17 20 371 https://staging.drfop.org/files/original/7904e0df9f82ca12c7c4e5cd88f6db97.pdf 28eeacacfe9b1b5e4ac2b081f46ce305 https://staging.drfop.org/files/original/82e7e39858aab0ffb26247e4ac66f8ff.jpg 9f927c763f3c0a435205f628539e33fd https://staging.drfop.org/files/original/959f68367f7cae905c928c179c005a3f.jpg 53b45497795ecaf6b411058791a39c7b https://staging.drfop.org/files/original/7b0e5455441dc18eff98d48d86415fb7.jpg bd46345d3be76766394dec62eb977ef7 https://staging.drfop.org/files/original/6c178a7d49b2ae565c5fdd88f9b45441.jpg dca58414c4ca42c275c9827d838c88d0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_01_051.pdf Year 1967 Volume 11 Issue 1 Page Number(s) 51 - 57 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/1967_01_051.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_01_051.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>Experiences with the Total-Contact Prosthesis</h2> <h5>Georg Bakalim, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>At the request of the Finnish Disabled Ex-Servicemen's Association, New York University arranged for a series of lectures on the fabrication of total-contact, above-knee sockets to be given in Helsinki in 1963. The lectures were intended for prosthetists and other interested persons. Since then some 300 prostheses of this type have been fabricated in Finland.</p> <p>The total-contact socket <a></a> is a further development of the conventional open-end socket. The proximal portion of a total-contact socket has the same contours as the corresponding portion of an open-end socket. The ischial seat, the relatively high anterior and lateral walls, the bulge into the femoral triangle, and the reliefs for the rectus femoris, for the adductor longus, and for the hamstring tendons are similar in both the open-end socket and the total-contact socket. The main difference is that the total-contact socket completely encases the stump, while the open-end socket, as its name implies, is open distally.</p> <p>This means that, in the total-contact socket, the stump end is surrounded by a vacuum which keeps the prosthesis in position without a pelvic joint and belt. The total-contact socket is kept in place by its intimate fit around the stump. There is a moderate vacuum during swing phase. The intimate fit of the total-contact socket, which is made of plastic, has been designed with a view toward imitating the mechanism of the physiological pumping action performed by the muscles while walking. the patellar-tendon-bearing (PTB) prosthesis acts in a similar fashion. The pumping effect is accomplished by the amputee as he walks. In fact, a principal advantage of the total-contact socket is the mild, gentle counterpressure on the distal end of the stump during the stance phase. This positive pressure, alternating with the negative during the swing phase, improves circulation and reduces edema in the stump.</p> <p>The total-contact socket is designed to reduce pressure on the stump proximally and increase the pressure distally. In cases where the diaphysis has been cut, the stump end never tolerates strong pressure. Therefore, pressure must be very carefully modified in each case.</p> <p>Distally, the plastic socket is joined to a wooden knee. The shank, too, is made of wood, to which a SACH foot is attached. Plastic has certain advantages over other materials. It is readily washed with soap and water. The surface can be made very smooth and free from pores. The chief drawback is airtightness. Plastic does not permit an exchange of air. The result is perspiration, particularly in the summer. Sweat gradually breaks down the plastic. In winter plastic is cold. Sometimes there are allergic reactions to plastic.</p> <p>In the Department of the State Supervisor of Prosthetic Services of the Ministry of Social Affairs, a follow-up study has been made of amputees fitted with total-contact prostheses. Initially, the amputees are given, for trial, prostheses which are not quite finished, although fit for wear. Some four to six weeks later the patients and their prostheses are examined at the Department of the State Supervisor, where the prostheses are approved or some modification or correction is prescribed. Only after this examination are the prostheses given their final finish. This applies to all prostheses paid for by the state. Six months after the patients have been fitted with their prostheses a questionnaire is sent to them, which they accomplish and return.</p> <p>Record cards are kept for all amputees on which are entered notations concerning new prostheses, repairs, and modifications.