17 20 371 https://staging.drfop.org/files/original/b76e176eea5ade74fc19b1a4179ee035.pdf 70fa24e8024de93a3dac3ead7a24a4c3 https://staging.drfop.org/files/original/8d4e4395448b88c9f47146d10e2bd761.jpg e7aecd53a8fb74f0db642462ee9eacbc DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_004.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 4 - 8 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_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 Objectives of the Upper-Extremity Prosthetics Program</h2> <h5>Craig L. Taylor, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The upper-extremity prosthetics program, under the sponsorship of the Advisory Committee on Artificial Limbs, National Research Council, has been a growing and evolving program from its inception in 1945. Its initial objectives were limited to time and motion study of amputees and to device invention and development. But from the vantage point of 1954 we may list many additional objectives that have been assumed according to the necessities of a national program dedicated to the welfare of the amputee. As new activities have been added, none of the original have been abandoned, although certain of the original ones have been reduced in relative emphasis and expenditure.</p> <p><b>Fig. 1</b> illustrates in schematic form the major phases of the upper-extremity program as they have waxed and waned over the years from 1946 to 1953. The scope and magnitude of these activities represent a program with few parallels in our peacetime economy. As is evident in <b>Fig. 1</b>, not all the activities were started (or even conceived) at the outset. But, as has been pointed out by Strong,<a style="text-decoration:none;">*</a> no one could predict at the outset the ramifications of a program dedicated to the tangible goal of putting new and improved prostheses on amputees. The appropriateness of this program under the auspices of the National Research Council was underscored by President Bronk, who praised the ACAL program as a fitting example of the service to the public welfare for which NRC was founded.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Trends in the upper-extremity prosthetics program, 1945-53. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Fundamental Studies</h4> <p>The study of normal and amputee biomechanics underlies all improvement in prosthetic replacement. A continuous program of inquiry in this field is therefore essential. Although much of such research is undertaken without immediate practical goal, free inquiry brings to light ideas which find widespread application, as has already been demonstrated time and again. The continuous observation of arm motions and of prosthetic motions provides a nourishing bed of interest and information from which the application phases draw strength and purpose.</p> <p>The program of fundamental studies has featured research on normal motions, analyzed in terms of physical mechanics and in terms of industrial time and motion concepts. These investigations have built up a body of information on the patterns of motion, speeds, forces, and skills that is invaluable in conceiving, planning, and predicting the results of new developments. A special phase of this program has had to do with cineplasty, where the direct utilization of muscle force has remarkable potentialities for prosthetic replacement but where intimate knowledge of the mechanics of the muscle is required in order to obtain successful operation of the prosthesis. Knowledge of stump shrinkage, of finger forces, of external power controls, of accessory body mechanics, of mechanical stresses in the prosthesis during use—all these are fundamental to the proper assessment of normal and of amputee biomechanics.</p> <p>The objectives of the program of fundamental studies in the upper extremity may be summarized as:</p> <ol> <li>To study the performance of manipulative activities in normal individuals and to analyze the activities in terms of biomechanics and of time and motion criteria.</li><li>To compare the motions of amputees with pros-theses with similar motions of normals in order to define the erns of altered and substitute motions peculiar amputees.</li><li>To measure the forces and displacements of muscles and muscle groups in relation to cineplasty, harness controls, and external power controls.</li><li>To define the alterations in general body mechanics in amputees as a result of the asymmetrical loss body weight.</li></ol> <h4>Development of Prosthetic Devices</h4> <p>The "bread and butter" of the ACAL program is the development of improved prosthetic devices, and a major emphasis has always been placed upon this phase of the program. Development of each device originates in the need shown by fundamental studies or by experience with amputees. design, experimental fabrication, amputee test, and field evaluation are the successive steps through which each device must pass. The past and present development laboratories include Northrop Aircraft, Inc., the Army Prosthetics Research Laboratory, and the University of California at Los Angeles, but other agencies, such as New York University and many cooperating industry limbshops, function in the final evaluation phases.</p> <p>ACAL developments in prosthetic devices include new inventions and many adaptations of mechanisms and materials from other technical fields. Engineers have delved deep into the rich heritage of American technology to find applications of plastics, lightweight metals, and mechanisms that have immensely improved the structural and functional characteristics of upper-extremity prostheses. In short, the development objectives are:</p> <ol> <li>To invent, adapt, and apply new materials and mechanisms so as to add new functions, or to improve old functions of prostheses, seeking in the end to provide an armamentarium of devices to meet the needs of every amputee type.</li><li>To design and redesign prosthetic components for simplicity and ease of manufacture, and for durability, without loss of essential function.</li><li>To create a system of interchangeable components which may be singly prescribed for the individual amputee case, but which can be combined into a functionally integrated and an esthetically compatible prosthesis.</li><li>To incorporate cosmetic and anthropomorphic principles into basic design so that prostheses are not abnormally conspicuous and are pleasing from the standpoint of color, texture, and form.</li></ol> <h4>Industry Advisory Participation</h4> <p>From earliest days, ACAL has recognized the benefit that would accrue to its activities if the experienced "know-how" of the industry could be utilized in an effective way. To attain this goal, it was considered necessary to bring into the planning meetings of the ACAL group the counsel of leading prosthetists and limb manufacturers. Accordingly, three members of the limb industry were made members of the Upper-Extremity Technical Committee to serve at the national level, while in Los Angeles a local Industry Advisory Committee was set up to advise and aid the UCLA project. These cooperative ventures have proved to be of great mutual benefit, the objectives being briefly as follows:</p> <ol> <li>To learn from the industry the needs for device development, for advancement in prosthetics technology, and for improvement of amputee services.</li><li>To utilize the experience and judgment of members of the limb industry in determining policy and in planning cooperative ventures involving field application studies.</li></ol> <h4>Contributions to Prosthetics Technology</h4> <p>With the wealth of World War II technological development to draw upon, the ACAL program rapidly adopted new materials and practices, not only in the design and development of new prostheses but also in shop fitting and fabrication practices. Most outstanding of these innovations is the incorporation of plastics for prosthetic use. The principal laboratories under the program, APRL, Northrop Aircraft, Inc., and UCLA, have exemplified these uses, and their reports have been a source of information to the industry.</p> <p>The objectives are:</p> <ol> <li>To adapt new and different materials for use in fitting and fabrication.</li><li>To introduce into prosthetics practice methods of measurement and fabrication tending to improve quality of service and economic efficiency.</li></ol> <h4>Amputee Case Study</h4> <p>In the early stages, the ACAL program emphasized research and development on devices, and amputees necessarily were fitted with experimental prostheses in order to conduct studies, trials, and tests of the equipment. It soon became apparent, however, that established practices in prescription, fitting, and training of amputees were highly variable and that, to round out consideration of all factors bearing on amputee rehabilitation, these practices themselves should become the subject of investigation. This objective was strengthened by the knowledge that no single design of prosthesis is superior for all amputees but rather that, of many types of equipment, the most suitable selection for a given amputee depends upon his individual personal, social, and occupational needs and desires. Accordingly, the Case Study Program was initiated at UCLA in 1950 and continued until 1952. The large amount of information on the 70 amputees in this study is being reduced for publication; much of it has been directly transferred into the Educational Program (see below).</p> <p>The case study of cineplastic amputees at APRL has followed in its major outline the procedures at UCLA, and much valuable information is being gathered on this important class of amputee.</p> <p>These programs serve an especially important role in bridging the gap between fundamental work in the laboratory and practice in the field. Prosthetics involves, in unique degree, a combination of science and technology with the practical arts. Every amputee is to some extent a special case. It has therefore been . necessary to incorporate the case-study phase in order to ensure the applicability of technical improvements.</p> <p>In concise form, the objectives of the Case Study Program may be stated as follows:</p> <ol> <li>To investigate the application of prostheses to a wide range of amputee types so that a rational procedure for prescription for the needs of the amputee can be formulated.</li><li>To test and develop the elements of physical and occupational therapy that apply to amputee rehabilitation and prosthetic use.</li><li>To discover the effect of occupation, education, recreational interest, and other personal factors of the amputee upon his prescription, fitting, and training.</li><li>To determine effective methods for evaluation of amputee service, not only pertaining to the quality of mechanical equipment but also to the results of training, to the end that the amputee obtains a truly functional prosthesis.</li></ol> <h4>Prosthetics Education</h4> <p>It has been a cardinal principle of the ACAL group that the products of its research, investigation, and development should be speedily disseminated to all technical and professional groups interested in applying such knowledge for the welfare of the amputee. The scope of these activities has steadily in-creased. Early discoveries were conveyed by means of technical reports which were primarily useful to the other member laboratories and to manufacturers within the industry. Later, as case study and other application phases of the program developed, the broader responsibility was assumed of supplying educational materials dealing with many aspects of technical and professional prosthetics service. Two volumes have been prepared. <i>Human Limbs and Their Substitutes</i> (McCraw-Hill, in press) supplies an authoritative reference on prosthetics, while the Manual of Upper-Extremity Prosthetics (University of California at Los Angeles, 1952) has been issued to serve as a shop guide for the practicing prosthetist.</p> <p>Valuable as the printed material has proved to be, it was found that the needs of the prosthetist for advanced training could not be met with sufficient rapidity and thoroughness. These craftsmen, lacking formal institutional training in their specialty, and with the highly variable backgrounds of apprentice training, displayed great need for direct instruction to bring "them up to the standard required by the new technology. Two other professional groups most concerned in amputee service, physical and occupational therapists and physicians and surgeons, were no less in need of learning the newer knowledge of prosthetics. This condition made it imperative to offer an accelerated advanced training in the theory and practical arts concerned in prosthetics.</p> <p>Accordingly, the Prosthetics Training Program was instituted at UCLA with the following objectives:</p> <ol> <li>To give for selected groups of prosthetists advanced training in the skills and knowledge needed to make and fit upper-extremity prostheses using many of the most recent refinements arising from research.</li><li>To give for selected groups of physical therapists and occupational therapists advanced training in the skills and knowledge needed to assist amputees in adjusting themselves physically, mentally, and vocationally to the use of the newer developments in upper-extremity prostheses.</li><li>To enable physicians and surgeons to expand their understanding of the possibilities and limitations of the more recent developments in prostheses and of some effective procedures for taking advantage of these developments.</li><li>To encourage the acceptance and practice of the "team approach" to the problem of prosthetic prescription, in which the physician or surgeon, as captain of the team, is assisted by professionally qualified physical therapists, occupational therapists, and prosthetists.</li></ol> <h4>Field Research Studies</h4> <p>To test the usefulness of the knowledge gathered during the ACAL research program, a field research project was instituted in Chicago during 1952. The intent was to determine whether the local rehabilitation people concerned with the problems of prosthetics-the physician, the therapist, and the prosthetist-would benefit from the new knowledge. Accordingly, a group of Chicago physicians, therapists, and prosthetists were invited to attend a "pilot" course in upper-extremity prosthetics at UCLA, the content of the course being based almost exclusively upon the research performed under the ACAL program.</p> <p>Upon completion of the training, a clinic-was established in Chicago, where a group of 50 amputees was processed in accordance with the information taught at UCLA. The status of each amputee was carefully evaluated both before and after clinic treatment. Results showed a dramatic and clear-cut improvement in the functional and psychological attributes of this group of amputees. Thus, initial field evaluation clearly demonstrated the practical usefulness of the research results when applied to amputees in the local situation.</p> <p>Upon completion of the Chicago study, and in close coordination with the educational program already described, nationwide field studies were instituted under the supervision of the Prosthetic Devices Study, New York University. The purposes of these studies, which are presently going on, are as follows:</p> <ol> <li>To ensure the proper application of the research findings to upper-extremity amputee cases throughout the country.</li><li>To provide the local clinics throughout the country with administrative and technical consultation so that assistance may be provided in the resolution of difficult problems.</li><li>To evaluate the effectiveness of these procedures when applied to amputees, in order to determine where problem areas still exist and thus to direct future research toward the resolution of these difficulties.</li></ol> <p>It is anticipated that, upon conclusion of the present field research program, studies will have been conducted in conjunction with clinics operating in some 40 of our largest communities.</p> <h4>Conclusion</h4> <p>As a result of the upper-extremity prosthetics program, arm amputees can now be provided with reasonably comfortable, functional prostheses. Studies indicate that between 80 and 90 percent of the arm amputees fitted during the UCLA Case Study Program and the Chicago Project continue to wear and use their prostheses. When this is compared with the 10-percent figure estimated for arm amputees throughout the country who wear prostheses, it appears that some measure of success has been achieved. But it is apparent to workers in this field that the progress made to date is merely a step in the proper direction and that we can expect continued improvement in all aspects of upper-extremity rehabilitation.</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">Bronk, D.W., President, National Academy of Sciences. Address to the Advisory Committee on Artificial Limbs, Annual Meeting, Washington, May 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">Strong, F. S., Jr., The Artificial Limb Program: Five Years of Progress. Advisory Committee on Artificial Limbs, NRC, Washington, November 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>Craig L. Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering and Biophysics, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council; chairman, Upper-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_004/January-1954-1.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 Upper-Extremity Prosthetics Program Creator An entity primarily responsible for making the resource Craig L. Taylor, Ph.D. * https://staging.drfop.org/files/original/6390d2b802a51debf473b9656b992a03.pdf 5239891523840188e87e90863af212cf Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_04_002.pdf Text Any textual data included in the document <h2>The Parents Experience</h2> <h5>James R. Cuchna&nbsp;<a style="text-decoration: none;">*</a><br />Anna Mae Cuchna&nbsp;<a style="text-decoration: none;">*</a></h5> <p>A new birth . . . another miracle . . . a baby is born . . . but why is our baby not made perfect like our friends and relatives? Life began, but it was not surrounded by complete joy. We were confronted with the inevitable—"Your child was born with spina bifida. She will, probably, live no longer than a week." We were asked, "Do you want to put her in an institution or leave her in the hospital?" Try to imagine the feeling that would rush through your mind at the onset of this occasion. It is unbelievable.</p> <p>Our immediate and only reaction was to take this child and love her just as if she were born "perfect." We accepted our daughter and were determined to treat her as if nothing was wrong. We had faith that God would help us through the problems we might encounter. This happened on March 21, 1966.</p> <p>Today, Cindy is 18 years old and is entering her first year of college. We also have a 17 year old daughter and a 9 year old daughter. We feel we have been richly blessed.</p> <p>Even though our first child was the one born with a physical problem, spina bifida, we really don't feel she has ever been "the problem." Society in general . . . everyone else's opinion, the medical profession, the people in government passing legislature, etc. are "the problems." Everyone thinks they know what "life is going to be like" for these children, what a "burden" they will be on the family. These statements infuriate us.</p> <p>Having had other children helped us substantiate our thoughts and feelings that a child born with a physical problem is "no different" than a child born "normal." We have had to deal with medical problems, hospital stays, doctors visits, etc. with all our children—maybe not as many problems as with Cindy, but, all have been traumatic for us. We have also had parents inflicted with cancer and have cared for them. To us, life is what a person makes of it. It is the positive attitude that surrounds any child or person that is so important. One can only try to make the best of things and live each day to the fullest.</p> <p>We are concerned for the babies that have doctors who perceive spina bifida as a dreadful defect/disability and make the decision of whether to treat or not. Cindy was not treated at birth but survived. Thoughts arise as to what more she could do had she been treated. Would her degree of paralysis and the kidney damage be less severe? We'll never know. Some doctors hesitate on treating babies born with spina bifida, but wouldn't give a second thought to treating victims of automobile, industrial or other accidents even though the outlook may be very bleak. An example of this is the president's aide, James Brady. What makes the difference?</p> <p>Another concern lies in the high cost of the medical supplies and equipment she will need the rest of her life. It doesn't seem fair that urostomy bags bought 11 years ago cost $13.95 and today are $42.50, that a set of full braces is $5,000 or more, that a wheelchair is over $1,000, that vans with lifts are $20,000, or that urine analysis that were $2.00 are now $10.00. Most of the people with physical problems have limitations in job opportunities. Very few will be able to hold high paying jobs. Where will the money come from to pay for their needs?</p> <p>Some places now want the money first and then they will bill your insurance. Where will she get the start to save money when she needs something? What happens when our 80 percent group insurance coverage lapses because she is an adult and then she cannot get insurance of her own because of her medical/physical involvement?</p> <p>Cindy feels good about herself and has accepted her handicap. She realizes that she has limitations but that these should not preclude her from being able to achieve the goals she sets. The fact she is paralyzed from the waist down and requires orthopedic bracing brought Cindy to the realization that she would have to work very hard for what she wants very early in life. She knows that nothing is going to be handed to her on a silver platter and does not think that she deserves special treatment because she is "physically challenged." All she wants is an equal opportunity to contribute to society and earn her way.</p> <p>Cindy has been a constant source of strength, love, and courage for us. As we watch her grow and see her achieve, our admiration for the child/young lady/soon-to-be woman grows. We truly believe that we have been more dependent on Cindy than she has been, or ever will be, upon us.</p> <p>We have been very fortunate in having benefitted from the professional services of very dedicated, talented, competent, and caring people in the areas of medicine, education, and orthotics. Yes, there have been differences of opinions between themselves as well as with us. There were goals that took longer than anticipated to be reached. But, can't we all say this happened to us also in our "normal" lives.</p> <p>It is one of our dreams and goals to see more medical professionals get involved with the National Spina Bifida Associaion of America and its local chapters. We don't need people to be afraid of spina bifida. We need help to spread a positive image, to achieve the establishment of a hospital for research and for the needs of all people with spina bifida. People need to know that children who are physically challenged don't need sympathy and things done for them. What they need is the opportunity to live, learn, grow in love and be loved—just as we all do.</p> <em><b>*Anna Mae Cuchna </b> Mr. and Mrs. Cuchna reside in Ohio and are the parents of Cynthia Cuchna.</em><br /><br /><em><b>*James R. Cuchna </b> Mr. and Mrs. Cuchna reside in Ohio and are the parents of Cynthia Cuchna.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 2 - 3 Year 1984 Volume 8 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Parents Experience Creator An entity primarily responsible for making the resource James R. Cuchna * Anna Mae Cuchna * https://staging.drfop.org/files/original/befcb86fff74a058e93e3af03fca5cb4.pdf 039187c0f904a1046950d24faf81834e https://staging.drfop.org/files/original/789116c760951063d9ff4663d56ebf11.jpg a9aab0226d3064cf534e81cdf298f8d4 https://staging.drfop.org/files/original/1d6f583a27b50e7e028c417b897f6e7b.jpg 15aa793539956fd62a25423d3bce7777 https://staging.drfop.org/files/original/9a407e0949fb0cacc06278d12c150165.jpg 2d7e8e8f2c1dc9463620a612fc5ec1ba DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_004.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 4 - 21 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_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 Past and Present Medical Significance of Hip Disarticulation</h2> <h5>Henry E. Loon, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Hip disarticulation, or amputation through the hip joint, is one of the most drastic surgical removals known to medicine. It is seldom justified as other than a last-resort, lifesaving measure and, as compared to other amputations, is seldom performed. Because of its severity, and because it has been used only for patients already on the verge of medical disaster, it has been attended by discouragingly high mortality rates throughout its 200-year history. By the same token, however, the record of the changing need for hip disarticulation is a record of medical progress against fatal disease and trauma of the lower extremity. Whereas hip disarticulation was first used extensively against gangrene or the ever-present threat of generalized infection, it is now most frequently one of the ultimate weapons against cancer. Moreover, the operation has lost much of its fearsomeness as general medical knowledge and surgical skill have increased and as the hope for prosthetic rehabilitation of these patients has become brighter.</p> <p>By presenting the medical aspects of hip disarticulation in historical perspective, it. is hoped to show here how the pathological conditions indicating hip disarticulation have changed as medical science has progressed, how the operative dangers of hip disarticulation have been largely overcome, and how the surgical fashioning of the stump (within the limits imposed by injury or disease) has helped in the prosthetic rehabilitation of patients. Finally, there is appended a discussion of the recent interest paid to systemic effects that may accompany any major loss of limb.</p> <h4>Historical Beginnings</h4> <p>Until the mid-eighteenth century, surgeons considered themselves helpless to treat complicated fractures or suppurative diseases of the upper part of the femur, let alone malignant growths in this region. Death from septic complications, gangrene, or, in the case of cancer, metastases, was the almost inevitable outcome of these conditions.</p> <p>Surgical disarticulation of the hip was apparently first conceived by Sauveur Francois Morand, a leading French surgeon of the early eighteenth century, and was formally proposed in 1739 by two of his pupils.<a></a> Long before the first true surgical disarticulation, however, the hip of a boy of 14 was nearly disarticulated by gangrene which resulted from his having eaten diseased rye. Observing the thigh to be connected to the trunk only by the round ligament, the sciatic nerve, and some shreds of tissue, the French surgeon Lacroix<a></a> cut these with scissors. The other leg, similarly affected, was cut from the hip in the same manner four days later, and the patient survived another 11 days. This case gave a great impetus to discussion of the matter. In 1759, the Royal Academy of Surgery offered a "double prize" for the best essay on the following subject: "Dans le cas ou l'amputation de la cuisse dans l'article paroitroit l'unique ressource pour sauver le vie a un malade, determiner si l'on doit pratiquer cette operation, et quelle seroit la methode plus avantageuse de la faire."<a style="text-decoration:none;">*</a> Of 44 essays submitted, 30 were in favor of performing the operation.<a></a></p> <p>Not until 1774 was it proved that death on the operating table was not a necessary consequence of this formidable operation. In that year, the first true surgical disarticulation of the hip was performed by William Kerr,<a></a> of Northampton, England, on an 11-year-old girl who had a tumor of the thigh and symptoms of pulmonary tuberculosis.<a style="text-decoration:none;">*</a> The disarticulation had probably not greatly influenced the course of the disease, and Kerr concluded his presentation optimistically (p. 342): "With regard to the expediency of the operation, I am so much convinced of it in certain cases, that in such I shall not, for the future, hesitate to perform it when they occur."</p> <p>Another disarticulation said to have been performed at about the same time by Henry Thomson at the London Hospital apparently terminated fatally<a></a> , and the operation was not reported again for nearly 20 years. The Wars of the French Revolution and the Napoleonic Wars brought with them a new series of hip disarticulations.</p> <h4>Shifts and Changes in Indication Over Two Centuries</h4> <p>Although the earliest hip disarticulations were performed for disease, in the following 100 years many more were done for gunshot wounds than for any civilian cause. Up to the end of the American Civil War, nearly two and a half times as many military as civilian operations had been reported from Europe and America, as recorded by Otis in <i>The Medical and Surgical History of the War of the Rebellion . </i><a></a> Since that time, the situation appears to have been reversed again owing to the decreased necessity for the operation fol- lowing battle injuries and its increased use to remove malignant growths. It would be instructive to be able to compare hip disarticulations of military and of civilian origin—as to exact incidences and indications—throughout the history of the operation, but unfortunately information is incomplete and many difficulties of interpretation arise. Nevertheless, a comparison of the indications given for each group points up the necessity of considering the two categories separately.</p> <h4>Indications in Military Surgery </h4> <p>The military surgeon has always been concerned mainly with trauma and ensuing infection, although infection plays a progressively less important role than formerly. In 1812, Dominique Jean Larrey,<a></a> the famous French surgeon and personal physician of Napoleon, who himself (Larrey) performed seven of the early disarticulations, stated the indications for the operation in military surgery as follows:</p> <ol> <li>A torn-off limb, or great laceration of the limb so close to the upper articulation that amputation in continuity would not be possible.</li><li>Fracture of the femur in the vicinity of the trochanters, accompanied by a rupture of the femoral artery or of the sciatic nerve.</li><li>Massive gangrene of the lower extremity extending to the vicinity of the upper articulation, as a result of extensive wounds of the soft tissues.</li></ol> <p>At the time of the American Civil War, these indications were still considered valid, and Otis<a></a> repeated the first two almost verbatim. Today, however, most severe fractures, and even many comminuted fractures, of the upper end of the femur, if not associated with irreparable vascular damage, can be treated conservatively. Most of the major amputations of extremities in World War II were the result of such extensive traumatic injury that no improvement in surgical technique could hope to effect repair. According to DeBakey and Simeone,<a></a> 69 percent of the 3177 major amputations performed in the European and Mediterranean Theaters were due to extensive trauma (by which was meant complete or nearly complete severance of the limb or part of the limb), 12 percent to infection, and 19 percent to major arterial injury.</p> <p>The relatively small percentage of amputations due solely to major arterial injury could probably now be reduced still more because of new techniques of repair and grafting of blood vessels. Some successful cases were reported from the Korean War, and knowledge is further advanced today.<a></a></p> <p>Statistics on the specific indications for the 56 recorded cases of hip disarticulation from World War II<a></a> are at present not available. The implications of the records seen is that the majority were traumatic amputations. For instance, of the 154 wounds of the hip joint observed between D-Day and VE-Day at the 802nd Hospital Center, none was treated by disarticulation. Regarding the incidence of infection, there was no report of rapidly spreading hemolytic streptococcic or staphylococcic infection, such as still occurred in World War I <a></a>. At the 802nd Hospital Center, infection occurred in 9 of 29 injuries of the femoral head or neck. Although these were cases of persistent, long-lasting infection, leading in two cases to death, no hip disarticulation was performed. Usually this tendency toward conservatism was justified, but in looking back, the Office of the Surgeon General has modified this attitude in the following statement:<a></a></p> <ol> <li>When there has been great mechanical destruction of the bone and soft parts and when retained foreign bodies carrying fragments of clothing cannot be removed, foci of infection are maintained for indefinite periods of time.</li><li>A prolonged delay before amputation merely results in exhaustion of the patient, so that, when the operation is eventually performed, it often poses a serious threat to life. ... It must be assumed that patients with large areas of mixed, penicillin-resistant infection deteriorate every day that they live and that their chances of survival after major surgery become progressively less as time passes. . . .</li><li>Observation of numerous instances of pyoarthro-sis of the hip joint at United States Army amputation centers made it clear that when the sciatic nerve is lacerated the indication for early disarticulation of the hip is particularly strong.</li></ol> <p>Fulminating gas gangrene is still an indication for amputation, but its incidence has been tremendously reduced by the employment of prompt and thorough debridement and the administration of antibiotics. It is impossible to determine from the available statistics whether any hip disarticulations were performed because of this infection.</p> <p>To sum up, in military surgery hip disarticulations-like other major amputations- appear to be performed today primarily when the limb is completely or almost completely severed from the trunk. To these traumatic amputations must be added those cases in which disarticulation is necessitated by major injury to the blood vessels or to the main nerve trunks (particularly the sciatic) and those in which multiple foci of antibiotic-resistant infection cannot otherwise be eliminated. That the number of hip disarticulations has not been greatly reduced in comparison with former wars is testimony to the increased destructiveness of modern weapons; the type of injury which used to necessitate hip disarticulation can usually be treated conservatively today.</p> <h4>Indications in Civil Surgery</h4> <p>The civilian surgeon has also always been concerned with trauma, but disease, and especially malignant disease, has played an increasingly important role. In 1839, Velpeau<a></a> stated the indications for hip disarticulation in peacetime as follows:</p> <blockquote><p>A comminuted fracture, a necrosis, caries, osteosarcoma, spina ventosa, or any incurable degeneration whatever, of the femur, extended above its shaft, or gangrene, or any other disease in fact which has progressed nearly as high up as the haunch, and which is of such serious character as to demand amputation, will claim disarticulation provided the cotyloid cavity and the bones of the pelvis are not affected.</p> </blockquote> <p>The major change in indications from the nineteenth to the twentieth century is best seen from a comparison of nonmilitary hip-disarticulation cases. It may be seen from <b>Fig. 1</b> that, although many of the conditions listed by Velpeau might today be considered indications for hip disarticulation, they do not in practice occur very often. Cancer is <i>the </i>indication now, whereas in the early period it was one among a number of causes. The indications given by Smith<a></a> for his historical survey of cases fall into the following categories: malignancy, 13; severe crushing injuries, 8; suppurative diseases of the femur, 7; tuberculosis, 4 (tubercular lesions of the bones, 3; tuberculoma of the thigh, 1); gangrene, 3; miscellaneous causes ("diseases of the femur," "coxalgia," pain, exostoses), 7.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Comparison of early and recent indications for hip disarticulation in peacetime. Data for the early period were taken from a compilation by Stephen Smith<a></a> of all known cases of hip disarticulation to 1852. Wartime operations and those for which the indication was not known were eliminated. Data for the recent period were derived from articles indexed under <i>Amputations </i>in the <i>Quarterly Cumulative Index Medicus </i>from 1935 through 1951 and in the <i>Current List of Medical Literature </i>from January 1952 through August 1957. Again, wartime operations and those for which the indication was not stated were eliminated. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Four of the tumors which Smith gave as indication were not classified by him as malignant. But from the description of the course of the disease they appear to have been, and they are therefore here grouped under malignancy. This is only one example of how difficult it is to determine with any certainty what the true indications for these early operations were. Another example is Kerr's case (page 5). Smith, following Kerr's own diagnosis, recorded the indication as tuberculosis; yet from the description of the case it seems conceivable that the patient had a malignant growth in the upper end of the femur and the innominate bone with metastases to the lungs.</p> <p>Methods of diagnosis are greatly improved today, but it is no less difficult to obtain reliable statistics on recent hip disarticulations. Cases that do not present striking medical or surgical aspects are no longer reported in the literature. In this country, unfortunately, no survey of the total number of amputees has ever been made, but even in countries like Germany or Great Britain, where the government has made such surveys for the larger categories of amputations, no information of the incidence of hip disarticulations, let alone the indications for them, seems to be available. </p> <p>In a literature survey covering the period from January 1935 through August 1957, there were reported (<b>Fig. 1</b>) 146 civilian hip disarticulations for which the indications were malignancy.<a></a> Two were done for tuberculosis<a></a> and one each for osteomyelitis following an injury<a></a>, phlegmon of thigh and general septicemia following an injury, <a></a> a suppurative process (etiology not stated) of the coxo-femoral articulation,<a></a> actinomycosis, <a></a> gangrene caused by thrombosis, <a></a> and paralysis and contracture caused by an extradural abscess. <a></a> It is a little surprising that, of all the reported civilian hip disarticulations, none was done primarily for trauma. I have myself seen one patient whose hip was disarticulated because of injuries in peacetime, and I am certain that there must have been a few others.</p> <p>Fortunately, not all malignant growths, even in the upper part of the thigh, call for such drastic treatment as disarticulation of the hip. In some cases wide excision of the neoplasm suffices to remove it entirely. The decision as to whether or not to disarticulate depends upon the site and the type of the neoplasm. The indications upon which modern surgeons agree are well stated by Pack and Ehrlich<a></a>, and the reader interested in these details is referred to that excellent paper.</p> <h4>Incidence Relative to All Leg Amputations</h4> <p>Comparison of the number of hip disarticulations with total numbers of lower-extremity amputations shows still more clearly how seldom hip disarticulation is performed. It has now become much rarer in military than in civilian practice. During the American Civil War<a></a> 86,413 wounds of the lower extremities were recorded. In 12,605 of these cases (less than 15 percent), the wounds resulted in major lower-extremity amputations. Of these, 66, or 0.5 percent of the amputations, were hip disarticulations (<b>Fig. 2</b>). In World War II<a></a>, 248,000 wounds of the lower extremities were recorded. Of these, 12,612 (5 percent) are estimated to have resulted in major amputation. Fifty-six, or 0.4 percent, of the amputations are estimated to have been hip disarticulations. Thus the percentage of hip disarticulations in relation to total lower-extremity amputations has changed very little; it has remained small. Both the number of hip disarticulations and the number of lower-extremity amputations have, however, decreased greatly relative to the number of wounded.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. One of the few survivors of disarticulation of the hip during the American Civil War. Note the large amount of soft tissue in the stump. From Otis<a></a>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In civilian cases the ratio of the number of hip disarticulations to all major lower-extremity amputations is probably somewhat higher but still less than 2 percent. Thus, of 70 lower-extremity amputees who underwent amputation or were treated at the University of California Medical Center from 1941 to 1955, only one had had a hip disarticulation.<a></a> Of 663 patients with major lower-extremity amputations who have passed through the Veterans Administration Hospital in Oakland since the end of World War II, eight have had hip disarticulations.<a></a> Even the records of an institution treating predominantly cancer patients show a very small number of hip disarticulations. The Bone Tumor Service of the Memorial Center for Cancer and Allied Diseases in New York City reported only 15 hip disarticulations from 1930 to 1946,<a></a> a fact which suggests that even today this operation is done only to forestall certain death.</p> <h4>The Long Struggle to Reduce Mortality </h4> <p>There was good reason why hip disarticulation was not attempted, or even conceived, until the eighteenth century. The surgical skills which had been developed up to that time were still grossly inadequate for an operation attended by so much danger of hemorrhage and shock.</p> <h4>Operative Mortality </h4> <p>When we consider that the operation had to be done as fast as possible, without benefit of anesthesia or knowledge of asepsis, it is surprising how many of the earliest patients survived even a few days or weeks. Larrey, <a></a> who was probably one of the most skilled surgeons of his time, has recounted cases in which, after ligating the femoral vessels together, he completed the procedure in 14 to 15 seconds. To achieve this speed, he used only four knife strokes. He drove a blade perpendicularly between the base of the femoral neck and the tendinous attachments of the lesser trochanter until it emerged posteriorly and, with an oblique downward stroke, cut the medial flap; raised the flap proximally to expose the articulation and with a stroke of the bistoury cut the articular capsule; abducted the thigh (nearly dislocating the head of the femur) and in a stroke cut the interarticular ligament; and with a downward and outward stroke of a small straight knife cut the lateral flap. The remaining arteries were then ligated. Larrey did not consider it necessary to suture the muscles. If there was no "irritation," the subcutaneous tissues and the skin were approximated with a few retention sutures. The edges of the wound were further drawn together by compresses dampened with red wine, and a large bandage was applied.</p> <p>Larrey reported that his first patient survived the operation well but a few hours later had to follow the army in a 24-hour forced march in winter, so that he died presumably of cold and exposure. His second patient also seemed well on the road to recovery when, six days postoperative, a soldier with the plague was bedded on the same straw mat with him. Larrey's patient became infected and died within 24 hours.</p> <p>The fate of these patients, who died not as a result of the operation itself, shows how difficult it is to establish the date of the first "successful" hip disarticulation. These two, together with others in which death occurred within a year after operation, were in early mortality statistics classed as fatalities.<a style="text-decoration:none;">*</a> On the other hand, there are no verifiable records of several of the early hip disarticulations claimed by later authors to have been successful. Otis on whose two works<a></a> the early figures given here are based, pointed to other frequent sources of fallacies in surgical statistics. He said:<a></a></p> <blockquote><p>The desire for distinction of ambitious operators sometimes tempts them to report successful results prematurely, and to fail to record unfortunate cases. Feverish partizans of particular operative procedures, in accumulating statistics, not unfrequently evince an unpardonable disregard for the fundamental rules of evidence, and admit testimony abounding in transparent fallacies. Some writers, in their zeal to gather together numerous observations, group those that are very dissimilar, and deduce inferences from the collection that are pertinent only to particular cases.</p> </blockquote> <p>He stated that in his own report the authenticity of cases was scrutinized and that doubtful cases were rigidly excluded.<a></a> Insofar as the records of earlier operations Otis recorded have been checked, he was indeed conscientious; yet in evaluating his figures it is essential to bear in mind all the limitations of this early material.</p> <p>According to Otis <a></a>, 111 known civilian cases of hip disarticulation were reported from Europe and America to the end of the American Civil War. Of these, 46 were considered successful and 65, or 59 percent, terminated fatally. In military surgery <a></a>, 254 authenticated hip disarticulations were reported, with 28 recoveries, 225 deaths, and one result unknown-a mortality rate of 89 percent. Of the 187 patients who underwent hip disarticulation prior to the American Civil War, 17 survived, giving a mortality rate of 91 percent. In the 67 cases occurring during the Civil War, 11 of the patients recovered-a mortality rate of 84 percent.</p> <p>In spite of this extremely high mortality rate, disarticulation gave better results than did more conservative methods of treatment for complicated fractures of the upper end of the femur. Of 252 patients with intracapsular shot fractures who were treated conservatively during the American Civil War, three recovered, giving a mortality rate of 99 percent.<a></a> Fifty-five excisions of the femoral head resulted in a mortality rate of 91 percent.<a></a> The mortality rate did not improve materially until well after the general introduction of asepsis in the 1880's. In 1878, Farabeuf,<a></a> when presenting his method of disarticulation to the Societe de Chirurgie in Paris, cited a still-persisting death rate of 75 percent. The American surgeon Wyeth,<a></a> writing in 1890, mentioned "the terrible death-rate after hip-joint amputation."</p> <h4><i>Improvements in Surgical Technique</i></h4> <p>After deaths from complications of infectious processes had been somewhat brought under control by the general introduction of aseptic surgical procedures, surgical shock still accounted for a large number of the operative deaths. A main contributing factor was hemorrhage.</p> <p><i>Reduction of Hemorrhagic Shock. </i>The arteries to the upper part of the thigh and the gluteal region branch out from several main trunks (<b>Fig. 3</b>), so that it is much more difficult to control the flow of blood for a hip disarticulation than for a thigh or leg amputation. Methods attempted for control ranged from a high tourniquet placed about the upper end of the thigh to compression of the aorta.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Arterial system in the hip and upper part of the thigh. Redrawn, by permission, from <i>Gray's Anatomy, </i>26th ed., Lea &amp; Febiger, Philadelphia, 1954. The original appeared in Eycleshymer and Jones' <i>Hand Atlas of Clinical Anatomy, </i>Lea &amp; Febiger, Philadelphia, 1925. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An ordinary touniquet is difficult to apply satisfactorily for a hip disarticulation. Placed about the thigh at the groin, it not only does not control bleeding from a number of the main vessels but it also slips out of place easily after enucleation of the promixal end of the femur. For this reason, there were developed various devices for holding a tourniquet in place, the best known being Trendelenburg's<a></a> and Wyeth's<a></a> systems of pins. In both procedures, long steel pins were driven through the soft tissues to prevent slippage of rubber tubing used to constrict the tissues.