referred to as "excessive heel rise." This excessive heel rise causes a delay in getting the foot-shank complex to move into extension which complicates the amputee's basic problem of not having active control of the knee. It seems that the harder the amputee tries to flex his hip, the worse the heel rise becomes.</p> <p>The O.K.C. system strives to solve these problems. It consists of a cable-housing arrangement (similar to that on a below-elbow prosthesis) that travels behind the hip joint and anterior to the knee axis (<a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-1.jpg"><b>Fig. 1</b></a>). The proximal end of the cable is attached to a belt similar to a Silesian bandage by a short piece of elastic webbing and Dacron tape which is adjustable via a 4-bar buckle. The distal end of the cable is fixed to the proximal anterior shank section of the prosthesis.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-1.jpg"><strong>Figure 1. Lateral views of prosthesis showing path and attachment points of the OKC running cable.</strong></a><br /> <p>When the hip joint starts to flex, just at the moment of "running toe off," tension in the cable causes a dynamic extension moment at the knee. In other words, power is being transferred to the knee joint directly from the action of hip flexion. When the thigh is fully flexed, the tension in the system is at its maximum. This turns out to be very desirable biomechanically, since the knee needs to be fully extended at heel strike. The O.K.C. system therefore supplies a dynamic force to the shank, much as the quadriceps does in the normal human leg during running (<a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-2.jpg"><b>Fig. 2</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-2.jpg"><strong>Figure 2. Running sequence showing action of the cable system.</strong></a><br /> <p>It has been our experience that it is easier to start using this system on children running on grass and advance to adults later for two reasons. First, children are not afraid to try to run, especially when the practitioner tells them they are now capable of it. Second, due to lower stresses in the system, the prosthetist can use conventional upper extremity cable and housing components that are readily available rather than specially made cable and hardware which are needed for adults. It has been noted that some children are able to remove the cable after a few months, (much as training wheels on a bicycle) and still do a fair job of running step over step. They gain confidence from the system and use it to fine tune their running capabilities. However, it has been our experience that when truly fast running is required as in competitive events, the patient prefers the O.K.C. System. Parents report that their children like to keep the system in place at all times since it gives them a natural dynamic quadriceps effect. However, some adults prefer to remove the O.K.C. System for normal locomotion.</p> <p>For adult running, we have found that special aircraft grade cable and terminal ends are required due to the increased stresses in the system. It has also been discovered that monofilament fishing line (300-500lb. test line) works quite nicely as the coefficient of friction between the cable and housing is reduced. A plastic housing such as polypropylene tubing (commonly used in air conditioner drains) works best with this monofilament.</p> <p>An extension aid of surgical tubing or elastic webbing augments the O.K.C. System and provides another method of fine tuning the system. Some competitive runners also like to use a flexion limiter with the system. This consists of a 3/4" thick piece of PE-LITE® at the back of the knee joint which does not allow the knee to flex completely. This flexion limiter acts as a compressive stop which tends to bounce the knee into extension and swings out of the way during normal walking. A variety of other methods of limiting flexion can be used.</p> <p>To our knowledge, the first above-knee amputee to ever run step over step on an above-knee prosthesis was in March, 1982 utilizing an O.K.C. System. Since that day, many adults who enjoy competitive running or just sports in general have been fit. The shortest residual limb fit successfully with the O.K.C. System was on a 17 year old above-knee male with a 2 7/8" femur. The longest have been knee disarticulation amputees.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-3.jpg"><strong style="font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen, Ubuntu, Cantarell, 'Open Sans', 'Helvetica Neue', sans-serif;">Figure 3. Series of photographs taken from video screen.</strong></a></p> <p>It is easier to implement this system if the patient is using an exoskeletal prosthesis, since the cable and housing have a natural surface to ride and sit on. However, we have placed several on endoskeletal systems with a little creative rigging (<a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-4.jpg"><b>Fig. 4</b></a>). It is also possible to laminate a track directly into the thigh portion of the prosthesis which eliminates the need for housing. However, this sometimes causes excessive breakage unless a section of housing is extended distally to reduce the bending radius distally about the knee.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-4.jpg"><strong>Figure 4. OKC running cable on an endoskeletal prosthesis. Aircraft cable and terminal ends were used in fabrication.</strong></a><br /> <p>Sitting can be a problem unless the cable or monofilament is placed in such a way as to allow the cable and housing to move posterior to the knee during sitting. This prevents the creation of a knee extension moment, which could be bothersome during sitting.