</p> <p>The present study covers 150 amputees fitted with total-contact prostheses. Of the amputees, 143 (95.3 per cent) were ex-servicemen and 7 (4.7 per cent) were insured civilians.</p> <p><b>Fig. 1</b>, which shows the ages of the amputees, indicates that the age group of 40 to 54 years is the largest. The high mean age of the ex-servicemen is accounted for by the time that has elapsed since World War II. The series includes two cases from the Finnish civil war of 1918. The youngest amputee was 24, the oldest 67. Only one was a recent amputee. In principle, every above-knee amputee should be fitted with a total-contact prosthesis from the outset in order to become used to it as soon as possible. This would accelerate the remodeling of the stump. Still, the stump of a recent amputee is often tender and swollen for some time. The total-contact prosthesis demands much of the stump. Consequently, a recent amputee may need a new socket at frequent intervals.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Ages of the amputees when they were fitted with total-contact prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 1</b> shows the occupations of the patients in the series. It is of major interest to ascertain whether the total-contact prosthesis can be worn while performing heavy labor of different kinds, particularly outdoors and at low temperatures. In northern Finland temperatures may be as low as -40 deg. C. Therefore, the occupations have been precisely specified. Whenever possible, amputees will usually choose labor that is not too heavy. The series includes 23 farmers (15.3 per cent), 1 lumberman, and 11 fitters. After World War II, retraining of invalids was arranged in the form of courses for watchmakers, storekeepers, fitters, shoemakers, etc. These occupations appear in the table.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 2</b> shows the lengths of the amputation stumps. The total-contact prosthesis has been worn successfully by amputees whose stumps measured only 10 cm to 15 cm. This series includes 10 such cases, but in two of these cases it became necessary to abandon the total-contact prosthesis. One of these patients received a conventional, wooden, open-end prosthesis; the other was fitted with a leather prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Lengths of the amputation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These cases (No. 8 and No. 9 in <b>Table 2</b>) will be discussed later.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. Amputees Who Could Not Wear the Total-Contact Prosthesis </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Replies to the questionnaire are presented below:</p> <ol> <li><i>Have you worn your prosthesis regularly; if not, for how long have you worn itf </i>According to the replies, 108 (72 per cent) had worn their prostheses regularly, while 42 (28 per cent) had not been able to do so for a variety of reasons.</li><li><i>Why have you not been able to wear your prosthesis regularly? </i>The replies were compared with the record cards, and causes were elicited as follows: <ul> <li>The knee joint in the prosthesis was too stiff.</li> <li>In eight cases there was profuse perspiration and a repulsive odor.</li> <li>In one case the prosthesis was too warm in the summer and too cold in the winter.</li> <li>In one case the prosthesis was too cold in the winter.</li> <li>In five cases the socket did not fit.</li> <li>The amputee put on weight and the socket became too tight.</li> <li>The inner surface of the socket became granular.</li> <li>The stump swelled.</li> <li>There were pains in the stump.</li> <li>Walking was difficult because of a heart condition.</li> <li>In two cases the socket split.</li> <li>There was a jarring sound from the knee joint of the prosthesis.</li> <li>In one case the amputee was so used to his old prosthesis that he preferred it.</li> <li>The SACH foot became loose, the socket was tight, and the knee mechanism functioned differently from what it did in the old prosthesis.</li> <li>In three cases the skin became irritated.</li> <li>In one case the stump was operated upon after the prosthesis had been finished.</li> <li>The socket became too wide.</li> <li>The stiffness of the knee mechanism was a hindrance while fishing.</li> <li>The socket became too tight.</li> <li>In many cases modification and repair of the prosthesis put an end to the trouble.</li> </ul></li><li><i>Have you worn your prosthesis (a) when working indoors, </i>(b) <i>when working outdoors, (c) when working outdoors in very cold weather? </i>Of those replying to the questionnaire, 128 (85.3 per cent) had worn their prostheses while working indoors, 100 (66.7 per cent) had worn their prostheses while working outdoors, and 72 (48.0 per cent) had worn them outdoors in very cold weather. Some amputees had been in a position to wear the prosthesis only during the warm season at the time of the questionnaire.