</p> <p>Of the more radical methods for compression of the parent trunks, some, such as a Davy's lever introduced through the rectum for the compression of the aorta, were dangerous, and they were not always reliable.<a></a> Other authors recommended making an abdominal incision and temporarily compressing<a></a> or lifting<a></a> or even permanently ligating<a></a> the common iliac artery. The latter procedure has been recommended as recently as 1954, <a></a> but it is not commonly used today. Many surgeons hesitate to add to the system an additional shock by making an incision into the abdominal cavity.</p> <p>In general, more conservative measures are and have been advocated. Although initial ligation of the femoral vessels does not provide a completely bloodless field (because of the many anastomoses from the obturator and gluteal arteries), it has usually been considered the most satisfactory method. As we have seen, Larrey in his early operations recommended preliminary ligation of the femoral artery and vein, and regardless of the type of incision this has been common practice to the present day. Farabeuf,<a></a> whose procedure is still widely used, especially in Latin American countries, recommended an anterior racquet incision. The stem of the inverted <i>Y</i> should be over the point at which the femoral vessels pass under the inguinal ligament, and the artery and vein are sectioned and ligated before proceeding with the operation. Farabeuf claimed that other arteries could satisfactorily be cut and compressed by assistants as they were encountered and then ligated before closing the wound. Marquardt<a></a> in a recent book stated that in Germany it is considered best to follow Angerer's two-stage procedure,<a></a> in which ligation of the femoral artery and vein is done through an incision in Scarpa's triangle one or two days before the proposed hip disarticulation. This expedient allows the vessels to become thrombosed so that there is little loss of blood during the disarticulation itself.</p> <p>Finally, blood may be conserved if, after ligation of the artery, the leg is elevated for several minutes to allow maximal drainage to the trunk before ligation of the vein.<a></a></p> <p>In addition to careful hemostasis, it is helpful to section the muscles, wherever possible, in the avascular areas close to the tendinous origins or insertions rather than through the muscle bellies. This principle, proclaimed by Callander<a></a> in 1935 for his amputation just above the knee, has been applied to hip disarticulations by Leriche,<a></a> Boyd,<a></a> Slocum,<a></a> and Piquinela.<a></a> In the days when speed of operation was the primary consideration, the principle was necessarily violated. If guillotine operations are excluded, it is hard to imagine a faster method than Larrey's, but cutting each flap with a single stroke, as Larrey did, meant sectioning the muscles through the richly vascularized bellies, thus contributing greatly to hemorrhage and shock. He was, of course, caught on the horns of a dilemma for those times, because speed, too, was essential to lessen shock.</p> <p><i>Other Techniques for Avoiding Shock. </i>Even in cases in which there has been no infection or excessive hemorrhage, shock often occurs. Bustos<a></a> gave this as reason for believing that conditions which could cause pain played the major role in causing shock. Gentle handling is considered essential by most modern surgeons. Layer-by-layer dissection, using a scalpel, was recommended by Petrovskii.<a></a> Caprio<a></a> recommended the use of an electric scalpel, with which he claimed that he could carry out the whole operation without even turning the patient over, as is usually done.</p> <p>Many surgeons have taken precautions to avoid shock that might result from overstimulation of the sciatic nerve. Since this large nerve trunk runs through the posterior portion of the thigh, it is ordinarily not sectioned until the latter part of the operation and is in the meantime subjected to a variety of tensions, particularly after the dislocation of the femoral head, when the half-severed limb hangs from the trunk, connected only by this nerve and associated soft tissue. Various methods for overcoming this problem have been suggested -proper support of the limb throughout surgery to avoid these tensions<a></a> ; injection of the nerve with procaine before sectioning it;<a></a> and even, in a debilitated case, section of the sciatic nerve (after injection with procaine) almost at the start of the operation<a></a>. In 1917, Morris, <a></a> using spinal anesthesia, began his operation by injecting the sciatic nerve with procaine through a small posterior incision and then proceeded through anterior incision with what is usually the first part of the operation. He stated that no shock was observed during the ensuing disarticulation.</p> <p>Recently, the use of spinal anesthesia has been questioned<a></a> on the grounds that hypotension results, which could be dangerous in view of the seriousness of hip disarticulation. However, hypotension does not occur routinely when the level of spinal anesthesia is so low that the splanchnic nerves are not anesthetized. <a></a> Injecting the sciatic nerve may appear superfluous if spinal block has been performed prior to the operation. It seems to be done as an additional precaution and as a means of blocking any afferent fibers that, traveling via the sympathetic chain, may enter the cord above the level of spinal anesthesia.</p> <p>A two-stage operation is sometimes advisable for patients who are in very poor condition. We have already mentioned Angerer's procedure of ligating the femoral vessels one or two days before the disarticulation, a method which aids in avoiding shock by reducing blood loss. Even a three-stage procedure has been recommended. <a></a> In most cases today, however, the operation is performed in one stage only.</p> <h4><i>Improvements in Adjunct Therapy</i></h4> <p>In the first quarter of the twentieth century, great progress in several fields decreased the risks of serious operations such as hip disarticulation. More careful debridement of wounds was supplemented by chemotherapy and the use of tetanus antitoxin. By the end of World War I, shock occurring in American Army soldiers was treated by fluid replacement and whole-blood transfusion.<a></a> Knowledge of the physiology and technique of blood transfusion was greatly advanced in the second quarter of the century. Methods of preserving whole blood and plasma were developed, although such problems as the occurrence of homologous-serum hepatitis virus in stored plasma remained unsolved and caused considerable damage. Surgical knowledge of the repair of fractures and of replacement of hopelessly damaged parts of bones by grafts of various types made conservative treatment possible in many more cases than before. The use of sulfa drugs and antibiotics greatly reduced the incidence of infection after severe wounds. Finally, psychotherapeutic measures to prevent psychic trauma and to facilitate recovery became an important adjunct to surgical care.</p> <p>Operative death has become rare, <a></a> but the extent of shock and the resulting damage to the system continue to deserve study.</p> <h4>Mortality From Cancer</h4> <p>Another mortality rate is, however, a matter of much greater concern today. As we have seen, most modern civilian hip disarticulations are performed for cancer. Since at the present time hip disarticulation is commonly not resorted to until other measures (radiation, wide excision) have failed, it often has only a palliative effect. The mortality, if studied for the 5-year-cure rate, is extremely high. Of a series of 52 patients operated upon at the Memorial Cancer Center in New York from 1926 to 1948, 44 (85 percent) died of cancer within five years.<a></a> Pack<a></a> and others<a></a> have emphasized that, if disarticulation is resorted to only at this late stage, the mortality rate in such cases will continue to be high. In a recent study of patients with malignant disease who underwent hemipelvectomy (an operation comparable to hip disarticulation for the purpose here), Lewis and Bickel<a></a> observed:</p> <blockquote><p>Twelve of the 18 patients who had had symptoms less than six months at the time of operation are still living (two with metastases), and 4 of the 6 who had had symptoms for six months to one year are still living (one with metastases), while only 8 of the 25 patients who had had symptoms for more than one year have survived the present follow-up periods, and one of these has evidence of metastases.</p> </blockquote> <p>Although there is sometimes justification for disarticulation as a palliative measure, it would be much more desirable to employ it as a cure. Disarticulation as a curative measure will, however, be possible only when surgeon and patient alike are willing to take this radical step at an early stage of the disease.</p> <p>To what extent will hip disarticulation be replaced by the even more drastic operation of hemipelvectomy? Hemipelvectomy is indicated if malignancy (or, for that matter, a severe crushing injury or a suppurative process such as that mentioned on page 8) has involved the tissues proximal to the coxofemoral joint. Leriche<a></a> went beyond this in 1937 when he predicted that hemipelvectomy would one day be considered the operation of choice for malignant growths of the upper part of the thigh. Lee and Alt<a></a> in 1953 compared hip-joint disarticulation with hemipelvectomy from the point of view of anatomy and surgical technique, extent of postoperative disability and use of prosthesis, and therapeutic effectiveness. They found that under modern conditions there was no great difference between the two operations so far as surgery or postoperative disability are concerned, whereas hemipelvectomy definitely offered better hope of a cure. They therefore considered hemipelvectomy the procedure of choice for high-grade soft-tissue or osteogenic malignant tumors of the upper thigh as well as of the pelvis.</p> <p>Not all modern surgeons go so far as this. Coley<a></a> has emphasized that it is essential to discriminate between cases, the decision depending upon the site and grade of malignancy of the tumor. Osteosarcomas and chondrosarcomas of the lower fourth of the femur do not call for hip disarticulation and are better treated by high thigh amputation, since then considerably less disability results.</p> <p>In sum, allowing a wider margin between the tumor and the incision is now generally recognized to be necessary to ensure elimination of all malignant cells. This means that the level of amputation has tended to move in a proximal direction. While some hip disarticulations have been replaced by hemipelvectomy, high thigh amputations have also been replaced by hip disarticulation, so that no appreciable decrease in the number of hip disarticulations is to be expected as a result of this trend.</p> <h4>Surgical Fashioning of Stumps</h4> <p>The surgical techniques of hip disarticulation practiced today have evolved as a result of this many-faceted experience. Throughout the history of the operation, the sequence of procedures has been dictated primarily by cumulative experience in combating hemorrhage and shock. The shape of the resulting stump has been affected primarily by the change in indication for the operation from predominantly traumatic to predominantly malignant cases. To a lesser degree, the shape has been affected by considerations of healing and subsequent fitting with a prosthesis.</p> <h4>THE LARGE SOFT-TISSUE STUMP</h4> <p>The large soft-tissue stump popular during the early history of hip disarticulation (<b>Fig. 2</b>) may originally have been developed through association with a high-thigh stump. Surgeons first experimenting with the dangerous operation of hip disarticulation may well have been loath to cut away too much soft tissue. But many of the early operations were actually done by first performing a circular high thigh amputation and then disarticulating the head of the femur through a lateral incision.<a></a></p> <p>During the latter half of the nineteenth century, many experiments were carried out with various kinds of subperiosteal amputations, in which a cuff of periosteum was left overlapping the end of the bone stump. Difficult as it was to perform, a subperiosteal hip disarticulation was done several times. Originally devised by Oilier of Lyons in 1859, it was carried out by James Shuter<a></a> of London in 1881. A circular amputation was first performed at the junction of the middle and upper thirds of the thigh. The vessels were ligated, and through a longitudinal incision on the lateral aspect of the thigh the remaining portion of the femur was dissected out, leaving the periosteum (peeled off up to the intertrochanteric line) in the flaps.</p> <p>The advantage of this method, according to Shuter and others who observed the patient over a year after operation, was that the residual periosteum provided a point of attachment for the muscles and caused a growth of what Shuter termed "new bone" but which other observers described as "a firm resisting cord",<a></a> cartilaginous rather than bony in character. Observers testified that this "cord" provided such a good attachment for the muscles that they were "in a high state of nutrition" and that the patient not only could flex, extend, adduct, and abduct the stump powerfully but also could communicate all these movements to the artificial limb. Durand<a></a> of Lyons had a woman patient who, more than four years after a similar operation, had a regenerative process resembling a tough fibrous stalk, which also provided an excellent attachment for the muscles. She was able, he stated, to lift a weight of 15 kg. with her flexed stump.</p> <p>In a modern case<a></a> the patient, although apparently not operated upon subperiosteally, was said to have had a stump with many of the characteristics claimed for the subperiosteal stumps. Disarticulation was done for osteomyelitis of the femoral shaft, trochanter, and neck, a sequel to extensive injuries of the thigh. The femur was carefully dissected out from the surrounding tissues, leaving a soft-tissue stump measuring 6 in. when relaxed. It was reported that "The muscles had become attached to each other by scar tissue, so that there was actiye flexion and extension of the stump if one grasped the muscles with his hands." The patient was able to wear a suction-socket prosthesis, which he could flex and extend at the hip joint "because of the fixation of the skin and muscles to the side of the socket by the suction exerted upon the distal end of the stump." This method of activating the prosthesis was compared to that used by crustaceans in activating their exoskeletons, and a point was made of the importance in this case of designing the socket so that, upon weight-bearing, the contracted muscle mass would be properly positioned on the ischial seat beneath the ischial tuberosity.<a style="text-decoration:none;">*</a> About the turn of the century, subperiosteal amputations were gradually abandoned, mainly because of the frequency of undesirable growths of new bone emanating from the periosteal cuff. Apparently only a few subperiosteal hip disarticulations were performed. In addition to the uncontrollability of new bone growth, other, even more important, reasons prevented the operation from becoming popular. One was the difficulty of stripping the periosteum from a healthy bone. Shuter's subperiosteal operation was done for a suppurative process of the femur, in the course of which the periosteum had already achieved a considerable degree of natural separation from the bone. Durand did not mention a similar condition in his patient, but his operation was done for tuberculosis, and possibly a suppurative process was present. Another reason, much more significant today, was that the retention of the periosteum made the procedure unsuited for any disarticulation done because of a malignant neoplasm.</p> <h3>The Compact Stump</h3> <p>After disarticulation for malignancy, the hip stump commonly fashioned today is compact, with the soft tissues reduced to a minimum. When involvement of the inguinal nodes is proved, or, in certain disease, even suspected, a radical groin dissection is also done, thus removing even more tissue from the body.</p> <p>Most incisions today, whether of the anterior racquet or semioval type, start just below the inguinal ligament and thus provide immediate access to the femoral vessels and nerve in Scarpa's triangle. These incisions create a long posterior flap and leave an anterior scar that is well removed from terminal and lateral pressure areas and from any possibility of fecal contamination before wound-healing is complete. The semioval incision has the advantage of eliminating the "handle" of the racquet, which, if carried too far, may easily invade a pressure area under the pelvic corset of the prosthesis. For this reason, it would seem to be the incision of choice for the use of the Canadian-type hip-disarticulation prosthesis, as may be seen from Fig. 11, page 37. This prosthesis is, however, very adaptable and can easily be modified to accommodate a larger or smaller amount of soft tissues (even dog-ears). Bony prominences are not necessary to anchor it. If the wound has healed by first intention, it is no longer critical whether the scar lies under a pressure area.</p> <p>For further information on the modern technique of hip disarticulation, the reader is referred to Slocum's procedure, which is detailed on pages 242-244 of his work, <i>An Atlas of Amputations .</i><a></a> The muscles are sectioned in the avascular areas close to their tendinous origins or insertions. Some additional precautions against shock, as already discussed, may be found desirable in certain cases. For cases in which involvement or suspected involvement of the inguinal nodes necessitates radical groin dissection, Pack and Ehrlich's standard method<a></a> can be followed. A racquet incision, with the handle of the inverted <i>Y </i>extending proximally, is recommended for this procedure, which is carried out before the hip disarticulation. The only problem here is that the large skin flaps, denuded of all underlying subcutaneous fat, lymphatic tissue, and fascia, are susceptible to necrosis and sloughing along their edges. Not much can be done about this, since in order to be effective the procedure has to be thorough. Since the wound does not ordinarily heal by first intention, the scar, extending as it does well above the line of the inguinal ligament, may present problems in the fitting of the Canadian-type hip-disarticulation prosthesis.</p> <h3>Possibility of Short Thigh Stump</h3> <p>Most cases of malignancy, as we have seen, require radical removal not only of the bone but also of as much soft tissue as possible. When the amputation follows trauma or disease other than cancer, however, the question may arise as to whether to disarticulate or to leave a very short thigh stump. The improvement of artificial limbs, as well as of surgical techniques, has made it possible to fit above-knee amputees of higher and higher amputation level with thigh prostheses rather than with hip-disarticulation prostheses. In 1930, Verrall<a></a> stated that any stump measuring less than 5 in. below the greater trochanter had to be fitted with a tilting-table (hip-disarticulation) prosthesis. In 1949, Slocum stated<a></a> that "When amputation approaches the level of the lesser trochanter, the function of this [hip] joint is nullified ..." and that therefore a patient with an amputation at this level or higher had to be fitted with some type of hip-disarticulation prosthesis. The possibility of fitting a suction socket depends, however, not only on the length of the residual bone but also on the volume of the soft tissues which provide the seal for holding suction. Indeed, in the case of the man with a completely boneless stump (cf. p. 14), the soft tissues alone enabled him to wear a suction-socket prosthesis.</p> <p>The leverage provided by even a small segment of the femur is, of course, a great advantage in activating a prosthesis. Tikhonov<a></a> reported interesting experiments to lengthen a short residual femur by bone grafts. He said that it was not possible to give an absolute measurement for the shortest thigh stump which could activate a thigh prosthesis, since this length depended also on the volume of soft tissues, which varied from stump to stump. Instead, he gave a formula based on the relation of length to circumference. He also noted that except for extreme cases a stump should measure somewhere between 8.5 and 13.5 cm. (3.3 and 5.3 in.) from the perineum in order to allow for piston action of 2 to 3 cm. (about an inch) yet still permit the prosthesis to be moved in any direction. For the patient with other handicaps in addition to the very short thigh stump (such as amputation of the contralateral extremity or an upper-extremity amputation), Tikhonov and his co-workers recommended that surgical lengthening of the short stump be considered as a means of increasing the patient's ability to get about.</p> <p>Tikhonov reported on the lengthening of three short thigh stumps by from 3 to 6 cm. (1.2 to 2.4 in.). A homoplastic graft, taken from the diaphysis of the fibula, was inserted into the medullary canal of the femur. After a maximum period of observation of 10 months, he reported that bony union had already been achieved in two of the lengthened stumps and that these were providing satisfactory additional leverage for activating a prosthesis.</p> <h4>Possible Systemic Effects of Major Loss of Limb</h4> <p>As more patients have survived these drastic operations and have become subjects for rehabilitation, increasing attention has been paid to the possible medical consequences of the loss of so large a part of the body. The entire limb can now be removed without great risk of operative death, the patient can be fitted successfully with a prosthesis, and appropriate attention can be given to his psychological and vocational readjustment. Then this question arises: What is the <i>medical </i>outlook for such a patient? The same kind of question has been raised in regard to many diseases and disabilities to which corrective measures have been applied. Frequently, all of the medical consequences of a selected course of therapy cannot be foreseen. The physician asks himself: Am I doing the right thing? Will the radiation therapy that appears so beneficial now give rise to untold medical harm later? In the recent literature of several European countries, there have been raised questions about possible systemic aftereffects of major amputation which could hold much significance for the rehabilitation of amputees. The answers have proved difficult. Many of the opinions expressed have been supported only by clinical impressions or by studies lacking in desirable controls. Many have been accompanied by enthusiastic but untested hypotheses. It appears that, before this mass of information can be evaluated properly and before definitive answers can be obtained, the questions may need to be rephrased and made the subject of carefully controlled studies.</p> <p>In their examinations of amputees, many physicians have observed signs and symptoms and have obtained in clinical tests results which have led them to suspect that amputation is followed by an increased incidence of systemic disease. The review of published observations made by Schulze in Germany in 1942 shows that major limb amputations had at that time already been thought capable of leading to a rather startling list of disorders, including obesity, abnormally increased perspiration, arteriosclerosis, enlargement of the heart, damage to the heart muscle, hypertension, pulmonary tuberculosis, aggravation of bronchial asthma, various disturbances of the digestive system, kidney disease, deformities of the healthy leg and foot, joint deformities, and worsening of varicose veins.<a></a> Some of these conditions are more likely to occur after major amputation than are others. Aside from further changes in the musculoskeletal system, the most frequently claimed effects have been cardiovascular disease- especially hypertension-and changes in the regulation of body heat-in particular, excessive perspiration. German authors have advanced hypotheses to explain the development of these clinically observed phenomena.</p> <p>Sturm appears to have been interested in these problems since 1940 and has published recently, with two colleagues,<a></a> a report of detailed clinical studies on 150 amputees. Of these patients, 130 were at Bad Nenndorf for a "cure." Medical histories were elicited from them by means of a questionnaire and were amended through interview and examination. In addition, various tests of cardiovascular function were made, with amputees appropriately grouped, in order to show that the incidence of cardiovascular abnormalities increases with the length of time since amputation. In an earlier paper, Sturm<a></a> described a syndrome characteristic of a few patients with long-standing amputations of the thigh and with a history of severe suppuration of the stump. Examination of such a patient showed a pale angiospastic face, a definite lability of pulse rate and blood pressure, marked dermographism, increased reflex activity, fine tremor of the hands, moist skin, and increased luster of the sclera. Most of Sturm's observations were offered in support of his hypothesis that "vegetative regulatory disturbances" in amputees result from chronic hypothalamic irritation, which in turn arises (by a stated neuro-physiological mechanism) from prolonged infection, pain, and vasoconstriction of vessels of the stump.</p> <p>Schneider, <a></a> who observed an increase of systolic pressure to over 140 mm. Hg in 20 percent, and of diastolic pressure to over 100 mm. Hg in 5 percent, of 67 amputees, developed Sturm's thesis further. He hypothesized that pain (triggered by a neuroma, long-lasting suppuration, deep-tissue scars, or even the pressure of the prosthesis) could, in constitutionally predisposed patients, excite the central sympathetic area of the hypothalamus and eventually create a central lesion with resulting hypertonia. Schneider also pointed out that the role of psychosomatic factors should not be underestimated. The frustration and resulting emotional conflicts experienced by amputees who were attempting to compete with normal individuals could contribute to an early development of essential hypertension.</p> <p>Another hypothesis concerns the heat-regulating mechanism of the body and the changes which result in it from the loss of a leg. Excessive perspiration in high-thigh and hip-disarticulation amputees has been frequently observed on a clinical basis. Schroder<a></a> com- mented on the role played by the extremities in the cooling system of the body in providing arteriovenous shunts to direct the flow of blood into deep or superficial vessels as needed and in providing a large surface area for evaporation. To him, the loss of a whole lower extremity would appear to mean the loss of a valuable part of the cooling system at the same time that extra demands on energy are being made, with resulting excessive production of heat. Such phenomena would indicate an unusual burden on the circulatory system.</p> <p>These views have excited interest and aroused controversy. Although clinicians may observe in amputees pathological conditions which strongly suggest themselves to be the aftereffects of amputation, analyses of government health records, and clinical studies based on them, have failed thus far to confirm these observations in amputees as compared with equivalent nonamputee populations.</p> <p>The difficulties of assessing the aftereffects of amputation are well reflected in the reports, annotated in <i>Lancet, </i><a></a> of the committee of the Ministry of Pensions in England which in 1950 was asked to find whether amputation of a limb, and subsequent wearing of a prosthesis, could initiate or aggravate cardiovascular disorder and whether such amputation reduces the expectation of life. The interim report of this committee in 1951, termed "somewhat inconclusive," revealed in living amputee pensioners a slight elevation of the mean blood pressure but no abnormal incidence of cardiovascular disease. A more detailed study of death certificates suggested, although not to the point of statistical significance, that patients with leg amputations died earlier, and more commonly from cardiovascular disease, than comparable pensioners with leg wounds not requiring amputation. The majority report of the committee in 1953 introduced a new factor—calling for further committee investigation—by suggesting that men who have suffered major sepsis, with or without amputation, have a higher late incidence of cardiovascular disease and an earlier average death. The committee then arranged for the medical examination of 5500 pensioners, of whom 4500 were to be amputees and 1000 were to be controls, but unfortunately so many of this sample "failed to attend" that no firm conclusions could be drawn. In 1955, however, the committee, after reviewing all of its evidence, made the following statement:<a></a></p> <blockquote><p>Limb amputations, and the subsequent wearing of a prosthesis do not, in time, produce effects on the body as a whole which may initiate, or aggravate, cardiovascular disorders to any significant extent. There is no material difference between the mortality rates of amputees, by reason of amputation, and that of the corresponding rates for pensioners who have suffered wounds not leading to amputation. Such excess as there is in both classes over that in the general population is quite small.</p> </blockquote> <p>For the German regional government of Schleswig-Holstein, Meyeringh and Stefani<a></a> sought to determine the incidence of hypertension in 794 above-knee amputees. They found a resting systolic blood pressure of over 150 mm. Hg in 9 percent, which they compared with an incidence of over 10 percent in the "average German population."</p> <p>In reviewing the articles pertinent to this controversy, one begins to suspect that a single careful distinction might do much to resolve it. This distinction would be between <i>(a) </i>asserting that systemic disease does occur in amputees and is due at least in part to the fact of amputation and <i>(b) </i>asserting that systemic disease occurs more frequently in amputees than in other persons. Conceivably, the same person who develops high blood pressure owing to physiological stresses imposed by amputation could also have developed high blood pressure for different reasons of physiological stress had he retained his leg. Whereas this explanation would seem too simple, it is not too difficult to imagine a complex of factors at work that could mask from certain types of statistical examination a true relation between amputation and subsequent disease.</p> <p>It would seem a pity should too much energy be expended in statistical quibble. The question of relative incidence of systemic disease in amputees and in normals is an important question for practical reasons-such as life insurance, pensions, and the allotment of research funds. Of more moment, however, to researcher, practitioner, and amputee alike, is the question of how and why systemic disease develops in amputees and whether it can be averted in rehabilitation. Furthermore, far from being dispensable, statistical analyses of data obtained from groups of amputees and from appropriate control groups would be a tool valuable to this elucidation.</p> <p>Many factors offering clues to the situation have been taken into consideration to a greater or lesser extent by individual authors-predisposition to hypertension, prolonged suppuration associated with amputation, difference in level of amputation or amount of body mass lost, age at amputation, and obesity. Owing to the differences-or obscurities-regarding the selection of subjects, the use of controls, and the criteria for systemic disease, the results of these authors cannot be compared satisfactorily or generalized. The possible importance of activity or inactivity, the wearing of a prosthesis, and the stresses attached to home and work environments has hardly begun to be considered from the medical viewpoint of systemic disease! Investigation into the systemic effects of amputation could lead to conclusions beneficial not only to amputees with hip disarticulations and high thigh amputations but also to amputees with less serious disabilities and even to persons suffering from other disorders.</p> <h4>Summary</h4> <p>Hip disarticulation is a drastic amputation used almost exclusively as a last-resort or life-saving measure. A review of the medical history of the operation during the last 200 years shows a number of changes. The one with the most far-reaching implications has been the major shift from operations indicated by injury or by disease other than cancer to operations indicated by malignant growth. Better methods for controlling hemorrhage and shock, together with progress in adjunct therapy, have reduced operative deaths from as high as 91 percent in pre-Civil War military cases to none in a recent American series done for malignancies. But the postoperative mortality in cancer cases continues to be extremely high (in the aforementioned recent series, 85 percent within five years of operation). For this reason some hip disarticulations, when indicated at all for cancer, may well be indicated much earlier in the course of the disease if the operation is to be therapeutic rather than merely palliative.</p> <p>The shift in indication has also influenced the surgical shaping of the stump to the extent that today, in contrast to earlier methods, a maximal removal of soft tissues as well as bone is considered essential in cases of malignancy. In the rarer cases in which the indication for operation is trauma or some other type of disease, it is advantageous to leave, whenever possible, a small segment of the femur and additional soft tissues in the stump, thus making possible the use of an above-knee rather than a hip-disarticulation prosthesis. With the Canadian-type hip-disarticulation prosthesis, the shape of the stump is not critical, because this device can readily accommodate any irregularities of body form.</p> <p>Whether disturbances of cardiovascular function, or of other functions such as thermoregulation, occur as a result of the loss of so large a part of the body is today a controversial subject. Although systemic disease has been noted frequently in amputees with major loss of limb, no controlled studies have demonstrated convincingly that the incidence of systemic disease is greater in amputees than in comparable nonamputees. Similarly, hypotheses that have been advanced to explain how systemic disease develops as a result of amputation are interesting but still without substantial verification physiologically. This area should be an attractive one for further research.</p> <h4>Acknowledgment</h4> <p>The author wishes to express his gratitude to the many members of the Biomechanics Laboratory whose generous help and cooperation made this paper possible. A particular debt is owing to our staff writer, Jean C. Lieberman, Ph.D., who was responsible for much of the historical research basic to the paper and for assistance in its composition.</p> <p><b>References:</b></p> <ol> <li><i>An account of the operation of amputating the thigh at the upper articulation, lately performed by Mr. William Kerr, Surgeon to the Royal Regiment of Horse-Guards Blue, and to the Hospital in North-hampton. Communicated to Dr. Duncan, by Dr. Toll, Surgeon to the Fourth Regiment of Dragoons, </i>M. &amp; Philos. Commentaries, 6:337 (1779).</li> <li>Angerer, H., <i>Ein einfaches Vorgehen zur Verrin-gerung der Operalionsgefahr bei Exartikulationen im Huft- und Schullergelenk, </i>Zentralbl. 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Med., 9:184 (1852).</li> <li>Stajano, C, <i>El mecanismo del "choc" en la desar-ticulacion de la cadera, </i>Arch. urug. med., 10: 642 (1937).</li> <li>Strauss, Kurt, <i>Exarliculatio coxae bei Schwanger-schaft und allgemeiner Sepsis, </i>Miinchen. med. Wchnschr., 86:1751 (1939).</li> <li>Sturm, Alexander, <i>Hochdruck nach Oberschenkelam-putation, </i>Med. Klin., 48:197 (1953).</li> <li>Sturm, A., W. Frisch, and H. W. Griinewald,<i>Interne Auswirkungen von Beinamputationen; Ergebnis einer Reihenuntersuchung, </i>Medizinische, No. 35:1132 (1954).</li> <li>Thomson, John, <i>Report of observations made in theBritish military hospitals in Belgium after the Battle of Waterloo, </i>Blackwood, Edinburgh, 1816. pp. 259-279.</li> <li>Tikhonov, V. M., <i>Short thigh stump in children, itslengthening and preparation for prosthesis, </i>Tr. Tsentr. Nauchnoissledov. inst. protez. Moskva, 72:258 (1949). In Russian.</li> <li>Tixier and Arnulf, <i>Auto-transfusion au cours d'unedesarticulation de la hanclie, en utilisant le sang du membre enleei. Disarticulation pour epithelioma diveloppt sur une ancienne brulure de la cuisse et de la /esse jusqu'd Vanus; anus de Pollosson (derivation totale) prealable, </i>Lyon chir., 32:443 (1935).</li> <li>Trendelenburg, F., <i>Ueber Exarticulation des Ober-schenkels, </i>Arch. klin. Chir., 26:858 (1881).</li> <li>U. S. Surgeon General's Office, <i>Circular No. 7: areport on amputations at the hip-joint in military surgery </i>[By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</li> <li>U. S. Surgeon General's Office, <i>The medical andsurgical history of the War of the Rebellion (1861-1865), </i>U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: <i>Surgical history. </i>pp. 88, 89, 127-168.</li> <li>U. S. Surgeon General's Office, <i>The Medical De-partment of the U. S. Army in the World War, </i>U. S. Gov't. Print. Off., Washington, D. C, 1921-1929. Vol. II, <i>Surgery, </i>Part 1 <i>{General surgery, orthopedic surgery, neurosurgery).</i></li> <li>Velpeau, Alf. A. L. M., <i>New elements of operativesurgery, </i>1st American ed., from last [2nd] Paris ed. [1839], translated by P. S. Townsend, under supervision of Valentine Mott, S. S. &amp; W. Wood, New York, 1847. Vol. 2, pp. 637-653.</li> <li>Verrall, P. Jenner, <i>Some amputation problems,</i>roc. Roy. Soc. Med., 24:183 (1930).</li> <li>Wyeth, John A., <i>Bloodless amputation at the hipjoint, </i>New York Med. J., 61:528 (1890).</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>35.</b> </td><td class="clsTextSmall">Meyeringh, H., and H. Stefani, Besteht nach einerAmputation des Oberschenkels eine Neigung zur Adipositas und zur Hypertension?, Deutsche med. Wchnschr., 81:10 (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>38.</b> </td><td class="clsTextSmall">Outlook for the amputee (Annotation), Lancet, 1:89 (1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">The fate of the amputee (Annotation), Lancet, 1:633 (1953).</td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Outlook for the amputee (Annotation), Lancet, 1:89 (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>47.</b> </td><td class="clsTextSmall">Schroder, Joachim, Zur Frage einer besonderenKreislaufbelastung bei Gliedmassenamputierten infolge einer Mehrbeanspruchung ihrer War-meregulation, Deutsche med. Wchnschr., 81:1620 (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>46.</b> </td><td class="clsTextSmall">Schneider, K. W., Zur Frage der Plethora und Hy-pertonic bei Amputierten, Klin. Wchnschr., 31:697 (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>56.</b> </td><td class="clsTextSmall">Sturm, Alexander, Hochdruck nach Oberschenkelam-putation, Med. Klin., 48:197 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Sturm, A., W. Frisch, and H. W. Griinewald,Interne Auswirkungen von Beinamputationen; Ergebnis einer Reihenuntersuchung, Medizinische, No. 35:1132 (1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Schulze, Karl, Uber den Einfluss grosser Amputa-lionen auf den Gesamtorganismus; eine Studie zur Frage der Spatschaden bei Oberschenkelampu-tierten, Arbeit u. Gesundh., No. 41:69 (1942).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Tikhonov, V. M., Short thigh stump in children, itslengthening and preparation for prosthesis, Tr. Tsentr. Nauchnoissledov. inst. protez. Moskva, 72:258 (1949). In Russian.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations,osby, St. Louis, 1949. pp. 239-247, 402-410.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>66.</b> </td><td class="clsTextSmall">Verrall, P. Jenner, Some amputation problems,roc. Roy. Soc. Med., 24:183 (1930).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Pack, George T., and Harry E. Ehrlich, Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), Ann. Surg., 123:965 (1946). Parts I &amp;II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations,osby, St. Louis, 1949. pp. 239-247, 402-410.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Cf. discussion of very short thigh stumps, page 15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Hutter, Charles G., Suction-socket prosthesis for ahip-disarticulation amputee, J. Bone &amp;Joint Surg., 35A:230 (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>13.</b> </td><td class="clsTextSmall">Durand, M., De la disarticulation sous-periostee dela hanche et de ses avantages sur la methode ordinaire, Rev. chir., Paris, 17:646 (1897).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Shuter, James, Subperiosteal amputation at the hip-joint: formation of new bone in the stump: moveable stump: patient wearing an artificial limb, Trans. Clin. Soc. London, 16:86 (1883).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Shuter, James, Subperiosteal amputation at the hip-joint: formation of new bone in the stump: moveable stump: patient wearing an artificial limb, Trans. Clin. Soc. London, 16:86 (1883).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>21.</b> </td><td class="clsTextSmall">Gross, S. D., Report of the committee on surgery,rans. Kentucky State Med. Soc, 2:99 (1853).</td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">[Shuter, James], Subperiosteal amputation at thehip-joint, Report of Clinical Society of London, Brit. Med. J., 1:314 (1883).</td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Trendelenburg, F., Ueber Exarticulation des Ober-schenkels, Arch. klin. Chir., 26:858 (1881).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Coley, Bradley L., Neoplasms of bone, Hoeber,ew York, 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>29.</b> </td><td class="clsTextSmall">Lee, C. Marshall, Jr., and Lewis P. Alt, Hemi-pelvectomy and hip disarticulation for malignant tumors of the pelvis and lower extremity, Ann. Surg., 137:704 (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>30.</b> </td><td class="clsTextSmall">Leriche, Rene, A propos de 13 cas de disarticulationde la hanche, Mem. Acad, chir., 63:1435 (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>31.</b> </td><td class="clsTextSmall">Lewis, Royce C, and William H. Bickel, Hemi-pelvectomy for malignant disease, J.A.M.A., 165:8 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Coley, Bradley L., Neoplasms of bone, Hoeber,ew York, 1949.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">James, Arthur G., and Wesley Furste, Radicalsurgery for cancer of the extremities, Am. J. Surg., 85:503 (1953).</td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Lee, C. Marshall, Jr., and Lewis P. Alt, Hemi-pelvectomy and hip disarticulation for malignant tumors of the pelvis and lower extremity, Ann. Surg., 137:704 (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>39.</b> </td><td class="clsTextSmall">Pack, George T., Major exarticulations for malignantneoplasms of the extremities: interscapulothoracic amputation, hip-joint disarticulation and in-terilioabdominal amputation, J. Bone &amp;Joint Surg., 38A:249 (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>39.</b> </td><td class="clsTextSmall">Pack, George T., Major exarticulations for malignantneoplasms of the extremities: interscapulothoracic amputation, hip-joint disarticulation and in-terilioabdominal amputation, J. Bone &amp;Joint Surg., 38A:249 (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>39.</b> </td><td class="clsTextSmall">Pack, George T., Major exarticulations for malignantneoplasms of the extremities: interscapulothoracic amputation, hip-joint disarticulation and in-terilioabdominal amputation, J. Bone &amp;Joint Surg., 38A:249 (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>64.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The Medical De-partment of the U. S. Army in the World War, U. S. Gov't. Print. Off., Washington, D. C, 1921-1929. Vol. II, Surgery, Part 1 {General surgery, orthopedic surgery, neurosurgery).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Huard, P., Etudes sur les amputations el disarticu-lations des membres, Masson, Paris, 1940.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Pitkin, George P., Conduction anesthesia, 2nd ed.,ames L. Southworth, Robert A. Hingson, and Winifred M. Pitkin, eds., Lippincott, Philadelphia, 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>40.</b> </td><td class="clsTextSmall">Pack, George T., and Harry E. Ehrlich, Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), Ann. Surg., 123:965 (1946). Parts I &amp;II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Morris, Robert T., Hip joint amputation, ventralhernia, appendicitis, salpingitis, a clinic at the New York Post Graduate Medical School April 18, 1917, West. M. Times, 37:1 (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>7.</b> </td><td class="clsTextSmall">Bustos, Fernando M., Desarticulacion coxofemoral(profilaxis del shock por seccidn primaria del cidtico), Bol. y trab. Acad, argent, cir., 32:195 (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>5.</b> </td><td class="clsTextSmall">Boyd, Harold B., Anatomic disarticulation of thehip, Surg., Gyn., &amp;Obstet., 84:346 (1947).</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Bustos, Fernando M., Desarticulacion coxofemoral(profilaxis del shock por seccidn primaria del cidtico), Bol. y trab. Acad, argent, cir., 32:195 (1948).</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Caprio, Gerardo, Grandes desarticulaciones en laraiz de los miembros, Bol. Soc. cir. Uruguay, 22:518 (1951).</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Coley, Bradley L., Neoplasms of bone, Hoeber,ew York, 1949.</td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Grey, Jorge de Moraes, Actinomicose do membroinferior e desarliculacao da coxa. Consideracoes clinicas e technicas em torno de duas desarlicu-lacaos da coxa, Rev. brasil. cir., 11:159 (1942).</td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Leriche, Rene, A propos de 13 cas de disarticulationde la hanche, Mem. Acad, chir., 63:1435 (1937).</td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Maynard, R. L., Hip-joint disarticulations, Trans.ew England Surg. Soc, 24:248 (1941).</td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Morris, Robert T., Hip joint amputation, ventralhernia, appendicitis, salpingitis, a clinic at the New York Post Graduate Medical School April 18, 1917, West. M. Times, 37:1 (1917).</td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Pack, George T., and Harry E. Ehrlich, Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), Ann. Surg., 123:965 (1946). Parts I &amp;II.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Petrovskii, B. V., Method of disarticulation of thehip, Vestnik khir., 72:50 (1952). In Russian.</td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations,osby, St. Louis, 1949. pp. 239-247, 402-410.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Stajano, C, El mecanismo del 'choc' en la desar-ticulacion de la cadera, Arch. urug. med., 10: 642 (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>9.</b> </td><td class="clsTextSmall">Caprio, Gerardo, Grandes desarticulaciones en laraiz de los miembros, Bol. Soc. cir. Uruguay, 22:518 (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>41.</b> </td><td class="clsTextSmall">Petrovskii, B. V., Method of disarticulation of thehip, Vestnik khir., 72:50 (1952). In Russian.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Bustos, Fernando M., Desarticulacion coxofemoral(profilaxis del shock por seccidn primaria del cidtico), Bol. y trab. Acad, argent, cir., 32:195 (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>42.</b> </td><td class="clsTextSmall">Piquinela, Jose A., Desarticulacion de cadera.-Sutecnica de acuerdo con los principios del metodo de Callander, Arch. urug. med., 48:191 (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>51.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations,osby, St. Louis, 1949. pp. 239-247, 402-410.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Boyd, Harold B., Anatomic disarticulation of thehip, Surg., Gyn., &amp;Obstet., 84:346 (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>30.