</p> <p>Last, we have found it most helpful that the heel portion of the prosthetic foot be soft enough to provide very easy planer-flexion so as to lessen the tendency for the knee to be forced into flexion by the ground reaction force at heel strike.</p> <em><strong>*John Sabolich, B.S., C.P.O.</strong> John Sabolich, B.S., C.P.O, is president of Sabolich Orthotic Prosthetic Center, 1017 N.W. 10th Street, Oklahoma City, Oklahoma 73106.<br /><br /><br /></em> Page Number(s) 169 - 172 Year 1987 Volume 11 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 4 http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-4.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The O.K.C. Above-Knee Running System Creator An entity primarily responsible for making the resource John Sabolich, B.S., C.P.O. * https://staging.drfop.org/files/original/75dc06cd0cb2f16f20c55049bd0bdbc7.pdf f76171ab4432c6a50cf6f259be7af891 https://staging.drfop.org/files/original/d81d51673f68ef5fe93f7930d455e5f8.jpg 7008a305e99a0abc591c52fc2411bb17 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_004.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 4 - 7 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_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>The Objectives of the Lower-Extremity Prosthetics Program</h2> <h5>Howard D. Eberhart, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p>Man depends upon his legs to support the body and to move it from place to place as occasion warrants. Since mobility is nearly indispensable to most human activities, the loss of part or all of a leg—through accident, war, or disease—imposes serious limitations and has always made a replacement of some sort more or less of a necessity. Accordingly, artificial legs of one kind or another have been made and used since the most ancient times. As a result of the long-continued effort, leg prostheses have undergone progressive, if slow, development through the centuries, so that many lower-extremity amputees have in the past been successfully restored to something resembling a normal life. With the advent of industrial development, and of improved tools and materials with which to work, the nineteenth century marked the appearance of many new lower-extremity devices and of new techniques in the medical treatment of amputations.</p> <p>Impetus provided by World Wars I and II gave rise to rapid advancement in all branches of technology and thus made possible a concerted attack on the problem of supplying the best possible artificial limbs. The term "lower-extremity prosthetics" has now come to mean the practice of rehabilitation of the leg amputee by providing him with an artificial limb that will restore lost functions to the greatest possible degree. But more than just the artificial leg is involved. The amputee himself is a most important part of the end-product, and amputees, like other people, are individuals with widely differing characteristics and abilities. Of course surgical procedures should be designed to secure a painless stump and to retain maximum function, and it would seem that the artificial leg, when properly fitted, should duplicate as closely as possible the normal activity of the lost part. Moreover, physical conditioning and gait training are both important phases of the whole rehabilitation process.</p> <p>This concept of lower-extremity prosthetics has developed during the years since the start in 1945 of the program of the Advisory Committee on Artificial Limbs, National Research Council. Initially, the primary objective was to develop improved devices, it being considered as obvious that, if a better prosthetic knee or ankle or foot could be devised, the amputee would benefit. Attempts to produce such items, however, made necessary the determination of functional requirements and thus immediately revealed the lack of necessary fundamental information. Basic research into the complicated phenomenon we call "locomotion" was therefore carried on simultaneously with the development of devices.<a style="text-decoration:none;">*</a> These investigations indicated a need for the application of basic mechanical principles to fitting and alignment of artificial legs. A three-pronged approach, all parts of which are complex and interrelated in various ways, has thus evolved. Basically, the three objectives are:</p> <ol> <li>To extend knowledge of the amputee, of lost and remaining functions affecting locomotion, and to collect information on the best possible medical treatment.</li><li>To improve fitting techniques and practices, including training, so that existing devices might be used with greater comfort and function.</li><li>To develop improved lower-extremity devices.</li></ol> <p>Relative emphasis on these three phases is shown in <b>Fig. 1</b>. Implied in such a program is the dissemination of information and techniques to those who serve the amputee. Many of the accomplishments to date are recorded, and fully documented with the report literature, in Klopsteg and Wilson's <i>Human Limbs and Their Substitutes </i>(McGraw-Hill, in press). In addition, various seminars and short courses for surgeons and prosthetists have been conducted throughout the program.