</li><li><i>Have you worn your prosthesis in some additional</i>-<i>part-time</i>-<i>occupation? </i>(The intention was to elicit data regarding incidental jobs, recreation, and hobbies.) Only eight amputees indicated that they had such activities: fishing in one case, gardening in one case, agricultural work and lumbering in two, work as a doorkeeper in one case, two cases in which the patients had built their own cottages, and one case in which the amputee participated in ball games.</li><li><i>Have you previously used a prosthesis of some other material (wood, leather, or light metal)? </i>Conventional prostheses of wood had been worn by 147 amputees (98 per cent), one (0.7 per cent) had worn a leather prosthesis, and one (0.7 per cent) had worn a prosthesis of light metal. One patient (0.7 per cent) was a recent amputee and had been fitted with his first prosthesis.</li><li><i>Have you been satisfied with your prosthesis? </i>There were 112 (74.5 per cent) satisfied wearers and 38 (25.5 per cent) who were dissatisfied.</li><li><i>Do you think this prosthesis is (a) better than, (b) just as good as, </i>(<i>c</i>) <i>not as good as your previous limb? </i>The replies were as follows: <br /> <table> <tbody><tr><td> <p>Better</p> </td> <td> <p>   81 (54.0 per cent)</p> </td> </tr> <tr><td> <p>Just as good</p> </td> <td> <p>   36 (24.0 per cent)</p> </td> </tr> <tr><td> <p>Not as good</p> </td> <td> <p>   33 (22.0 per cent)</p> </td> </tr> </tbody></table><br /></li><li><i>What defects or drawbacks have you observed in your total-contact prosthesis? </i>Listed below are the complaints of 39 patients (26 per cent). In 32 cases the stump had caused trouble and in seven cases there was something wrong with the prosthesis. But no sharp distinction can be drawn between these two groups. Quite frequently, the prosthesis is the ultimate source of the discomfort.<br /> <table> <tbody><tr> <td> <p><b>Amputation stump</b></p> </td> <td> <p></p> </td> </tr> <tr> <td> <p>The skin did not tolerate the prosthesis</p> </td> <td> <p>   12</p> </td> </tr> <tr> <td> <p>Perspiration from the stump and an unpleasant odor</p> </td> <td> <p>   15</p> </td> </tr> <tr> <td> <p>Cold in winter</p> </td> <td> <p>   2</p> </td> </tr> <tr> <td> <p>Stump end became discolored</p> </td> <td> <p>   1</p> </td> </tr> <tr> <td> <p>Warm in summer, cold in winter</p> </td> <td> <p>   2</p> </td> </tr> <tr> <td> <p>Totals</p> </td> <td> <p>   32</p> </td> </tr> </tbody></table><br /> <table> <tbody><tr> <td> <p><b>Prosthesis</b></p> </td> <td> <p></p> </td> </tr> <tr><td> <p>Plastic socket split</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p>Socket was too closed</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p>Socket did not fit</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p>Socket too tight</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p>Totals</p> </td> <td> <p>   7</p> </td> </tr> </tbody></table><br /> </li><li><i>Has perspiration of the stump constituted a problem? </i>In 33 cases (22 per cent) perspiration had been profuse, in 99 cases (66 per cent) moderate, and in 17 (11.3 per cent) it had caused no trouble. Only one patient (0.7 per cent) stated that perspiration gradually became less of a problem. As a rule, summer was the worst season from this standpoint.</li><li><i>Has perspiration caused any repulsive odorf </i>The replies of 113 amputees (74.7 per cent) were in the affirmative, while 37 patients (25.3 per cent) replied in the negative. When the odor of the sweat in the closed socket mingled with the odor of the plastic, which is particularly strong in new sockets still containing traces of the solvents used in the fabrication, the effect is extremely disagreeable to both the amputee and his environment. The plastic socket can be washed with soap and water, but personal hygiene varies widely. Many patients have stated that perspiration is not a major problem, if the stump and the prosthesis are washed regularly.</li><li><i>Has the skin on the stump tolerated the total-contact prosthesis? </i>In 118 cases (79.0 per cent) the skin on the stump had shown no symptoms, while in 32 cases (21.0 per cent) it had not tolerated the strain of the intimate fit of the socket.</li><li><i>Have reddening of the skin and eczema occurred? </i>In 51 cases (34 per cent) there had been reddening, which may be a transient phenomenon of no significance, but 23 amputees (15.3 per cent) had had eczema, and ulceration had occurred in 18 cases (12 per cent).