</b> </td><td class="clsTextSmall">Leriche, Rene, A propos de 13 cas de disarticulationde la hanche, Mem. Acad, chir., 63:1435 (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>8.</b> </td><td class="clsTextSmall">Callander, C. Latimer, A new amputation in thelower third of the thigh, J.A.M.A., 105:1746 (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>11.</b> </td><td class="clsTextSmall">Coley, Bradley L., Neoplasms of bone, Hoeber,ew York, 1949.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">GUlis, Leon, Amputations, Heinemann, London, 1954.</td></tr><tr><td class="clsTextSmall"><b> 25.</b> </td><td class="clsTextSmall">James, Arthur G., and Wesley Furste, Radicalsurgery for cancer of the extremities, Am. J. Surg., 85:503 (1953).</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">27. Kirk, Norman T., and Leonard T. Peterson,Amputations, Chapter 10 in Lewis' Practice of surgery, Prior, Hagerstown, Md., 1944. Vol. 3, pp. 84-87.</td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Pack, George T., and Harry E. Ehrlich, Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), Ann. Surg., 123:965 (1946). Parts I &amp;II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Angerer, H., Ein einfaches Vorgehen zur Verrin-gerung der Operalionsgefahr bei Exartikulationen im Huft- und Schullergelenk, Zentralbl. Chir., 69:1647 (1942).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Marquardt, Wolfgang, Gliedmassenamputationenund Gliederersatz, Wissensch. Verlagsges., Stuttgart, 1950. pp. 82-85.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire, 4thd., Masson, Paris, 1893-1895. pp. 648-678.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Giles, Roscoe C, and William T. Keig, The controlof bleeding in disarticulation of the hip by ligation of the common iliac artery and vein, Illinois Med. J., 106:209 (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>6.</b> </td><td class="clsTextSmall">Brooks, Barney, Exarticulation of the hip joint;with preliminary ligation of the common iliac artery, J.A.M.A., 76:94 (1921).</td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Halsted, W. S., The effect of ligation of the commoniliac artery on the circulation and function of the lower extremity. Report of a cure of ilio-femoral aneurism by the application of an aluminum band to that vessel, Bull. Johns Hopkins Hosp., 23:191 (1912).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Ghitzesco, C. I., La disarticulation de la hanche sousI'hemostase provisoire de l'artere iliaque primitive ou de I'hypogaslrique correspondante, Presse meU, 43:243 (1935).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">McBurney, Charles, Direct intra-abdominal finger-compression of the common iliac artery during amputation at the hip-joint, Ann. Surg., 25:610 (1897).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">[Shuter, James], Subperiosteal amputation at thehip-joint, Report of Clinical Society of London, Brit. Med. J., 1:314 (1883).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">Wyeth, John A., Bloodless amputation at the hipjoint, New York Med. J., 61:528 (1890).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Trendelenburg, F., Ueber Exarticulation des Ober-schenkels, Arch. klin. Chir., 26:858 (1881).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">Wyeth, John A., Bloodless amputation at the hipjoint, New York Med. J., 61:528 (1890).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, [L. H.], Communication orale sur ladisarticulation coxo-femorale, Bull, et mem. Soc. de chir., 4:180(1878).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, Circular No. 7: areport on amputations at the hip-joint in military surgery [By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, Circular No. 7: areport on amputations at the hip-joint in military surgery [By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, Circular No. 7: areport on amputations at the hip-joint in military surgery [By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>62.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, Circular No. 7: areport on amputations at the hip-joint in military surgery [By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Thus the figures that follow are not statistics of operative or even hospital deaths alone.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Larrey, Dominique Jean, Memoires de chirurgiemilitaire, et campagnes, J. Smith, Paris, 1812. Vol. 2, pp. 180-195. Vol. 3, p. 350.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Coley, Bradley L., Neoplasms of bone, Hoeber,ew York, 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>26.</b> </td><td class="clsTextSmall">Katz, Elias, Private communication.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Katz, Elias, Private communication.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, Circular No. 7: areport on amputations at the hip-joint in military surgery [By G. A. Otis], U. S. Gov't. Print. Off., Washington, D. C, 1867.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Beebe, Gilbert W., and Michael E. DeBakey,Battle casualties: incidence, mortality, and logistic considerations, Thomas, Springfield, Ill., 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>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Pack, George T., and Harry E. Ehrlich, Exarticu-lations of the lower extremities for malignant tumors: hip joint disarticulation (with and without deep iliac dissection) and sacro-iliac disarticulation (hemipelvectomy), Ann. Surg., 123:965 (1946). Parts I &amp;II.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Maynard, R. L., Hip-joint disarticulations, Trans.ew England Surg. Soc, 24:248 (1941).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Maynard, R. L., Hip-joint disarticulations, Trans.ew England Surg. Soc, 24:248 (1941).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Grey, Jorge de Moraes, Actinomicose do membroinferior e desarliculacao da coxa. Consideracoes clinicas e technicas em torno de duas desarlicu-lacaos da coxa, Rev. brasil. cir., 11:159 (1942).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Bustos, Fernando M., Desarticulacion coxofemoral(profilaxis del shock por seccidn primaria del cidtico), Bol. y trab. Acad, argent, cir., 32:195 (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>55.</b> </td><td class="clsTextSmall">Strauss, Kurt, Exarliculatio coxae bei Schwanger-schaft und allgemeiner Sepsis, Miinchen. med. Wchnschr., 86:1751 (1939).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Hutter, Charles G., Suction-socket prosthesis for ahip-disarticulation amputee, J. Bone &amp;Joint Surg., 35A:230 (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>30.</b> </td><td class="clsTextSmall">Leriche, Rene, A propos de 13 cas de disarticulationde la hanche, Mem. Acad, chir., 63:1435 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bolot, F., and P. Merz, Disarticulation de la hanchepour un osteosarcome du fimur ayant envahi les parties molles et provoque une himorragie grave, Maroc. med., 31:560 (1952). (Only title seen.)</td></tr><tr><td class="clsTextSmall"><b> 9.</b> </td><td class="clsTextSmall">Caprio, Gerardo, Grandes desarticulaciones en laraiz de los miembros, Bol. Soc. cir. Uruguay, 22:518 (1951).</td></tr><tr><td class="clsTextSmall"><b> 17.</b> </td><td class="clsTextSmall">Ghitzesco, C. I., La disarticulation de la hanche sousI'hemostase provisoire de l'artere iliaque primitive ou de I'hypogaslrique correspondante, Presse meU, 43:243 (1935).</td></tr><tr><td class="clsTextSmall"><b> 18.</b> </td><td class="clsTextSmall">Giles, Roscoe C, and William T. Keig, The controlof bleeding in disarticulation of the hip by ligation of the common iliac artery and vein, Illinois Med. J., 106:209 (1954).</td></tr><tr><td class="clsTextSmall"><b> 20.</b> </td><td class="clsTextSmall">Grey, Jorge de Moraes, Actinomicose do membroinferior e desarliculacao da coxa. Consideracoes clinicas e technicas em torno de duas desarlicu-lacaos da coxa, Rev. brasil. cir., 11:159 (1942).</td></tr><tr><td class="clsTextSmall"><b> 25.</b> </td><td class="clsTextSmall">James, Arthur G., and Wesley Furste, Radicalsurgery for cancer of the extremities, Am. J. Surg., 85:503 (1953).</td></tr><tr><td class="clsTextSmall"><b> 29.</b> </td><td class="clsTextSmall">Lee, C. Marshall, Jr., and Lewis P. Alt, Hemi-pelvectomy and hip disarticulation for malignant tumors of the pelvis and lower extremity, Ann. Surg., 137:704 (1953).</td></tr><tr><td class="clsTextSmall"><b> 30.</b> </td><td class="clsTextSmall">Leriche, Rene, A propos de 13 cas de disarticulationde la hanche, Mem. Acad, chir., 63:1435 (1937).</td></tr><tr><td class="clsTextSmall"><b> 34.</b> </td><td class="clsTextSmall">Maynard, R. L., Hip-joint disarticulations, Trans.ew England Surg. Soc, 24:248 (1941).</td></tr><tr><td class="clsTextSmall"><b> 39.</b> </td><td class="clsTextSmall">Pack, George T., Major exarticulations for malignantneoplasms of the extremities: interscapulothoracic amputation, hip-joint disarticulation and in-terilioabdominal amputation, J. Bone &amp;Joint Surg., 38A:249 (1956).</td></tr><tr><td class="clsTextSmall"><b> 41.</b> </td><td class="clsTextSmall">Petrovskii, B. V., Method of disarticulation of thehip, Vestnik khir., 72:50 (1952). In Russian.</td></tr><tr><td class="clsTextSmall"><b> 42.</b> </td><td class="clsTextSmall">Piquinela, Jose A., Desarticulacion de cadera.-Sutecnica de acuerdo con los principios del metodo de Callander, Arch. urug. med., 48:191 (1956).</td></tr><tr><td class="clsTextSmall"><b> 45.</b> </td><td class="clsTextSmall">Saltzstein, Harry C, Osteogenic sarcoma of upperthird of femur; well ten years after disarticulation at the hip joint, J. Michigan Med. Soc, 43:145 (1944).</td></tr><tr><td class="clsTextSmall"><b> 52.</b> </td><td class="clsTextSmall">Smith, Beverly Chew, Disarticulation of the hip forendothelioma (Ewing's tumor): 31-year follow-up, Ann. Surg., 115:318 (1942).</td></tr><tr><td class="clsTextSmall"><b> 54.</b> </td><td class="clsTextSmall">Stajano, C, El mecanismo del 'choc' en la desar-ticulacion de la cadera, Arch. urug. med., 10: 642 (1937).</td></tr><tr><td class="clsTextSmall"><b> 60.</b> </td><td class="clsTextSmall">Tixier and Arnulf, Auto-transfusion au cours d'unedesarticulation de la hanclie, en utilisant le sang du membre enleei. Disarticulation pour epithelioma diveloppt sur une ancienne brulure de la cuisse et de la /esse jusqu'd Vanus; anus de Pollosson (derivation totale) prealable, Lyon chir., 32:443 (1935).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Smith, S., Statistics of the operation of amputation atthe hip-joint, New York J. Med., 9:184 (1852).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Smith, S., Statistics of the operation of amputation atthe hip-joint, New York J. Med., 9:184 (1852).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Velpeau, Alf. A. L. M., New elements of operativesurgery, 1st American ed., from last [2nd] Paris ed. [1839], translated by P. S. Townsend, under supervision of Valentine Mott, S. S. &amp;W. Wood, New York, 1847. Vol. 2, pp. 637-653.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Coates, John Boyd, ed., Orthopedic surgery in theEuropean Theater of Operations, Office of the Surgeon General, Dept. of the Army, Washington, D. C, 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">Coates, John Boyd, ed., Orthopedic surgery in theEuropean Theater of Operations, Office of the Surgeon General, Dept. of the Army, Washington, D. C, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Beebe, Gilbert W., and Michael E. DeBakey,Battle casualties: incidence, mortality, and logistic considerations, Thomas, Springfield, Ill., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Coates, John Boyd, ed., Orthopedic surgery in theEuropean Theater of Operations, Office of the Surgeon General, Dept. of the Army, Washington, D. C, 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>12.</b> </td><td class="clsTextSmall">DeBakey, Michael E., and Fiorindo A. Simeone,Battle injuries of the arteries in World War II, Ann. Surg., 123:534 (1946).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Larrey, Dominique Jean, Memoires de chirurgiemilitaire, et campagnes, J. Smith, Paris, 1812. Vol. 2, pp. 180-195. Vol. 3, p. 350.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">U. S. Surgeon General's Office, The medical andsurgical history of the War of the Rebellion (1861-1865), U. S. Gov't. Print. Off., Washington, D. C, 1870-88. Part 3, vol. 2: Surgical history. pp. 88, 89, 127-168.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Thomson, John, Report of observations made in theBritish military hospitals in Belgium after the Battle of Waterloo, Blackwood, Edinburgh, 1816. pp. 259-279.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Or possibly a metastatic cancer of the lungs. At her death, 18 days after operation, an autopsy showed them to be almost totally reduced to matter.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">An account of the operation of amputating the thigh at the upper articulation, lately performed by Mr. William Kerr, Surgeon to the Royal Regiment of Horse-Guards Blue, and to the Hospital in North-hampton. Communicated to Dr. Duncan, by Dr. Toll, Surgeon to the Fourth Regiment of Dragoons, M. &amp; Philos. Commentaries, 6:337 (1779).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Morand, Sauveur Francois, Opuscules de chirurgie,esprez, Paris, 1768. Vol. 1, pp. 176-228.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In a case in which amputation of the thigh at the articulation with the hip bone appears to be the last resort for saving the life of a sick man, to determine whether this operation should be performed, and what would be the most advantageous method of doing it.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Richerand, cited in 60, p. 8.</td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Velpeau, Alf. A. L. M., New elements of operativesurgery, 1st American ed., from last [2nd] Paris ed. [1839], translated by P. S. Townsend, under supervision of Valentine Mott, S. S. &amp;W. Wood, New York, 1847. Vol. 2, pp. 637-653.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Morand, Sauveur Francois, Opuscules de chirurgie,esprez, Paris, 1768. Vol. 1, pp. 176-228.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Henry E. Loon, M.D. </b></td></tr><tr><td class="clsTextSmall">Research Orthopaedist, Biomechanics Laboratory, University of California Medical Center, San Francisco.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_02_004/aut57a-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_02_004/aut57a-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_02_004/aut57a-003.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 Past and Present Medical Significance of Hip Disarticulation Creator An entity primarily responsible for making the resource Henry E. Loon, M.D. * https://staging.drfop.org/files/original/ccadc98869e6d29f1877b5a8fac163d2.pdf 4a2ad8e2d9b2d3bb7c740d25f0dce310 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1962_02_001.pdf Year 1962 Volume 6 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1962_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1962_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Patellar-Tendon-Bearing Prosthesis</h2> <h5>Gabriel Rosenkranz, MD <a style="text-decoration:none;">*</a><br /></h5> <p>Obviously there is no "ideal" leg substitute short of regenerating or transplanting another normal leg. The surgeon, the prosthetist, and the amputee alike have long accepted major deficiencies in leg prostheses as inescapable concomitants of aid in a situation demanding drastic compromise. Substitution of an artificial leg for a natural one involves not only manual skills and the principles of inanimate mechanisms but is also dependent on anatomy, physiology, and biomechanics. Mutual application of these disciplines toward the advancement of leg prosthetics was slow in coming. As the science of astronomy emerged from the superstitions of astrology, so too there is sound reason to hope that the profession of prosthetics will continue to grow increasingly rapidly beyond the great dependence on "experience in the finger tips" of the ancient skill of limbmaking by adding to its art more general application of the discoveries of science.</p> <p>Time after time, like recurrent approaches of a comet from its far-reaching orbit, dazzling prospects of improvements in prostheses for below-knee amputees have illuminated the prosthetics scene. The slip socket, the many attempts at end-weight-bearing, the "muley" leg without side joints or corset, the single sidebar, the various polycentric joints, and the several attempts at below-knee suction sockets have been spectacular objects visible for varying periods in Europe, the United States, or alternately in both regions. Unhappily, these phenomena, like comets, have often receded into outer darkness as abruptly as they appeared, leaving the typical amputee with crutches, peg leg, or the centuries-old "conventional" prosthesis.</p> <p>Pads, straps, locks, and similar devices often reflect either lack of knowledge or incomplete application of such knowledge as there is to control pressure or to overcome instability. Freedom of the human knee joint, distribution of forces in proportion to tolerance of tissues, improved rather than constricted circulation, and better kinesthetic appreciation-all major goals in recent years-demand simplicity of mechanism and reduction of the false joint between the prosthesis and the body by use of an intimate fit.</p> <p>The patellar-tendon-bearing (PTB) prosthesis developed by the Biomechanics Laboratory of the University of California, to which much of this issue is devoted, combines many long-controversial features-each long used by some, yet rejected by others. PTB is almost a code name integrating a long list of elements which the prosthetist through logical principles and teachable techniques employs to distribute forces comfortably. Because of individual variations, not all so-called "PTB prostheses" contain all the major features. The name implies weight-bearing on the patellar tendon, more properly called the patellar ligament. Because in fact the nearby retinacula also share weight, perhaps the name might well be the "patellar-tendon-bearing" prosthesis! Actually, as later pages of this issue describe, many other areas of the socket (notably the closed distal end) are at least in contact with the stump, and some <i>(e.g., </i>the flares supporting the tibial condyles) share substantial portions of body weight.</p> <p>Because of its typical use of cuff suspension, with consequent freedom from thigh corset, the PTB prosthesis is often erroneously identified with the "muley" leg, which has stomped the field for as much as a century and yet has so often developed complications during prolonged use. One may speculate that the common complaints of instability of the knee attributed to the "muley" principle were at least partially related to poor alignment between socket and foot, excessive extension or even hyperextension of the socket axis and hence of the human knee, and needlessly low brim levels offering less than maximum stability to the stump. Careful prescription and medical supervision, not available for the earlier "muley," should also characterize use of the PTB and greatly enhance its chances of success.</p> <p>This writer's personal observations, from visits to the birthplace of PTB and to numerous clinics throughout the United States, have indicated misconceptions of the role of knee flexion in initial alignment of the socket axis. Certainly hyperextension is to be avoided and mild flexion sought. Because the <i>cast </i>is taken with the knee in substantial (possibly excessive?) flexion, some newly trained prosthetists initially aligned the socket bore similarly but with a very large angle of flexion. The horizontal components of forces on the condyles were reduced; but the resulting extreme bent-knee gait was tiring, the quadriceps were unduly stressed in their atrophied state immediately after their release from bondage within the thigh corset, and the unique mechanical stability of the extended human knee was transformed into the capability of substantial horizontal rotation of the flexed knee. In the below-knee amputee lacking an actively steerable ankle and foot, an unimpaired but controlled horizontal rotation in the knee joint must be considered of added importance. Thus neither the rigid "screw-home" of final extension nor the gross instability of major flexion will be as suitable as mild flexion with control of unencumbered hamstrings as internal and external rotators.</p> <p>In many past efforts too little attention has been paid to the popliteal space. The PTB includes logical principles allowing a higher brim in the popliteal space (and indeed on all aspects) than has been customary in a majority of cases yet freedom for action of the hamstrings and avoidance of bulging of tissue during sitting. The high brims medially and laterally, reflecting better appreciation of anatomy and of the force patterns dictated by biomechanics. should give greater mediolateral stability than was typically available with a "muley" limb. Eventual use of brims of tapering flexibility, by avoiding sharp pressure points at the very edge, may ultimately allow still better fitting.</p> <p>No one, especially among its developers, would acclaim the PTB as the ultimate solution. Some of its features represent successive reincarnations over a century, each with a higher survival percentage. Yet the PTB is only an evolutionary step toward greater mechanical freedom under butter neuromuscular discipline. Many apparent failures can be salvaged by careful adherence to the principles and techniques enunciated in the UCB manual and its recent revision and in the following papers of this issue of Artificial Limbs.</p> <p>The conveniences which the PTB leg accords its wearer are so numerous that continued efforts seem assured. Though a single breaker may recede, the tide is surely coming in.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Gabriel Rosenkranz, MD </b></td></tr><tr><td class="clsTextSmall">Surgical Consultant, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York 1, New York.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Patellar-Tendon-Bearing Prosthesis Creator An entity primarily responsible for making the resource Gabriel Rosenkranz, MD * https://staging.drfop.org/files/original/c8a6de84d03266c8bc9f6d6fbbd73688.pdf d1910921582f687b0864172e72031731 https://staging.drfop.org/files/original/1485e4d578f1b428ab1272868a562fc9.jpg 7f8190e7460853fcb6038029386ab1b8 https://staging.drfop.org/files/original/50626bc64a6c233af5c84abb7e6df06f.jpg cc5e165fe7160341865c6791ffbdf829 https://staging.drfop.org/files/original/a164e3f6134e5ced2d7e9cbcdad0579e.jpg 5901261c3142163ed97b63077e119af1 https://staging.drfop.org/files/original/3eb28fac21b5adb765e964436bd2f075.jpg aa6fff355b3e7a00e8413bfd9665f54c https://staging.drfop.org/files/original/f0969d5ad22c3d7d3386e1840992de54.jpg 40d2b29106fe4f7b4648d916a305851e https://staging.drfop.org/files/original/b8a15397236070a1928f734b01eb7ada.jpg aa0f0ea19415d3b62b627c9f367e717a https://staging.drfop.org/files/original/cb45f9034e87770a17262895139a95e2.jpg 0a2949048e4a5d562595657a3d9747e4 https://staging.drfop.org/files/original/ddfff8a45792bdbaff35b784cf009351.jpg ba30758487795821efba0587640fe3a8 https://staging.drfop.org/files/original/07ffd06b6d225ed567e2848bba985e83.jpg e3b152af1db7fd6c4894d6db133288ad https://staging.drfop.org/files/original/97f84bc7e3ced60be18d3ffe0df9cdca.jpg 2040d3bd5e41d0d2959bed152fa4c1cc https://staging.drfop.org/files/original/e57ff3235c3552832ed937f2e20f0f02.jpg 866160e477f752c327061c13dc0be413 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_004.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 4 - 13 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_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 Patellar-Tendon-Bearing Prosthesis for Below-Knee Amputees, a Review of Technique and Criteria</h2> <h5>James Foort, M.A.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p><i>At a recent meeting of the Workshop Panel on Lower-Extremity Fitting <a></a>, which is sponsored by the Subcommittee on Design and Development of the Committee on Prosthetics Research and Development, there was prolonged discussion of below-knee prostheses. Questions were raised concerning the adequacy of the PTB design for many patients, especially patients who were longtime users of the joint-corset, below-knee limb. The view was expressed that the expenditures of time and money in achieving a successful PTB fit did not justify the selection of the PTB prosthesis or a conversion to it, and that the use of a joint-corset prosthesis initially would shorten the prosthetic restoration process for most patients.</i></p> <p><i>It was recognized that the private practitioner is often forced to elect the simplest and least expensive procedure for his patient. Institutional facilities, on the other hand, can take more of the patient's time, without having the often-required succession of visits reflected in direct cost to the patient or to the sponsor. Yet, the panel was of the opinion that some prosthetists probably are still committing errors in fitting PTB prostheses, resulting in deterioration of the stump, excessive shrinkage, or edema. Moreover, criteria for use of the joint-corset prosthesis are still misunderstood.</i></p> <p><i>Fortunately, the Workshop Panel on Lower-Extremity Fitting had the benefit of the counsel of James Foort, formerly of the University of California (Berkeley) but now of the Prosthetics-Orthotics Research and Development Unit at Manitoba Rehabilitation Hospital, Winnipeg, Canada Mr. Fool spoke at length on the PTB design and then agreed to put his comments in writing for the benefit of clinicians the world over. Presented below is his helpful review of the subject.</i></p> <p><i>We are indeed indebted to Mr. Foort for his contribution. The clear expression of certain axioms will, hopefully, solve some of the problems experienced in the fitting of this very important prosthetic appliance.</i></p> <p><i>Anthony Staros <a style="text-decoration:none;">*</a> - Chairman, Workshop Panel on Lower-Extremity Fitting</i></p> <p>The patellar-tendon-bearing (PTB) prosthesis has been in use for more than five years. It was fully discussed in the June 1962 issue of <i>Artificial Limbs <a></a>. </i>Although experience suggests that approximately 90 per cent of all below-knee amputees can benefit from the use of the PTB prosthesis, a substantial number of prosthetists continue to fit joint-corset prostheses to a large proportion of their patients. Apparently, these prosthetists and their clients have found that maintenance and replacement costs outweighed the fabrication and functional advantages of PTB prostheses. Difficulties developing from the use of the PTB prosthesis are said to be edema, stump breakdown, and stump shrinkage. With these difficulties in mind, the purpose of this review is to examine the fitting technique for PTB's, emphasizing factors to be considered in avoiding or overcoming the difficulties and outlining criteria for use of joint-corset prostheses.</p> <h3>PTB Fitting Technique</h3> <p>The most common error made with a PTB socket is an excessively tight fit in the popliteal area of the stump. Too large a bulge in the popliteal area can be constrictive, affecting circulation, causing edema, and in turn leading to deterioration of the stump end. <i>Posterior pressure needed to balance the posteriorly directed force against the patellar tendon by the weight-bearing bar of the socket must be provided by the posterior and posteromedial aspects of the tibial condyles and the overlying tendonous structures, as well as by the popliteal area of the stump. (First factor.)</i></p> <p>Emphasis on the patellar tendon as a weight-bearing structure has contributed to constriction of the stump in the popliteal area. <i>The posterior and posteromedial aspects of the tibial condyles and the overlying tendonous structures are important weight-bearing surfaces of the stump. (Second factor.)</i></p> <p>In order to make the area for pressure against the popliteal surface of the stump larger, many prosthetists have extended the back of the socket up into the space between the hamstring tendons, cutting grooves to relieve the tendons during knee flexion. This design can contribute to constriction of circulation in the popliteal area when the amputee stands or sits. <i>The back brim of the socket should be formed into a broad, flared surface against which the hamstring tendons can rest when the amputee sits. (Third factor.) </i>So shaped, the back brim of the socket can be made sufficiently high to provide the large support area needed to minimize pressure while holding the patellar tendon in position on the weight-bearing bar and still ensure sitting comfort (<b>Fig. 1</b>). When the back brim is made higher, as for a short stump, the flare also lifts the stump out of the socket and supports it when the amputee sits.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Two views of a temporary plastic PTB socket showing the flared posterior brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Edema is also caused by constriction at the mid-stump level, and such constriction can result from the cumulative effects of modifying the plaster stump model. The least desirable modification is that made in the lateral fibula area. This modification is meant to help stabilize the stump mediolaterally in the socket, but the fibula is a poor structure against which to stabilize. <i>To achieve mediolateral stability of the stump in the socket, the socket should fit securely against either side of the tibial crest and against the medial and lateral surfaces of the knee joint. (Fourth factor.) </i>Mediolateral stability is a problem only if the foot is set in or out too far. <i>The socket should be placed over the foot so that there is little tendency for the prosthesis to tilt medially or laterally on the slump as the amputee walks. (Fifth factor)</i></p> <p>Although breakdown at the end of the stump is sometimes attributed to pressure on the end, a more likely cause is constriction at the mid-stump level. Tightness around the middle third of the stump gives the amputee the feeling that the end is contacting the bottom of the socket or that the tissues are being pulled up against the end of the bone. There are, however, circumstances in which end pressure is damaging and painful. <i>The socket should support distal tissues with sufficient pressure to aid venous and lymphatic return without pressing against the bone ends. (Sixth factor.) </i>If the stump has been amputated through cancellous bone, however, the bone end may be an important weight-bearing surface (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. A very short stump which is capable of bearing considerable weight on the end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Frequently, the anterodistal tibia area is painful because of the thin cutaneous covering; it is also vulnerable to excessive pressure because of poor circulation. Hollowing out the socket in this region usually does not give the expected relief. Foot alignment, as viewed from the side, and a stiff heel action can be the causes of difficulty. <i>The foot should be pliant and aligned to give a smooth rolling action as the amputee walks, as though the foot were a segment of a wheel run. (Seventh factor.) </i>If, so to speak, the "hub of the wheel" is too far back, the end of the stump is forced forward painfully against the socket as the amputee attempts to control the prosthesis at heel contact by active extension of the knee. This problem is especially pronounced with recent amputees who have not become skilled at regulating the forces against the stump by appropriate coordination of knee and body actions. A softer heel wedge, increased plantar-flexion of the foot (or extension of the socket), or moving the foot forward (least likely) can reduce discomfort at the anterodistal end of the stump resulting from these causes.</p> <p>General tightness is sometimes considered a source of trouble-and may be initially. But a socket should fit snugly, especially for a recent amputee or one who has not worn a PTB prosthesis before. The newly fitted amputee may have to remove the insert from the socket shell, put it on the stump, powder it, and force it back into the socket shell, even when he is wearing only a cast sock over the stump. One should be sure, however, that the socket bears weight evenly on the main support areas and that it also supports the distal tissues. If the socket does provide proper support, the imprint of the stump sock on the skin will be even in appearance, with the important support areas on the stump somewhat reddened. During the early phases of walking, the amputee should not use the prosthesis excessively. Soon his stump will become accommodated, and then he will be able to use a wool sock. <i>Tissues which are snugly pressed in a socket will shrink until pressures are reduced to suitable levels. (Eighth factor.) </i>Sometimes when the stump is fitted snugly, a vacuum develops during the swing phase and has a tendency to produce edema. To correct this problem, holes -sufficiently large to prevent hissing noises- may be drilled into the prosthesis, or the suspension system should be made more effective.</p> <p>All these factors must be kept in mind when an impression is made over the stump and the plaster model of the stump is shaped for use as a socket mold.</p> <h4>Taking The Plaster Impression</h4> <p>It is not easy to outline a specific procedure for taking a plaster cast of an amputee's stump. Stumps vary in the amount and resiliency of tissue covering the skeletal frame to be fitted. Moreover, the size, strength, and shape of prosthetists' hands and their sense of pressure-all unique to the individual-vary considerably. But if the impression is made tightly over the weight-bearing areas of the stump, these areas will be better defined than if the cast is made looser, regardless of these other differences.</p> <ol> <li>The impression should be started at the knee. The plaster-of-Paris bandage is wrapped tight, starting at the superior edge of the patella. As each pass is made around the knee, the plaster is formed up higher on either side of the knee by guiding it upward with the fingers of the left hand (<b>Fig. 3</b>). At the back, the cast should cover the knee crease by about two finger widths. Wrapping continues in this manner down to the level of the tibial tubercle.</li><li>Next, an effort must be made to obtain an accurate imprint of the medial flare of the tibia (<b>Fig. 4</b>). The plaster-of-Paris bandage is pulled up against the medial flare with even tension, and each turn is anchored to the lateral surface of the knee. Thus tissue tension is prevented from driving the plaster away from this important support area.</li><li>The rest of the stump is wrapped with less tension.</li><li>The plaster is smoothed over the entire stump and worked around the bony areas. As the plaster is worked, the stump is palpated to determine how it should be held for shaping.</li><li>Just before the plaster begins to set, the thumbtips are positioned on either side of the patellar tendon, close to its edges, so that the plaster-of-Paris bandage is pulled in against the tendon as pressure is applied. This position of the thumbs precludes intrusion into the spaces under the edge of the patella medially and laterally. The fingers are placed around the media] flare of the tibia and held flat against the back of the stump. It is important <i>not </i>to push into the popliteal space with the fingertips. Where the fingers encircle the lateral side of the stump, they are not in contact, Across the back of the stump, they are straight and exert pressure against the posterior aspects of the lateral tibial condyle and the popliteal area. Very little force should be used. The cast has been wrapped tight at the top to obtain an imprint of the stump close to the required shape, and the cast is held to ensure that the required support areas will be well defined when it sets (<b>Fig. 5</b>).</li><li>When the plaster impression can hold its shape, the thumbs are used to obtain a clear imprint of the anterior crest of the tibia by moderately caving in the semi-set plaster along a 3/4-in. strip on each side of the tibia to within an inch of the end (<b>Fig. 6</b>). The impression will now be wedge-shaped in front. Just before the plaster sets firmly, the hands are returned to the holding position, and the cast is held until it can be taken from the stump. This holding-squeezing action flattens the back and ensures retention of the required anteroposterior width.</li></ol> <p><b>Fig. 3</b>, <b>Fig. 4</b>, <b>Fig. 5</b>, <b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Starting the plaster impression and guiding the plaster upward along the sides of the knee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Pulling the plaster-of-Paris bandage against the medial flare of the tibia to obtain an accurate impression of this important support area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Holding the cast with moderate pressure and with the fingers flat across the back. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Caving in the plaster on either side of the tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Modifying The Model</h4> <p>It is desirable to modify the plaster stump model as soon as possible after the impression is taken, while the recollection of details is still strong.</p> <ol> <li>A groove is carved in the patellar-tendon ridge with a 1/2-in. self-cleaning rasp to a depth of about 1/2 in. The groove is made halfway between the inferior edge of the patella and the tibial tubercle. The groove should be about 3/4-in. wide between the upper and lower edge, and the edges should be smoothly curved toward the patella and toward the tibial tubercle (see <b>Fig. 7</b>).</li><li>Modifications on either side of the crest of the tibia are made in the usual way. <a></a></li><li>The medial flare area is smoothed first with a curved self-cleaning rasp to make the flare blend in with lower sections of the model and then with wire screening, which should be swept around the natural contours of the flare extending into the posterior area and even over the hamstring tendons (see <b>Fig. 8</b>).</li><li>The back of the model is flattened and smoothed over the popliteal area; care must be taken <i>not </i>to indent this area.</li><li>The flattened surface at the back of the model is extended downward and blended in with the more distal parts of the model by shaving off small amounts of plaster.</li><li>The model is smoothed on either side of the knee. If necessary, material is carved away to reduce the model to the measured width of the knee. This area is important, because it contributes to stabilization of the stump in the socket. The lateral side of the socket stabilizes the medial flare of the tibia against its weight-bearing surface in the socket. Sometimes a very slender amputee will find that when he sits, the wide part of his femoral condyles binds against the socket at the top. To correct this, the socket should be heated in that area and forced outward to give relief.</li><li>Plaster is added to the model in bony areas such as the head of the fibula, the crest of the tibia (especially toward the distal end), and the ends of the fibula and tibia. If the crests of the tibial condyles are prominent, extra space should be provided for them in the socket. They and the tibial tubercle seldom present problems if the patellar-tendon shelf has the proper dimensions, because then the socket is forced away from those prominences.</li><li>Before constructing the posterior flare on the plaster model, it is necessary to mark the socket trim lines on the model. First, a line is drawn circumscribing the model at the mid-patellar-tendon level and perpendicular to the long axis of the model. This line defines the back brim for the average type of stump. <i>A </i>shorter stump will be fitted higher at the back, depending on how short it is. Next, a line drawn through the middle of the patella and upward on either side gives the shape of the medial and lateral extensions of the socket. On the lateral side, the line will pass straight down through the posterolateral corner of the model to cross the posterior reference line. The corner can be rounded so that the lines join with a 1/2-in. radius. On the medial side, the trim line should be further in from the side so that the posteromedial curve is retained in the socket to help provide posterior support to the stump. This is possible because the medial hamstring tendons are toward the midline of the stump. After the model has been secured in a vise with the popliteal area up and the long axis of the model horizontal, plaster is poured above the trim line at the back (<b>Fig. 9</b>). When the plaster has set slightly, a 3/4-in. flare is formed by smoothing the plaster with wet fingers and thumb. It is seldom necessary to adjust the fit of the flare for relief of the low-set medial hamstring tendons, even though the socket curves around to the back on that side, because the flare allows the tendons to support considerable pressure comfortably. (For a medial view of the modified model, see <b>Fig. 10</b>.)</li></ol> <p><b>Fig. 7</b>, <b>Fig. 8</b>, <b>Fig. 9</b>, <b>Fig. 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The patellar-tenclon groove. A, Carving the groove in the patellar-tendon ridge on the plaster model; B, the finished form of the groove. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The finished form of the medial flare area on the plaster model. A, An anterior view; B, a posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Marking and forming the posterior flare on the plaster model, which has been secured in a vise with the popliteal area up. Top, the line circumscribing the model at mid-patellar-tendon level defines the level of the back brim of the socket. Center, plaster is poured onto the model above the trim line and allowed to set slightly. Bottom, wet fingers and thumb are used to form the posterior flare. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Medial view of the modified model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Stump Shrinkage</h4> <p>Even the seasoned stump can shrink. To the prosthetist this is a problem of economic significance, because his guarantee provides for repair or replacement. The worst of it is that when the socket of a PTB prosthesis is no longer satisfactory and must be replaced, there is little the prosthetist can do but rebuild the prosthesis completely. The least that can be done is to lay in material between the socket shell and the insert or to cast RTV Silastic resin under the stump. This sometimes affects alignment, which then must be adjusted. If the weight-bearing area can be modified easily, it is good practice to take a new cast of the stump, prepare a new model, and make a new insert over it. The new insert will support the stump distally, while the modified brim area gives satisfactory weight support and stabilization.</p> <p>Actually, what is needed is a different approach to the provision of prostheses. The recent amputee should be provided with a well-fitted limb to which a series of sockets can be easily attached until the stump has become stable. Then a final fitting can be made. At present, the permanent limb is often fitted as soon as the shrinker bandage treatment has been completed. The forces imposed on the stump by the prosthesis are much greater than can be developed by the shrinker bandage. Also, the socket forces are different in location. In addition to the loss of control and harmful forces that develop between the stump and the prosthesis, the reduced bulk of distal tissues leaves them unsupported and prone to edema.</p> <p>When the stump is fitted tightly, as recommended here, the initial discomfort will diminish as the stump shrinks and molds into shape. Finally, the amputee will be able to don his prosthesis while wearing a wool stump sock.</p> <h4>Perspiration and Maceration of the Stump</h4> <p>There have always been amputees who have suffered maceration of the stump end as a result of accumulation of perspiration in their sockets. Contributing to the heat in a PTB prosthesis are the rubber-leather insert, the thick plastic shell and surrounding materials, the closed end of the socket, and the tightness of fit. Ventilation is poor, even when holes are drilled through the walls of the socket. Use of a valve system, such as that designed at the Navy Prosthetics Research Laboratory, which allows air to enter slowly and forces it to escape up through the sock, could be helpful provided noise is avoided; and porous plastic laminates, such as have been developed at the Army Medical Biomechanical Research Laboratory, may be of some use as a solution to the problem. The most likely immediate solution is to make the socket thin, somewhat pliable, perforated, and without an insert. Such a socket must be titled with care, since there is no soft insert to provide a margin for error and to permit easy modification of the socket. A socket constructed of four to six layers of stockinet laminated with two turns of glass-cloth covering from the top to the tibial tubercle will serve. The socket, supported in a plastic receptacle (<b>Fig. 11</b>), can easily be replaced without seriously affecting the entire prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Temporary plastic socket and the receptacle into which it fits. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Use of Joint-Corset Prostheses</h3> <p>Under ideal conditions, the percentage of amputees who use joint-corset prostheses might be as low as 10 per cent. There is no doubt that the joint-corset system can make up for deficiencies in the fit of the socket and thereby serve as a safety factor when the proper lit of a PTB prosthesis is not achieved or maintained. Hut there are definite criteria which can be used for the prescription of a joint-corset prosthesis.</p> <p>Sometimes the amputee's occupatjon requires him to use his prosthesis under heavy-duty conditions; he may be required to pry up or lift heavy objects. <i>When the amputee must place a force on his prosthesis which is considerably greater than the weight of his body, a joint-corset prosthesis aids him by permitting part of the weight to be borne on the thigh. (First criterion </i>) The joint-corset system is especially effective when the knee is slightly flexed so that forces are borne by the back of the thigh and are transmitted to the shank through the side joints. When the thrust on the prosthesis is along its axis, the amputee can prepare for it by temporarily tightening his thigh corset.</p> <p>Many amputees kneel, climb ladders, or climb stairs frequently. Such activities may be especially difficult or troublesome to the bilateral amputee because of rotation of the PTB prosthesis on the stump. <i>The joint-corset system prevents the prosthesis from rotating about the amputated leg when the joints are flexed. (Second criterion.)</i></p> <p>There is the rare amputee whose knee is unstable, or whose musculature is so weak that the joint-corset system is required. <i>The joint-corset system can stabilize an unstable knee against extreme mediolateral motions; against dislocations; and, when a back-check is used, against hyperextension of the knee. (Third criterion.)</i></p> <p>For the amputee with a stable knee, however, the corset is functionally limited as a mediolateral stabilizer because of the thinness of the joints, the fleshy nature of the thigh, and the pliability of the leather corset. Only if the amputee also bears weight on the corset", or has an extremely atrophied thigh against which he laces the corset tightly, or the corset extends to the peroneal level with cross braces between the side joints, will the corset be of much value as a mediolateral stabilizer.</p> <p>Also rare are amputees who cannot bear weight effectively either on the stump or through the femur. <i>An amputee who cannot bear weight on the stump should be fitted with a quadrilateral ischial-gluteal weight-bearing support and have straps connecting the thigh to the side joints above the knee for control of flexion and extension and for suspension of the prosthesis. (Fourth criterion.)</i></p> <p>Sometimes an amputee is mentally retarded or senile. In such an event, especially if there are no qualified helpers to ensure that the prosthesis is donned correctly, the joint-corset system should be used. <i>The joint-corset system is an aid in ensuring that a prosthesis is correctly placed on the amputated limb when the amputee's judgment is questionable. (Fifth criterion.)