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Trends in the lower-extremity prosthetics program, 1945-54, projected through 1956 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fundamental Studies</h3> <p>Detailed and comprehensive study of normal human locomotion is the basic key to improvement in all phases of the lower-extremity problem. Walking is to all appearances so natural and simple a process that it is difficult to conceive of its complexity. A knowledge of the behavior and the contribution of each anatomical part in providing the many services required of legs in normal use is essential to determine the functions that have been lost through amputation and the functions that still remain. The surgeon needs such information in order to provide the best amputation stump with maximum remaining function. The prosthetist must understand the limitations and potentialities of the amputee-prosthesis combination for optimum fitting, alignment, and adjustment. The designer needs detailed information on angles, displacements, velocities, accelerations, forces, energy requirements, and functions in order to improve existing devices and to develop new ones. And finally, the amputee himself has problems that require a fundamental approach. Causes and treatment of phantom or other pain, circulatory difficulties resulting from amputation, skin tolerance to pressure in areas never intended for such use, as well as the better understanding of the psychological problems of the amputee are examples of important areas of investigation.</p> <p>The objectives of the program of fundamental studies of the lower extremity may be summarized as:</p> <ol> <li>To study the phenomenon of locomotion in a sample of normal individuals and to analyze the results for use by the surgeon, the designer, and the prosthetist.</li><li>To develop design criteria for new or improved devices and as a basis for evaluating existing devices.</li><li>To develop an understanding of the compensatory mechanism of the human body and its ability to adapt itself to overcome functional deficiencies of its parts.</li><li>To provide a frame of reference for evaluating the degree of success obtained in replacing lost functions by means of an artificial leg.</li><li>To obtain information on the cause and possible treatment of phantom pain and other medical problems of the amputee.<a style="text-decoration:none;">*</a></li></ol> <h3>Development of Techniques of Fitting and Alignment</h3> <p>It appears obvious that, no matter to what degree an artificial leg is perfected mechanically, its effectiveness will depend upon the comfort afforded the wearer. Comfort is a function of the fit and alignment of the prosthesis.</p> <p>Although the artificial-limb industry has, through the years, developed reasonably successful techniques for fitting and aligning artificial legs, the results have been obtained mostly by trial-and-error methods; seldom have basic mechanical and anatomical principles been employed. It was found, for instance, that even among the most successful prosthetists there existed little agreement as to what constituted a satisfactory fit. For these reasons it appeared necessary to include in the lower-extremity program a project to develop fitting and alignment techniques based on sound scientific principles and to include, if necessary, the development of auxiliary tools and a study of materials and of methods of suspension.</p> <p>The study was launched with the following objectives in mind:</p> <ol> <li>To learn from the artificial-limb industry the procedures used in fitting and alignment of artificial legs.</li><li>To work with the industry in applying fundamental principles to the problem of fit and alignment and to formulate the guiding principles involved.</li><li>To develop mechanical aids to improve fit and alignment and to serve as tools to simplify shop operations.</li><li>To investigate and evaluate types of suspension as well as materials and methods used in socket fabrication.</li><li>To develop simplified methods of evaluating the amputee-limb combination-to be used as a check by the prosthetist, the surgeon, and the physiotherapist.</li><li>To improve methods of training the lower-extremity amputee in order to get better functional and more effective use of his prosthesis.</li></ol> <p>Out of this study have come such developments as the introduction of the above-knee suction socket and the University of California adjustable legs and alignment duplication jig. The study of fitting and alignment continues at the University of California, Berkeley Campus.</p> <h3>Development of Prosthetic Devices</h3> <p>New and improved devices have always been a major objective of the ACAL program. Great effort has been expended in this direction, often without the necessary or valid criteria. Although engineering designs can be made to accomplish nearly any specified function, the end result of any given design may be unsatisfactory if the specifications were unrealistic. The device may be too complicated, too heavy, uneconomical for the improvements obtained—or it may actually interfere with some service functions though improving others. Since the beginning of the ACAL research program, a number of outstanding industrial firms have engaged in development of devices. As a result of these activities, a great deal has been learned about what is possible—and about what <i>not </i>to do. Together with the fundamental studies, a body of knowledge has been developed to provide a realistic approach to design criteria. A number of devices based on this information are now in the development stage; they show promise for the future.</p> <p>Criteria for improved knee joints for above-knee amputees have undergone great changes as fundamental knowledge of locomotion has increased and as various knees, alleged to be improved ones, have been tested on amputees. Similarly, dependence of knee performance on ankle function, fit and alignment, training, and total coordination is becoming better understood. In the light of present knowledge, it seems clear that "super-devices" are not apt to be the solution to improved artificial legs and that considerations of natural appearance, minimum energy consumption, and simplicity of mechanism for maintenance and economy will in the end be the controlling factors. Of course no device should be made available for general distribution until it has been checked thoroughly for function, strength, maintenance requirements, life expectancy, and adaptability to different types of amputees. A complete testing program has there- fore been established under the direction of New York University to ensure the adequacy of each device approved under the program.