</li><li><i>Has the end of the stump become discolored after adoption of the new prosthesis? </i>Discoloration of the end of the stump had occurred in 34 cases (22.7 per cent). This phenomenon is the result of circulatory disturbances in the end of the stump. The most frequent cause is that pressure on the blood vessels is too strong.</li><li><i>Did reddening, eczema, or ulceration of the stump occur before you started wearing a total-contact prosthesis? </i>Reddening had occurred in 60 cases (40 per cent), eczema in 45 (20 per cent), and ulceration in 5 <i>(3.3 </i>per cent). These replies do not differ greatly from those to question No. 12. But it must be remembered that the previous, conventional prosthesis of wood, leather, or light metal had been worn for a long time, while the total-contact prosthesis had been worn only one-half year to one year. Therefore, the two groups cannot be directly compared.</li><li><i>What are your experiences with the new prosthesis outdoors in cold weather? </i>Thirty-two patients (35.1 per cent) had not experienced discomfort during the winter, while 61 (64.9 per cent) had found their prostheses very cold.</li><li><i>Have you skied with the new prosthesis? </i>Only 23 (15.3 per cent) patients answered in the affirmative. As a rule, above-knee amputees are not likely to participate in this sport. The below-knee amputees found on skis are much more numerous.</li><li><i>If you experienced phantom pains previously, have they been aggravated or alleviated after adoption of the new prosthesis? </i>The replies were as follows:<br /> <table> <tbody><tr> <td> <p>No previous phantom pains</p> </td> <td> <p>   32 (22 per cent)</p> </td> </tr> <tr> <td> <p>Phantom pains aggravated</p> </td> <td> <p>   15 (10 per cent)</p> </td> </tr> <tr> <td> <p>Phantom pains unchanged</p> </td> <td> <p>   94 (62.3 per cent)</p> </td> </tr> <tr> <td> <p>Phantom pains alleviated</p> </td> <td> <p>   8 (5.3 per cent)</p> </td> </tr> <tr> <td> <p>Total</p> </td> <td> <p>   149 (99.6 per cent)</p> </td> </tr> </tbody></table><br /></li><li><i>Have you had pains in the amputation stump (a) after adoption of the new prosthesis, (b) with the old prosthesis? </i>Sixty-six patients (44 per cent) had experienced pain after adoption of the new prosthesis, and 66 (44 per cent) had had pains while wearing their old limb. In this respect the type of prosthesis seemed to make no difference. But it should be noted that no direct comparison is possible because the total-contact prosthesis had been worn for a shorter period than the old one. In nine cases the total-contact prosthesis was abandoned in favor of the open-end prosthesis previously worn. These cases were subjected to a more detailed study, presented in <b>Table 2</b>.</li></ol> <p>The table discloses that the occupations of the patients had little to do with the failure. The ages of the patients did not differ from the mean age of the series as a whole. In two cases the stump was short, 12 cm and 15 cm, respectively. In the entire series there were 10 stumps measuring 10 cm to 15 cm, three measuring 16 cm, six measuring 17 cm, and five measuring 18 cm. In all cases except the two mentioned at first, fitting with a total-contact prosthesis proved successful. In general, short stumps constitute a problem to the prosthetist. No. 8 in <b>Table 2</b> was one of a number of amputees who had not been able to wear any prosthesis without complications. No. 9 was the only patient who was tested for allergy.</p> <p>As appears from the replies to the questionnaire, perspiration and skin changes constituted problems in the wearing of total-contact prostheses. These troubles arose from the properties of the socket: its intimate fit around the stump, and the airtightness of the plastic material. Partly because of the solvents used in the fabrication, the plastic socket sometimes has an irritating effect on the skin, especially when it is new. This irritation is increased by the decomposition of the sweat caused by the heat of the closed socket. In a considerable number of cases, however, the difficulties may have been caused by inadequate curing of the plastic laminate. Also, prostheses made of wood or leather are not free from perspiration.</p> <p>The possible occurrence of allergic reactions is another problem. In Finland, amputees suspected of allergy are remitted to the Dermatological Department of the Helsinki University Central Hospital. The present series includes only one such case. Perhaps the question of allergy has not been sufficiently taken into account.</p> <p>The majority of the remaining troubles were readily dealt with in the prosthetist's shop.