</i></p> <p>A problem often faced by the prosthetist fitting a PTB prosthesis to an experienced wearer of a joint-corset prosthesis is that the amputee is not prepared to make the change, either because he doubts that he can do so successfully or easily, or because he has a definite bias toward the joint-corset prosthesis. <i>The joint-corset system should be used when there are definite psychological pressures favoring it. (Sixth criterion.)</i></p> <h3>Conclusions</h3> <p>Probably many prosthetists who fit the PTB prosthesis successfully have discovered for themselves, or have learned from previous experience with other prostheses, how to deviate from established procedures. For those who have difficulties, this review may be of assistance. But it may be necessary to have those who are successful demonstrate to those who are not. Short-term or immediate success should not mislead those who are trying to establish improvements. Often it is only after a year or so that results can be judged. Meanwhile, encouragement should be given to those who seek to develop devices and techniques which will eliminate as many as possible of the craft-oriented tasks needed to fit amputees, thereby increasing reliability and uniformity.</p> <p><b>References:</b></p> <ol> <li>Artificial Limbs, June 1962.</li> <li>National Academy of Sciences-National Research Council, Committee on Prosthetics Research and Development, <i>Report of third workshop panel on lower-extremity fitting, November 4-6, 1964.</i></li> <li>Radcliffe, C. W., and J. Foort, <i>The patellar-tendon-bearing below-knee prosthesis, </i>Biomechanics Laboratory, University of California (Berkeley and San Francisco), 1961.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California (Berkeley and San Francisco), 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Artificial Limbs, June 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Director, Veterans Administration Prosthetics Center, 252 Seventh Avenue, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">National Academy of Sciences-National Research Council, Committee on Prosthetics Research and Development, Report of third workshop panel on lower-extremity fitting, November 4-6, 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>James Foort, M.A.Sc. </b></td></tr><tr><td class="clsTextSmall">Technical Director, Prosthetics-Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, 800 Sherbrook St., Winnipeg 2, Man.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1965_01_004/tmp1F18-11.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 Patellar-Tendon-Bearing Prosthesis for Below-Knee Amputees, a Review of Technique and Criteria Creator An entity primarily responsible for making the resource James Foort, M.A.Sc. * https://staging.drfop.org/files/original/d824e24cf044272c06c6c6eef12d0ea7.pdf c91b6f3dbdcb7034212884899f66193b DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_02_00i.pdf Year 1968 Volume 12 Issue 2 Page Number(s) i - iii Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_02_00i.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_02_00i.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 Problem of the Geriatric Amputee</h2> <h5>Herbert E. Pedersen, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>It has been demonstrated that 70 to 90 per cent of all peacetime amputations result from gangrene in the lower extremities of elderly patients. Hansson<a></a> reported that in Sweden the amputation rate in males over 60 years of age rose from 34 per 100,000 population in 1947 to 129 per 100,000 in 1962. He predicted that those rates would continue to rise. Our experience in the United States seems to parallel that in Sweden, and therefore interest in the specific problems of the "geriatric" amputee is now high.</p> <p>During the period of increasing incidence, the mortality rate following amputation for gangrene has declined sharply, from 45 per cent to approximately 5 per cent for all amputations. Furthermore, studies show that, following amputation, patients live long enough to justify every effort at their rehabilitation, and that when they effectively use a prosthesis they live longer and the remaining extremity survives longer.</p> <p>For some time it has been recognized that the lower the level of a successful amputation the greater the chance that the patient will effectively use a suitable prosthesis. The most important factor in the ability of the geriatric amputee to use effectively a satisfactory prosthesis is the presence of the knee joint. In the absence of other complications, the patient who was able to walk before the onset of his disease should be able to walk with any type of satisfactory prosthesis after amputation below the knee once the stump is well healed.</p> <p>It is apparent that the current problem of the geriatric amputee is not primarily one of prosthetic components, prosthesis design, fitting and alignment, or gait training. The current problem of the geriatric amputee is preservation of the knee joint.</p> <p>For at least 20 years literature has been available which discusses the specific indications for amputation levels of the lower extremity and details the surgical techniques necessary to ensure successful amputations at low levels in the ischemic extremity. The principles set forth in that literature became very important to surgeons who were particularly interested in amputations. Recently, as the result of the work of Burgess et al. on immediate postsurgical fitting and the concomitant upsurge of interest in amputations, many more surgeons have come to recognize the importance of these principles. The research project headed by Burgess and sponsored by the Prosthetic and Sensory Aids Service of the Veterans Administration, aside from its other important contributions, has done more to stimulate interest in amputations than any other single peacetime venture.</p> <p>Despite the renewed interest in amputations, it is still true, unfortunately, that most amputations for gangrene are performed by surgeons who are much more interested in other problems. Far too many feel that the nature of the disease makes amputation above the knee inevitable, or that the mortality and morbidity associated with unsuccessful attempts at amputation at low levels preclude such efforts. The techniques for successful management of delayed healing are poorly understood. In many areas it is still not recognized that the problem in diabetes, leading to progressive lower-extremity tissue necrosis, is frequently uncontrolled infection, rather than ischemia.</p> <p>This all suggests that in terms of man-hours, dollars, and total available facilities, great improvement in the rehabilitation of the geriatric amputee can come from a more efficient educational program which will lead to a higher incidence of successful amputations at low levels.</p> <p>It has been suggested that to reach the surgeons who perform most of the amputations for gangrene there is need for a document which is generally accepted and widely distributed, and which will be read by those surgeons. In 1961 the Committee on Prosthetics Research and Development, recognizing the need for improvement in the rehabilitation of the geriatric amputee, sponsored a conference for the purpose of stimulating research in that area. The report of the conference, <i>The Geriatric Amputee </i>(NAS Publication 919), was well received, and, in addition to serving its original purpose as a reference for research personnel, has been used extensively in education and training of medical and paramedical personnel. New knowledge has made obsolete much that is contained in <i>The Geriatric Amputee</i>, and CPRD has recommended to the Committee on Prosthetic-Orthotic Education that the necessary steps be taken to provide an authoritative document that will be useful to all who are engaged or expect to be engaged in the rehabilitation of the geriatric amputee. To this end, CPOE is calling upon a number of individuals from various disciplines with vast experience to assist in the preparation of such a document.</p> <p>Surgeons need not wait, however, until publication of this volume to begin to take positive action to improve the lot of future geriatric amputees. They should review the literature and take every action possible to retain the knee joint in the geriatric case when amputation is indicated.</p> <p><b>References:</b></p> <ol> <li>Hansson, Jan, <i>The leg amputee</i>, Acta Orthop. Scand. (Suppl.), <b>69</b>:1-104, 1964.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Hansson, Jan, The leg amputee, Acta Orthop. Scand. (Suppl.), 69:1-104, 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>Herbert E. Pedersen, M.D. </b></td></tr><tr><td class="clsTextSmall">Chairman, Committee on Prosthetic-Orthotic Education, National Research Council, 2101 Constitution Ave., N.W., Washington, D. C. 20418; Chairman, Department of Orthopaedic Surgery, Wayne State University Medical School, Detroit, Mich. 48207</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 Problem of the Geriatric Amputee Creator An entity primarily responsible for making the resource Herbert E. Pedersen, M.D. * https://staging.drfop.org/files/original/99ea32a0e2c94d4c7589431c1ce25157.pdf 2e7fbc0fa2eb0306b0ca796e5ddda33f https://staging.drfop.org/files/original/db98a4319f901a5df31650f9d7aaafee.jpg 0fa803d29cb641dc7320e3d9a863936f https://staging.drfop.org/files/original/64d9411b67eb520fc954e715926b9298.jpg 726bcec99286d9cecafabb7eb8dc978d https://staging.drfop.org/files/original/16c6695c898c94d3672358c548efdb97.jpg 79d67a4e4d9d172c26b6a84ae56bf6d9 https://staging.drfop.org/files/original/52576dcdb3ac9adc947bf94d02d02a39.jpg ea6217584377d64348133ea09815076b https://staging.drfop.org/files/original/58f2050e89cae296d63c129ffca2499c.jpg e164595194dd9613126ebed26bc18d6f https://staging.drfop.org/files/original/e2bcd7e4954572b656575f76c6af042f.jpg a1cd131317ea4a80a7ff5fa68bb4b971 https://staging.drfop.org/files/original/ab3796e5b9f95a10bab6a6a4709fa759.jpg 929d3223aba1e1b2a7483eeebec5b0cd https://staging.drfop.org/files/original/c6047dac85ad7f0f42b9c09184f5c29b.jpg 65c71a86ab2789401328078e47ef9466 https://staging.drfop.org/files/original/ecf16ce9b6a02f16a28b7068eae7fa6a.jpg bfd62cca40c1d6ea9aa12468949eb70a https://staging.drfop.org/files/original/f517f80846ccc5574405da3e9e1627c2.jpg fde37795ae610a1848e2baff68929c95 https://staging.drfop.org/files/original/f762ec99d412e60f2d8d35ce9d55db87.jpg e26a637f131da62ed04ac2a515036959 https://staging.drfop.org/files/original/b166d882aab8ca9bff2a7ca99b8d8045.jpg 5dfee50cca7846001283b3b9c216796f https://staging.drfop.org/files/original/d6e1c536ddb7878b64b3bb95f1c31c0f.jpg c09e884e976731eb2d27af842c9614ad https://staging.drfop.org/files/original/c751d02f21559b315e9457299166cfeb.jpg 8d9e303bb98ad2f59b8056e9ffca5dca DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_001.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 1 - 18 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_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 Prosthetics and Orthotics Program</h2> <h5>A. Bennett Wilson. Jr. <a style="text-decoration:none;">*</a><br /></h5> <p> Early in 1945, at the request of the Surgeon General of the Army, the National Research Council sponsored a conference of surgeons, engineers, physicists, and prosthetists to consider the feasibility of effecting improvements in artificial limbs<a></a>. Conclusions that emerged from the conference were that virtually no organized research of significance had been conducted in the field of limb prosthetics, and that application of technology already in existence should produce improved devices. </p> <p> Organization of Research Program</p> <p>Subsequently, at the request of the surgeon general, the NRC established the Committee on Prosthetic Devices (later the Committee on Artificial Limbs) to organize a research program<a></a>. (The members of the Committee on Prosthetic Devices were: Paul E. Klopsteg, Ph.D., Chairman; Harold R. Conn, M.D.; Roy D. McClure, M.D.; Robert R. McMath, D.Sc; Mieth Maeser; Paul B. Magnuson, M.D.; Edmond M. Wagner; and Philip D. Wilson, M.D. Consultants: Robert S. Allen and Charles F. Kettering.) Subcontracts were entered into with sixteen universities, industrial laboratories, and foundations: </p> <ul> <li>Adel Precision Products Corp., Burbank, Calif. </li><li>Armour Research Foundation, Chicago, Ill. </li><li>C. C. Bradley and Sons, Inc., Syracuse, N.Y. (Catranis, Inc.) </li><li> Goodyear Tire and Rubber Co., Akron, Ohio </li><li>A. J. Hosmer Corp., Los Angeles, Calif. </li><li>International Business Machines Corp., Endicott, N.Y. </li><li> Mellon Institute of Industrial Research, Pittsburgh, Pa. </li> <li> National Research and Manufacturing Co., San Diego, Calif. </li> <li> Northrop Aircraft, Inc., Hawthorne, Calif. </li> <li> Northwestern University, Evanston, Ill. </li> <li> Research Institute Foundation, Detroit, Mich. </li> <li> Sierra Engineering Co., Sierra Madre, Calif. </li> <li> United States Plywood Corp., New Rochelle, N.Y. </li> <li> University of California, Berkeley and San Francisco, and Los Angeles </li> <li> Vard, Inc., Pasadena, Calif. </li> </ul> <p> Funds were initially supplied by the Office of Scientific Research and Development. With the impending disestablishment of OSRD shortly after World War II, the Office of the Surgeon General of the Army for a short time assumed fiscal responsibility for the program. Then, for fiscal year 1947, the Army and the Veterans Administration shared the support. The Army, the Navy, and the Veterans Administration cooperated by establishing laboratories within their own organizations. </p> <p> In some laboratories, development of components and application of new materials was begun, but it soon became clear to the committee that more knowledge of the patients' requirements was needed if significant progress was to be made. This in turn required a more detailed knowledge of the biomechanics of human extremities, and thus projects in this area were started. Also, anthropometric data were obtained with the idea of selecting rationally a series of standard sizes of components. </p> <p> The activities of the various groups were initially coordinated by the Committee on Artificial Limbs, and considerable progress was made during the first two years. By the spring of 1947, the committee felt that it had completed its task of establishing an organized program and suggested that contracts between the government and the research laboratories be made directly, and that the committee be reconstituted as an advisory group to the sponsoring agency. At that time, the majority of service-connected amputees had been discharged from the armed forces, and their medical care had become the responsibility of the Veterans Administration. Therefore, new contracts were effected between the VA and those laboratories in which promising developments were identifiable (1947: Catranis, Inc.; Northrop Aircraft, Inc.; University of California, Berkeley and San Francisco, and Los Angeles; 1948: New York University.) At the request of the VA, the NRC established the Advisory Committee on Artificial Limbs to continue the coordination and the correlation of the program. The Army, the Navy, and the VA continued to operate their own laboratories. </p> <p> The general feeling at the beginning of the program was that the solution to the problem of providing better prostheses lay in developing new devices, and rapid advances were made by applying new materials and fabrication methods. It was apparent, however, that fit, suspension, and control were at least as important as components were in the successful use of an artificial limb, and perhaps even more so. Letters of inquiry were sent by the committee early in its history to all known limb manufacturers, and one of the first subcontracts was made with the Research Institute Foundation, a laboratory operated by the Orthopedic Appliance and Limb Manufacturers Association. </p> <p> In the spring of 1946, arrangements were made with certain prosthetists to fit experimental suction-socket above-knee limbs, with cooperation from local surgeons and assistance from the committee staff. Studies to establish the principles of socket configuration, fitting, and alignment were initiated as supplements to the existing projects. Both fitting and harnessing of artificial arms were studied at other projects. </p> <h4> Public Law 729 </h4> <p> In 1948, the Eightieth Congress, recognizing the need for continuity in a program of this kind, passed Public Law 729, which authorized the expenditure of $1,000,000 annually for research in limb prosthetics and sensory aids (amended by P.L. 85-56, Eighty-fifth Congress, to remove the $1,000,000 limitation). The Veterans Administration was designated as the appropriate agency for the administration of the funds, and the Administrator of Veterans Affairs was authorized and encouraged to make the results of the proposed program widely available, so that all disabled persons might benefit. </p> <h4> Suction-Socket "Schools" </h4> <p> By October 1948, experience in a number of experimental settings indicated that the suction socket provided significant advantages over other methods of fitting and suspension for above-knee amputations, and that the technique should be released for general use. Because of the many factors which enter into the successful application of the suction socket, however, the publication of a teaching manual was not considered sufficient to ensure success. Therefore, with the assistance of the Orthopedic Appliance and Limb Manufacturers Association (now the American Orthotic and Prosthetic Association) and a distinguished group of surgeons, the NRC organized a series of regional workshops to teach surgeons and prosthetists the proper application of the suction socket. The University of California at Berkeley was assigned the initial responsibility for this program. The regional workshops were continued under VA auspices with cooperation of OALMA through 1952, by which time it was felt that the suction-socket technique had become established. During the entire program, approximately forty workshops were held. </p> <h4> Prosthetics Education Program </h4> <p> Through the findings of the UCLA case study and other endeavors, a considerable body of knowledge in upper-extremity prosthetics had been accumulated by 1952. Hence, the development was undertaken of a medium through which knowledge about the greatly improved devices and techniques that were available could be disseminated throughout the nation. Since the new developments involved the use of plastic laminates for all upper-extremity amputation levels, the time required for thorough instruction in fabrication of prostheses ruled out the use of regional teaching sessions. The Veterans Administration therefore financed the organization and operation of the Prosthetics Education Program at the University of California at Los Angeles. Following a pilot school in 1952 for teams from the Chicago area, participation in the UCLA cources was ultimately extended to surgeons, physicians, occupational and physical therapists, and prosthetists from all over the United States. Prosthetists attended for six weeks; they were joined by the therapists for the last two weeks, and by the physicians and surgeons for the final week, during which these disciplines worked together as a clinic team. </p> <p> The upper-extremity courses proved to be extremely popular and very successful. During the initial, intensive phase of the program (1953-55), 12 courses were conducted. As a result of these efforts, personnel constituting 75 specialized amputee clinics, and representing 30 states and the District of Columbia, were trained. Twenty-eight of these clinics were held at Veterans Administration installations, while 47 were at other public and private institutions. Concomitant with the upper-extremity education program, the VA funded a nationwide field study, conducted by New York University, to assess the value not only of specific devices but also of the treatment program taught at the schools. This study gathered much useful information and also served to reinforce the instructional material. </p> <p> This combined education-research program not only served to introduce new improved concepts in the management of upper-extremity amputees, but also was a tremendous stimulus to the formation of amputee clinics and clinic teams throughout the nation. Today, more than 400 amputee clinics staffed with trained personnel are in operation in the United States. This treatment concept has also spread to other countries throughout the world. </p> <p> The education program at UCLA proved to be so successful that the VA sponsored the establishment of a similar education program at New York University in 1956 to meet the needs of clinic personnel. Subsequently, the Vocational Rehabilitation Administration funded an additional prosthetics school at Northwestern University in 1959. As new devices and techniques emerged from the research program, additional courses were developed at all three schools, so that today every aspect of amputee management is covered. </p> <h4> Present Program Organization</h4> <p> By 1953, the Advisory Committee on Artificial Limbs recognized that child amputees had special problems, and began to work with the Michigan Crippled Children Commission to determine what might be done to solve some of these problems. The Children's Bureau supported the establishment of several research centers, and in 1955 the committee created the Subcommittee on Child Prosthetics Problems. </p> <p> From the beginning, the committee had felt that much of the experience gained in research in limb prosthetics was applicable to the field of orthopedic bracing, but it recognized that problems in orthotics were even more complex. Therefore, work was initially concentrated on prosthetics. About 1960, the Committee on Prosthetics Research and Development took steps to assist in the development of improved orthotic devices and techniques. At the present time, an active program in orthotics, supplementary and complementary to the prosthetics program, is under way. </p> <p> In 1966, at the request of the Veterans Administration, CPRD formed the Subcommittee on Sensory Aids to advise the VA concerning its research program in that area. The subcommittee also serves the Social and Rehabilitation Service in the same capacity. </p> <p> Prior to 1954, most of the research, development, and education activities in prosthetics and orthotics in the United States were supported by the Veterans Administration. In 1954, Congress enacted the Vocational Rehabilitation Act, which for the first time authorized the Office of Vocational Rehabilitation (later the Vocational Rehabilitation Administration and now the Social and Rehabilitation Service of the Department of Health, Education, and Welfare) to support research and education in rehabilitation. The prosthetics and orthotics research and education programs of the VRA were initiated gradually, beginning in 1955-a significant milestone being the assumption of the fiscal responsibility for the three prosthetics schools. </p> <p> Today the Veterans Administration, the Social and Rehabilitation Service, the Maternal and Child Health Service, and, to a limited extent, the National Institutes of Health, all support extramural research in these fields. The VA, the Army, and the Navy also operate research and development laboratories as part of their respective organizational endeavors. </p> <p> The VA, SRS, and MCHS support the Committee on Prosthetics Research and Development, which is responsible for correlating the various research projects and for advising the interested governmental agencies on matters related to prosthetics and orthotics. The VA and SRS also support the Committee on Prosthetic-Orthotic Education of the Division of Medical Sciences, National Academy of Sciences—National Research Council. CPOE's activities are directed toward the stimulation of educational programs for medical and paramedical personnel. </p> <p> Laboratories supported by the VA, SRS, MCHS, the Army, and the Navy, and their areas of interest, are listed at the end of this article. </p> <h4> Accomplishments </h4> <p> As a result of the research program, virtually every aspect of the management of amputees has been changed and improved. A similar program has now been initiated in orthotics, with the findings of the prosthetics program already strongly influencing research and clinical practice in orthotics. </p> <h4> Fundamental Studies </h4> <p> The fundamental studies supported originally by the VA, supplemented later by support from SRS and NIH mainly at the University of California at Berkeley and at Los Angeles<a></a>, have widely increased our knowledge about human locomotion, phantom pain, the functions of the upper extremities, the properties of voluntary muscle, and energy consumption. These studies not only have provided the basis for most of the new designs that have emerged from the research program but also have proven to be a stimulus to others to investigate the basic principles underlying the neuromuscular system. It is anticipated that fundamental studies will continue to contribute to the total research effort. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical force-plate results for a normal subject during level walking, illustrative of the information obtained in fundamental studies. (From Klopsteg, Wilson, et at., "Human Limbs and Their Substitutes,'' p. 453.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Fitting, Alignment, and Harnessing Techniques </h4> <p> Prior to the research program, it was the general surgical practice to amputate at certain specified levels, referred to as "sites of election." Most lower-extremity amputations resulted either in below-knee stumps that were six inches or shorter, or, in the case of above-knee amputations, in stumps no longer than two-thirds the length of the original thigh. Similar circumstances prevailed for upper-extremity amputations. The primary reason for these surgical practices was the lack of satisfactory techniques for fitting the longer stumps, especially those involving disarticulation, despite the fact that, in most cases, the longer the stump, the more functional it is. Improved techniques have now been developed for fitting stumps at all levels, and surgeons have been encouraged to save all length medically feasible. <b>Fig. 2</b>,<b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Force-length measurement of a biceps tunnel. (From "Human Limbs and Their Substitutes," p. 328.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Total-tension I, passive P, and developed-tension ? curves for flexor muscles of the human forearm. (From "Human Limbs and Their Substitutes," p. 328.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> New approaches to alignment based on biomechanics have been established for most amputation levels. New devices to aid in achieving optimum alignment have been devised and made available commercially. Descriptions of the new alignment principles, techniques, and instruments have been widely published, and their application is stressed in the Prosthetics Education Program. <b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. A quadrilateral, total-contact socket developed for above-knee amputees under the program at University of California, Los Angeles. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> As an outcome of biomechanical analyses, new lower-extremity socket designs have been developed for all levels of amputation. The new socket designs have revolutionized fitting practices not only in the United States but also throughout the world. <b>Fig. 5</b>,<b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The figure-eight, ring-type harness for below-elbow amputees developed at Northwestern University. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The prosthesis for a Syme's amputation developed by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> New harnessing techniques for upper-extremity prostheses, also based on biomechanical analyses, have been developed and made available for general use. </p> <p> Not only have the new fitting, alignment, and harnessing techniques provided the patient with increased function and comfort, but they also are easier for the prosthetist to apply than the older methods. <b>Fig. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The casting jig for above-knee stumps developed by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Among the more significant techniques developed under the program are: the plastic Syme prosthesis, the patellar-tendon-bearing below-knee prosthesis and its variations, the quadrilateral total-contact above-knee socket (with or without suction suspension), the Canadian-type hip-disarticulation and hemipelvectomy prostheses, and various plastic-socket designs for upper-extremity amputations. </p> <h4> Devices </h4> <p> A large number of mechanical components have been developed to provide additional or improved functions. While most of the designs have involved individual components, each was planned in relation to the total prosthesis. Hence, these new items can be used in various combinations to meet the needs of each individual patient. Noteworthy examples among the components developed through the research program are: the harness-operated elbow lock, the APRL voluntary-closing hand and hook, the Northrop 2-load hook, voluntary-opening hand sizes 1-5, the SACH foot, the Henschke-Mauch "Hydraulik" knee units, the Hosmer-DuPaCo "Hermes" unit, and the UCB pneumatic knee unit. <b>Fig. 8</b>,<b>Fig. 9</b>,<b>Fig. 10</b>,<b>Fig. 11</b><b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The Henschke-Mauch "Hydraulik" knee unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The APRL-Sierra Model 44C artificial hand (without glove). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. The Northrop Model C elbow unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The Multiplex above-knee pylon-type prosthesis. Various knee-control devices are interchangeable when this unit is used. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. A below-knee prosthesis fabricated of synthetic balata, with a cosmetic cover, developed by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Clinic-Team Concept </h4> <p> As a planned objective of the VA research program, the clinic-team concept was introduced and encouraged as the preferred method of amputee management. The results achieved have fully established the validity of this concept in providing superior service to the amputee and in promoting more successful use of prostheses. Today, utilization of the amputee clinic team is standard practice in the VA, and many state agencies have followed the lead of the VA by insisting that their patients be treated by a clinic team. Moreover, as a result of the VA experience, the Children's Bureau has encouraged the establishment of more than twenty specialized clinics throughout the United States to serve child amputees. <b>Fig. 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Steps in the clinic-team procedure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Specifications and Checkout Procedures</h4> <p> In the course of the research program, specifications for manufactured components have been developed. The Veterans Administration Prosthetics Center in New York City regularly checks components against the specifications in order to insure that quality is being maintained. This procedure not only insures the provision of safe, durable devices to veterans, but also helps to keep the quality of the devices used by others at a high level. </p> <p> Procedures designed to assure that the total prosthesis is adequately constructed, fitted, and aligned have been developed for the use of clinic teams. These "checkout" procedures are modified as new devices and techniques become available, and have been of great assistance in raising the quality of amputee management. </p> <h4> Reduction in Rehabilitation Time </h4> <p> As a result of the introduction of immediate postoperative fitting procedures<a></a>and early fitting procedures, a substantial reduction in the time between amputation and return to home and job has been effected. The use of a rigid dressing immediately after amputation also helps to reduce edema and pain. </p> <p> At one time it was the rule in many hospitals, once the decision was made to remove part of a limb because of peripheral vascular disease, to amputate through the thigh because of the better blood supply in that region. Various studies have shown, however, that the knee joints in peripheral vascular cases can, with judicious care, be saved. As a result of these studies, rehabilitation time for many geriatric cases has been reduced even further. Indeed, the probability of rehabilitation itself can be markedly increased. </p> <h4> Reduction in Costs </h4> <p> The Veterans Administration has shown that, because of improved devices and procedures for fitting and aligning prostheses, artificial limbs were lasting twice as long in 1968 as they were in 1948. Although the average cost of artificial limbs increased 116.5% during that period, the increased "life" reduced the cost per year per eligible amputee veteran to about the same as it was in 1948.<a></a> </p> <p> In addition to an effective reduction in the cost of the devices, repair, maintenance, and clinic visits were also reduced substantially. There has been no discernible increase in the number of prosthetists in the United States over the past 20 years, yet the number of patients being served has increased considerably during that period, owing to the increase in the general population and to an increase in the number of amputations because of peripheral vascular disease in a population surviving to greater ages. </p> <h4> Dissemination of Information </h4> <p> <i>Prosthetics Education Program</i> </p> <p> The Prosthetics Education Programs originally established by the VA for training its clinic teams have proven to be extremely successful. The short-term courses have made possible the rapid and effective introduction to clinic teams of the new devices and techniques developed by the research program. </p> <p> Since the Prosthetics Education Program was organized in 1953, over 15,000 students have attended the courses offered by the three participating schools-New York University, Northwestern University, and the University of California at Los Angeles. </p> <p> <i>Degree and Associate in Arts Programs</i> </p> <p> Historically, the provision of educational opportunities in a given discipline has tended to create a demand for further education. This phenomenon has also been true of prosthetists and ortho-tists, and has led to the establishment of longer-term courses at several institutions. <b>Fig. 14</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. A typical laboratory scene in prosthetics-orthotics education. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> New York University undertook the most ambitious venture by establishing, in 1964, a four-year curriculum in prosthetics and orthotics leading to the Bachelor of Science degree. Two-year courses leading to the degree of Associate in Arts in prosthetics were begun at Chicago City Junior College (1965) and Cerritos College (1964). </p> <p> These expanding educational endeavors, plus numerous additional offerings such as the certificate course at UCLA and the technicians course at Delgado College, have raised the standard of prosthetics- orthotics practice at all levels, and have exerted a steady upward pressure on the requirements for certification. </p> <p> <i>Publications</i> </p> <p> From the beginning of the research program, it has been the policy of the sponsoring agencies to make new information available as it is developed to those concerned with the welfare of the amputee. This program, which has involved both periodic and special reports,<a></a> was financed initially by the Veterans Administration. SRS and the MCHS have since added their support. </p> <p> <i>Artificial Limbs, </i>a semiannual journal, was created in 1953 to provide a vehicle for dissemination of timely information, primarily to clinic-team personnel. Publication and distribution of the journal is the responsibility of the Committee on Prosthetics Research and Development, and it is mailed gratis to more than 4300 physicians, surgeons, therapists, pros-thetists, and research personnel. </p> <p> In 1961, the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development inaugurated the publication of the <i>Inter-Clinic Information Bulletin, </i>a monthly bulletin which serves as a vehicle for the exchange of information between child amputee clinics. The material for each issue is provided on a regularly scheduled basis by the 29 clinics affiliated with the SCPP's cooperative research program. More than 2500 copies of the ICIB are distributed gratis each month to interested individuals and institutions in the United States and abroad. </p> <p> In 1964, the Prosthetic and Sensory Aids Service of the VA began publication of its own semiannual journal, the <i>Bulletin of Prosthetics Research, </i>which is designed primarily to meet the needs of PSAS and covers a wide range of topics. It is available from the Superintendent of Documents of the U.S. Government Printing Office. Typically, some 2300 copies of each issue are sold, in addition to an official distribution of 3500 copies. </p> <p> In 1954, <i>Human Limbs and Their Substitutes<a></a>, </i>published by McGraw-Hill Book Company, was prepared principally from manuscripts developed by research personnel supported by the VA, and with the collaboration of the Office of the Surgeon General of the Army. This book was essentially a report on the results of the research program up to that time, and contains much basic information. Four thousand copies were printed, and the book had been out of print after 1960 until it was reprinted by the Hafner Publishing Company in 1968. </p> <p> Reports of special conferences organized by the Committee on Prosthetics Research and Development have been prepared in order to provide information useful to others as well as to those attending the meeting.<a></a> </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>TR 10-6, Prosthetic and Sensory Aids Service, Veterans Administration, August 1969. </li> <li>Committee on Artificial Limbs, National Research Council, <i>Terminal research reports on artificial limbs covering the period from 1 April 1945 through 30 June 1947 </i>(to the Office of the Surgeon General of the Army and the U.S. Veterans Administration).</li> <li>Committee on Prosthetics Research and Development, Selected bibliography on limb prosthetics, <i>Artif. Limbs, </i>12:2:42-48, Autumn 1968. </li> <li>Klopsteg, Paul E., Philip D. Wilson, et al., <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954. (Reprint edition, Hafner, 1968) </li> <li>Talley, William H., Prosthetics research-a cost reduction program, an editorial, <i>Bull. Pros. Res. </i>10-10, Fall 1968. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>Report to the Committee on Artificial Limbs, National Research Council, 1947, two volumes. </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">Committee on Prosthetics Research and Development, Selected bibliography on limb prosthetics, Artif. Limbs, 12:2:42-48, Autumn 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>4.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human limbs and their substitutes, McGraw-Hill, New York, 1954. (Reprint edition, Hafner, 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>3.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Selected bibliography on limb prosthetics, Artif. Limbs, 12:2:42-48, Autumn 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>5.</b> </td><td class="clsTextSmall">Talley, William H., Prosthetics research-a cost reduction program, an editorial, Bull. Pros. Res. 10-10, Fall 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>1.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, The management of lower-extremity amputations, TR 10-6, Prosthetic and Sensory Aids Service, Veterans Administration, August 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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 (Berkeley), Prosthetic Devices Research Project, Fundamental studies of human locomotion and other information relating to design of artificial limbs, Report to the Committee on Artificial Limbs, National Research Council, 1947, two volumes. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Terminal research reports on artificial limbs covering the period from 1 April 1945 through 30 June 1947 (to the Office of the Surgeon General of the Army and the U.S. Veterans Administration).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Committee on Artificial Limbs, National Research Council, Terminal research reports on artificial limbs covering the period from 1 April 1945 through 30 June 1947 (to the Office of the Surgeon General of the Army and the U.S. Veterans Administration).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson. Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-14.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 Prosthetics and Orthotics Program Creator An entity primarily responsible for making the resource A. Bennett Wilson. Jr. * https://staging.drfop.org/files/original/affc6aca870d2691c532bcb1de52320b.pdf 6da74b52fefbfd84763702e128d153bc https://staging.drfop.org/files/original/4855abea0e973f4417c0b317f993c386.jpg ef252a1fdf4eaa98400bc4eafd5598f5 https://staging.drfop.org/files/original/5f532646ed4a4826e06c36271fd690b0.jpg 86bd762152af57f1311a4b7bda41f25e https://staging.drfop.org/files/original/f10066429e8178e00674e849efd5ad63.jpg 035865f6b9ab5f776a3d2d22e9eaef11 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_009.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 9 - 14 Text Any textual data included in the document The Prosthetics Clinic Team <h5>Charles O. Bechtol, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>With the increasing complexity of medicine and its related sciences, the day is past when a single man can cope successfully with all the specialized problems in the treatment of injury and disease. The "horse-and-buggy" doctor did an excellent job considering the limited number of drugs and facilities avail-able to him. His results, however, can in no way compare with those obtained at a well-conducted, modern clinic, where a team of physicians as well as representatives of all the allied medical specialties are available. A comparable situation now prevails in the field of artificial limbs.</p> <p>The basic Prosthetics Clinic Team is composed of a physician, a therapist, and a prothetist. Workers in other fields, say a psychiatrist or psychologist, a social worker, a vocational counselor, or an engineer, should be available for consultation when the basic team considers that such services are required.</p> <p>Each member of the team has been trained to perform one particular job well, and, despite the considerable education and experience of each of these team members, no one man could be expected to carry out the entire procedure beginning with surgery and ending with the fitting and training of the patient. Although it is not generally stated, the patient himself is also a member of the team, since during the period of fitting and training he must cooperate by carrying out the instructions of the various team members and at the same time make and convey his own observations on the good and bad qualities of the prosthesis.<br /><br /></p> <h3>Function of Each Team Member</h3> <h4>The Physician</h4> <p>The physician acts as the chief of the clinic team. His particular training has prepared him to coordinate various ancillary services in the solution of all types of medical and surgical problems and to follow the progress of the patient until the difficulty for which medical care was sought has been corrected. In the past, this has been known as the "end result idea," more recently as <i>Rehabilitation</i>. The physician, in addition to his specific duties, is able to act in this same supervisory capacity in the prosthetics clinic team.</p> <p>First, the physician can evaluate the general medical status of the patient and either carry out any necessary surgery or, if he is not a surgeon, refer the patient to a properly qualified one. Immediate postoperative care in the hospital is under his direction. Then the prescription for physical therapy, whether preoperative or postoperative, is in his hands, and he is also the person who assumes ultimate responsibility for prescribing the prosthesis.<a style="text-decoration: none;">*</a> Moreover, the physician supervises evaluation of the prosthesis and renders final approval. And lastly, it is his responsibility to ensure that adequate training in use of the prosthesis is provided, to the end that the amputee may be able to gain the full functional advantages offered by a properly constructed, modern prosthesis.</p> <h4>The Therapist</h4> <p>The particular field of the physical and occupational therapists lies in preoperative and postoperative training and physical conditioning. The therapist is almost solely responsible for training in use of the prosthesis and usually for details of the checkout and evaluation procedures. These functions, however, are no more important than are those of physical conditioning and training in use of the prosthesis. And hence the therapist is a most necessary consultant in decisions relating to time of fitting, type of prosthesis, and type of post prosthetic training.</p> <h4>The Prosthetist</h4> <p>The special problem of the prosthetist, of course, is the actual fabrication and fitting of the artificial limb. Thus he is an indispensable member of the team. His consultation is particularly valuable at the time of prescription of the prosthesis. Using the medical data supplied him by the physician and the therapist, he can give excellent advice as to the relative degree of function that can be offered by different artificial-limb components. With cooperation in this respect, later changes in the prosthesis can be held to a minimum and possibly avoided entirely.</p> <h4>Other Consultants</h4> <p>In complex cases, the team will often feel a need for the services of others. It may be necessary to call upon a psychiatrist or psychologist to determine whether the mental attitude of the patient is such that a prosthesis can be used. Or a design engineer may be able to devise a mechanism or component that will be useful in special cases. Finally, the services of a vocational counselor or social worker may be needed in determining some of the future requirements of the amputee.</p> <h4>Administrative Personnel</h4> <p>In addition to the professional services involved, it is mandatory that someone assume the usual administrative responsibilities. An orderly clinic cannot be conducted without someone to schedule the patients' visits, to maintain individual records, and to carry out other administrative functions. This is of course true of any type of clinic operation, but it is perhaps even more important here because of the many factors involved and the numerous disciplines required.</p> <h4>Procedures in the Clinic</h4> <p>An amputee appears before the team a minimum of three times, as shown graphically in <b>Fig. 1</b>. The first visit is for the purpose of preparing the prosthetics prescription, the second to evaluate the amputee and his prosthesis before training, the third to evaluate the amputee and his prosthesis after training.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 1. Steps in the clinic--Team procedure.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h4>Visit No. 1</h4> <p>If, in the opinion of the team, the amputee is ready for fitting, a prescription is prepared. If for some reason—medical or otherwise—he is not ready, appropriate therapeutic measures are recommended.</p> <p>On hand is a preprescription form (<b>Fig. 2</b>) on which have been recorded such data as the cause of amputation, the patient's background, his physical limitations, and his desires for the future. Before attempting to prepare a prescription, each team member should be thoroughly familiar with the information given in the preprescription form. Unless the therapist is familiar with the case, it is desirable to check any existing physical limitations.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 2. Typical preprescription information form for upper-extremity amputation.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>The prescription is prepared through the cooperative effort of the team and is signed by the physician. Fitting is then carried out by the prosthetist in accordance with the prescription. A prescription form for upper-extremity amputees is shown in <b>Fig. 3</b>.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Typical prescription form for upper-extremity prostheses.