</p> <p>Present objectives for the development of prosthetic devices may be stated as:</p> <ol> <li>To invent new mechanisms, improve and adapt existing mechanisms, and apply new materials so as to add functions, or to improve presently provided functions of prostheses, seeking in the end to provide better devices to meet the needs of every amputee type.</li><li>To perfect those functions involved in level walking, with the best possible solution for oilier services such as sitting down, walking on slopes and stairs, etc.</li><li>To adapt devices that take advantage of remaining functions in the amputee's stump.</li><li>To increase stability during the weight-bearing phase but to reduce the energy requirement during transition as well as during the entire cycle of walking.</li></ol> <h3>Clinical Study</h3> <p>Throughout the program, amputees have been fitted with experimental prostheses in order to conduct studies, trials, and tests of the equipment. Techniques and practices involved in fitting amputees are so varied, however, that some orderly means of investigating these areas became necessary. Accordingly, in 1952 a program of clinical studies was established under the project at the University of California, Berkeley, in space at the Artificial Limb Shop of the U. S. Naval Hospital at Oakland, California. Here an orderly approach can be made to a review and formulation of best practice in lower-extremity prescription, fabrication, fitting and alignment, and training in the use of the prosthesis. Complete documentation of each step in the process, as applied to a variety of amputee types, under the supervision of an advisory panel and with the cooperation of members of the limb industry in the San Francisco Bay-Area, will serve to close the gap between fundamental work in the laboratory and practice in the field. Besides this, it will serve to supply source material for the information of the various professions involved in physical rehabilitation of the amputee as well as to define areas where more information or new devices are required.</p> <p>In addition to establishing what is the best prosthetic practice, the objective of the clinical study is to develop, for distribution to each member of the rehabilitation team, including the amputee, information such as:</p> <ol> <li>Medical data for use by the surgeon in connection with amputee problems.</li><li>Criteria for use in proper prescription of a prosthesis.</li><li>Principles and practices of fabrication, fitting, and alignment of a prosthesis.</li><li>Suggested means of evaluating prosthesis and amputee, Including gait analysis, performance checks, and achievement tests for use by the prosthetist, the surgeon, and the physical therapist.</li><li>Suggested curriculum for training the amputee in the use of his prosthesis.</li><li>A comprehensive list of specific prosthetic appliances and devices, with descriptions of their individual characteristics and functions, for use in preparing prescriptions.</li><li>Suggested curriculum for training the prosthetist, the surgeon, and other members of the clinic team in lower-extremity prosthetics.</li><li>Data useful to the research and development laboratories in continuing their studies.</li></ol> <h3>Future Program</h3> <p>The investigation and development involved in a lower-extremity prosthetics program are complicated and time-consuming. And since it appears impossible to reach the ultimate goal of replacement of all functions that have been lost, the task must be considered as never-ending. For the immediate future it is contemplated that development of devices, the clinical study, fitting and alignment studies, and fundamental research will continue. The relative emphasis on each phase is projected on <b>Fig. 1</b> through 1956.</p> <p>As progress is reflected in the results of the clinical study, some means must be developed for effectively transmitting this information to orthopedic clinic teams throughout the nation. Whether this is to be accomplished periodically at a central location, or whether through field teams on a continuing basis, will depend to a large extent upon the results obtained in the clinical study during the coming year. Whatever method evolves, every effort will be made to ensure that any useful information is disseminated to the field as quickly and efficiently as possible.</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">It should be noted that the work on phantom pain is applicable to both upper- and lower-extremity amputations.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 more logical and systematic approach, had there been sufficient time, might have been to postpone device development until the results of the basic work became available. But the urgency of amputee demands at the end of World War II made such an approach less desirable than the one adopted.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Howard D. Eberhart, M.S. </b></td></tr><tr><td class="clsTextSmall">Professor of Civil Engineering, University of California, Berkeley; member, Advisory Committee on Artificial Limbs, National Research Council; chairman, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_004/May-1954OCRBatch1-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Objectives of the Lower-Extremity Prosthetics Program Creator An entity primarily responsible for making the resource Howard D. Eberhart, M.S. *