</p> <p>It should be emphasized, however, that the view of the total-contact prosthesis derived from the replies that have been reported may be too unfavorable. To the amputee, it is a great advantage to be able to walk with greater ease than with a conventional prosthesis, because of the firm adherence of the total-contact socket to the stump. No pelvic joint and belt are needed. As mentioned earlier in this article, a principal advantage of the total-contact socket is the mild, gentle counterpressure on the distal end of the stump during the stance phase. This positive pressure, alternating with the negative during the swing phase, assists circulation. Some of the cases with derma-tologic problems had poor fits, usually as the result of stump changes. In a number of cases, the difficulties may well have been caused by inadequate curing of the plastic laminate. Also, a number of the problems did not relate to the principle of the total-contact socket as such but would have occurred with other designs.</p> <h3>Summary</h3> <p>This study was performed on 150 amputees fitted with total-contact prostheses. It is based on personal follow-up examinations, replies to questionnaires, and data obtained from record cards kept on the amputees.</p> <p>The age group 40 through 54 years is the largest. War veterans constitute the majority (96.3 per cent of the series).</p> <p>Seventy-two per cent had worn their prostheses regularly from the outset, and 74.5 per cent were satisfied with them. The airtightness of the socket elicited unfavorable reactions from the skin of a number of the patients (21 per cent). Twenty-two per cent of the amputees complained of profuse, and 66 per cent of moderate, perspiration of the stump. Some of the cases with dermatological problems had poorly fitting sockets, usually as the result of stump changes. In a considerable number of the cases, the difficulties may well have resulted from inadequate curing of the plastic laminate. The majority of the problems were readily dealt with in the prosthetist's shop.</p> <p>The skin requires meticulous hygiene. In contrast to leather and wood, the plastic socket is readily washed. Conventional prostheses are not free from dermatological problems.</p> <p>The total-contact prosthesis has been used in the performance of heavy labor and while outdoors in cold weather.</p> <p>Some of the problems of the patients did not relate to the principle of the total-contact socket and would have occurred with other designs.</p> <p>The gentle, alternating, positive and negative pressure afforded by the total-contact socket to the patient as he walks improves the circulation of the stump and constitutes one of the socket's main advantages.</p> <p><b>References:</b></p> <ol> <li>Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1963.</li> <li>Foort, J., and N. C. Johnson, Edema in lower-extremity amputees, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1962.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1963.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Foort, J., and N. C. Johnson, Edema in lower-extremity amputees, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 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>Georg Bakalim, M.D. </b></td></tr><tr><td class="clsTextSmall">State Supervisor of Prosthetic Services, Ministry of Social Affairs, Helsinki, Finland.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-4.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experiences with the Total-Contact Prosthesis Creator An entity primarily responsible for making the resource Georg Bakalim, M.D. * https://staging.drfop.org/files/original/db74232ff919eba50ae953fc5d8e15df.pdf 4106376d5c34e536f4d1f88cbe77c124 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_001.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 1 - 4 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/1967_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_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>Still a Long Way to Go</h2> <h5>D. S. McKenzie, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>It is probably a common experience to those of us who work in the field of artificial limbs to receive odious comparison between the relatively primitive prostheses and the sophisticated hardware deriving from space technology, nuclear physics, and the like. The implication usually is that, if similar expenditure on research were made in our field, similar dramatic advances would be made. I do not think that the problem is as simple as this reasoning would imply, and there is some evidence to support my view. I am told that, once upon a time, a great American aviation company undertook to develop an artificial arm and that, some years and a million or two dollars later, they reverted with relief to the relatively simple matter of designing aircraft.