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h4>Visit No. 2</h4> <p>Upon completion of the prosthesis, but before training, the amputee is brought before the clinic team a second time. Here emphasis is placed on "before training." Taken literally, this may mean that the amputee will have no conception of even the simpler control movements. In the final stages of fitting the upper-extremity amputee, however, it is necessary that the prosthetist instruct the amputee in basic control motions in order to ensure that the prosthesis is capable of function as fitted. Accordingly, the prosthetist must be thoroughly familiar with initial training procedures lest unnatural motions have to be unlearned.</p> <p>The primary purpose of the second clinic visit is to ensure that the amputee is ready for training. Included is an evaluation of his physical and mental condition as well as of the degree of comfort and function provided by the prosthesis. A simple but comprehensive series of tests has been developed to aid in evaluating functional aspects in upper-extremity cases, and a description of these appears elsewhere in this issue.</p> <p>When the team is satisfied that training is in order, the patient is referred to the therapist for this phase of the rehabilitation procedure. Although a patient and his prosthesis may meet all the criteria of the checkout procedures during the clinic session, quite often use of the prosthesis or changes of the stump during training make modifications necessary. Hence, the more familiar the therapist is with the functional aspects of the various components of the prosthesis the more quickly can he call such deficiencies to the attention of the team. Not only is time saved, but factors which tend to discourage many amputees are eliminated. The over-all result is added confidence in the prosthetics team.</p> <h4>Visit No. 3</h4> <p>Upon completion of training, the amputee is once more brought before the clinic team for a final evaluation of his ability to resume an active role in society. The patient should be encouraged to request the services of the team whenever required and also to report for follow-up examinations at regular intervals. The length of time between visits depends, of course, upon the peculiarities of each case, but as a rule it is best that the patient be examined at least once a year.</p> <h4>Conclusion</h4> <p>The concept of the Prosthetics Clinic Team is not a mere theory. Under the direction of Dr. Augustus Thorndike, the Prosthetic and Sensory Aids Service of the Veterans Administration has established 30 such teams since 1949. Others are in operation in private clinics and within the Armed Services. The initial success of these teams, often under very difficult operating conditions, has led the Advisory Committee on Artificial Limbs to stimulate development of evaluation techniques that can be used under clinical conditions and to encourage the use of the clinic-team approach for amputee rehabilitation generally.</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 must be emphasized that these prescriptions, even though they be signed by the physician, should correctly be the product of consultation by the entire team. It is perhaps in the preparation of these prescriptions that the knowledge of each team member is utilized to the fullest.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <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 O. Bechtol, M.D. </b></td> </tr> <tr> <td class="clsTextSmall">Assistant Clinical Professor of Orthopedic Surgery, University of California; Western Area Consultant for Prosthetic and Orthopedic Clinics, Veterans Administration; member of the Upper- and Lower-Extremity Technical Committees of ACAL.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_009/January-1954-2.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_01_009/ReplacewithFig2.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_01_009/ReplacewithFig3.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 Prosthetics Clinic Team Creator An entity primarily responsible for making the resource Charles O. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_038.pdf Text Any textual data included in the document <h2>The Rancho Syme Prosthesis with the Regnell Foot</h2> <h5>Michael J. Quigley, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Sam E. Hamontree, CP.&nbsp;<a style="text-decoration: none;">*</a><br />Joe Antorietto&nbsp;</h5> <p>The Syme amputation has been with us since 1842, when James Symes developed it for three reasons, "(1) the risk to life will be smaller, (2) a more comfortable stump will be afforded, (3) the limb will be more seemly and useful for ambulation."<a></a> Since then, the major improvement in the surgical technique has been the introduction of the two stage Syme amputation,<a></a> which was developed to increase the success rate in dysvascular and infected patients. Wagner further refined the technique at Rancho Los Amigos Hospital, and increased his success rate to 95% by the use of Doppler ultrasound to determine adequate blood flow.<a></a> Wagner also advocates removing the flares of the tibia and fibula during the second stage to narrow the distal end and provide better cos-mesis.</p> <p>The advantages of the Syme level of amputation are many (<b>Fig. 1</b>), but the design of the prosthesis has been a constant challenge for prosthetists (<b>Fig. 2</b>). The Syme level amputee is typically more active, walks at a faster pace, and expends less energy than the below-knee amputee;<a></a> for these reasons the demands on the prosthesis are greater. Breakage of Syme prostheses has been a constant problem, especially with prosthetic designs that have openings (medial opening, posterior opening, etc.). Syme prostheses that have no openings must allow enough room for the bulbous end of the leg to pass through, giving a "stovepipe" appearance to the leg. In addition, the "no opening" designs had other advantages, i.e., the silastic bladder expandable wall design was not durable and tended to delaminate, the full insert type added additional bulk to the prosthesis, and the removable pad design needed constant adjustment.</p> <p>The Rancho expandable wall prosthesis eliminates many of the problems inherent in other designs. This prosthesis was first described in the AAOS Atlas of Limb Prosthetics although fabrication was not detailed at that time. The Rancho expandable wall prosthesis incorporates the following features:</p> <ol> <li> <p><b>Strength</b>—The "no opening" design laminated to the Regnell foot provides maximum strength and durability.</p> </li> <li> <p><b>Expandable liner</b>—A durable elastic window sewn in a thin flexible inner liner eliminates problems with silastic or Pe-lite™ inserts, which will tear or add excess bulk.</p> </li> <li> <p><b>Cosmesis</b>—No buckles or straps are required. No line or seam at ankle joint. Bulk is kept to a minimum with thin wall thickness.</p> </li> <li> <p><b>Ease of adjustment</b>—Although the expandable inner is bonded in place permanently, it can be left unbonded for the first month of wear to allow for adjustments.</p> </li> <li> <p><b>Can accommodate large distal ends</b>—Two expandable windows can be made in the flexible liner to allow for large distal ends.</p> </li> </ol> <h3>Negative Impression Procedure and Measurements</h3> <p>The plaster negative impression is taken in the conventional manner. Reliefs are made over the bony prominences by the use of 1/8" padding before the impression is taken. The circumferences of the distal end and the narrowest part of the ankle should be compared. Maximum cosmesis is attained when the malleoli have been trimmed and the largest circumference at the distal end is about 3/4" greater than the smallest ankle circumference.</p> <p><i>Fabrication</i></p> <p>After the necessary modifications are made to the positive model, measure the M-L at the distal end, then move the calipers proximally until the model has the same M-L. This will determine the length of the elastic panel (<b>Fig. 3</b>). If the circumference of the distal end is 1 1/4" or greater than the narrowest part of the model, two elastic panels will be necessary.</p> <strong>Figures 3A &amp; 3B. Measure distal end with M-L calipers and move proximally until the same M-L is found to determine the length of polyethylene panels and the buildup needed on the inner socket.</strong><br /> <p>To allow space for the elastic panel, polyethylene "inserts" (<b>Fig. 4</b>) are cut to the length determined above, and are inserted between two nylon stockinettes for the expandable liner. The polyethylene inserts are laminated into the nylon using a 80% flexible, 20% rigid resin.</p> <strong>Figure 4. A: Medial/lateral polyethylene inserts are inserted between the two points made by the calipers. B: Inserts are laminated into expandable bladder using 80% flex and 20% rigid.</strong><br /> <p>The PVA bag is left on the lamination and a polyurethene foam buildup is made over the lamination (<b>Fig. 5</b>); this is then measured and shaped down to 1/4" less than the circumference of the distal end. A PVA bag is pulled over the foam and an outer shell of 6 nylon is laminated using rigid (90-10) resin (<b>Fig. 6</b>). After the resin sets, a hole is drilled in the distal end and the outer lamination is forced off the model using compressed air (<b>Fig. 7</b>). The polyurethene foam buildup and PVA bag are then removed from the inner lamination.</p> <strong>Figure 5. Foam buildup which results in the void necessary for the expandable bladder to open, allowing the patient to don the prosthesis.</strong><br /><br /><strong>Figure 6. Laminated outer shell over the expandable bladder with the foam buildup.</strong><br /><br /><strong>Figure 7. Bladder being pulled out of the laminated outer shell.</strong><br /> <p>Remove the polyethylene inserts by drilling small holes in the center of each end and slitting the outer nylon with a razor (<b>Fig. 8</b> and <b>Fig. 9</b>). Most of the laminated nylon covering the outside of the polyethylene sleeve is removed, leaving a 1/4" overlap to hold the stitching for the elastic panel. A single vertical razor slit is made on the inside of the liner to allow expansion. Use the polyethylene sleeves as patterns to cut out one-way stretch elastic. The proper elastic for this procedure, called grip-net, is difficult to find, as it must have a heavy durable weave and comes in a wide roll (8" or greater).</p> <strong>Figure 8. Drilling holes at widest proximal and distal points to properly position the slit in the bladder for the elastic panels.</strong><br /><br /><strong>Figure 9. Slit the lamination with a razor vertically to connect the drill holes. The polyethylene panels are used to determine the shape and size of the elastic panels that have been trimmed to size and are to be inserted into the bladder.</strong><br /> <p>The elastic panels are temporarily taped in place and then sewn in place in a long arm patcher sewing machine (<b>Fig. 10</b>). The liner may have to be folded and/or lubricated with silicone to allow the machine to reach the end of the insert. The prosthesis is now ready for static alignment on the Regnell foot (<b>Fig. 11</b>).</p> <strong>Figure 10. The elastic panels are inserted; it helps to tape them in temporarily at the proper width in preparation for sewing in the elastic</strong><br /><br /><strong>Figure 11. Outer socket and inner expandable socket with elastic panels sewn in place.</strong><br /> <p>The Regnell foot is an external keel design specifically suited for Syme prostheses because the distal end of the socket can be placed very close to the floor: a thin sole and heel cushion take little space under the prosthesis. No ankle bolt is needed, and the finished laminated external keel provides good cosmesis. The toe break is located and designed to allow for more optimum A-P alignment of the socket, resulting in smoother functional rollover and more cosmetic shaping.</p> <p><i>Static Alignment</i></p> <p>Static alignment can be set up by either sinking the socket into the keel of the foot, or by cutting off the top of the foot with a bandsaw, leaving only the amount equal to the leg length discrepancy (<b>Fig. 12</b>). The socket is then sunk into the block cut-off of the foot and tack glued to the prosthesis (<b>Fig. 13</b>). The second method allows the prosthetist easier M-L and A-P and toe-out adjustments by simply moving the block on the prosthesis and regluing. Dynamic alignment is achieved in the usual manner.</p> <strong>Figure 12. Socket is set into the block, aligned, and glued to the Regnell foot.</strong><br /><br /><strong>Figure 13. Lateral view of static aligned prosthesis ready for fitting.</strong><br /> <p><i>Finishing</i></p> <p>Following dynamic alignment, the socket is shaped to blend into the foot and roughed up. All soft parts of the foot are taped off and the final lamination of 2 nylon is made. The sole of the foot is not removed during lamination (<b>Fig. 14</b>). The lamination is then trimmed away, leaving the sole and toe break free (<b>Fig. 15</b>).</p> <strong>Figure 14. Following dynamic alignment with the patient, the socket is shaped to the foot and made ready for finishing of the outer prosthesis. Two nylons are used with rigid laminate with the sole in place and taped off.</strong><br /><br /><strong>Figure 15. The finished, laminated prosthesis. Expandable liner must be permanently bonded to the outer socket at same point, but can be left separate initially to allow for adjustments.</strong><br /> <p>The expandable liner is inserted into the outer shell. If no adjustments are anticipated, the liner is bonded to the outer shell at the proximal border with sealing resin.</p> <h3>Summary</h3> <p>The Rancho expandable wall Syme prosthesis, when used with a Regnell foot, provides a very practical solution to the problems existing in other Syme prostheses. Many of the durability and cosmesis problems have been eliminated. Whenever possible, prosthetists should encourage physicians to perform more Syme level amputations, and to try to achieve less bulky distal ends when these amputations are performed.</p> <h3>Acknowledgments</h3> <p>The prosthesis described here was developed in response to the needs of Richard Voner, CP., of Orthomedics and William Wagner, M.D., of Rancho Los Amigos Hospital, Downey, CA.</p> <p>The fabrication procedure was developed by Ortho-medics Central Fabrication, which also provided the fabrication photos.</p> <strong>Figure 16. Syme patient holding expandle liner.</strong><br /><br /><strong>Figure 17. Syme patient pulling on the liner. Note the expansion of the elastic panels; normally this would not be seen as the liner would be bonded to the outer socket.</strong><br /><br /><strong>Figure 18. Patient standing on the finished prosthesis.</strong> <p><b>References:</b></p> <ol> <li>Syme, J. "Amputation at the Ankle Joint," <i>London Edinburgh Monthly J. Medical Science</i>, 2, 1843, p. 93</li> <li>Harris, R.I. "Syme Amputation," <i>J. Bone and Joint Surgery</i>, 38B, 1956, p. 614.</li> <li>Spitther, A.W., J.J. Brennen, and J.W. Payne, "Syme Amputation Performed in Two Stages," <i>J. Bone and Joint Surgery</i>, 55A, 1973, p. 568</li> <li>Wagner W., "The Syme Amputation," <i>AAOS Atlas of Limb Prosthetics</i>.</li> <li>Waters, R.L., J. Perry, D. Antonelli, and H. Hislep, <i>Energy Costs of Walking of Amputees, The Influence of Level of Amputations</i>.</li> <li>Voner, R,, "The Syme Amputate: Prosthetic Management," <i>AAOS Atlas of Limb Prosthetics</i>, pp. 334-340.</li> </ol> <em><b>*Sam E. Hamontree, CP. </b> Sam E. Hamontree, CP., is Executive Vice President of Orthomedics, 2950 E. Imperial Hwy., Brea, California 92621.</em><br /><br /><em><b>*Michael J. Quigley, C.P.O. </b> Michael J. Quigley, C.P.O., is President of Oakbrook Orthopedic Services, Ltd., 1 South 224 Summit Avenue, Oakbrook Terrace, Illinois 60181.<br /><br /><br /></em> Page Number(s) 38 - 40 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Needs Revision- See Trello Figure 6 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-14.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1988_01_038/1988_01_038-15.jpg Figure 16 missing Figure 17 missing Figure 18 missing Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Rancho Syme Prosthesis with the Regnell Foot Creator An entity primarily responsible for making the resource Michael J. Quigley, C.P.O. * Sam E. Hamontree, CP. * Joe Antorietto  https://staging.drfop.org/files/original/d473917f5c93279c86fec167ec3e6f8d.pdf 52522a97179122f2dab8aa3dded039d2 https://staging.drfop.org/files/original/cd42d129793a2e44547062aae35b954c.jpg 7fa5af2ce6f8ad613bc3161879335a63 https://staging.drfop.org/files/original/bb210c41d31ba6d69894ab5f0678324e.jpg b4f8eac8a1df5167a5581f3d8051bb22 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_04_230.pdf Text Any textual data included in the document <h2>The Relationship Between Orthotics and Gainful Employment of the Disabled</h2> <h5>J.E. Yourist, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />Z.A. Latif, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />S.T. Layton, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />J.H. Bowker, M.D.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Statement of Problem</h3> <p>Physical and sensory disabilities restrict individuals from functional access to the environment.<a></a> Since our environment is best suited to the average person, losses such as these represent formidable barriers to fruitful interactions with the environment and society.</p> <p>Of special significance in this regard is the ability to function productively in gainful employment. National statistics reveal that the unemployment rate among the disabled is tenfold that of the general population (70% versus 7%).<a></a> Barring all other variables, this statistic reflects that our environment is especially inaccessible to the disabled.</p> <p>There are several factors which contribute to this serious unemployment problem.<a></a> Notable among these is the fact that the disabled are unable to return to work due to "access" deficiencies caused by the nature of their disability. In this sense "access" means to bridge the barriers to the environment imposed by physical or sensory disability (<a href="/files/original/bb210c41d31ba6d69894ab5f0678324e.jpg"><b>Fig. 2</b></a>). This paper deals with the probable relationships between adaptive devices and employment/economic opportunities for the disabled.</p> <h3>Probable Solutions to Access Deficiencies</h3> <p>Appropriate solutions to these "access" problems can be complex, but all necessitate the use of orthotic or adaptive devices. Typically, these devices will aid the disabled to achieve a level of performance that, at best, approaches that of the able-bodied person.</p> <p>The primary device for the severely disabled remains the wheelchair which, when appropriately prescribed and adapted, provides mobility throughout the workplace and good sitting posture for proper interface with tools at the workstation. A stand-up chair allows the worker to utilize a standard file cabinet and reach objects on higher shelving. Quadriplegics can manipulate keyboard sticks either with wrist-driven flexor-hinge orthoses if C-6 function is present or with the use of a universal utensil holder for those with C-5 function.</p> <p>The advent of high-technology electronic devices such as computers and robots has greatly expanded the horizons of the severely disabled in the workplace. These devices, which are cost and energy efficient, can transform minimum physical energy into tangible and impressive work events. A simple example is that of a quadriplegic operating a microcomputer by activating a switch by a "sip and puff" device or speech-recognition software and hardware.</p> <p>For the purpose of this discussion, it is necessary to focus on the relevance of these devices to independent living and the achievement of gainful employment for the disabled. A behavioral model for task performance may be considered which allows the definition of the necessary device required to achieve a particular task.</p> <p><a href="/files/original/cd42d129793a2e44547062aae35b954c.jpg"><b>Fig. 1</b></a> is a schematic representation of the performance of a common task by an able-bodied individual. In this illustration, an intent or desire to perform a particular task is first identified.<a></a> After assessing the person's inherent capabilities and resources, the activity can then be performed. Consequently, the immediate environment is altered, a purposeful response is made, and the consequences are appreciated.</p> <p><a href="/files/original/bb210c41d31ba6d69894ab5f0678324e.jpg"><b>Fig. 2</b></a> depicts the same task presented to a disabled individual. This schematic is altered to demonstrate the physical and/or sensory barriers to completing a similar task.<a></a> A disabled person may have a desire to perform this task, but may not have the same inherent capabilities or the resources as the able-bodied counterpart. At this juncture, "access" deficits to the environment become obvious. An adaptive device is required to facilitate the fulfillment of this task. One might expect the appreciation factor to be much higher compared to the able-bodied person.</p> <h3>Improvement of Function</h3> <p>For many years orthoses have been successfully fitted to restore and sustain the ability to carry out common activities of daily living. These biomechanical devices have improved the ability of the disabled person to perform such physical tasks as sitting, walking reaching, and grasping.</p> <p>Functionally, many of these activities are no different than those found in the current workplace. Those disabled persons previously employed in manual labor or manufacturing jobs would probably be displaced from their previous employment. This is due, in part, to the fact that conventional orthoses have definite limitations in their ability to replace the physical potential of the able-bodied.</p> <p>Therefore, till now, the highly disproportionate number of unemployed disabled persons does not indicate a positive correlation between employment and the use of traditional orthoses or adaptive devices. However, the emergence of microcomputer technology during the last decade has provided new potential for more effective use of these devices. Furthermore, the microcomputer can be regarded as both a biomechanical accessibility device and an employment tool which can be utilized for physical and economic rehabilitation.</p> <h3>The Change in Definition of Work</h3> <p>Our global economy is rapidly evolving from an "industrial" to an "information" age.<a></a> Jobs are becoming more knowledge-based with increasing dependence on computer technology as the sole productivity tool.<a></a> Indeed, the management of information is being realized as a central resource or commodity for jobs. Consequently, demand for manual labor is being steadily replaced by a demand for workers who can effectively manage information. In the coming decade, more than 50 percent of all jobs in this country will be found in high technology based information management. The personal computer is the principal instrument used in these jobs.<a></a></p> <p>These events are quite beneficial to those who are physically disabled, because the labor market will depend in a large degree on mental rather than physical capabilities. Coinciden-tally, the tool used in these new jobs is the same tool that can be used to access the environment: the microcomputer.</p> <p><i>Economic Rehabilitation</i></p> <p>Even in view of recent economic and technological developments, the question of the high ratio of unemployment among the severely disabled remains a serious and complex problem. In most cases, the severely disabled are displaced from their previous careers and require intensive rehabilitation to re-enter the job market. This implies that rehabilitation is certainly not complete until educational/retraining and economic goals are met to achieve financial independence. Therefore, complete rehabilitation is defined here as the process by which a person who is disabled and unemployed, can be physically and, more importantly, functionally and economically rehabilitated. This can only be achieved through a comprehensive program which includes not only conventional strategies of physical and occupational therapy, but vocational diagnostics, vocational counselling and retraining, and lastly, job placement.</p> <p><i>MEED (Microcomputer Education for the Employment of the Disabled)</i></p> <p>Appropriate vocational diagnostics and job retraining are key elements in successful economic rehabilitation. In most instances, this training has been inadequate, frequently resulting in supported job placement. Such a disincentive is often compounded by the possible loss of government-subsidized unemployment benefits and health care coverages.</p> <p>Therefore, at the University of Miami, we have developed an economic rehabilitation program based on high-technology called MEED, or Microcomputer Education for Employment of the Disabled. MEED was conceived from the federal Projects With Industry (PWI) model to pilot a high-technology approach to rehabilitative training. It is a microcomputer-based training and placement program for the severely disabled, teaching information management skills which are necessary for competitive employment in business. This training is comprehensive, job-targeted, and cost-effective.</p> <h3>Other Causes of High Unemployment</h3> <p>Although access barriers are keeping many disabled persons from the workplace, their high rates of unemployment certainly reflect a minimal relationship between employment and adaptive devices. These devices may promote job function, but may not significantly increase the chance of that person acquiring a job. Many other factors come into play, especially the social issues facing disabled individuals and the marketability of their job skills. Other factors also contribute, including: first, unavailability of suitable retraining programs; second, chronic health problems; and third, government-established major work disincentives, such as disability payments.</p> <h3>Conclusions</h3> <p>In our judgement, feasible vocational retraining approaches are needed. They must be designed to equip disabled individuals with marketable skills which are necessary for competitive employment. Partnerships among several sectors of the community are essential to make these efforts a success. These include academia, government, business and industry, and the rehabilitation and health-care communities.</p> <p>Conventional orthoses will play a significant role in complementing the function of high technology devices. For example, various splints and universal utensils will improve computer keyboard access and function.</p> <p>However, technology holds the key to the future of economic rehabilitation. We believe that the computer, particularly the microcomputer, is central to achieving this goal. The microcomputer is not only a valuable business productivity tool, but is also a vehicle through which a severely disabled individual can "access" his environment. In a sense, the microcomputer itself can be viewed as an orthotic or adaptive device. It is an extension of not only the body, but also the mind. So, in the "information age," the microcomputer is assuming a pivotal role in improving the quality of life for the able-bodied as well as, and even more importantly, for the physically disabled.</p> <p><b>References:</b></p> <ol> <li>DeJong, Gerben, and Lifchez, Raymond, "Physical Disability and Public Policy," <i>Scientific American</i>, June, 1983, vol. 248, no. 6, pp. 40-49.</li> <li>Bowe, Frank, Ph.D., "Making Computers Accessible to Disabled People," <i>Technology Review</i>, January, 1987, pp. 54-59.</li> <li>Jaffee, David, "High Technology and New 'Access Devices'" from lecture and written material at High Technology Education for Employment of Disabled Conference, Miami, Florida, March, 1987.</li> <li>Harris and Associates, Inc., <i>The ICD Survey of Disabled Americans Bringing Disabled Americans into the Mainstream</i>, March, 1986.</li> <li>Spencer, William, M.D., "Technology and Rehabilitation," lecture at Symposium on Computers in Medical Care and Education, Washington, D.C, October, 1986.</li> <li>Cornish, Edward, "The New Industrial Revolution: How Microelectronics May Change the Workplace," <i>Careers Tomorrow</i>, C. Norman, 1983, pp. 26-35.</li> <li>Cornish, Edward, "Careers with a Future: Where the Jobs Will Be in the 1990s," <i>Careers Tomorrow</i>, M. Cetron andT. O'Toole, 1983, pp. 10-19.</li> </ol> <em><b>*J.H. Bowker, M.D. </b> John H. Bowker, M.D., is a professor and Associate Chairman of the Department of Orthopaedics and Rehabilitation at the University of Miami Schools of Medicine. He is also the Medical Director of the University of Miami/ Jackson Memorial Rehabilitation Center in Miami, Florida.</em><br /><br /><em><b>*S.T. Layton, Ph.D. </b> S.T. Layton, Ph.D., is Associate Director of the MEED Program at the University of Miami School of Continuing Studies.</em><br /><br /><em><b>*Z.A. Latif, Ph.D. </b> Z.A. Latif, Ph.D., is Assistant Professor in the Department of Medicine and Consultant to the MEED Program at the University of Miami School of Medicine.</em><br /><br /><em><b>*J.E. Yourist, Ph.D. </b> Jay E. Yourist, Ph.D., is Assistant Professor in the Department of Medicine and the Director of the MEED Program at the University of Miami Schools of Medicine and Continuing Studies, P.O. Box 016960, Miami, Florida 33101.<br /><br /><br /></em> Page Number(s) 230 - 234 Year 1987 Volume 11 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1987_04_230/1987_04_230-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 2 http://www.oandplibrary.org/cpo/images/1987_04_230/1987_04_230-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Relationship Between Orthotics and Gainful Employment of the Disabled Creator An entity primarily responsible for making the resource J.E. Yourist, Ph.D. * Z.A. Latif, Ph.D. * S.T. Layton, Ph.D. * J.H. Bowker, M.D. * https://staging.drfop.org/files/original/3736a23e738166381c6803e355cc30aa.pdf cb532dab7ed020184153028bdd91a2d2 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_02_003.pdf Text Any textual data included in the document <h2>The Role of Orthoses in the Care of Knee Ligament Injuries</h2> <h5>Kenneth E. DeHaven, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The role of braces in the management of knee ligament injuries, particularly in high risk athletics, continues to receive a great deal of attention. There are a multitude of braces currently being manufactured and marketed with various claims relating to the effectiveness, comfort, durability, and cost.</p> <p>Two key questions remain for most clinicians: (1) Should knee braces be used at all?, and (2) If so, what type of brace should be used and under what circumstances? At present there is a paucity of scientific data available to answer either of these questions with certainty, but there are encouraging signs that this essential information will be forthcoming from current and future research. Until an adequate scientific basis has been established it is necessary to develop a philosophy about bracing in athletics that is consistent with the data that is available and our clinical observations.</p> <h3>Should braces be used at all?</h3> <p>There is frequently an ego problem for both the athlete (who views a brace as a sign of weakness) and the physician (concern that a brace reflects less than optimal results) who delight in the statement "Doc, I don't need that brace—I can run and cut without it." Definitive treatment, whether rehabilitation or surgery followed by rehabilitation, must provide the functional stability, and it is rare in my experience that an unstable knee is made stable simply by applying a brace. However, no matter how good it might feel to the athlete, a knee that has previously sustained major ligament injury is not normal, and in fact has suffered ligament disruption at a time when it was normal. The role of bracing, therefore, is not to provide stability but to help prevent reinjury by keeping the knee from going into extreme positions when subjected to sudden stress. When presented in this light, the concept of protective bracing after major ligament injury to the knee is more reasonable and more acceptable to both the athlete and the physician.</p> <h3>What type of brace should be used and under what circumstances?</h3> <p>While not definitively established, it appears that the beneficial effects of knee orthoses are related not only to their mechanical strength but also to providing increased proprioceptive input from the knee area (which can explain how some patients feel more stable in braces that provide little or no mechanical support). Optimal support is provided by braces that protect against varus/valgus and hyperextension stresses and are utilized routinely in our Center following ligament repair or reconstruction of collateral and/or cruciate ligaments. The brace is initially worn for ambulation in the early postoperative period (two or four months) and later for agility, contact, or other types of "high risk" sports. Less sophisticated braces that provide just varus/valgus support usually are sufficient for athletes returning to similar sports in the same season following Grade II collateral ligament sprains. The practicality, efficacy, and cost effectiveness of prophylactic bracing to prevent injury in contact sports such as football is also a topic of great interest but remains unresolved at present.</p> <p>It is important to emphasize that this represents personal philosophy and recommendations based upon the information available at this time. It is recognized that while these concepts appear to be reasonable they are largely unproven, and there continues to be great need for more biomechanical and clinical research to firmly establish a scientific basis for knee bracing in athletics.</p> <em><b>*Kenneth E. DeHaven, M.D. </b> Professor of Orthopaedics, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, New York 14642.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 3 - 4 Year 1984 Volume 8 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 Role of Orthoses in the Care of Knee Ligament Injuries Creator An entity primarily responsible for making the resource Kenneth E. DeHaven, M.D. * https://staging.drfop.org/files/original/ff3340abee0b201874784eb994f1540f.pdf c2e3cc34fa9285809d54831e90850af8 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_011.pdf Text Any textual data included in the document <h2>The Role of Test Socket Procedures in Today's Prosthetic Practices</h2> <h5>Michael J. Quigley, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The proper role of a test socket procedure is a controversial topic in today's practice of prosthetics. A test socket procedure can be defined as that stage in the design of a prosthesis when a socket is fabricated solely for the purpose of determining proper socket fit. Although test sockets were originally used for upper limb prostheses, the true advent of the test socket was in 1972 when Mooney and Snelson<a></a> described the polycarbonate clear test socket as developed at Rancho Los Amigos Hospital. During the 13 years since that article, the proper role of the test socket procedure has still not been defined.</p> <p>There are several reasons for the controversy over test sockets. First, when a test socket procedure is done, there is an implication that the mold, mold modifications, and socket design principles instilled in the prosthetist may not be correct. After all, if the prosthetist's techniques were perfect, the socket would fit perfectly and the need for a test socket would be obviated. However, any time a clear test socket is used, the prosthetist immediately notices a few things he would like to change in the definitive socket or, in some cases, the next test socket.</p> <p>It is safe to say that the majority of United States prosthetists believe in the value of test sockets and use them on a regular basis. Indeed, insurance companies and most other third party reimbursers, including Medicare, pay for test sockets, thereby recognizing twin values. A test socket procedure makes good sense, and there is no question that it improves prosthetic fitting. However, it is also true that many prosthetists do not use these sockets, or use them only rarely. The group that does not use test sockets feels that they can fit nearly all prostheses well without test sockets and do not want to spend the additional effort that test sockets require, or they simply do not want to change the methods they learned many years ago. The present Veterans Administration's (VA) procedure for obtaining approval for test sockets seems to favor this latter group, since it is an intentionally cumbersome system that, in effect, discourages test socket procedures on VA patients.</p> <p>Test socket users also include prosthetists who routinely use multiple test sockets on every patient, with the principle that each successive socket brings you one step closer to the perfect fit. If one test socket procedure is good, shouldn't two be better? Or three? Or more? This is a major area of controversy that could be discussed here but not resolved. Probably the best example of this use of test sockets is at the Institute for the Advancement of Prosthetics (IAP) in Lansing, Michigan (although a number of other prosthetic practices are also using multiple test sockets, or featuring them as a type of "first class" service).</p> <p>An average of six test socket procedures are done on each patient in Lansing: beginning with static fittings in clear sockets with the patient wearing no prosthetic socks, going on to clear socket dynamic (walking) fittings, and progressing to a definitive socket with a gel liner for below knee amputees. The patient is seen every day for two to three weeks until the socket fit is perfected, and only then is the prosthesis finished. This, of course, is an expensive undertaking, but it seems logical to assume that with so much time and energy spent, the patient would end up with a better fit. The multiple test socket users lead an Utopian existence, seeking the perfect fit, and see only one or two patients every week or continue fittings for many months if they are seen only on a weekly basis. For the average prosthetist who fits 100 or more patients alone each year, the sheer logistics of using multiple test sockets on every patient is staggering.</p> <p>Another area of controversy regarding test sockets is that they provide an incentive for prosthetists to delay being satisfied with the socket fit if they are paid separately for every test socket used. If they fit six test sockets, they are paid six times more than if they fit one test socket. The only response to this problem is that there are a few difficult cases where the only way a good fitting can be achieved is with multiple sockets, and the prosthetist should be reimbursed for his effort. On the other hand, there are always the few people who will abuse the system. In practice, less than five percent of all prosthetists have the time or inclination to routinely use multiple test sockets. After all, there are also very few patients or insurers who want to bear the expense, are able to make all the appointments necessary, and are willing to wait the many months for a finished prosthesis when multiple test sockets are used.</p> <p>Before summarizing, one final comment is necessary. Having test socket procedures available and using test sockets properly are two different things. There are no standardized, recommended, or documented procedures for the proper use of a test socket. Some people use clear sockets, some do not. Some use "wet fit" procedures with no prosthetics socks; others use prosthetic socks. Some test sockets are used statically, others dynamically. Alginate procedures are used in some areas. Even when a clear socket is used directly against the skin, how do we interpret what we are seeing? The result of the confusion over the proper use of a test socket is that the prosthetist converts one of the few objective tools he has available (a clear socket) into a subjective one by having to use educated guesses to determine the modifications needed to improve socket fit. The whole area concerning the optimum use of test socket procedures is in great need of study and documentation.</p> <p>In summary, test socket procedures are good procedures. When a prosthetist knows that the socket he is fitting is not the final product, he is more likely to make major socket modifications and, therefore, less likely to provide a poor fitting prostheses. Multiple or successive test sockets will always be required on a few difficult cases. In some areas, the patient and prosthetist will afford the luxury to use successive test sockets to try to achieve the perfect fit, but this will probably include less than one percent of the patient population.</p> <p>It is obvious that these socket procedures are here to stay and that the use of test sockets will increase as new materials and techniques are introduced. Hopefully, some meaningful documentation will be developed to enable prosthetists to obtain as much information as possible from a test socket procedure. Without a true understanding of how to properly use a test socket, each prosthetist is left to practice and develop his own technique, and the art of prosthetics again overwhelms the science.</p> <p><b>References:</b></p> <ol> <li>Mooney, V. and Snelson, R., "Fabrications and Applications of Transparent Polycarbonate Sockets," Orthotics and Prosthetics, 26 (1), p.p. 1-13, March 1972.</li> <li>Personal communication, Jan Stokosa, CP., May 6, 1985, Lansing, Michigan.</li> </ol> <p><b><em>*Michael J. Quigley, C.P.O. </em></b><em> Michael J. Quigley, C.P.O. is President of Oakbrook Orthopedic Services, Ltd. 1 South 132 Summit Ave, Ste 102, Oakbrook Terrace, IL 60181.</em></p> <p><em>&nbsp;</em></p> Page Number(s) 11 - 12 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 Role of Test Socket Procedures in Today's Prosthetic Practices Creator An entity primarily responsible for making the resource Michael J. Quigley, C.P.O. * https://staging.drfop.org/files/original/4762f350fbaca4d7dceedcfd3c7d363e.pdf 7281217b29c631bcd7ebf10f4c376c5e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_001.pdf Year 1965 Volume 9 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/1965_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_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 Score</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The past twenty years of the Artificial Limb Program comprise predominantly a series of wins, a few losses, and some ties awaiting replays. Participants, coaches, and managers in this prolonged struggle against nature and ignorance have enjoyed some spectacular seasons, but they also have endured grueling practice and frustrating defeats. </p> <p>Wide interest in artificial limbs accompanies major wars. Ancient armorers made cleverly articulated limbs. The Napoleonic and Crimean Wars stimulated active development in Europe. The American Civil War led to numerous private inventions of prostheses. During World War I vigorous and systematic programs were conducted on both sides. These ended soon after the war, partly because of inflation and other disturbances, and partly because of confidence that limbs had been substantially improved. Everywhere there was a return to "normalcy," but the general impression that amputations are infrequent in peacetime is erroneous. Dr. Glattly's recent survey <i>(Artificial Limbs, </i>Spring 1963) corroborates the claim that for a variety of reasons very substantial numbers of civilians face this major operation in peacetime. </p> <p>In World War II both the Army and the Navy of the United States set up large amputation centers to provide definitive surgery, artificial limbs, and other rehabilitation. Both Services introduced some new materials and mechanisms. To combat severe shortages they used prefabricated, standardized parts and division of labor for fitting and assembling instead of the slow, painstaking custom craftsmanship in very small shops typical of the American limb industry. Dramatic successes occurred. Nevertheless, Service Centers, amputees, commercial limb shops, and, increasingly, the general public were made conscious of the severe limitations of even the best prostheses. </p> <p>The Surgeon General of the Army, therefore, called a conference in January 1945 which was supposed to agree upon the best available prosthetic components. The principal conclusion was that <i>none </i>of the available limbs was really adequate, so research was needed. </p> <p>The Surgeon General then asked the National Research Council to set up a committee to conduct a research and development program. The resulting committee and its descendants have had a variety of designations, membership, organizational structures, and sponsors. Originally the work was supported by the wartime Office of Scientific Research and Development, then by the Army. The Veterans Administration, for many years the sole sponsor of contractual research in prosthetics, still continues important support, but in recent years various agencies within the Department of Health, Education, and Welfare have assumed major financial responsibility. </p> <p>When the original Committee on Prosthetic Devices asked its surgeons to appraise the artificial limbs available in the summer of 1945, the two chief demands to its engineers were for development of a functional artificial hand that looked normal and for stance-phase stability for above-knee artificial legs, presumably from a lock released during swing phase. Patent files and technical literature were littered with descriptions of inadequate attempts by several generations of inventors. </p> <p>The surgeons' demands reflected a primary conception of the Committee's role to concentrate on <i>devices, </i>susceptible to engineering design. In an era when many orthopaedists still were active in military amputation centers and physical medicine was only emerging, the surgeons were not yet concerned with development of new surgical techniques or with prosthetics education. </p> <p>Neither were the surgeons primarily concerned with fitting, though its importance was realized. The second subcontract of the Committee, to develop further a saucer socket for the hip-disarticulation case, was with the Research Institute Foundation, a tiny laboratory which had been set up by the Artificial Limb Manufacturers Association. (This project incidentally initiated a number of ideas which later and independently were developed vigorously at larger laboratories.) Both Committee and limb industry a score of years ago considered the fitting of limbs to be a handicraft, often a sculpture-like art, learned by long experience but scarcely susceptible to systematic research. </p> <p>German studies of alignment principles in World War I had relatively little immediate impact on American practices. Alignment of the above-knee prosthesis in 1945 typically placed the artificial foot far out under the head of the femur "so the amputee would not fall over to the amputated side" and made the axis of the socket bore vertical "so as not to give in to flexion contracture." Thus, while standing on the prosthesis, the amputee leaned against his pelvic band and mechanical hip joint, stressing them severely, in an effort to shift his center of gravity nearer to the foot. Likewise, after exhausting the possibilities of lordosis and unsymmetrical gait in an effort to control a free knee joint after maximum hyperextension of a slightly flexed stump in a straight socket, the recent amputee demanded a mechanical knee lock; a stiff heel bumper or a "long" prosthetic step (caused by inadequate knee friction) only increased instability at heel contact and made the demand for a knee lock more insistent. </p> <p>The early years of the Artificial Limb Program were dramatic, in some senses wasteful, yet in others very fruitful. Some efforts were lost, but unquestionably the whole field of upper-extremity prosthetics was changed for the better by fundamental studies, development, and improved management of the individual amputee. Some unilateral amputees found the APRL hand adequately functional, and careful testing proved its cosmetic glove passed unrecognized in a wide variety of social situations. Thus one complaint was at least marginally resolved. </p> <p>Vigorous study of locomotion proceeded concurrently with numerous development projects. Reintroduction of the suction socket, almost a side activity, forced attention to principles of fitting and alignment, to fostering of cooperation among doctor, limb fitter, therapist, and amputee, and to prosthetics education. Improved alignment as well as added gait training reduced the clamor for knee locks for stance control, and attention shifted toward the swing phase. Several swing-phase mechanisms are now widely used. The Henschke-Mauch Model "A" hydraulic stance-plus-swing-control mechanism has finally been recommended after prolonged development and evaluation. If clinical application studies of the Henschke-Mauch Model "A," including application to recent amputees, prove as encouraging as now seems likely, this device will answer at last the second complaint of the surgeons back in 1945. </p> <p>But many problems remain. The Program has gradually spread its field of vision beyond the mere development of mechanical components. Fundamental research has provided data on locomotion, biomechanics, muscle action, pain, and other problems. Clinical studies have been made of amputation surgery, cineplasty, myoplasty, and early postsurgical fitting, though further studies of surgery and wound healing are needed. Fitting and alignment now can profit from better anatomical and biomechanical principles, new shop tools, improved materials, clearer analysis of defects, and greater insight into causes. The necessary skill and artistry of the increasingly professional prosthetist can be used more effectively. The team principle has become widely practiced, to the reassurance of all concerned. </p> <p>Continuing soul-searching has steadily spurred the participants in this battle against ignorance. The best artificial limbs are still crude. Very little has yet been done about orthotics, deliberately kept in abeyance because braces are worn for such a wide variety of conditions that analysis is difficult. The Subcommittee on Sensory Aids, resuming the tasks of the wartime Committee on Sensory Devices, is only beginning its task of reviewing the present VA projects on aids for the blind. CPRD is studying its possibilities and responsibilities in the broad field of bioengineering. </p> <p>The past score of years has given the Committee an intensive series of encounters, sometimes bruising-but often exhilarating-with problems of mechanisms, their human users, the man-machine interfaces, and the idio-syncracies of the professions concerned. </p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Member, Editorial Board, Artificial Limbs; Chief, Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001.