</p> <p>And yet we must acknowledge that the externally powered upper-extremity prostheses of today are poor things. It is very doubtful indeed whether the unilateral arm amputee can obtain from them any functional or emotional gain over that deriving from the conventional body-powered prosthesis; indeed, in some respects there may be a loss. It is even doubtful whether any bilateral amputee with measurable humeral stumps would be improved, except perhaps by making it possible to superimpose an additional degree of freedom such as pronation-supination on the existing body-powered prostheses. Indeed, I would go so far as to say that the amelics and bilateral shoulder-disarticulation patients would be better off functionally if they only had sufficient sites available for harnessing with sufficient power and excursion for body-powered control. Currently available externally powered limbs are acceptable to these patients only because a little function is better than none at all. How little that is, is exemplified by the readiness with which the children with upper-extremity amelia and normal lower limbs revert to using their feet for prehension and manipulation.</p> <p>It is of more than passing interest to attempt to analyze why these things should be so, and I think there are a number of reasons.</p> <p>First, the power-weight ratio of available actuators and power storage components is still not advantageous enough for us to provide truly acceptable responses.</p> <p>Second, we have not yet discovered enough control sites capable of providing a sufficient number of degrees of freedom to position the hand or terminal device in space, to put it in the optimum attitude in relation to each task to be performed, and still leave an adequate reserve for prehension.</p> <p>The problem of simulating normal prehension has not been solved, nor, in my opinion, has a truly acceptable compromise been attained. Most writers agree that a well-designed hook is more functional than any of the many so-called functional hands, and yet few would claim that the hook contributes anything to cosmetic restoration or that it is likely to be emotionally satisfying to more than a small proportion of patients. Various ingenious hands purport to provide a selection of different types of grasp, such as the power grasp, precision grasp, "three-jaw chuck," and so forth, and some even achieve this. But none of them, nor of the hooks for that matter, is capable of manipulation within the grasp. This results in the exasperating experience for the user that any object he picks up is seldom immediately in a position of function; he is unable to manipulate it into such a position and has to resort to inelegant procedures such as transferring the object to the mouth and back to the hand again. Furthermore, many tasks that we do are achieved by manipulation-screwing, modeling, squeezing, and a host of others--which, for the amputee, have to be done by energy-consuming gross arm movements or even gross body movements, and he cannot feel what he is doing. It is not surprising that the unilateral amputee elects to use his remaining hand, and the amelic his toes.</p> <p>The foregoing difficulties apply in the main both to externally powered and body-powered prostheses, and I have said little about sensory feedback, a degree of which is available to the users of the latter systems. The control cable offers a built-in position servo, while a great deal of information about the forces applied at the output can be derived from the reactions of the harness against the body and those of the socket on the stump. When external power is used, these afferent channels either cease to exist or are severely attenuated, and it becomes necessary to consider the provision of artificial sensory loops which in their turn introduce difficulties in interpretation.</p> <p>We are thus confronted with what I believe to be the main barrier to progress in externally powered prostheses-the man-machine interface. This should be taken to mean not only the physical attachment of the prosthesis to the wearer, but also the boundary through which all command signals from the biological system of the wearer must pass to the mechanical system of the prosthesis and through which all information relating to the output of the prosthesis must return to the biological system if the wearer is to make the best use of such information to modulate performance.