</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 Score Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/2579b493cff96641963df1959617da9c.pdf 7a040dc0c6d8940381d830ff94df216c https://staging.drfop.org/files/original/9b5a594f58f0c51923251fd92a135602.jpg 57b06d3b863d2d96e319e45c7e311ec2 https://staging.drfop.org/files/original/b27d9746413c7245b9c9d57b6c78296c.jpg c3f708f42d9205528c3d92eaa69c5f8d https://staging.drfop.org/files/original/489333ee5663a0918fc1188cd04de355.jpg 6246ddbb7c073c52f3680d9cc2e692d5 https://staging.drfop.org/files/original/0f1a2c0ffe09ce58f56c671508caf8d0.jpg 9ace1443273e65a96546085fac38ccff https://staging.drfop.org/files/original/b757babe164755ddc45d09d746d12a25.jpg bb43beeaee57a9d23d027255cfe57a90 https://staging.drfop.org/files/original/28098c9ae09a1b29b5e2746fbf9dae57.jpg 146ed72dacbc879d115802dfe7b040ec https://staging.drfop.org/files/original/101b4a63eb00b02f48dd5cceb047df08.jpg a8b81c922b4a290b5521ca6debc85bc1 https://staging.drfop.org/files/original/72a60b523a40a4d235c1d18c8b9b7261.jpg c8c5932ddfd82c4f9b5bb9c021a4057c https://staging.drfop.org/files/original/dca53dfdadc820d9695f082cef6c3cc6.jpg 6844b1ba2d83cec4968a44656a93d8c4 https://staging.drfop.org/files/original/4a2c27c0bdc553dc08831ffd607191a8.jpg 28ad5e1095f6eea7da754bc99dddcfd2 https://staging.drfop.org/files/original/895503c909a9093928949c6025df2493.jpg b6dcdac7b597f6d539a04096e67f49a8 https://staging.drfop.org/files/original/ce093d59e2f69e93fb1e12645cdaa70c.jpg 4d30dc7c5aaece3d4f6ec528523d2cc3 https://staging.drfop.org/files/original/85aef58e9738f2b66ee033e80c6a23e1.jpg 8d5b678b30f6204ae837a9fe4db7cd24 https://staging.drfop.org/files/original/03c3b38192c1044ec4565bd3d585f5d9.jpg a1b1b398e8264b9b4130b912c592a94d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1956_01_020.pdf Year 1956 Volume 3 Issue 1 Page Number(s) 20 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1956_01_020.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1956_01_020.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 Skin Problems of the Lower-Extremity Amputee</h2> <h5>S. William Levy, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Since the establishment, in the autumn of 1954, of the skin-study group of the Lower-Extremity Amputee Research Project at the University of California, other physicians within the Project have referred to us for observation and treatment those amputees having cutaneous problems associated with the wearing of a prosthesis. Out of this nidus, specific information regarding the various clinical problems has been assembled and correlated in an effort to benefit the individual amputee. Some of the clinical problems have aroused interest in basic dermatologic research, so that investigation has not been of a purely clinical nature.</p> <p>The cutaneous difficulties associated with the wearing of a leg prosthesis have been evaluated in more than 200 patient-visits, and every effort has been made to classify cutaneous disorders specifically. Approximately the same number of above- and below-knee amputees have been carefully screened and examined. Complete histories have been taken, and physical examinations of the skin have been performed. Skin biopsies have been obtained in many instances, and histopathologic sections have been examined carefully in an effort to determine the course of a specific disorder.</p> <p>Other laboratory aids, such as skin scrapings for fungi or patch tests for contact dermatitis, have been utilized. Stump hygiene is important in relation to many clinical disorders of the skin, and accordingly a specific hygienic program for the care of the stump is being developed.</p> <p>Skin lesions, however minute they may appear, are nevertheless of great importance since they may be the beginning of an extensive cutaneous disorder that may be mentally, socially, and economically disastrous to a given individual. It is best to view any minor irritation as a potentially dangerous symptom and to deal with it as early as possible. Once the skin problem has begun, it should not be ignored in the hope that it will heal of its own accord. Nothing can be more frustrating to the lower-extremity amputee than to be told to remain off his prosthesis or to go on crutches because he has neglected a minor skin eruption.</p> <p>This article is devoted to the common skin problems and danger signals associated with the wearing of a lower-extremity prosthesis. Most of our experience has been gained with the above-knee amputee using the suction-socket suspension, but it is believed that the same or similar problems arise in patients using the more conventional types of suspension.</p> <h4>Stump Hygiene</h4> <p>Hygienic measures are of the utmost importance in the daily care of amputation stumps and in the use of prostheses. A neglect of cleanliness can easily result in damage to the skin and thus open the door to a number of cutaneous disorders which can require temporary removal of the prosthesis. There is no unanimity of opinion on exactly what measures should be employed routinely. Amputees have come to us with many varied and weird ideas. Some have used strong soaps and alkalies on their stumps, some alcohol, and others formaldehyde. These hygienic measures have been handed down from one person to another and frequently without reason or logical explanation. Some patients fail to wash either the stump or the socket, thereby giving rise to maceration and malodor.</p> <p>A simple hygienic program using a sudsing detergent has in many instances prevented or eliminated a cutaneous disorder, and hence we frequently request an amputee to follow a given routine. He is advised against the use of any preparation which would leave a deposit in the socket or any solvent which might affect the interior finish. A simple procedure for cleaning the socket is to wash the inner surface with a lukewarm, soapy cloth or one containing a detergent, remove the soapy residue with a clean wet cloth, and then dry out the socket with a towel. The prosthesis should not be put on for several minutes so that it may have an opportunity to dry completely.</p> <p>For the stumps of most individuals, a bland soap or liquid detergent provides a good cleansing without irritating the skin. Soaps or detergents containing hexachlorophene provide a bacteriostatic action, in addition to cleansing, and may aid in reducing the danger of infection. An amputee is frequently advised to purchase a plastic squeeze bottle of pHisoHex,® an item available in every drugstore, relatively inexpensive, and to be had without a prescription. He is instructed to spread over the amputation stump a small amount of this antibacterial sudsing detergent containing hexachlorophene. A little water is added and the material worked into a lather. More and more water is added to increase the amount of sudsing. He is told to avoid washing off the suds until ready for thorough rinsing. When well cleansed, the site is then rinsed off with lukewarm water, and the stump is dried by patting rather than by vigorous rubbing. This simple routine should be followed nightly, or every other night, depending upon the rate of perspiration, the degree of malodor, and the bathing habits of the individual. In the treatment of some persistent eczemas of the stump, this simple hygienic program was found to be curative.</p> <h4>Clinical Problems</h4> <p>Some amputees go along for months or years without difficulty or irritation of the stump skin. In others, the skin is a weak tissue, and frequent difficulties arise. Persons concerned with amputees should be aware of certain pathologic conditions-certain danger signals-which are frequently the forerunners of seriously incapacitating cutaneous disorders. Early recognition and treatment of these conditions can avert much mental anguish and loss of social or economic activity. It should be remembered that, once on a prosthesis, the amputee desires to stay on, and it is of vital concern to the physician and prosthetist to prevent any disorder which may return him to crutches or bed rest. What, then, are some of these danger signals?</p> <h4>Stump Edema Syndrome</h4> <p>When an amputee first starts wearing a suction-socket prosthesis, he can expect to see edema or swelling and reddish-brown pigmentation, roughening, and drying of the skin of the terminal portion of the stump (<b>Fig. 1</b>). These changes are the almost inevitable result of the altered conditions forced upon the skin and subcutaneous tissues. They are relatively innocent, do not usually require therapy, and are partially prevented by gradually compressing the stump tissues with an elastic bandage prior to use of the prosthesis. An incorrectly fitted socket may predispose a leg amputee to this disorder.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Stump edema syndrome. <i>A, </i>In a 33-year-old male above-knee amputee wearing a suction-socket prosthesis. Note the swelling of the <i>end </i>of the stump, with pigmentation and hemorrhage into the skin. <i>B, </i>Enlarged view of <i>A. </i>showing hemorrhagic nodules with superficial erosion. <i>C, </i>In a 38-year-old male above-knee ampulee wearing a suction-socket prosthesis, with swelling and hemorrhagic plaque. No erosion or ulceration has occurred. <i>D, </i>Same patient as in C, showing socket-rim pigmentation and irritation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In several of our patients the edema has been massive, and distal pigmentation has followed, with the formation of hemorrhagic papules and nodules. Superficial erosion of the skin in these regions is not uncommon, and, in rare instances, deep ulcers can result from the poor cutaneous nutrition (<b>Fig. 2</b>). Multiple biopsies have been taken in order to determine the pathogenesis of this disorder. Special staining of the sections revealed that the pigmentary changes were due to the blood pigment, hemosiderin, within the tissue (<b>Fig. 3</b>). The collagen of the dermis was thickened by newly formed fibrous connective tissue, and there was an abnormal proliferation and dilatation of blood vessels. It may be that this kind of disorder is vascular in origin and that a venous and lymphatic congestion is productive of the edema and hemorrhage. It is hoped that the basic pathogenesis will be clarified as more patients with this syndrome are studied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Chronic ischemic ulcer, in a 43-year-okl male below-knee amputee. Poor prosthetic fit with venous obstruction was productive of this lesion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Pigmentation following stump edema syndrome. <i>A, </i>Brown pigmentation of the skin of the distal portion of the stump. <i>B, </i>Microscopic section of A, showing a marked increase in the thickness of the epidermis, with sclerosis of collagen and infiltration of pigment-laden cells. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Edematous portions of the skin of the distal part of the stump may become pinched and strangulated within the socket (<b>Fig. 4</b>). Such areas may ulcerate or become gangrenous owing to impaired blood supply.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Strangulated skin. Unusual view, showing the distal stump skin resting on the foam-rubber cushion, as seen through the valve opening of a suction-socket prosthesis. A portion of the skin has become partially strangulated, resulting in stasis, edema, and pain. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Contact Dermatitis</h4> <p>Contact dermatitis (<b>Fig. 5</b>) is caused by contact of the skin with a chemical that acts either as a primary irritant or as a specific allergic sensitizer. As defined by Schwartz,<a></a> "A Primary Cutaneous Irritant is an agent which will cause dermatitis by direct action on the normal skin at the site of contact if it is permitted to act in sufficient intensity or quantity for a sufficient length of time." Again using Schwartz' definition <a></a>, "A Cutaneous Sensitizer is an agent which does not necessarily cause demonstrable cutaneous changes on first contact but may effect such specific changes in the skin that, after five to seven days or more, further contact on the same or other parts of the body will cause dermatitis." Contact dermatitis may be acute, subacute, or chronic, and moderately severe to severe itching is present in most forms. In the acute and subacute types, diffuse erythema, edema, oozing, and crusting predominate. In addition, vesicles are often present if a specific allergic sensitizer is the cause. In chronic forms, erythema, scaling, and lichenification (thickening) prevail.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Contact dermatitis. <i>A, </i>Chronic, of the distal stump skin, due to contact with a plastic-covered cushion on the bottom of a suction socket. Removal of the cushion provided complete clearing in one week. Patch tests were positive for allergic sensitivity to the plastic <i>B, </i>Of the distal stum]) skin, due to contact with a foam-rubber pad on the bottom of a prosthetic socket. Note the circular zone of erythema and edema. Rapid clearing and disappearance of itching followed removal of the pad C, Left, the foam-rubber pad removed from the socket of the patient in <i>B; </i>right, the small piece of the material (4 mm in diameter) used in patch-testing <i>D, </i>Skin of the upper arm of the same patient as in <i>B, </i>showing a positive reaction to foam rubber. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>We have seen a number of patients with contact dermatitis of the amputation stump. In order to understand the problem, we have had to learn about the plastics and resins used in the external and internal finishes of the different types of prostheses. In some instances, we found only by carefully taken history that the use of a new cream, lubricant, or cleansing agent coincided with the onset of the dermatitis. Some amputees use a foam-rubber cushion, others a plastic-covered pad on the bottom of their socket. These are also capable of producing a contact dermatitis of the skin weeks, months, or even years after use (<b>Fig. 5</b>, <i>A </i>and <i>B).</i></p> <p>On patients exhibiting the clinical manifestations of contact dermatitis, every attempt has been made to determine the exact contactant. Patch tests (<b>Fig. 5</b>, <i>C </i>and <i>D) </i>have been most informative with respect to specific substances as the cause of the dermatitis. In diagnostic patch-testing, a small amount of the suspected substance is applied to a site of normal skin on the patient. It is covered with an innocuous, impermeable material such as cellophane, which is then sealed to the skin by adhesive plaster. It is usually sufficient to leave the patch on for 24 to 48 hours. Upon removal of the patch, a positive reaction is signified by erythema, vesiculation, or blister formation at the site of application.</p> <p>Because patch-testing with strong concentrations of known primary irritants will result in reactions on any skin, solutions of such substances are first diluted according to published lists<a></a> in order to prevent a false positive reaction and possible injury to the skin. A generalized eruption following the patch test indicates a high degree of sensitivity, but fortunately such eruptions are rare. Experience and good clinical judgment are necessary in choosing the correct chemical concentration of the irritant and the proper time for performing the patch test.</p> <p>The sockets of leg prostheses are commonly finished on the inside by the application of a varnish or lacquer and on the outside by coating with plastics and resins. These complex organic substances are capable of causing a contact dermatitis in a given individual who has become sensitized. This sensitization is similar to that produced by poison oak or poison ivy, and the intensity of reaction may vary under different conditions of heat, humidity, and friction. The epoxy resins,<a></a> if incompletely cured in their manufacture, may, in addition to being a specific allergic sensitizer, produce a primary-irritant dermatitis. These resins are frequently used to improve the appearance of a socket and to render it impervious to external agents. In the uncured state at room temperature they are viscous, amber-colored liquids. Curing agents, known as catalysts or hardeners, are added to solidify the plastic material. These agents are organic amines of various types and, when left in excess by incomplete baking or curing at high temperatures, are able to produce a primary-irritant dermatitis.</p> <p>We have had several patients with proven contact dermatitis to Ambroid,® C-8 epoxy resin, polyethylene, foam-rubber pads, and plastic-covered cushions. Removal of the suspicious contactant resulted in a cure, and subsequent patch-testing proved the diagnosis.</p> <p>In those instances of contact dermatitis where the irritant has not been obvious and the patch tests have been inconclusive, temporary therapy has alleviated the symptoms. Cool compresses, bland antipruritic lotions, and the topical use of hydrocortisone or fluorohydro-cortisone preparations have been most beneficial.</p> <h4>Post-Traumatic Epidermoid Cysts</h4> <p>Young, <a></a> in 1951, described the appearance of multiple cysts in the skin of an amputee's thigh in association with the wearing of an artificial limb. Other authors<a></a> have described similar nodules in the skin under the rim of the socket. In the typical case (<b>Fig. 6</b>), the cysts do not appear until the patient has worn an artificial limb for months or possibly years. They occur most frequently in above-knee amputees in the areas covered by the upper medial margin of the prosthesis but have also been described in below-knee amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Post-traumatic epidermoid cysts. <i>A, </i>Early phase, in a Negro patient. Tiny follicular keratin plugs have developed in the skin of the adductor region. Some have enlarged to form tender nodules. <i>B, </i>Slightly later phase, in a 15-year-old white female. <i>C, </i>Still later phase, in the adductor region of a white male, where the nodules are larger and have become firm, tender, and cystic. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Characteristically, in the above-knee amputee small follicular keratin plugs develop in the skin of the adductor region of the thigh along the upper edge of the prosthesis. In the beginning they appear as small lumps or nodules and will, at times, disappear when the prosthesis is removed temporarily. Under the constant friction and pressure of the prosthesis, they become larger and more numerous. Some become pea-sized, round, or oval swellings deep within the skin. Gradually, with enlargement, they become sensitive and tender to the touch. The skin may break down and erode or ulcerate. With continued irritation by the prosthesis, the nodular swelling may suddenly burst and discharge an opaque, purulent fluid. The discharging sinus may become chronic and thus make it impossible for the patient to use his prosthesis. In other instances, the break may take place within the deeper portion of the skin, and subcutaneous intercommunicating sinuses may develop.</p> <p>The larger nodules become especially tender and necessitate removal of the prosthesis. These should not be confused with ordinary furuncles or boils (<b>Fig. 7</b>), which may occur on any portion of the stump. Surgical excision of the chronic, isolated, noninfected nodule may give relief, but no completely satisfactory method of treatment is known. In the acutely infected phase, hot compresses and antibiotics are indicated. As the process localizes, incision and drainage may be beneficial temporarily. <i>Micrococcus pyogenes (Staphylococcus aureus) </i>is frequently a secondary bacterial invader and at times resistant to many antibacterial agents. In some of the cystic lesions, the contained fluid is sterile.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Furuncle, or boil. Subsiding, on the distal stump skin of a below-knee amputee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cysts range in size from microscopic papules to large nodules that can be palpated with the fingers. The microscopic picture, therefore, is variable, depending upon the size of the lesion and the extent of secondary irritation or infection. In the earliest phase, a keratin plug is seen to form. Later this plug invaginates the epidermis, and pockets of keratin appear in the subepidermal region of the skin. The invaginated epidermis containing keratin may be superficial or deep within the corium. As the keratin cyst enlarges and becomes secondarily infected, acute, subacute, and chronic inflammatory cells are seen. Foreign-body giant cells and newly formed capillaries and fibroblasts are not uncommon about the disintegrating cyst wall.</p> <p>Many authors have written extensively on the cause of these so-called "prosthetic nodules and abscesses," so frequently the concern of the physician, the limbfitter, and the amputee. Their occurrence is not restricted to wearers of the suction-socket prosthesis, since amputees complained of these inflamed swellings long before the suction socket came into widespread use. In the first third of this century, German investigators<a></a> ascribed the lesions to foreign bodies and wrote of finding "chamois-leather" particles, fine hairs, talc, and amorphous substances in the giant cells of the fully developed cyst. Other writers <i>{2,3,15) </i>disputed these foreign bodies as the cause and attributed the formation of the nodules to pressure and irritation from the socket and to epidermal keratin forced inward by this pressure. Some present-day investigators<a></a> regard the cysts as sebaceous adenomata and speak of sebaceous adenitis as being of frequent occurrence in the adductor region of the thigh stump. These and similar lesions have also been described in the hands and fingers following trauma.<a></a></p> <p>Although our studies have been limited, and although we are only now beginning to see these nodules in various stages of development, it appears that the condition is one in which the surface keratin and epidermis becomes invaginated, acting as a "foreign body." Under the influence of friction and pressure from the prosthesis, the keratin plug and its underlying epidermis are displaced into the corium. The result is the production of nonspecific inflammatory tissue and implanted epidermoid cysts. These can remain quiescent for a long period of time or can, with secondary bacterial invasion, become abscessed and produce the characteristic clinical and pathologic picture previously described.</p> <p>Recurrent and secondarily infected nodules may require the attention of a dermatologist or a surgeon. Some lesions necessitate incision and drainage. For others, total excision of the cyst under local anesthesia is the treatment of choice. These methods, however, do not solve the entire problem and may only succeed in alleviating an acute phase. The chronic problem can, in some instances, be mitigated or successfully eliminated by proper fit and alignment of the prosthesis.</p> <p>At the present time we are attempting the clinical trial of topical agents in an effort to prevent or retard the formation of the keratin plug, which may be the precursor of the epidermoid cyst. We are endeavoring to develop a stump sock or adductor rim sock for use with the suction-socket prosthesis to prevent cyst formation, but to date this effort has been of an experimental nature only. In our experience, there is no completely satisfactory method of treatment, and each amputee with the problem offers a therapeutic challenge.</p> <h4>Folliculitis and Furuncles</h4> <p>Folliculitis, usually caused by staphylococci, is a superficial bacterial infection of the hair follicle in which the primary lesion is an inflammatory papule or pustule. In contrast, a furuncle (<b>Fig. 7</b>) is a larger, more deep-seated, painful, bacterial infection of the pilosebaceous apparatus and is invariably caused by a staphylococcus or a streptococcus. Whereas folliculitis typically consists of multiple, small. itching, red papules, the furuncle, or "boil," is usually a tender, deep-red nodule which eventually rises to the surface of the skin and discharges its necrotic core.</p> <p>Folliculitis is a commonly encountered problem in the amputee, particularly in dark-complexioned, hairy persons with an oily skin. The condition is aggravated by the use of an artificial leg (<b>Fig. 8</b>). It is usually worse in summer, when increased warmth and moisture from perspiration promotes maceration of the skin, which, in turn, favors invasion of the hair follicle by bacteria. Ordinarily this process is not serious, but sometimes it progresses to boil formation, cellulitis, or an eczem-atous, weeping and crusted, superficial pyoderma.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Skin changes acompanying the early use of prosthesis <i>A. B, </i>and <i>C </i>show the skin of the same below-knee amputee. .1, Normal stump skin before the prosthesis was worn. <i>B, </i>Reactive hyperemia with itching and tingling, shortly after the prosthesis was used for the first time. Compare the flush with the normal skin color, which returns under pressure by the glass slide <i>C. </i>Small areas of folliculitis on the skin, which began to develop after wearing of the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Folliculitis and boils may follow upon poor hygiene of the stump or the socket or both. In several patients, chronic recurrent folliculitis was essentially cured by having the amputee adhere to the routine hygienic program using pHisoHex.® The hexachlorophene in this product is a hundred times more effective than is soap in eliminating skin bacteria, and that circumstance possibly accounts for the effectiveness of this program. In other instances, therapy may require the use of wet dressings, the incision and drainage of boils after localization, the oral or parenteral use of antibacterial substances, and the application of local bactericides, but we do not subscribe to the use of epilating doses of roentgen-ray therapy, which has been reported by Heller.<a></a> Since these conditions of the stump are frequently chronic or recurring, it is best to choose relatively nonsensitizing substances for topical application.</p> <h4>Additional Cutaneous Problems</h4> <p><i>Fungous Infections</i></p> <p>Superficial fungous infections of the stump may be difficult to eradicate completely because of continued moisture, warmth, and maceration of the skin within the enclosed socket of the artificial leg. Tinea corporis<a></a> , or ringworm of the nonhairy portions of the skin, is characterized by oval to round, scaly, erythematous, itching lesions, usually appearing only on the part of the stump enclosed by the socket. The diagnosis is confirmed by microscopic demonstration of the fungal filaments in scales or vesicles removed from a lesion. Therapy consists of the application of fungistatic creams and powders over an extended period.</p> <p><i>Nonspecific Eczematization</i></p> <p>Nonspecific eczematization of the stump skin has been seen in a number of instances (<b>Fig. 9</b> and <b>Fig. 10</b>). Here the amputee presents a weeping, itching, nonhealing plaque of dermatitis over the distal portion of the stump. The lesion is dry and scaly and then suddenly becomes moist without reason. It waxes and wanes over a period of months to years and may be a major source of mental anxiety.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Erosion and eczematization ot the stump skin from poor prosthetic fit and alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Nonspecific eczematization. <i>A, </i>Of three months' duration on the stump skin of a 32-year-old above-knee amputee who presented unusually poor stump cleanliness. <i>B, </i>Enlarged view of <i>A, </i>showing erythema, edema, and vesiculation. After a simple hygienic program with a sudsing detergent containing hexachlorophene, the eczematous process disappeared completely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>We have tried to find the cause through either history, physical examination, or laboratory tests, or through studying the clinical course of the eczematous process. At times we have been able to elicit a significant history of recurrent allergic eczema or to demonstrate active eczematous lesions on other portions of the body to account for the eruption on the stump. In other instances, the eczema was secondary to edema and congestion of the terminal portion of the stump, so that only with the alleviation of these problems did the condition clear. Drug sensitivities from the internal use of an agent such as penicillin may present themselves on the amputation stump. Ideally, whenever possible, the cause of the eczema should be found and removed. Temporary symptomatic treatment with topical hydrocortisone or fluorohydrocortisone preparations is effective, but the condition will frequently recur unless the cause is eliminated.</p> <p><i>Generalized Disorders</i></p> <p>The localization of other skin disorders on the amputee's stump is not an uncommon occurrence. We have seen patients with acne vulgaris of the face and back develop acne lesions of the stump. We have seen similar localizations in patients with seborrheic dermatitis, folliculitis, and eczema. There are recorded instances of psoriasis and lichen planus developing on the stump skin with few lesions present elsewhere on the body <i>{9). </i>Here again, it is important to diagnose the generalized cutaneous disorder and to treat it der-matologically in order to improve the stump condition.</p> <p><i>Intertriginous Dermatitis</i></p> <p>An intertriginous dermatitis is an irritative condition of those skin surfaces which are in constant apposition and between which there is a hypersecretion and a retention of sweat. This situation usually occurs in the crotch (<b>Fig. 11</b>), but on occasion it occurs in the folds at the end of the stump where two regions of skin rub each other and where the protective layer of keratin is removed by the friction. A chronic disorder may develop, with deep, painful fissures and with infection and eczematization. Hygienic measures to cleanse the apposing folds and the use of drying powders are beneficial. At times, it may be necessary to re-excise the bulky, infolded stump skin in an effort to provide a linear scar which would preclude this form of disorder.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Skin irritation in the crotch area. <i>A, </i>Chronic, resulting from continued friction and pressure from the socket. <i>B, </i>Enlarged view of <i>A</i>, showing thickened (lichenified) and pigmented skin containing the early phase of post-traumatic epidermoid cysts. The skin of this area may become eroded or ulcerated. In some instances, these problems may be corrected by proper prosthetic fit and alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Adherent Scars</i></p> <p>With repeated infection and ulceration of the skin, the scar may become adherent to the underlying subcutaneous tissues (<b>Fig. 12</b>), a condition which invites further erosion and ulceration. Long wear and tear from the use of a prosthesis may necessitate surgical revision in order to free the scar in the bound area.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Scar tissue of several years' duration on the distal stump skin. Through repeated years of wear and tear from using a prosthesis, the skin has become adherent to the underlying tissue. Such abnormalities are capable of causing repeated infection, erosion, and ulceration. This below-knee amputee .was treated by surgical revision of the scarred area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Chronic Ulcers</i></p> <p>Chronic ulcers (<b>Fig. 2</b>) of the stump may result from bacterial infection or from poor cutaneous nutrition secondary to an underlying vascular disorder. In every instance, the underlying cause should be investigated and appropriate treatment provided. Malignant ulcers have developed within old, persistent stump ulcerations, and hence every effort should be made to diagnose the condition before it becomes chronic.</p> <p><i>Tumors</i></p> <p>Tumors of the stump may be malignant or benign. We have seen innocent hyperkeratosis, or callus formation, and have removed verru-cae, or viral warts, from the stump skin. Simple "skin tags," or cutaneous papillomas, are easily removed dermatologically under local anesthesia. A cutaneous horn (<b>Fig. 13</b>) on an amputation stump has been recorded<a></a>, and we have removed one from a below-knee amputee wearing a conventional prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Cutaneous horn of several years' duration in a below-knee amputee. Local excision of the lesion was curative. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Extensive verrucous hyperplasia (<b>Fig. 14</b>) of the entire terminal stump skin has been seen in one instance. A surgical biopsy failed to reveal the pathologic picture of viral verrucae. This hyperplastic condition was felt to be secondary to an underlying vascular disorder, bacterial infection, and poor prosthetic fit and alignment. Treatment to date has consisted of adequate control of the bacterial process and gradual end-bearing maneuvers to improve the vascular stasis. A new prosthesis is being manufactured to correct the fit and alignment. Here is an example of the need for the services of the entire clinic team to provide the maximum benefit to the individual amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Verrucous hyperplasia of the distal stump skin. <i>A, </i>Distal view, showing the warty nature of the skin. This hyperplastic condition was felt to be secondary to an underlying vascular disorder, bacterial infection, and poor prosthetic fit and alignment. <i>B, </i>Microscopic section of a warty nodule in <i>A. </i>Note the hyperplasia of the epidermis, with sclerosis of the collagen and chronic inflammation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Malignant tumors of the stump skin have been recorded by others, but we have not as yet encountered any primary cancers in our series of patients.</p> <h4>Summary</h4> <p>The cutaneous problems of the lower-extremity amputee are many and varied. They are real problems, which can begin insidiously without creating additional disability and then, through neglect and mistreatment, seriously threaten the social and economic rehabilitation of the amputee. A variety of skin disorders are found to localize on the skin of the lower-extremity stump because of the many new insults to which it is subjected when a prosthesis is worn. These disorders may require dermatologic consultation for either diagnosis or treatment.</p> <p>In the past year, the cutaneous difficulties associated with the wearing of a leg prosthesis have been evaluated during more than 200 patient-visits to the Lower-Extremity Amputee Research Project at the University of California Medical Center in San Francisco. Hygiene is important in relation to many skin disorders of the stump, and consequently a specific hygienic program is being developed, The danger signals and the clinical problems which have been found to require medical attention include the stump edema syndrome, contact dermatitis, post-traumatic epidermoid cysts, folliculitis and furuncles, superficial fungous infections, nonspecific eczematization, intertriginous dermatitis, chronic ulcers, and tumors of the stump.</p> <p>The skin-study group is a comparatively recent addition to the Lower-Extremity Amputee Research Project of the University of California. It is hoped that, through this study group, the varied cutaneous disorders associated with the lower-extremity amputee will, over a period of time, be fully classified and thereby be prevented.</p> <h4>Acknowledgments</h4> <p>The author is indebted to Mrs. Ellen Brennan for her coverage of the literature and to Mr. Leo Sakovich for his help with the photographs. Sincere appreciation is expressed to these laboratory technicians and to the other personnel of the University of California Medical Center in San Francisco for their aid in the completion of this paper.</p> <p><b>References:</b></p> <ol> <li>Conn, H. R., <i>Amputation stumps of lower ex- tremities: the causes and treatment of prolonged disability, </i>Surg., Gyn., &amp; Obstet., 43:524 (1926).</li> <li>Gillis, Leon, <i>Amputations, </i>William Heinemann Medical Books, Ltd., London, 1954.</li> <li>Gillis, Leon, <i>Infected traumatic epidermoid cysts, the result of rubbing by an artificial limb, </i>Proc. Roy. Soc. Med., 47:9 (1954).</li> <li>Heller, W., <i>Zur Behandlung von Furunkeln und Follikuliliden, am Amputationsstumpf, </i>Deutsche med. Wchnschr., 69:812 (1943).</li> <li>King, E. S. J., <i>Post-traumatic epidermoid cysts of hands and fingers, </i>Brit. J. Surg., 21:29 (1933).</li> <li>Makai, Endre, <i>Lipogranulomatosis subcutanea am A mputationssliimpfe (Prolhesenrandknoten)</i>, Zent-ralbl. f. Chir., 57:590 (1930).</li> <li>Mayne, F. E., and L. O'Shaughnessy, <i>Cutaneous horn on an amputation stump, </i>Brit. Med. J., 1: 624 (1931).</li> <li>Savitt, Leonard E., <i>Contact dermatitis encountered in the production of epoxy resins, </i>A. M. A. Arch. Dermat. &amp; Syphilol., 71:212 (1955).</li> <li>Schamberg, I. L., <i>Dermatitis of lower limb amputa- tion slump, </i>J. Am. Med. Assoc, 150:1653 (1952).</li> <li>Schwartz, Louis, <i>Allergic occupational dermatitis in our war industries, </i>Ann. Allergy, 2:387 (1944).</li> <li>Schwartz, L., L. Tulipan, and S. M. Peck, <i>Occupa- tional diseases of the skin, </i>2nd ed., Lea &amp; Febiger, Philadelphia, 1947.</li> <li>Slocum, Donald B., <i>An atlas of amputations,</i> Mosby, St. Louis, 1949. pp. 254-288.</li> <li>Thomas, A., and C. C. Haddan, <i>Amputation prosthesis, </i>Lippincott, Philadelphia, 1945. pp. 54-67.</li> <li>Wohlvill, Fr., <i>Über "Prothesenrandknoten," </i>Virchows Arch. f. path, Anat.. 288:576 (1933).</li> <li>Young, Freida, <i>Post-traumatic epidermoid cysts,</i> Lancet, 1:716 (1951).</li> <li>zur Verth, [M.], <i>Prothesenrandknoten und Pro- thesenrandabszesse, </i>Zentralbl. f. Chir., 63:322 (1926).</li> <li>zur Verth, [M.], <i>Prothesenrandknoten und ihre Entstehung, </i>Dermat. Wchnschr., 88:45 (1929).</li> <li>zur Verth, M., and K. H. Vohwinkel, <i>Prothesen- randknoten, </i>Deutsche Ztschr. f. Chir., 205:302 (1927).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Mayne, F. E., and L. O'Shaughnessy, Cutaneous horn on an amputation stump, Brit. Med. J., 1: 624 (1931).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Schamberg, I. L., Dermatitis of lower limb amputa- tion slump, J. Am. Med. Assoc, 150:1653 (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>4.</b> </td><td class="clsTextSmall">Heller, W., Zur Behandlung von Furunkeln und Follikuliliden, am Amputationsstumpf, Deutsche med. Wchnschr., 69:812 (1943).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Conn, H. R., Amputation stumps of lower ex- tremities: the causes and treatment of prolonged disability, Surg., Gyn., &amp;Obstet., 43:524 (1926).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">King, E. S. J., Post-traumatic epidermoid cysts of hands and fingers, Brit. J. Surg., 21:29 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations, Mosby, St. Louis, 1949. pp. 254-288.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Thomas, A., and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945. pp. 54-67.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Makai, Endre, Lipogranulomatosis subcutanea am A mputationssliimpfe (Prolhesenrandknoten), Zent-ralbl. f. Chir., 57:590 (1930).</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Wohlvill, Fr., Über 'Prothesenrandknoten,' Virchows Arch. f. path, Anat.. 288:576 (1933).</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">zur Verth, [M.], Prothesenrandknoten und Pro- thesenrandabszesse, Zentralbl. f. Chir., 63:322 (1926).</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">zur Verth, [M.], Prothesenrandknoten und ihre Entstehung, Dermat. Wchnschr., 88:45 (1929).</td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">zur Verth, M., and K. H. Vohwinkel, Prothesen- randknoten, Deutsche Ztschr. f. Chir., 205:302 (1927).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Gillis, Leon, Amputations, William Heinemann Medical Books, Ltd., London, 1954.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Gillis, Leon, Infected traumatic epidermoid cysts, the result of rubbing by an artificial limb, Proc. Roy. Soc. Med., 47:9 (1954).</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Makai, Endre, Lipogranulomatosis subcutanea am A mputationssliimpfe (Prolhesenrandknoten), Zent-ralbl. f. Chir., 57:590 (1930).</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Thomas, A., and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945. pp. 54-67.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Wohlvill, Fr., Über 'Prothesenrandknoten,' Virchows Arch. f. path, Anat.. 288:576 (1933).</td></tr><tr><td class="clsTextSmall"><b> 16.</b> </td><td class="clsTextSmall">zur Verth, [M.], Prothesenrandknoten und Pro- thesenrandabszesse, Zentralbl. f. Chir., 63:322 (1926).</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">zur Verth, [M.], Prothesenrandknoten und ihre Entstehung, Dermat. Wchnschr., 88:45 (1929).</td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">zur Verth, M., and K. H. Vohwinkel, Prothesen- randknoten, Deutsche Ztschr. f. Chir., 205:302 (1927).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Young, Freida, Post-traumatic epidermoid cysts, Lancet, 1:716 (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>8.</b> </td><td class="clsTextSmall">Savitt, Leonard E., Contact dermatitis encountered in the production of epoxy resins, A. M. A. Arch. Dermat. &amp;Syphilol., 71:212 (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">Schwartz, L., L. Tulipan, and S. M. Peck, Occupa- tional diseases of the skin, 2nd ed., Lea &amp;Febiger, Philadelphia, 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>10.</b> </td><td class="clsTextSmall">Schwartz, Louis, Allergic occupational dermatitis in our war industries, Ann. Allergy, 2:387 (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>10.</b> </td><td class="clsTextSmall">Schwartz, Louis, Allergic occupational dermatitis in our war industries, Ann. Allergy, 2:387 (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>S. William Levy, M.D. </b></td></tr><tr><td class="clsTextSmall">Clinical Instructor in Dermatology, School of Medicine, University of California Medical Center, San Francisco, and supervisor of the Study Group on Dermatology, Lower-Extremity Amputee Research Project, University of California, Berkeley and San Francisco.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b001.jpg Figure 2 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b002.jpg Figure 3 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b003.jpg Figure 4 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b004.jpg Figure 5 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b005.jpg Figure 6 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b006.jpg Figure 7 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b007.jpg Figure 8 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b008.jpg Figure 9 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b009.jpg Figure 10 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b010.jpg Figure 11 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b011.jpg Figure 12 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b012.jpg Figure 13 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b013.jpg Figure 14 http://www.oandplibrary.org/al/images/1956_01_020/sp56-b014.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 Skin Problems of the Lower-Extremity Amputee Creator An entity primarily responsible for making the resource S. William Levy, M.D. * https://staging.drfop.org/files/original/134d9851f6fd34f10b98fac119946d9b.pdf c9a03496075767605fc06bd5d6ac4780 https://staging.drfop.org/files/original/fea6766a6495664f5260b51cbff436da.jpg 2e5dfdcbd0b96f663f5470b95ebe80a0 https://staging.drfop.org/files/original/b0db79c79f26f20be00e643367cdaa15.jpg 33873f40f357926954a3ccc9907a4e72 https://staging.drfop.org/files/original/3a7f8361eb473cf4b078c9f8d8c050a5.jpg 0ce7d7a42e382acb91b859f476cc606c https://staging.drfop.org/files/original/ca3ca8e14a2047103f815a282222d402.jpg 0606d742b82c86d87ae8e3750f3f4ce5 https://staging.drfop.org/files/original/ba4b3555b1b4d3697712c9583451c279.jpg 4dd8248ec379a7a364390de2dd9e4097 https://staging.drfop.org/files/original/0a4be97418198a9f496239b0614dbc9f.jpg 0ece3b4b41b32030ebfd864956ad1720 https://staging.drfop.org/files/original/b5afeb1c4d62e046282c3d489417b9be.jpg c67123038b2fd3fd5c451d5fa83d1552 https://staging.drfop.org/files/original/819880245c9711ba14636f81f2b4dfbb.jpg 32a971bc21c5714eaf7d010fd9ebf314 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_005.pdf Text Any textual data included in the document <h2>The Stat Limb: A Prosthesis for Immediate Postoperative Fitting of AK and BK Amputations</h2> <h5>Joseph CM. Sheehan, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Michael J. Quigley, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> <p>Postoperative care of amputation wounds varies significantly ranging from simple daily dressings to rigid immobilization. These variations make it difficult for the occasional surgeon to judge the virtues of each method from available literature. A basic prefabricated plastic supportive structure is described here to simplify the use of an immediate postoperative prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-1.jpg"><b>Fig. 1</b>)</a>.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-1.jpg"><strong>Figure 1. The Stat Limb is a prefabricated high density polyethylene shell that can be applied in less than ten minutes in the operating room.</strong></a><br /> <p>Although immediate post surgical fittings (IPSF) were in common use 20 years ago, they are used only in isolated areas today. The reasons for the decline of IPSF were both educational and logistical. Most amputations today are done by general and vascular surgeons who are not trained in IPSF principles or rehabilitation, and who do not have a working relationship with a prosthetist. Secondly, to use the conventional IPSF technique as taught by Weiss and Burgess, a prosthetist needs to be available at surgery with a number of special socks, attachment plates, tubes, padding materials and the associated tools needed to apply the prosthesis. Scheduling the prosthetist caused logistical problems, so physicians began to simply apply a rigid dressing in surgery and call the prosthetist in a week or so later to apply a shrinker. A preparatory prosthesis is not usually prescribed until three to four weeks post-surgery.</p> <h3>Advantages Of Early Mobilization</h3> <p>The postoperative disease problems of the amputee are typical of any long term illness encountered in medical practice. Thinking solely of the amputated limb is a grave mistake, not only for the mental health of the patient, but also for the surgical wound itself.</p> <p>Early mobilization after surgery is a necessity in preventing bowel, bladder and cardiopulmonary complications. The post-amputated patient is usually a high risk patient. Often, severe diabetes with restricted cardiopulmonary reserve is a common associated medical problem. Small pulmonary emboli cause major cardiac changes, and bladder/bowel stasis of recumbency may lead to recurrent septicemias. Each day of postoperative immobilization adds a significant risk to ultimate survival. First or second day mobilization into the standing position is a necessity to reduce basilar atelectasis, reduce the residual urine volume in the bladder, and allow feces to move into the rectum for evacuation.</p> <p>Even without the psychological and balance effect of a second limb, the process of getting a weak postoperative patient to stand on the unaffected leg alone is next to impossible. However, a rigid locked knee above a "weightless" prosthesis gives the patient more stability than when they had a painful necrotic leg before surgery. It is possible to mobilize a patient within 24 hours post-surgically or to at least have the patient stand and transfer to a commode or wheelchair using a limb, even though they have been bedridden entirely for many weeks preoperatively. Minimal ambulation in therapy from the second day onwards is important. The wound risk involved with minimal weight bearing and the brief stance phase on the amputated leg is outweighed by all the general advantages to the patient for ultimate survival.</p> <p>The Stat Limb was designed to allow even the surgeon doing an occasional amputation to apply an immediate postoperative prosthesis himself following surgery. The Stat Limb comes in one size that fits both right and left legs, eliminating the requirement for inventory. The patient receives all the advantages of a rigid dressing, with the added advantages of early weight bearing. The psychological boost given to a patient who wakes up following surgery with two feet under the covers cannot be easily measured, but is definitely a positive factor. In addition, the medical team working with the patient (physician, nurse, therapist, etc.) automatically become rehabilitation oriented. The patient is no longer laying in bed week after week waiting for his new leg. Early ambulation is safe and is encouraged as early as one day postoperatively. The lack of knee flexion in the prosthesis poses no particular problem to the patient during walking, and the extremely light prosthesis allows the patient to move the leg around easily in the sitting and supine positions.</p> <p>Patients who have worn the Stat Limb make the transfer to a preparatory prosthesis very easily; they already know how to walk and are not afraid to place weight on the residual limb.</p> <h3>Application Procedure</h3> <p>The major advantages of the Stat Limb immediate postoperative fitting are as follows:</p> <ol> <li> <p>a rigid dressing,</p> </li> <li> <p>the knee fixed in hyperextension,</p> </li> <li> <p>rapid application of the prosthesis while the patient is under anesthesia,</p> </li> <li> <p>light weight due to the structural strength at the periphery of the prosthesis, and</p> </li> <li> <p>modification of the limb as rehabilitation continues.</p> </li> </ol> <p><i>Rigid Dressing</i></p> <p>The application of a rigid protective dressing is important to the survival of a poorly perfused limb. By surrounding the limb in a soft, heat-insulated environment, free of shearing forces, the limb is maintained at near 37 degrees centigrade, which is optimal for almost all physiological functions of wound healing, tissue resistance, and arteriolar dilation, and gives the surgery its best chance of success. Daily opening of the wound by tearing off adherent, coagulated dressings is not only painful, but rarely indicated unless for observation of unexplained pyrexias or blood loss.</p> <p>The dressing is nothing other than a gauze dressing over the wound site, to allow for any drainage which might occur, followed by multiple layers of cotton, giving a total of about two centimeters of thickness of cotton from groin to the distal end. A thin layer of fiberglass casting material is then applied to provide a rigid outer layer, preventing knee flexion and maintaining the residual limb shape, and protecting the wound (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-2.jpg"><b>Fig. 2</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-3jpg"><b>Fig. 3</b></a>). If plaster is used for the rigid dressing, it must be allowed to dry 24 hours before the Stat Limb is applied. At no stage is compression ever applied in the application of the rigid dressing. The speed of limb application is important in the critically ill, and with prior experience of one or two applications, it should be successfully applied in less than eight minutes (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-4.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-2.jpg"><strong>Figure 2. A simple dressing creates pressure between the skin and bone and forces the weight of the gastrosolei flap to pull on the wound against the amputated distal tibia.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-3.jpg"><strong>Figure 3. The rigid dressing maintains the knee in extension.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-4.jpg"><strong>Figure 4. Left, a bulbous residual limb after compression wrap. Right, a cylindrical residual limb after rigid dressing.</strong></a><br /> <p><i>Stat Limb Application</i></p> <p>Following the application of the rigid dressing, the Stat Limb is applied. The Stat Limb is designed to fit both left and right legs and can be cut to fit around the rigid dressing in nearly all cases.</p> <p>The desired length of the Stat Limb is approximated by either measuring the sound side, or by laying the Stat Limb next to the patient and marking the section to be cut off. The top edge of the Stat Limb should be trimmed a few inches short of the top of the rigid dressing (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-5.jpg"><b>Fig. 5</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-5.jpg"><strong>Figure 5. The rigid dressing consists of a gauze bandage over the wound, about two centimeters thickness of cast padding, and two layers of fiberglass casting tape to mid-thigh. The Stat Limb should be one centimeter shorter than the sound side, and the knee cast in extension.</strong></a><br /> <p>Six vertical cuts are then made in the Stat Limb to allow it to form around the rigid dressing (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-6.jpg"><b>Fig. 6</b></a>). Alignment is approximated while wrapping the Stat Limb onto the rigid dressing. The Stat Limb should be about a half inch shorter than the sound limb to allow toe clearance with an extended knee (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-7.jpg"><b>Fig. 7</b></a>). Toe out, foot in-set and out-set, and the anterior-posterior positioning of the foot should be held in a normal position as the casting material sets (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-8.jpg"><b>Fig. 8</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-6.jpg"><strong>Figure 6. A scissors or cast saw is used to cut off excess length and multivalve the Stat Limb. Six longitudinal cuts are recommended. The cuts may have to extend past the end of the rigid dressing if a bulbous end is present.</strong></a><br /><strong><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-7.jpg">Figure 7. For most applications, the vertical cuts can stop two centimeters from the distal end of the rigid dressing, and the proximal edge of the Stat Limb should be a few centimeters distal to the rigid dressings upper edge. A drain hole can be punctured through the Stat Limb, allowing removal in 24-48 hours.</a></strong><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-8.jpg"><strong>Figure 8. A double layer of fiberglass material is used to fasten the Stat Limb to the rigid dressing. All of the vertical slits should be covered. For heavy duty users, reinforce the ankle area with casting material as well. Normal toe-out and foot positioning should be maintained while the casting material sets.</strong></a><br /> <p><i>Knee in Extension</i></p> <p>Keeping the knee in extension, or locking it in about two degrees of hyperextension, makes the knee stable at the tibiofemoral joint. Subsequently, the quadriceps, hamstrings, and gastrocnemius are reflexly relaxed. Pain and associated spasms are reduced. The reduction of spasm of the gastrocnemius reduces the stress placed upon the distal myodesis and, indirectly, on the wound itself.</p> <p>With the knee in extension, the distal residual limb can be molded to prevent posterior migration of the long posterior flap. In extension, limb application is easier and it is easier to judge valgus, varus, rotation, and length of the limb. Application under anesthesia is justifiable because the patient is relaxed and this avoids fighting with a flexed knee joint four days later.</p> <p><i>Lightweight Due to Exoskeletal Construction</i></p> <p>Using the mechanical principles of the square area of inertia, the prosthetic material and the intended forces acting through the prosthesis are distributed to the periphery. This allows the use of a minimum amount of material while gaining the maximum strength to the prosthesis. A semi-pliable thermoplastic of high density polyethylene is used to give toughness to the prosthesis, to reduce the chance of any brittle failures, and to allow for cold forming of the prosthesis around the rigid dressing.</p> <h3>Modification As Rehabilitation Continues</h3> <p>As the patient's healing improves and rehabilitation continues, the thigh length rigid dressing is changed for a padded P.T.B, socket, also made of fiberglass cast material and attached to the limb. Depending on the strength of the quadriceps and hamstrings, the suspension is either a supracondylar strap or a simple single axis hinge from a knee orthosis; this usually occurs at the end of the second week. At the end of the seventh week, the residual limb is usually mature enough for a standard P.T.B, prosthesis. In a similar manner, the prefabricated limb can be used with less complexity for an above-knee prosthesis.</p> <p>A non slip sole material should always be worn when a patient is using the Stat Limb, as the plastic foot section is very slippery. A hospital slipper can be used as can elastoplast adhesive tape.</p> <p>On some occasions, buckling of the plastic at the ankle has occurred. This is usually a sign that the patient has become either very active or is wearing the prosthesis for a longer time than for which it was designed. Reinforce the ankle and foot with fiberglass tape during the original application process if it is felt that the patient will be a heavy user.</p> <p>The same Stat Limb module can be used for cast changes. However, it is important to cut off the cast carefully to prevent damage to the Stat Limb. It is not recommended to reuse the Stat Limb on other patients since it is designed for limited use.</p> <p>The earlier a prosthesis is applied, the more successful and pain free is the final fitting. The problems encountered in the use of any system have to be recognized, but it is difficult to scientifically explain why a minimally weighted limb can impede wound healing. If the prosthesis is not applied to the patient for a few days, we note the rate of progress is retarded. This is detrimental to the functional recovery of wound healing and the entire patient.</p> <h3>Case History</h3> <p>Although over 1,000 Stat Limbs have been used to date, one case history will be presented to illustrate the benefits of the Stat Limb in a community hospital setting.</p> <p>Patient A.B. is an 80 year old woman who had a right below-knee amputation, secondary to diabetic gangrene, two years ago. She was fit with a Stat Limb immediately and began weight bearing in physical therapy two days later. A cast change was made 12 days postoperatively when the stitches were removed. The Stat Limb was reapplied and the patient was discharged home with a walker and wheelchair. Two weeks later, a second cast change was made and measurements were also taken for a preparatory prosthesis. The following week, the Stat Limb was removed and the patient was fitted with her prosthesis. She walked six full lengths of the parallel bars without hesitation.</p> <p>One year later, the same patient lost her left leg below the knee and was immediately fit with a Stat Limb. Within two weeks she was home with a walker using a definitive right below-knee prosthesis and her Stat Limb. Without the availability of the Stat Limb in this case, this patient would have been wheelchair bound for weeks, the time needed for physical therapy would be lengthened, and many activities of daily living would have required assistance.</p> <h3>Summary</h3> <p>With the decline in use of immediate postsurgical fitting of prostheses, most amputees do not walk for several weeks post-surgically. The Stat Limb is designed for easy application by even the occasional surgeon and allows weight bearing within days following surgery.</p> <p>The Stat Limb does not provide the answer to every amputation. Each patient is entirely different from another in any series, and many other factors must be taken into account, including the initial pathology, age, cooperation of the patient, availability of nursing and physical therapy care, and other associated problems.</p> <p>The Stat Limb does remove most of the logistical and educational problems that are associated with IPSF, and should allow many new amputees to benefit from early weight bearing and walking.</p> <p><em><b>*Michael J. Quigley, C.P.O. </b> Michael J. Quigley, CPO is President of Oakbrook Orthopedic Services, Ltd., 1 South 132 Summit Avenue, Oakbrook Terrace, Illinois 60181.</em></p> <p style="width: 400px;"><em><b>*Joseph CM. Sheehan, M.D. </b> Dr. Joseph CM. Sheehan is Associate Clinical Professor for Orthopedic Surgery and Rehabilitation at Loyola University in Chicago, Illinois. He is also Attending Surgeon at Marianjoy Rehabilitation Center in Wheaton, Illinois.</em><br /><br /><br /></p> Page Number(s) 5 - 10 Year 1987 Volume 11 Issue 1 Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-8.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-1.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 Stat Limb: A Prosthesis for Immediate Postoperative Fitting of AK and BK Amputations Creator An entity primarily responsible for making the resource Joseph CM. Sheehan, M.D. * Michael J. Quigley, C.P.O. * https://staging.drfop.org/files/original/d926666429d9f2cdaf83ae21fe646c4f.pdf fc83de5564adb8c10840e56fc70c62ee https://staging.drfop.org/files/original/3b5e2b430dabd8baf145e6318ad9a8ac.jpg 01ae62dacd8de2696172979a524bc346 https://staging.drfop.org/files/original/c3618fa7bba7b72cca5c7f35c50ccebf.jpg 6ffb262220815834326298815ce4703a https://staging.drfop.org/files/original/6e60ab4bfaa6a84d3cd16563dd3a1b00.jpg b7d55619ad69dca45bb140cb75b7ff3d https://staging.drfop.org/files/original/6cef018bad60db66a6ccacad7eaa8947.jpg 5567ec543d1d62d47c68c307b1277865 https://staging.drfop.org/files/original/720bdb4a059cfeabf344aa1141a372ae.jpg 6858cb4c2244e6b253e500666c4e1865 https://staging.drfop.org/files/original/92e2ffc11c03bf7e45ccd8ceb1d94c1a.jpg 9c8423654d6cb14560a481688f433867 https://staging.drfop.org/files/original/7ccbc9292d966c3628e96d4de8252295.jpg 829221dd8b8b0904dfb59d0079def2c8 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_061.pdf Text Any textual data included in the document <h2>The Susceptible Insensate Foot</h2> <h5>Mitchell E. Kalter, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Richard L. Jacobs, M.D.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Patients with limbs which are both insensate and functionless often are best treated with amputation to improve hygiene, functional potential with prosthetics, and often cosmesis. There exists, however, a large population of patients whose lower extremities are insensate, but remain functional. Because of continued functional demands, and the loss of important protective mechanisms, breakdown of the delicate articulations occurs resulting in neuropathic arthropathy.</p> <p>While there are a multiplicity of disease states associated with neuropathic arthropathy, there are certain general principles and characteristics inherent in the final common pathway of the Charcot joint. In years past, neuro-syphillis was the major cause. Nowadays, diabetes mellitus is by far the most common cause.</p> <p>This article will explore some of the historical aspects, causes, pathophysiology, clinical manifestations, and principles of treatment as they relate to neuropathic arthropathy of the susceptible insensate foot.</p> <h3>Historical Aspects</h3> <p>Jean Martin Charcot, at La Salpetriere in 1868, first called attention to "ataxic" forms of arthropathy associated with neurological diseases, the most commonly recognized cause being tabes dorsalis.<a></a> Charcot attributed the acute and destructive arthropathy to the loss of certain "neurotrophic influences" ncessary to support the normal joints.<a></a></p> <p>Charcot's contemporaries, Volkmann and Virchow, disagreed with this "trophic," or what was known as the "French" theory.<a></a> They argued that the arthropathy was due to continued mechanical stress and trauma on an insensitive biological structure.<a></a> These stresses continued in the absence of normal protective reflexes, which inevitably lead to a cycle of injury, inflammation, further injury, and finally instability and joint destruction. The end result, now the "Charcot joint."</p> <p>This basic process was gradually recognized in an ever broadening horizon of disease entities. Myelitis and syringomyelia were recognized as causes in 1875 and 1892 respectively.<a></a> It was not until 1936 that Jordan described neuropathic arthropathy in the diabetic,<a></a> now the most common cause of Charcot joints.<a></a></p> <h3>Etiologic Factors</h3> <p>The myriad of conditions which can produce Charcot joints is well outlined elsewhere.<a></a> The three most common causes are diabetes mellitus, tabes dorsalis, and syringomyelia.<a></a> The prevalence of neuropathic arthropathy in diabetes is only 0.1% to 0.5%, as compared to tabes dorsalis and syringomyelia which are 5% to 10% and 25%, respectively.<a></a> The almost epidemic numbers of diabetics makes them the largest group seen clinically, however.</p> <p>Various theories have been espoused, such as Charcot's "neurotrophic" theory, Volk-mann's "mechanistic" theory, and "neurovascular" theories.<a></a> Each stresses some aspect of the observations made in the neuropathic ar-</p> <p>thropathy process. Certainly, "trophic" nerves have never been proven.<a></a> Mechanical trauma most certainly has a major role in the process, as is noted by many authors.<a></a></p> <p>The basic concept of the mechanical theory is the blunting or eliminating of pain and proprioceptive information received from the involved body part. This dampens the afferent input for both conscious and nociflexive response patterns which have evolved to protect the extremity from intolerable mechanical stresses, and thus avoid injury.<a></a> The loss of proprioceptive and fine sensory input leads to ataxic gait patterns which further increase mechanical stresses.</p> <p>The spectrum of sensory deficit can be from an apparently normal sensory examination, to complete anesthesia.<a></a> Patients can experience pain, but it is invariably much less than expected for the degree of trauma and distortion of bone and soft tissues.<a></a> When pain does occur, it is usually secondary to severe posttraumatic inflammation of richly innervated synovial and pericapsular structures.<a></a> Joint proprioception, which normally inhibits hypermo-bility, is diminished, or absent, allowing instability to develop and progress.<a></a></p> <p>Attempts to explain the rapidity of the process and bony reabsorption, seen especially in the diabetic patient,<a></a> have been made with the "neurovascular" theory.<a></a> This theory states that an abnormal "neurovascular reflex"<a></a> increases blood flow, resulting in bony washout, and hyperemic distensible soft tissue supports, all of which predispose the joint to a destructive process with normal stresses. The high incidence of objective autonomic dysfunction in diabetics lends some support to this theory.<a></a></p> <p>As stated by Hurzwurm and Barja,<a></a> ". . . a more plausible explanation is that all of the above theories play a role . . . ," but to different degrees in each patient.</p> <p>Simply, relatively minor fractures in an otherwise normal foot or ankle can lead to rapid Charcot arthropathy if neuropathy is present.<a></a></p> <p>One can think about the insensate foot like the insensate mouth after our friendly dentist mercifully relieves pain. If we insist on eating before the anesthetic wears off, despite his instructions, we can induce a "Charcot mouth." We will have pain for our indiscretion within several hours. The patient with neuropathy will continue to "chew away," oblivious of the damage he creates.</p> <h3>Clinical Features</h3> <p>The foot is the most commonly affected part of the appendicular skeleton.<a></a> However, it should be noted that different distributions of skeletal involvement can be seen, such as primarily upper extremity involvement with syringomyelia. The spine, knee, and hip may also be involved.<a></a> Why one joint in an insensate extremity is involved, while other joints remain normal, has remained unanswered.<a></a></p> <p>Patients commonly present with the chief complaint of swelling, deformity, or mal perforant ulcers.<a></a> Pain may or may not be present, but is usually dependent upon presence of acute inflammation.<a></a></p> <p>As described by Charcot and Volkmann,<a></a> the process of joint disruption begins with a period of swelling, erythema, local hyperemia, and effusion. This acute phase presentation is a manifestation of a normal acute inflammatory response to injury. If the injury is not perceived, the already edematous and hyperemic tissues receive continued trauma, recurrent inflammation, and poor, inadequate healing occurs. This eventually, if unchecked, leads to progressive soft tissue and bony deformity,<a></a> more characteristic of the chronic phase. An important distinction must be made between acute inflammation and infection, as both can present with the same local findings of swelling, erythema, and increased skin temperature. In the Charcot joint, however, laboratory studies, such as the white blood and differential counts and sedimentation rate, are normal; and importantly, there are no systemic manifestations such as fever or signs of sepsis.<a></a></p> <p>Usual deformities include increasing flat foot to complete arch collapse, ankle and hindfoot valgus (or varus), and forefoot external rotation and eversion.<a></a> Mal perforans ulcers are formed intradermally, under heavy callous, caused by abnormal weight bearing.<a></a> A 50% association of diabetic mal perforans with neuroarthropathy has been described,<a></a> usually occurring at the metatarsophylangeal joint level.</p> <p>Patterns of joint involvement have been described in the diabetic. Primary ankle and subtalar joint patterns are frequent, with mid-tarsal joints most frequently involved.<a></a> Tarsometatarsal and metatarsophalangeal involvement have each been described in up to 30% of cases<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-1.jpg"><b>Fig. 1A</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg"><b>Fig. 1B</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg"><b>Fig.1C</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-4.jpg"><b>Fig. 1D (1)</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-5.jpg"><b>Fig. 1D (2)</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-6.jpg"><b>Fig. 1E</b></a>, and <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg"><b>Fig. 2</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-1.jpg"><strong>Figure 1A. Initial evaluation of a 54 year old female diabetic. Normal AP, lateral, and oblique views of the left foot.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg"><strong>Figure 1B. At age 59 years, the lateral view is still normal.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg"><strong>Figure 1C. Only ten months later, lateral view of same foot shows advanced Charcot changes of the ankle, subtalar, and metatarsalphylangeal joints.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-4.jpg"><strong>Figure 1D. AP view.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-5.jpg"><strong>Figure 1D. Oblique view.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-6.jpg"><strong>Figure 1E. AP and mortise views of the ankle at the same time as 1C and ID.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg"><strong>Figure 2. The right foot of same patient in Figure 1. Lateral, oblique, and AP views show mid-tarsal, tarsal-metatarsal, as well as interphylan-geal Charcot joint changes—a different pattern of joint involvement in the same patient. Elements of bone fragmentation, joint subluxation and dislocation and bone formation are represented.</strong></a><br /> <p>Radiological characteristics of neuropathic arthropathy progress from debris at the articular margins and periarticular calcifications, to diffuse bony fragmentation which can coalesce to larger fragments and large osteophytes.<a></a> Later changes include bony marginal sclerosis in attempts to reform articulations<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg"><b>Fig. 2</b></a>).</p> <p>Pathologic examination reveals bone and cartilage fragments in the synovial tissues, and fibroblastic reaction with some round cell infiltrates in ligamentous and capsular soft tissues.<a></a></p> <p>Circulatory status may be good in the Charcot foot,<a></a> but it is crucial to establish the diagnosis of vascular compromise on first evaluation as this can drastically affect treatment and outcome, especially in the diabetic.<a></a></p> <p>Neuropathic arthropathy can be the presenting problem with previously undiagnosed diabetics.<a></a></p> <p>Complicating factors in the clinical course are spontaneous fractures, which can hasten the degenerative process; deformity, which can be quite rapid in syringomyelia, tabes dorsalis, and with varus deformities; and soft tissue injury, predominantly neurotrophic plantar ulcers.<a></a></p> <h3>Treatment</h3> <p>Treatment follows from the recognition that the extremity is injured; and is likely to have continued trauma because of the neuropathy. Early recognition should allow curtailment of the progression, but because of the 'nature of the beast', there is often significant arthropathy at presentation.</p> <p>Control of neuropathy, if this is possible, should be a primary consideration. This should be followed by attention to soft tissue injuries, or skin ulcerations which may require local debridement.<a></a> Evaluation of circulation is also part of the initial evaluation,<a></a> with necessary vascular intervention performed if this is a concomitant problem.</p> <p>Cast immobilization to decrease edema, allow bony and soft tissue healing, and avoid or correct deformity, has been advocated by many authors.<a></a> Prolonged immobilization is essential to allow healing and stabilization.<a></a> Casting should continue until the local temperature has returned to that of the uninvolved or inactive side. It can then be assumed that the acute repair process has abated, and progression to supportive and protective orthoses is possible.<a></a></p> <p>Because of the potential for rapid progression, periodic x-rays must be obtained to assess progression which may alter therapy<a></a> (Compare <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg"><b>Fig. 1B</b></a>&nbsp;and <a href="http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg"><b>Fig.1C</b></a>).</p> <p>The indications for orthopaedic surgical intervention include unacceptable deformity, making shoeing difficult; bony prominences, causing ulceration; concomitant infection, requiring debridement and drainage; and deformities with a high likelihood of progression (i.e. varus).<a></a> "Bumpectomies," decompressive fusions of digits, Keller bunionectomies, and subtalar or ankle debridements and fusions are some of the more commonly indicated procedures.<a></a> Total joint arthroplasty has no place in the neuropathic patient as it will inevitably be disrupted by the same process that destroyed the natural joint.<a></a></p> <h3>Conclusions</h3> <p>The major problem of the insensate foot is its susceptibility. Ataxia, secondary to neuropathy, imparts abnormal stresses and trauma to an extremity no longer able to detect injury. The neuropathy is usually irreversible, so defensive measures must be taken to control the process of joint destruction. Well fit ankle and foot orthoses to support unstable joints and redistribute weight bearing forces more evenly are the next line of defense once cast immobilization has controlled the injury reaction and allowed healing. Surgery is useful to correct unacceptable or unstable deformities and relieve skin pressures.</p> <p>By understanding the patient's perceptions, and the pathophysiology of the Charcot foot, we can provide treatment to prolong the functional life and avoid the complications of the insensate foot.</p> <p><b>References:</b></p> <ol> <li>Curtiss, P.H., "Neurologic Diseases of the Foot," <i>Foot Disorders: Medical and Surgical Management</i>, Editor N.J. Giannestras, Lea &amp; Febiger, Philadelphia, 1973, pp. 500-503.</li> <li>Delano, P.J., "The Pathogenesis of Charcot's Joint," <i>American Journal of Radiology</i>, 2:56, August, 1946, pp. 189-200.</li> <li>Donovan, J.C. and J.L. Rowbotham, "Foot Lesions in Diabetic Patients: Cause, Prevention, and Treatment," <i>Joslins's Diabetes Mellitus</i>, 12th Edition, Editors A. Marble, et al., Lea &amp; Febiger, Philadelphia, 1985, pp. 732-736.</li> <li>Herzwurm, P.J. and R.H. Barja, "Charcot Joints of the Foot," <i>Contemporary Orthopaedics</i>, 3:14, March, 1987, pp. 17-22.</li> <li>Jacobs, R.L., "Neuropathic Foot in the Diabetic Patient," <i>Foot Science</i>, Editor M.E. Bateman, W.B. Saunders Co., 1976, pp. 235-253.</li> <li>Jacobs, R.L. and A.M. Karmody, "The Charcot Foot," <i>The Foot</i>, Editor M. Jahss, W.B. Saunders Co., 1982, pp. 1248-1265.</li> <li>Kristiansen, B., "Ankle and Foot Fractures in Diabetics Provoking Neuropathic Joint Changes," <i>Acta Orthopaedics Scandanavia</i>, 51, 1980, pp. 975-979.</li> <li>Locke, S. and D. Tarsy, "The Nervous System and Diabetes," <i>Joslin's Diabetes Mellitus</i>, 12th Edition, Editors A. Marble, et al., Lea &amp; Febiger, Philadelphia, 1985, pp. 665-685.</li> <li>Mooney, V. and W. Wagoner, "Neurocirculatory Disorders of the Foot," <i>Clinical Orthopaedics</i>, 122, January-February, 1977, pp. 53-61.</li> <li>Podolsky, S. and A. Marble, "Diverse Abnormalities Associated with Diabetes," <i>Joslin's Diabetes Mellitus</i>, 12th Edition, Editors A. Marble, et al., Lea &amp; Febiger, Philadelphia, 1985, pp. 843-866.</li> <li>Salter, R.B., "Degenerative Disorders of Joints and Related Structures," <i>Textbook of Disorders and Injuries of the Musculoskeletal System</i>, Williams &amp; Wilkins Co., Baltimore, 1970, pp. 219-220.</li> </ol> <p><em><b>*Richard L. Jacobs, M.D. </b> Division of Orthopedic Surgery at Albany Medical College, Albany, New York</em></p> <p><em><b>*Mitchell E. Kalter, M.D. </b> Division of Orthopedic Surgery at Albany Medical College, Albany, New York<br /><br /><br /></em></p> Page Number(s) 61 - 66 Year 1988 Volume 12 Issue 2 Figure 1 FIG 1A http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-1.jpg FIG1B http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-2.jpg FIG 1C http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-3.jpg FIG 1D-1 http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-4.jpg FIG 1D-2 http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-5.jpg FIG 1E http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-6.jpg Figure 2 FIG 2 http://www.oandplibrary.org/cpo/images/1988_02_061/1988_02_061-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. 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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_04_201.pdf Text Any textual data included in the document <h2>The Team Approach to Orthotic Management in Quadriplegia</h2> <h5>Wayne R. Rosen, CO.&nbsp;<a style="text-decoration: none;">*</a><br />Janie J. McColey, O.T.R.&nbsp;<a style="text-decoration: none;">*</a><br />John H. Bowker, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>This article presents the approach to orthotic intervention in quadriplegia taken at the University of Miami/Jackson Memorial Rehabilitation Center. To begin, it must be emphasized that quadriplegia implies not only loss of walking, but also loss of normal use of the hands. Since our hands are the tools with which we sustain life, a major goal of rehabilitation must be to restore the ability to independently carry out common activities of daily living such as feeding, grooming, and manipulation of devices which may allow resumption of educational and vocational goals.<a></a> As health care professionals in the rehabilitation field, we must be aware of advances in technique and equipment which can enhance the ever-increasing life span of this young population whose educational, economic, and social progress has been so severely curtailed.<a></a> The role of the orthotist and occupational therapist as members of the rehabilitation team is to address this very underemphasized problem of upper limb management.</p> <p>When the spinal cord team is first asked to evaluate and treat a newly injured quadriplegic patient, they must take into consideration all aspects of care, not just those in their individual areas of specialization. During the acute medical phase, the emphasis is on preserving life and preventing further neurological damage. At this stage, there is little concern for joint positioning or splinting. After life-threatening problems have been addressed, however, prompt management of the upper limbs is of primary importance if we are to avoid joint stiffness and/or deformity which would interfere with the progression of rehabilitation.<a></a> This approach to the upper limbs involves a number of basic methods: frequent joint range of motion, limb positioning with and without positioning devices (temporary and permanent), dynamic orthoses (temporary and permanent), and externally powered orthoses. In our facility, spinal cord injured patients are initially placed on Roto-Rest beds. These beds, with their continuously alternating side-to-side motion, have proven to have a positive effect on the respiratory, renal and circulatory systems, as well as providing skin protection for the S.C.I. patient.<a></a> There is, however, potential for loss of glenohumeral and scapular mobility with its use for extended periods. We have currently adapted the bed so as to allow positioning of the shoulders in abduction and external rotation, alternating with the usual adduction and internal rotation. This change of shoulder position has been included in our regular routine of joint range of motion and should reduce the pain and stiffness that often interferes with arm placement and coordination.<a></a> Elbow flexion-forearm supination deformity is another potential problem, especially in C5 quadriplegics.<a></a> This may be managed by positioning the elbow in extension and pronation between range of motion sessions. The use of thermoplastic elbow-extension splints (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-01.jpg"><b>Fig. 1</b></a>), bivalved casts (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-02.jpg"><b>Fig. 2</b></a>), or serial casting (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-03.jpg"><b>Fig. 3</b></a>), will assist the therapist in maintaining proper position. Functional hand position should be maintained with the use of a resting hand splint (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-04.jpg"><b>Fig. 4</b></a>) or a functional long opponens splint with C-bar and lumbrical bar (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-05.jpg"><b>Fig. 5</b></a>), to avoid the development of a flat "simian" hand.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-01.jpg"><strong>Figure 1. Elbow Control Orthosis.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-02.jpg"><strong>Figure 2. Bivalved plaster cast.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-03.jpg"><strong>Figure 3. Serial casting (Plaster of Paris).</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-04.jpg"><strong>Figure 4. Thermoplastic resting splint.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-05.jpg"><strong>Figure 5. Long opponens with MCP extension stop.</strong></a><br /> <p>Once the patient is medically stable, he is able to begin a more active phase of rehabilitation, including the use of functional orthoses, if appropriate. His response to this whole process depends largely on the success of the first few days, which in turn depends on how the treatment team constructs the patient's first experiences of sitting, trunk balancing, and functional arm placement. Only when control of these factors is satisfactory will it be appropriate to introduce orthoses for function. This becomes a critical point in time for the patient and therapist, because two possible approaches to future functional activities exist. The first approach is based on the use of adaptive devices which will allow some patients to perform specific functions such as self-feeding and oral-facial hygiene. However, it is our feeling that even at this early stage, multipurpose temporary functional orthoses must be introduced if definitive orthoses are to play a useful part in the patient's life. Therapists should be prepared to fabricate and properly fit a training orthosis, which will allow the patient reasonable options in developing his functional goals.<a></a></p> <p>The following chart provides guidelines for management techniques according to the level of remaining neurologic function. Many of the orthotic options listed in the "Recommended Management" column are from the N.Y.U. Upper Extremity Orthotics Manual.<a></a></p> <p><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-07.jpg"><b>Chart</b>, <b>Chart (cont'd)</b></a></p> <p>The guidelines listed above have been generally accepted throughout the world as the rational basis for orthotic intervention. The following variables, however, must receive equal consideration before an orthosis can be successfully fit to a patient.</p> <p><i>Locality</i></p> <p>The patient should reside not only reasonably close to a facility capable of adjusting his orthosis, but should have accessible transportation available if a problem arises.</p> <p><i>Cost</i></p> <p>Sufficient funds must be allocated to cover not only the initial cost of the orthosis prescribed but also maintenance and replacement as necessary.<a></a></p> <p><i>Gadget Tolerance</i></p> <p>The patient must have the patience to don and doff the orthosis or he will discard it because it "takes too long to apply." He may then actually prefer to sacrifice his independent performance of intricate manual tasks by either choosing a less effective piece of adaptive equipment or relying on another person for assistance. We, as practitioners, must monitor the attitude of a candidate to be sure that the function of the orthosis will be greater than the perceived inconvenience of wearing it.<a></a></p> <p><i>Dominance</i></p> <p>The hand preferred prior to injury for writing and activities of daily living will usually be maintained as the dominant hand. This hand should be fit initially and the patient's progress monitored with specific activities before fitting the nondominant hand. Specific activity usage will determine whether or not the second orthosis is indicated.<a></a></p> <p><i>Vocation/Avocation</i></p> <p>The patient's ability to perform fundamental activities of daily living is basic to maximum restoration, but it is equally important to determine additional intended uses of the orthosis, both vocationally and avocationally (i.e., manual work, desk work, telephone answering services). These data will help determine the type of materials suitable for fabrication or even the type of orthosis that would best suit the individual's needs.<a></a></p> <p><i>Psychological/Familial Roles</i></p> <p>Assessment of the patient's psychological status is vital in establishing a treatment plan. Psychological make-up of the individual can play a very large role as to whether or not the patient will accept an orthosis. In this regard, cosmesis may play as important a role as function when dealing with a person's already altered body image. Psychological intervention is necessary to assist the patient through the stages of denial, anger, and depression to final adaptation. Indeed, the team members may need help in dealing with their own value systems regarding quality of life in relation to long term disability.</p> <p>The personalities of the patient and family members, as well as those of the orthotist and occupational therapist, play important roles in rehabilitation after a spinal cord injury. An air of confidence emanates from professionals who are comfortable and confident with the task at hand. This confidence can be passed on to the patient, who will in turn become comfortable and confident with the orthosis being fitted. Too often, however, therapists and orthotists are not comfortable with the intricacies of fabricating upper limb orthoses, leaving the patient at a disadvantage as he begins his rehabilitation process, in that he may not be made aware of all the options available, but rather only those preferred by the professionals. Therefore, it is necessary to assemble a team of practitioners who are well versed in all aspects of their respective specialties so as to not hinder the patient in an already stressful situation. Family support is also extremely important as a reinforcement of professional recommendations. Clear, concise instructions should be given to the patient and family members in order to increase the effective use of the orthosis.<a></a></p> <p><i>Economics</i></p> <p>Since most orthotists in private practice cannot afford the luxury of skill maintenance for the small part of orthotic practice represented by upper limb orthotics, the majority of these devices are being made in an institutional setting, where an orthotist and occupational therapist on staff service the needs of quadriplegics. More time and energy can then be devoted, with less concern for monetary return, to fabrication and fitting of a complex device such as a wrist-driven prehension orthosis. Being on-site means quicker response time to the patient with no travel time for the practitioner, which also means that more time can be spent actually working with the patient as the need for adjustment arises. The expertise afforded by a qualified and skilled team of practitioners to the patient can only help an already trying and difficult situation.<a></a></p> <p>Through a team approach to orthotic evaluation of the spinal cord injured patient, the best orthosis for that individual should be provided. That does not necessarily mean the most complex or expensive orthosis. It means that, given a specific clinical picture, an orthosis is chosen based on all the factors previously discussed. The purpose of setting standards and guidelines is to increase the success rate of our patients, in allowing them every opportunity to return to a meaningful lifestyle. When this occurs, we as practitioners have done our job and can consider the input of our specialty a success. Conversely, our failures have a negative effect on both the patient and the practitioner. For the patient, it becomes a setback in that his hospital stay may be extended or, more importantly, the potential for independence may be lost because of rejection of the orthosis. For the practitioner, it may be not only a time of second-guessing, but a learning experience at the patient's expense.</p> <p>Our approach to fitting of functional orthoses is as follows. All candidates for wrist driven prehension orthoses are initially fitted by the occupational therapist with a temporary training orthosis, namely the Rehabilitation Institute of Chicago (R.I.C.) tenodesis splint (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-06.jpg"><b>Fig. 6</b></a>). The patient then trains for a period of time determined by the therapist. Once he has mastered this device, he can be fit by the orthotist with a definitive orthosis. The choice at our facility is the Engen wrist-driven prehension orthosis (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-09.jpg"><b>Figure 7</b></a>, <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-10.jpg"><b>Fig. 8</b></a>, and <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-11.jpg"><b>Fig. 9</b></a>). We feel this device best suits our needs because of ease of fit, adjustability, and cosmesis.<a></a> The occupational therapist trains the patient to use his orthosis for activities of daily living, including the important function of self-catheterization of the bladder.<a></a> By virtue of thorough training, we feel the acceptance rate of orthoses is increased.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-06.jpg"><strong>Figure 6. R.I.C., Tenodesis (temporary) splint with wrist extended and fingers apposed.</strong></a><br /><strong><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-09.jpg">Figure 7. Wrist-driven prehension orthosis with wrist in neutral position and fingers open-Ranchos Los Amigos type.</a></strong><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-10.jpg"><strong>Figure 8. Wrist-driven prehension orthosis with wrist extended and fingers apposed-Engen type.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-11.jpg"><strong>Figure 9. Wrist-driven prehension orthosis (Modified N.Y.U.-I.R.M. system).</strong></a><br /> <p>Unfortunately, our success rate with the Externally Powered Prehension Orthosis (EPPO) has not been as favorable as that of the wrist driven type (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-12.jpg"><b>Fig. 10</b></a>). Two-thirds of all EPPOs that have been fit at our institution have not been used long-term. The feedback from our patients is that they were trained throughout the long rehabilitation process to adapt with the aid of special equipment and then, just prior to discharge, given a brace to replace the adaptive equipment. The patient who spent four to six months in the rehabilitation facility would have perhaps a week to learn to function with his new orthosis. It is hardly surprising that, in most cases, the orthosis was discarded in favor of the adapted equipment with which they were familiar. The problem has been, that for high cervical injuries, a training version of an externally powered prehension orthosis does not exist. This problem could be solved by development of a training EPPO in which the components could be reused on different patients. The only parts of the orthosis that would need to be custom-made would be the hand shells. The cost to the patient for these would be minimal and in the long run we could save the patient the cost of a very expensive "closet trophy" if he proved to be a poor candidate. We have initiated this project as a joint effort of the Occupational Therapy Department and the Department of Orthotics.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-12.jpg">Figure 10. Externally powered prehension orthosis.</a><br /></strong><br /> <h3>Summary</h3> <p>The fabrication and fitting of functional upper limb orthoses in quadriplegia requires close team work, especially between the orthotist and occupational therapist if the ultimate goal of acceptance of the orthosis as a useful aid to activities of daily living is to be achieved. We feel strongly that quadriplegics with wrist extensors should be fitted early with a functional training orthosis rather than supplied with activity-specific adaptive equipment. A confident, caring attitude on the part of the occupational therapist and orthotist can also do much toward achieving this goal. For quadriplegics with shoulder and elbow motion but no wrist extension, a training version of an externally powered prehension orthosis is badly needed for evaluation prior to ordering a definitive device. Success in the fitting of complex orthoses such as these requires almost unlimited "gadget-tolerance" on the part of the practitioner, if not the patient. The ultimate professional responsibility is to be equipped with both the manual skills and the objectivity to introduce all available options to our patients for their acceptance or rejection.</p> <p><b>References:</b></p> <ol> <li>Abrahams, D., R.D. Shrosbree, and A.G. Key, "A Functional Splint for the C5 Tetraplegic Arm," <i>Paraplegia</i>, 17:2, July, 1979, pp. 198-203.</li> <li>Allen, V.R., "Follow-up Study of Wrist-Driven Flexor-Hinge-Splint Use," <i>The American Journal of Occupational Therapy</i>, 25:8, 1971, pp. 420-422.</li> <li>Becker, D., M. Gonzalez, G. Amilcare, F. Eismont, and B. Green, "Prevention of Deep Venous Thrombosis in Patients with Acute Spinal Cord Injuries: Use of Rotating Treatment Tables," <i>Neurosurgery</i>, 20:5, 1987, pp. 675-677.</li> <li>Berard, E., J. Depassio, N. Pangaud, and J. Landi, "Self Catheterization: Urinary Complications and the Social Resettlement of Spinal Cord Injured Patients," <i>Paraplegia</i>, 23, 1985, p. 386.</li> <li>DeVivo, M.J., P.R. Fine, H.M. Maetz, and S.L. Stover, "Prevalence of Spinal Cord Injury: A Re-estimation Employing Life Table Techniques," <i>Archives of Neurology</i>, 37, 1980, pp. 707-708.</li> <li>Eisenberg, M.G. and D.O. Tierney, "Changing Demographic Profile of the Spinal Cord Injury Population: Implications for Health Care Support Systems," <i>Paraplegia</i>, 23, 1985, pp. 335-343.</li> <li>Fishman, S., et al., <i>The Upper Extremity Orthotics Manual</i>, New York University Post-graduate Medical School.</li> <li>Lamb, Jr., C.R., A.J. Booth, and M.E. Godfrey, "Flexor Hinge Splint: Modification to Allow Radial Deviation," <i>Archives of Physical Medicine and Rehabilitation</i>, 55, July, 1974, pp. 322-323.</li> <li>Meyer, C.M.H., R.D. Shrosbree, and D.L. Abrahams, "A Method of Rehabilitating the C6 Tetraplegic Hand," <i>Paraplegia</i>, 17, 1979-80, pp. 170-175.</li> <li>Nichols, P.J.R., S.L. Peach, R.J. Haworth, and J. Ennis, "The Value of Flexor Hand Splints," <i>Prosthetics and Orthotics International</i>, 2, 1978, pp. 86-94.</li> <li>Patterson, R.P., D. Halpern, and W.G. Kubicek, "A Proportionally Controlled Externally Powered Hand Splint," <i>Archives of Physical Medicine and Rehabilitation</i>, 52:9, September, 1971, pp. 434-438.</li> <li>Spieker, J.L. and B.J. Lethcoe, "Upper Extremity Functional Bracing: A Follow-Up Study," <i>The American Journal of Occupational Therapy</i>, 25:8, 1971, pp. 398-401.</li> <li>Stauffer, E.S. and V.L. Nickel, "Control Systems for Upper Extremity Function in Traumatic Quadriplegia," <i>Paraplegia</i>, 10, 1972, pp. 3-10.</li> <li>Yarkony, G.M., L.M. Bass, V. Keenan, III, and P.R. Meyer, Jr., "Contractures Complicating Spinal Cord Injury: Incidence and Comparison Between Spinal Cord Centre and General Hospital Acute Care," <i>Paraplegia</i>, 23, 1985, pp. 265-271.</li> <li>Zrubecky, G. and M. Stoger, "The Orthosis for Restoration of Prehensile Function in Tetraplegics," <i>Paraplegia</i>, 11, 1973, pp. 228-237.</li> </ol> <em><b>*John H. Bowker, M.D. </b> John H. Bowker, M.D., is Professor and Associate Chairman of the Department of Orthopaedics and Rehabilitation at the University of Miami School of Medicine and Medical Director of the University of Miami/Jackson Memorial Rehabilitation Center in Miami, Florida.</em><br /><br /><em><strong>*Janie J. McColey, O.T.R.,</strong> is the Supervisor of Occupational Therapy, Spinal Cord Unit at the University of Miami/Jackson Memorial Rehabilitation Center in Miami.</em><br /><br /><em><b>*Wayne R. Rosen, CO. </b> Wayne R. Rosen, CO., C.P.E.D., is Chief Orthotist, Department of Prosthetics and Orthotics at the University of Miami/Jackson Memorial Rehabilitation Center, 1611 N.W. 12th Avenue, Miami, Florida 33136.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 201 - 209 Year 1987 Volume 11 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-05.jpg Figure 6 CHART http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-07.jpg CHART CONT. http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-08.jpg Figure 7 FIGURE 6 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-06.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 FIGURE 7 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-09.jpg Figure 9 FIGURE 8 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-10.jpg Figure 10 FIGURE 9 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-11.jpg Figure 11 FIGURE 10 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-12.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Team Approach to Orthotic Management in Quadriplegia Creator An entity primarily responsible for making the resource Wayne R. Rosen, CO. * Janie J. McColey, O.T.R. * John H. Bowker, M.D. * https://staging.drfop.org/files/original/366a1b6eaf8bdac3bf9bcd5f96e1e444.pdf c15a1b90ec331cb4018325209aeb65ef https://staging.drfop.org/files/original/b3dc33d12739a97901cabea5ed23bb64.jpg 8e66cf5f8e78aecdf2a5e3408530f798 https://staging.drfop.org/files/original/92afbcf437362864c05cee1d9fa423c2.jpg c0d649cd24f105d7e78a3eab0426d1cf https://staging.drfop.org/files/original/0f39a6e5637d2eeb1b906bc972b06ff7.jpg a90f1c11e95d0e45be2d704ef73f3783 https://staging.drfop.org/files/original/a3d1bce9c03ac1f72a552321aa0bc80e.jpg 5061311d76421aff2b48d025e41524ac https://staging.drfop.org/files/original/869a037a5d6fd31b16b0c2f6ccbfe210.jpg a90f1c11e95d0e45be2d704ef73f3783 https://staging.drfop.org/files/original/7fb21f3f118ac4cef50e01d0f5ea9dc4.jpg 6a18a10291eac44ee2e3b2f40d37a99c https://staging.drfop.org/files/original/104394cd613cd757fc34ae6b51dfc916.jpg 0cbd76a6321d43132c8d653b6a6537d5 https://staging.drfop.org/files/original/ae525dd9f2a300f6da5093b8e9111117.jpg 5018452d2616ca984b0b8fbc9ddf3f8e https://staging.drfop.org/files/original/b0b1518c7c3d7343a5f0d147218d622b.jpg 79e8f6d9e08cb4a44e6e7bbdb9e3957a https://staging.drfop.org/files/original/05e3f4224a7bf14e0a1994fa8f1bc64a.jpg 4c431528b25733c9af6035131de80b91 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_02_004.pdf Text Any textual data included in the document <h2>The Technical Aspects of the Orthopaedic Treatment of the Knee after Sports Injuries</h2> <h5>Andre Bähler&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The last decades have shown a marked increase in the number of people, both young and old, participating in sporting activities. As a result of systematic education and schooling, it has become generally recognized that a certain amount of physical exercise is necessary for a healthy body.</p> <p>The mass media—radio, television, the press—as well as schools and private insurance companies, have systematically reported the advantages to be gained by participating in physical activities.</p> <p>Sports are no longer the prerogative of the young; there is no age limit for those engaged in sports in one form or another. Senior citizen keep-fit groups, jogging, and the like, have proven to many older people that age is not a justified reason to neglect physical fitness, and they have become aware that exercise is a means of showing the body the respect it deserves.</p> <p>However, this almost revolutionary attitude towards sports is not limited to amateurs, but has also brought changes into the world of top athletes. Today, the degree of involvement is greater than ever before, but so accordingly are the associated risks. Many forms of sports seem to have lost sight of the original ideal of sportsmanship. Enjoyment and leisure have been replaced by a deadly seriousness in attitude that only total dedication will bring the desired results. Not only in the competition itself, but in the long months and sometimes years of training prior to it, the body is stretched to its utmost. Success at any price is the motto of the day, and such an attitude consciously calculates and accepts casualties and losses as part of the "game."</p> <p>It has been proven that this type of approach to sports results in an increase in injuries, strain, and general wear, particularly in the joints of the lower limbs. Clearly, modern sports put the knee-joint under great pressure. Be it cycling, football, skiing or ice-hockey, the movement of the knee is of central importance, as changing techniques increase the pressure put on it.</p> <p>The large number of knee injuries are a cause of great concern to modern sports medicine. The top athletes in particular, are anxious to start training again as soon as possible after injury. Although the knee is capable of taking great strain, mobility is often restricted, either by external injuries, or because of wear within the joint itself.</p> <p>Immobilization of the joint after injury or surgery can damage the cartilage, hindering the assimilation of nutrients. The ligaments begin to lose their tensility, there is a loss of coordination between muscle groups, and muscles atrophy.</p> <p>Finally, immobilization of a limb also affects the whole organism, particularly circulation, respiration, and the digestive system, and last but not least, the psychological effect of immobilization should not be underestimated.</p> <p>Controlled movement of the knee-joint after ligament surgery has great advantages during rehabilitation: movement between 20-60 degrees does not strain the collateral or cruciate ligaments to any degree.</p> <p>The muscles are also activated within pre-controlled limits. In tests, Hettinger found that 20-30 percent of the maximum pressure was sufficient to retain normal muscle strength. However, in order to increase muscle strength, the pressure must be at least 40-50 percent, and this is not possible after surgery. Therefore, rehabilitation requires electro-stimulation. A pre-condition of functional treatment is the exact restoration of all the anatomical elements, (e.g. cruciate and collateral ligaments).</p> <h3>Rehabilitation Phases</h3> <p><i>Pre-operative Treatment</i></p> <p>When reconstructive surgery is required in the case of an old injury to the knee, the time before the operation should be used to improve and retain muscle strength, for coordination exercises, and to instruct and explain the postoperative treatment</p> <p><i>Post-operative Treatment</i></p> <p><b>Day 1</b>: For the rest period, the leg should be held in a preoperative prepared plaster-splint with a flexion angle of 20-30 degrees.</p> <p><b>Day 5</b>: A knee-orthosis with a 20-50 degree range of movement is fitted and a gentle swinging movement is allowed. The orthosis is also worn in the pool but the injured leg should not actually be used for swimming. Rehabilitation at this stage should also include controlled extension and flexion exercises between 20-60 degrees and isometric quadricep training.</p> <p><b>Fifth to sixth week</b>: Flexion and extension exercises from 0-90 degrees should be practiced. For walking, the orthosis must be locked in extension with the swiss-lock.</p> <p><b>After eight weeks</b>: The lock can be removed and the patient may be allowed to walk with free movement of the joint. The orthosis is usually worn for approximately one year.</p> <h3>The Principles of Fixation and Correction with the Orthosis</h3> <p>Both the upper and lower leg must be securely held all round. If necessary, support at the thigh is given on the same principle as a prosthetic support. If the upper and lower leg are kept straight, then it is best to use a physiological (polycentric, Ed.) knee-joint.</p> <p>However, if the securing bands of the orthosis are made of rubber or a similar material, then a simple single-axis knee-joint is sufficient.</p> <p>Besides the above mentioned points, the orthosis for post-operative rehabilitation after ligament reconstruction must also exhibit the following characteristics:</p> <ol> <li> <p>The program of correction or fixation must be exactly determined in advance.</p> </li> <li> <p>The upper and lower leg must be securely held in the orthosis.</p> </li> <li> <p>The construction of the joint must allow for varying ranges of mobility:</p> <ol> <li> <p>20-50 degrees</p> </li> <li> <p>0-90 degrees with the option of a locking device</p> </li> <li> <p>0-120 degrees with free movement.</p> </li> </ol> </li> </ol> <h3>Procedure to Relieve the Medial or Lateral Ligaments</h3> <p><i>Principle: Triple-point correction (<a href="/files/original/b3dc33d12739a97901cabea5ed23bb64.jpg"><b>Fig. 1</b></a>)</i></p> <p><strong><a href="/files/original/b3dc33d12739a97901cabea5ed23bb64.jpg">Figure 1</a>. Triple-point correction to relieve the medial or lateral ligaments.&nbsp;</strong><br /><br />The principle underlying the triple-point correction, forms the basis for efficient correction of genu varum or genu valgum. With young patients, it is possible to position the correcting pressure-pads exactly, but with older patients, because of the flaccid tissue, pressure must be applied over as large an area as possible, e.g., with splints which distribute the pressure equally. For technical as well as anatomical reasons, it is often not possible to apply pressure at the centre of the joint itself, therefore pressure must be applied above and below the joint, but as near to it as possible.</p> <p>If the splints do not fit securely, then the orthosis will twist inwards when bent and this results in a reduction of the correcting forces at extension.</p> <h3>Procedure for Controlling the Posterior Drawer</h3> <p><i>Principle: Posterior pressure on the proximal lower leg and anterior pressure on the distal upper leg (<a href="/files/original/92afbcf437362864c05cee1d9fa423c2.jpg"><b>Fig. 2</b></a>)</i></p> <strong><a href="/files/original/92afbcf437362864c05cee1d9fa423c2.jpg">Figure 2</a>. Controlling the posterior drawer.</strong><br /> <p>There are two biomechanical procedures to choose from:</p> <ol> <li> <p>Fixation of the upper and lower leg with the orthosis on the basis of the triple-point method. With this method, the splints are fitted individually to the upper and lower leg and the correcting pressures are placed so that a posterior drawer is held firmly.</p> </li> <li> <p>Placing the correcting pressures in such a way that together with the knee-joint of the orthosis, they act as a lever. Here too, it is advantageous to distribute the pressure over as large a surface as possible (<a href="/files/original/0f39a6e5637d2eeb1b906bc972b06ff7.jpg"><b>Fig. 3</b></a>).</p> <strong><a href="/files/original/0f39a6e5637d2eeb1b906bc972b06ff7.jpg">Figure 3.</a> An alternative approach</strong></li> </ol> <h3>Procedure to Correct the Anterior Drawer</h3> <p><i>Principle: Anterior pressure on the proximal lower leg and posterior pressure on the distal upper leg</i></p> <p>This involves, first, the fixation of the upper and lower leg with the orthosis on the basis of the triple-point principle (<a href="/files/original/a3d1bce9c03ac1f72a552321aa0bc80e.jpg"><b>Fig. 4</b></a>), and second, placing the correcting pressure so that together with the knee-joint of the orthosis, they act as a lever. The greater the distance between the knee and the external counter-pressure, the better the corrective effect (<a href="/files/original/869a037a5d6fd31b16b0c2f6ccbfe210.jpg"><b>Fig. 5</b></a>).</p> <strong><a href="/files/original/a3d1bce9c03ac1f72a552321aa0bc80e.jpg">Figure 4</a>. Fixation of the upper and lower leg.&nbsp;</strong><br /><br /><strong><a href="/files/original/869a037a5d6fd31b16b0c2f6ccbfe210.jpg">Figure 5</a>. Increase the distance between the knee and the external counter-pressure</strong><br /> <h3><br />Restricting Rotation</h3> <p>The restriction of rotation depends on how well the orthosis fits the upper and lower leg. The efficiency of the orthosis in restricting rotation is determined less by the type of orthosis, than by the size and type of the surface area of support. In practice, the following points must be checked:</p> <ol> <li> <p>Any fixation of the knee-joint must conform to the principles of biomechanics.</p> </li> <li> <p>The orthosis and all bandages should cover the leg properly to ensure that the orthosis does not slip.</p> </li> <li> <p>The orthosis must fit so as not to hinder or limit muscle activity.</p> </li> </ol> <p>As we found that the orthotic devices available at present did not completely satisfy our needs, we devised a system of our own which we would now like to explain with the help of some photographs.</p> <h3>Type I: Sport Orthosis for Old Injuries to the Knee, or for Instability of the Joint</h3> <p>In order to keep the reduction in fitness to a minimum, the athlete aims to return to training as soon as possible. However, the knee is often not strong enough to cope with the high demands made upon it and needs some form of support, without however, limiting the range of movement.</p> <p>This orthosis guides the joint and eliminates the forward and backward drawer as well as movements to the side (<a href="/files/original/7fb21f3f118ac4cef50e01d0f5ea9dc4.jpg"><b>Fig. 6</b></a>, <a href="/files/original/104394cd613cd757fc34ae6b51dfc916.jpg"><b>Fig. 7</b></a>, <a href="/files/original/ae525dd9f2a300f6da5093b8e9111117.jpg"><b>Fig. 8</b></a>). If necessary, it can also be fitted so as to restrict all extreme movements. The half-splints of the orthosis are made of the new Plexiglass XTO (natur) by the Röhm Company (Darmstadt 1). This material is much tougher than the well-known Plexidur. It is easy to form, and locks can be fitted to the joints without first having to be strengthened. In order to stop the splints from slipping, they are lined with a thin layer of foam-rubber. The best results are achieved when the orthosis is formed from a plaster model of the leg.</p> <strong><a href="/files/original/7fb21f3f118ac4cef50e01d0f5ea9dc4.jpg">Figure 6.</a> The sport orthosis eliminates forward and backward drawer.&nbsp;</strong><br /><br /><strong><a href="/files/original/104394cd613cd757fc34ae6b51dfc916.jpg">Figure 7.</a> The orthosis can be fit to eliminate all extreme movements.&nbsp;</strong><br /><br /><strong><a href="/files/original/ae525dd9f2a300f6da5093b8e9111117.jpg">Figure 8.</a> The half-splints are made of Plexiglass XTO.</strong><br /> <h3>Type II: Orthosis for Operative Ligament Reconstruction, or Other Similar Serious Knee Injuries</h3> <p>Basically the same orthosis is made as in Type I (<a href="/files/original/a3d1bce9c03ac1f72a552321aa0bc80e.jpg"><b>Fig. 4</b></a>, <a href="/files/original/869a037a5d6fd31b16b0c2f6ccbfe210.jpg"><b>Fig. 5</b></a>, <a href="/files/original/7fb21f3f118ac4cef50e01d0f5ea9dc4.jpg"><b>Fig. 6</b></a>) but with the difference that a lock and positioning-screw are fixed to the outside of the splint (<a href="/files/original/b0b1518c7c3d7343a5f0d147218d622b.jpg"><b>Fig. 9</b></a>, <a href="/files/original/05e3f4224a7bf14e0a1994fa8f1bc64a.jpg"><b>Fig. 10</b></a>). As already mentioned, the positioning screw allows a movement between 20-60 degrees. After a while, this can be removed and the lock used to hold the leg in extension.</p> <strong><a href="/files/original/b0b1518c7c3d7343a5f0d147218d622b.jpg">Figure 9</a>. A lock and positioning screw are fixed to the outside of the splint.</strong><br /> <p><strong><a href="/files/original/05e3f4224a7bf14e0a1994fa8f1bc64a.jpg">Figure 10</a>. The positioning screw allows movement between 20-60 degrees.&nbsp;</strong><br /><br />Depending on the injury, the half-splints are placed either at the front or at the back of the upper and lower leg. Securing straps and pressure-pads increase the corrective effect.</p> <em><b>*Andre Bähler </b> Andre Bähler is an Orthotist/Prosthetist from Zurich, Switzerland.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 4 - 7 Year 1984 Volume 8 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-02.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-05.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/1984_02_004/1984_02_004-06.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-03.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1984_02_004/1984_02_004-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Technical Aspects of the Orthopaedic Treatment of the Knee after Sports Injuries Creator An entity primarily responsible for making the resource Andre Bähler * https://staging.drfop.org/files/original/d386a411367e3ccde8de539fc4a1242f.pdf 4ed3a9095b43b4bd7f3819c9eb8dfa7a https://staging.drfop.org/files/original/7a5e8868268876fcf1e3856884e6c69c.jpg fd74970347d887a411311884e1262354 https://staging.drfop.org/files/original/caec0103bc664a9d5e8457d1901a9e15.jpg 6b145520feb78ecf54f8c9a9684c4a26 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_01_029.pdf Text Any textual data included in the document <h2>The Total Contact Partial Foot Prosthesis</h2> <h5>Richard LaTorre, CO.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The purpose of this paper is to present a prosthetic fitting procedure for a "Partial Foot" level amputation. The "Transmetatarsal," "Lisfranc," "Chopart," and "Pirogoff" type amputations are all treated with this procedure with some modification, mainly in length of forefoot. The partial foot as a category presents more anxiety among physicians and prosthetists and clinics, than is generally realized. For the avascular patient, a "toe filler" is not adequate, no matter how cosmetic it appears. Classically, patients who are diabetics and have been given toe filler type prostheses tend to develop eversion, a tightening of the Achilles tendon, and are usually doomed to perforating ulcers on the distal plantar anterior or distal anterior portion of the residual foot.</p> <p>The solution presented here is an ultra-lightweight prosthesis, one that removes stress (caused by torque on the leg), protects the extremity from shock at heel strike and toe off, controls plantar and dorsi-flexion, controls eversion, controls edema, and still is cosmetically acceptable. This style prosthesis has been in use since March, 1974. By 1977, 62 prostheses of this type had been successfully delivered. The largest group of patients was between 45 and 65 years of age and almost equally divided between males and females. The next largest group was geriatrics (over 65) and only four patients were in the 20 to 45 age group. Only one patient went on to further amputation.</p> <p>As a result of wearing this type of prosthesis, the residual limb is usually warm, free of ulcers, callosities, and edema. When compared to the contra-indicated extremity, it appears to be generally healthier and most patients state "it feels better than my other leg."</p> <p>By 1984, this type of prosthesis was being fabricated at the rate of one every three weeks. At present, the average is one every two weeks.</p> <p>"Lower Profile" partial foot prostheses are also fitted, but only after the patient has successfully worn this two piece design for at least six months. This insures, if trouble starts with a Low Profile prosthesis, there is no "down time" for the patient; they simply go back to "old faithful."</p> <p>Incidentally, we have also developed three different styles of the Low Profile partial foot prosthesis (that we have not described in the literature), but have never been able to develop a series of four or more successes for each design.</p> <h3>Evaluation and Casting</h3> <p>Prior to casting, a prosthetic evaluation is made to determine joint limitations, noting mainly inversion/eversion and degree of plantar flexion/dorsi-flexion. Old scars are noted, as is the condition of skin over bony prominences and any possible weeping of draining areas. The patient's weight, height, and occupation are included in the evaluation before casting. Determination of material, usually polypropylene, thickness of material selected, and length of the prosthesis to be fitted is made at this time. The negative cast is usually taken with the patient in the sitting position. Any scab or draining area is covered with Saran Wrap® or its equal. Stockinette is then applied to the extremity from the toe to the supracondylar area. With indelible pencil the malleoli, anterior crest of the tibia, head of the fibula, old scars, and any extremely sensitive-to-touch areas, as well as those that may cause future problems, are marked.</p> <p>Casting is a two step procedure. The residual foot should be barely touching the floor and the foot to tibia relationship should be 90°. Splints of plaster of Paris are laid on the anterior tibia from a point approximately 2 cm. distal of the level of the tibial tuberosity distally to the point of floor contact. If it has been decided to weight-relieve the ankle complex, the well known P.T.B, casting procedure is used at this point.</p> <p>The extremity is now wrapped with Coban bandage. Coban is a plastic seersucker type material that acts as a waterproof Ace bandage and will not adhere to plaster. This technique enables the practitioner to make a thin-walled cast that is easier to remove from the tender extremity. The "Coban Technique" gives an eggshell hard cast, because it compresses the plaster, thus enabling the user to use less plaster and still obtain a firm satisfactory cast.</p> <p>As soon as the extremity is wrapped, it is replaced in the original position, (i.e. foot to tibia relationship of 90°). After the cast has sufficiently hardened, the bandage is removed and rerolled for future use.</p> <p>The already cured plaster and stockinette are now coated with K-Y Jelly. Plaster strips 4" x 12" are applied vertically to the posterior and lateral aspects of the extremity, overlapping the anterior cured cast from 3/4" to 2". The extremity is wrapped once again with the Coban bandage and returned to the sitting position. The Coban bandage is removed and reference lines are horizontally laddered across the cast overlapping areas when the posterior section has hardened. The exterior cast is carefully removed, the stockinette is cut away posteriorly, and the anterior "shell" carefully removed. Both sections are quickly re-oriented to each other and sealed together.</p> <p>In the laboratory, the negative cast is rinsed with a solution of soap or detergent, the surplus is poured out, the cast is placed in a sandbox, and the positive model is poured with bulk plaster. A pipe is placed in the cast and held in place until the plaster has set.</p> <h3>Fabrication</h3> <p>When the model is hard, the negative cast is stripped away. The model is held in a bench vise, sanded smooth, and plaster is added to problem areas noted at the time of casting. The amount added is 6-7 mm. at both malleoli, fibular head, and along the tibial crest. A 3mm. buildup over any scar or weeping area is sufficient. At this point, the model is covered with a layer of stockinette.</p> <p>An appropriately cut section of sheet polypropylene is placed in an oven at 400°F for ten minutes. The material is draped over the anterior portion of the model. The material will have the consistency of taffy when removed from the oven. If any wrinkles appear, the plastic must be discarded and a new piece cut and molded. Sometimes several trials are necessary until satisfactory results are achieved.</p> <p>When cooled, the anterior portion is removed from the model, trimmed, and all edges smoothed to the touch. The plantar trimline is just anterior of the os-calcis. The medial and lateral trim lines are on the midlines viewed in the sagittal plane. The original technique has been modified so as to provide a more posterior plantar trim line that now encompasses the os-calcis. This reassembles an inverted "T" shape.</p> <p>The model, minus the anterior molded shell, is further prepared by tacking a leather inner-sole that fits the patient's shoe (or opposite foot pattern inverted) to the plantar surface of the model. One inch nails are driven into the anterior portion of the positive model to provide an anchor for the plaster to be added next.</p> <p>The cast with the innersole attached is placed on a casting board. This is usually done with the aid of a vertical alignment jig, but can be accomplished manually without a jig if great care is exercised. This aligns the model to simulate the normal contour of the shoe relative to ball and heel. Bulk plaster is now applied to the innersole and built up onto the anterior foot portion. When firm, the plaster is trimmed to the edges of the innersole.</p> <p>The model is placed back in the vise horizontally and rotated so the posterior surface faces the fabricator. Appropriate size plastic is laid out and cut, and the molding process is repeated.</p> <p>Once cooled, the posterior shell is removed from the model. The forefoot is trimmed away laterally so all that remains, from midfoot running distally, is an innersole-like projection (i.e., it resembles a molded polypropylene solid ankle-ankle-foot orthosis).</p> <p>The anterior buildup of plaster is now removed from the original model. The polypropylene anterior shell snaps back on the model and the posterior shell goes over it. A Velcro® closure is attached to the proximal portion and a filler is cemented onto the innersole portion to simulate the forefoot and fill the shoe. The material used is plastazote bonded with barge cement.</p> <p>This version was used until 1983 when a woodsman who complained that "the toes lose their spring" was encountered. This was found not to be a problem with other patients. To satisfy this patient, roughly ten modifications of the forefoot section were tried. Unsuccessful were thicker polypropylene, metal reinforcement (spring steel), "double soling" the forefoot, and many other less involved changes. All met with patient displeasure. Success came with the fabrication of a forefoot "box section."</p> <p>To fabricate one, bulk plaster is poured into a shoe box top to provide a mold. Polypropylene is molded over this. The molded plastic is cut into quarters and the four corner pieces are arranged in such a manner that the corners fit together forming a three dimensional cross shape. Place them onto the anterior "sole" of the prosthesis. Trim to fit the edges of the sole. Rivet the two anterior (left and right) sections to each other and then to the toe section of the prosthesis. Next, rivet the remaining two pieces together and place this section against the anterior shell. Trim and fit it until a 5/8" gap is formed between it and the "anterior box" section. Rivet the remaining loose box section to the sole (<a href="http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-1.jpg"><b>Fig. 1</b></a>). The 5/8" gap between the two "box" sections is filled with foam rubber (<a href="http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-2.jpg"><b>Fig. 2</b></a>). The durometer selected depends on how firm a toe break is desired. This design has provided the more agressive patient with a toe action that simulates the push-off activity of the contralateral foot.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-1.jpg"><strong>Figure 1. Box sections rivetted in place. Anterior shell shown in the back ground.</strong></a><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-2.jpg">Figure 2. Foam rubber bumper laying beside forefoot section. Anterior shell in place.</a><br /></strong><br /> <h3>Fitting</h3> <p>The prosthesis is now ready for fitting. Shoes used have usually been of the double depth type with removable innersole. This type is preferred because it gives extra depth inside the shoe for the affected extremity and allows room for, and needed balancing of, the remaining foot. Most often the patient has been fit with the extra depth shoes and they later purchase ordinary footwear and manage without incident.</p> <p>It is felt that the total contact principle that has been so beneficial to other amputees has been adopted successfully in the design of this prosthesis. By encapsulating the extremity, edamatous problems have been prevented and circulation boosted, or so the patients have reported. The skin texture is soft and warm by comparison to the contraindicated limb. In fact, many patients have remarked that the extremity had always felt cold but now the other leg feels cold by comparison. This prosthesis prevents the problem of distal end friction that can result in further amputation.</p> <p>It is not possible for a shoe to cause friction to any part of the residual limb. One patient, who is a farm machinery repairman, has also found that it prevents the problem of bruising of the shin he encountered in his occupation.</p> <p>This style prosthesis, for all its length and function, weighs little more than the toe-filler type prostheses and is certainly lighter than other versions. It is relatively more expensive than most toe-fillers, but considerably less expensive than other types of prostheses, such as a conventional Chopart.</p> <p>On heel strike, the material "puckers" slightly, cushioning the impact. On foot flat, as well as at toe-off, the action of the foresection simulates the norm. In many patients, better gait on the affected extremity than on the contra-indicated limb has been observed.</p> <p>The gaits of all patients fitted have improved dramatically and some are undetectable to the eyes of even trained personnel.</p> <h3>Conclusion</h3> <p>Experience to date is that the above described prosthesis provides superior gait, less cost, less weight, and better patient acceptance than other types of Chopart prostheses. The material will torque with the extremity and does cause friction to tissue of poor quality.</p> <p>This material was originally presented in 1974 and not submitted for publication because it was thought that it would be outdated within a year or two. Evidently, this was a wrong assumption. With an ever increasing number of surgeons doing more distal amputations, there have been more and more requests for this information.</p> <h3>Acknowledgments</h3> We thank Siegfried Paul, C.P.O., for awakening us to thermoplastics, Thorkild Engen, CO., for introducing us to polypropylene, and Dr. Richard Jacobs for being all that a great physician should be.<br /><br /><em><b>*Richard LaTorre, CO. </b> Richard LaTorre, CO., is President of LaTorre Orthopedic Laboratory, 846 State Street, Schenectady, New York 12307.<br /><br /></em> <div style="width: 400px;"></div> Page Number(s) 29 - 32 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_029/1988_01_029-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Total Contact Partial Foot Prosthesis Creator An entity primarily responsible for making the resource Richard LaTorre, CO. * https://staging.drfop.org/files/original/f27b5d0368f4e859eccd1d6f3bbc38f3.pdf 2f3ebf3eaaf369545618afd8223fa39a https://staging.drfop.org/files/original/f035dc301e4fd1b9f7d498b18103cf33.jpg bc8736187d5b1cf372db15bae5fecbd1 https://staging.drfop.org/files/original/2f7fa7cb9146f525c58ba9d5bcdceee4.jpg d214434a7961b9d5b14e264027271d7a https://staging.drfop.org/files/original/3a3c0bf2056231987373ba4f3814cbdf.jpg 23890f5cc143cafe9297a430b85fd568 https://staging.drfop.org/files/original/1a23101ee14ed4cb9aada341d3d3c26e.jpg 93936696164a3d915c3460beb861e616 https://staging.drfop.org/files/original/448a0c6b9b0421ba2d64bccc76c9c0ea.jpg d170fb3ae9f4307cbf7564df55fca257 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_114.pdf Text Any textual data included in the document <h2>The UCLA Anatomical Hip Disarticulation Prosthesis</h2> <h5>David H. Littig, B.A., CP.&nbsp;<a style="text-decoration: none;">*</a><br />Judd E. Lundt, B.S., A.E.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>This article discusses a new approach to hip disarticulation and hemipelvectomy fittings developed at the UCLA Prosthetics Education Program. It employs fundamental principles and methods in a new and different combination to produce a more complex and more natural biomechanical system. The results include:</p> <ul> <li> <p>a smoother, and apparently less energy consuming gait</p> </li> <li> <p>improved stability</p> </li> <li> <p>improved suspension</p> </li> <li> <p>improved wearer comfort</p> </li> </ul> <h3>Introduction</h3> <p>For several years now, the UCLA Prosthetics Education Program has been involved in an effort to understand, develop, and refine a teaching method for the CAT-CAM Socket,<a></a> the anatomically shaped above-knee socket. The very essence of this effort is a broader and more detailed understanding of the pelvic anatomy and its optimal containment within the socket. With the dramatic above-knee results that have been achieved through this understanding has come a compelling and obvious need to examine the application of the same principles to hip disarticulation fittings.</p> <p>It was felt that a hip disarticulation socket design, which would encapsulate the ischium and ischial ramus in a more anatomical contour than previous socket designs, might produce an improved prosthetic fitting.<a></a> Since much of the CAT-CAM experience alluded to employed a frame supported flexible polyethylene socket, the flexibility of such a design applied to a hip socket seemed a reasonable way to provide more comfort. These factors formed the basis for this work.</p> <p>To date, three hip disarticulation patients and one complete hemipelvectomy patient have been successfully fit with the design described. The hemipelvectomy application followed the hip patient fittings by a number of months and was tried only as a whimsical experiment. Based upon the initial understanding of the biomechanics, this fitting was not expected to succeed. However, the results were quite surprising and motivated another look at the biomechanical analysis. Two of the hip cases and the hemipelvectomy case will be described in this article along with the biomechanics.</p> <h3>Patient Experience</h3> <p>The first hip disarticulation patient is a 23 year old male who had an amputation on the right side at age five for tumor, and who has rejected a prosthesis since age ten because it was too limiting and cumbersome. Owing to immature muscular and skeletal development at the time of amputation, he is significantly atrophied on the amputated side. This individual is extremely active, participates and excels in athletics as an equal with the able-bodied, and is impressively agile on crutches. Consequently, his remaining limb is hyperdeveloped to the extent that the thigh musculature extends well past the midline of the body.</p> <p>The second hip case, a right amputee as well, could be described as a more typical patient. He is a 40 year old professional, amputated at age 28, also due to a tumor. He has worn a prosthesis continuously since his amputation, the most recent being an Otto Bock en-doskeletal design. When this project was begun, he had recently taken delivery of a new one-piece flexible socket prosthesis which combined a Flex-Foot™ with Otto Bock endo-skeletal knee and hip components.</p> <p>The hemipelvectomy case was a 26 year old male who had undergone complete amputation on the left side for a massive tumor in the hip joint. At the time of the work described here, which was six months post-surgery, he had not yet been fit for a definitive prosthesis, but was wearing a socket only for sitting comfort. This patient was first seen as a demonstration subject for prosthetic certificate students at UCLA. For that program, he was fit with a fairly conventional design. However, since his level of amputation is somewhat uncommon, and because the patient was willing to experiment, the design was altered to include the suspension system that had been found to be so successful with the hip disarticulation patients.</p> <h3>Fabrication</h3> <p>The hip patients were cast using a similar technique with splints, circular wrap, iliac crest definition, anterior and posterior compression, and ischial weight-bearing while the plaster hardened. Since this was an attempt at a more anatomical socket, contours detailing the ischial ramus angle and the medial inclination of the ischium were included in the cast. Unlike the above-knee socket which flexes and extends with the femur through each stride, the hip socket is expected to remain relatively fixed, relative to the pelvic anatomy. Thus, the medial brim need not extend as high or contain as much of the ischial ramus. If properly executed, a cast which includes the bony contours of the pelvis will take much of the guesswork out of cast modification and fitting and should reduce the number of check sockets needed to attain an optimum result.</p> <p>The initial concept for a hip disarticulation socket was a one-piece polyethylene design with a laminated frame to which the hip joint would be attached. Accordingly, such a system was fabricated for the first fitting. The results were reasonably successful. However, sound side comfort and piston action of the resulting prosthesis were not wholly satisfying. Since this was an experiment, it was decided to push further. Through several reiterations of socket size, volume and shape, and through several experiments with suspension, the design described in this article was arrived at: a two-piece system composed of a laminated anatomically shaped socket, encompassing only the amputated side and connected to a polyethylene suspension segment for the sound side waist with Dacron® webbing (<b>Fig. 1</b>).</p> <strong><a href="/files/original/f035dc301e4fd1b9f7d498b18103cf33.jpg">Figure 1</a>. Posterior view of suspension system showing "X" pattern strapping.</strong><br /> <p>Fabrication of the socket for the hip patients was relatively simple because of the two-piece design. The original model was split and only the amputated side laminated. For the contralateral side, a shell of Aliplast®-lined polyethylene was vacuum formed over that half to serve as the suspension system.</p> <p>Since the initial fitting of the hemipelvectomy patient was meant to instruct the certificate students in basic prosthetics for this level of amputation, the approach was very straightforward. He was cast in a suspended attitude with a simple circular wrap. Modification involved little more than smoothing of the model. A total flexible polyethylene socket was vacuum formed over the entire model. Following this, a frame for mounting the hip joint was laminated over the amputated side only of the polyethylene socket. As this was a demonstration fitting with no intent to finish, the hip joint was only temporarily attached.</p> <p>Prostheses for all patients were assembled with Otto Bock endoskeletal 7E7 hip joints and 3R20/3R36 knee units. Several feet were experimented with on the first patient until an Otto Bock single axis foot proved optimum. The Flex-Foot™ that had been included with the second patient's recently delivered prosthesis was incorporated into his set-up. The hemipelvectomy patient was also fit with an Otto Bock single axis foot.</p> <p>The socket and sound side suspension segment for the hip disarticulations were joined posteriorally with Dacron® webbing. Using temporarily attached four-bar buckles and the webbing, the proximal and distal aspects of the socket and the polyethylene segment were connected with the webbing to form an "X" pattern across the posterior gap (<b>Fig. 1</b>). At their cross point, the straps are not connected but are allowed to freely move with respect to each other. The buckles were found to be necessary for "fine tuning" adjustments of the suspension during fitting and alignment. Anteriorly, a single strap attached at the distal aspect of the laminated socket was passed through a loop on the polyethylene portion and back to a roller buckle on the anterior proximal socket (<b>Fig. 2</b>).</p> <strong><a href="/files/original/2f7fa7cb9146f525c58ba9d5bcdceee4.jpg">Figure 2</a>. Anterior view of suspension system.<br /></strong><br /> <h3>Functional Results</h3> <p>Results achieved with this combination of socket and suspension were dramatic. After some adjustments, the hip patients felt no discomfort from the socket, despite the obvious upward curve of the medial brim in the perineum. This edge, along with the distal portion of the socket, particularly under the ischium, were lightly padded with 1/8" Pe-Lite™, as is customary in most hip sockets. Neither patient perceived any piston action or discomfort from the proximal brim of the socket or the polyethylene waist segment. The most obvious benefit was a significant reduction in lateral trunk bending that is so common with hip disarticulation amputees. In fact, this gait anomaly was reduced beyond that usually seen with many above-knee amputees. Both patients were impressed with the comfort and secure feeling that the design afforded.</p> <p>With the adjustable diagonal posterior straps, which in the finished prosthesis are replaced with buckleless double Dacron® webbing, the socket can be optimally positioned under the pelvis to more effectively encapsulate the bony pelvic anatomy. This is somewhat akin to adducting an above-knee socket of similar medial brim design (CAT-CAM). By a careful balance in the strap length adjustments, comfort and suspension in the entire system can be achieved.</p> <p>Because of the success that had been achieved with the hip disarticulation patients with this suspension technique, it was decided to try it on the hemipelvectomy patient. His reasonably comfortable and functional single piece socket was modified by removing the center portion of polyethylene in the posterior and rejoining the two separate segments with Dacron® webbing in the same cross strap pattern. An anterior closure as previously described was also employed (<b>Fig. 3</b>). The result was about 1/8" of piston action and improved comfort over the one-piece design, probably because the prosthetic socket could more accurately follow the body contours.</p> <strong><a href="/files/original/3a3c0bf2056231987373ba4f3814cbdf.jpg">Figure 3.</a> Posterior view of hemipelvectomy setup showing adjustable cross strapping.<br /></strong><br /> <h3>Biomechanics</h3> <p>In all cases, it appears that during the gait cycle the polyethylene segment that encompasses the contralateral hip will tilt from the vertical as it follows the changing sound side body contour. The forces thus imposed on each of the posterior straps will vary alternately, and their crosspoint will shift slightly with each stride. For example, as the amputee reaches heel strike on the prosthesis, tension in the strap originating at the posterior proximal socket (the lateral support strap) will build as the body moves forward, and the center of gravity begins to shift laterally. As the patient progresses, this force reaches its maximum at mid-stance (<b>Fig. 4</b>) and then begins to fall off. Tension in the other (suspension strap) is at its lowest at mid-stance on the prosthetic side and then begins to build toward its peak when the amputee reaches mid swing-through (<b>Fig. 5</b>). The cycle then repeats itself with each successive stride. This alternating action in the straps, coupled with an accurately contoured socket, provides a continuously snug and secure suspension without the need for excessive tightness.</p> <strong><a href="/files/original/1a23101ee14ed4cb9aada341d3d3c26e.jpg">Figure 4</a>. Suspension system forces at mid-stance.</strong><br /><br /><strong><a href="/files/original/448a0c6b9b0421ba2d64bccc76c9c0ea.jpg">Figure 5</a>. Suspension system forces during swing.</strong><br /> <p>At the outset of these efforts, it was believed that much of the success of the suspension system depended upon a well-contoured medial brim, which accurately encapsulated the ischium and ischial ramus. The hemipelvectomy fitting quickly dispelled this consideration as a major factor. However, all hip disarticulation patients fit to date have perceived far greater comfort and control when in a socket so described. The idea behind ischial containment is to provide greater mediolateral stability in the prosthesis. It appears that the cross strap suspension is contributing the better part of this stability.</p> <p>Results to date suggest that the two-part socket and posterior cross strapping provide a mechanism which more closely conforms to changing soft tissue and muscle contours through the gait cycle. With a one-piece socket, regardless of flexibility, slight and subtle motions about all three body axes are not fully accommodated by "give" in the socket, as well as they seem to be in the one described here. Thus, the body must either move inside the socket or limit its movements due to the restrictions imposed by the rigidity of the socket. In either case, the result is a less natural gait and a greater apparent expenditure of energy. With this new approach, these shortcomings of the hip and hemipelvectomy fittings seem to be significantly reduced.</p> <p><b>References:</b></p> <ol> <li>Sabolich, John, "Contoured Adducted Trocanteric Controlled Alignment Method (CAT-CAM): Introduction and Basic Principles," Clinical Prosthetics and Orthotics, Vol. 9, No. 4, Fall, 1985, pp. 15-26.</li> <li>Sabolich, John and Tom Guth, "CAT-CAM Innovations," Ability, Vol. 6, No. 3, Winter, 1986, p. 48.</li> </ol> <p><em><b>*Judd E. Lundt, B.S., A.E. </b> UCLA Prosthetics Education Program, Rehabilitation Center, 1000 Veteran Avenue, Room 22-41, Los Angeles, California 90024.</em></p> <p><em><b>*David H. Littig, B.A., CP. </b> UCLA Prosthetics Education Program, Rehabilitation Center, 1000 Veteran Avenue, Room 22-41, Los Angeles, California 90024.</em></p> Page Number(s) 114 - 118 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_114/1988_03_114-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The UCLA Anatomical Hip Disarticulation Prosthesis Creator An entity primarily responsible for making the resource David H. Littig, B.A., CP. * Judd E. Lundt, B.S., A.E. *