</p> <p>It is on these channels of communication that the effective control of externally powered devices depends. I am quite certain that we do not know enough about their mechanism to exploit them to best advantage. No one has yet attempted to measure the "goodness" of the channels-for example, in terms of communication theory-and yet I believe that effective systems design would follow on such data as surely as night after day.</p> <p>One of the greatest virtues of biological systems is that they are highly adaptive. The human control system-and in particular the computer as represented by the central nervous system-is no exception to this. The pattern of manual activity which we require in order to enjoy a full life is so infinitely variable that I have very serious doubts whether any form of programmed operation within the prosthetic system will satisfy a user for any length of time. The concept of programming the trajectory of the terminal device so as to limit the decision-making demand upon the user to commanding the system to move it from <i>A </i>to <i>B </i>is open to this criticism. Even if provision were made for the user to override the program and revert to voluntary control, I suspect that the switch would soon be left permanently in the override position. In any event, the case for this sort of programming seems to me to be accepting that the interface is inevitably poor in a communications sense. It may be that a better understanding of the interface will make this an unduly pessimistic view.</p> <p>Reverting to the adaptive properties of the biological system in general, and of the central nervous system in particular, it seems to me that significant progress in externally powered limbs will be made only when it becomes possible to link the central nervous system "on line" with the prosthetic control system. Servo loops crossing the interface would make an integrated and adaptive system. It might be said that a start had already been made on this by exploiting the myoelectric discharges for control. In such an integrated system, however, the command signal is being derived by tapping the middle of the efferent loop. Such sensory information as returns by afferent channels is derived from the muscles and their tendons. Essentially, this is a backwater of the main stream of the afferent channel of the man-machine complex. It follows that information about the output of the man-machine system can only be inferred rather than known. In my view, Simpson's position-controlled servos and Bottomley's pressure-demand pneumatic valve have more prospects of achieving a truly adaptive output and might be regarded as among the first breaches in the man-machine interface.</p> <p>Taking all these matters into consideration, besides many other difficulties which I will not discuss for reasons of space, we are in no position to be complacent about externally powered arms. Indeed, the state of the art is so relatively primitive that the only overriding indication for prescribing them at this time is bilateral high-level amputation or the equivalent-only a handful of patients out of the total upper-extremity case load of any prosthetic service and an even smaller proportion of the total case load. The difficulties are so great, and the amount of fundamental information lacking is so formidable, that one is continually surprised at the surge of interest in the field and the amount of effort that is going into it. Indeed the budget for prosthetics research and development in Great Britain for next year envisages that over 30 per cent of the total expenditure will go to work on external power. From what I saw when I visited the United States in May 1967, I would think that a similar proportional expenditure is being made there. Taking into account the tiny number of immediate beneficiaries-although admittedly they are among the most severely disabled-it is proper to take stock and consider whether this level of expenditure of money and effort is justified. Have we got our priorities right? Of course, there is much common ground in the orthotics field, and many developments arising from purely prosthetics requirements would have direct application here. This would increase the number of potential beneficiaries, but they would still be a small proportion of the total disabled population. I think the justification as well as the reason for the interest in the subject is the fact that we believe the possibility of introducing a new order of function to <i>all </i>upper-extremity amputees lies in external power and possibly to lower-limb amputees as well.</p> <p>May I use these pages to make a plea, if not that hardware development should cease, at least that some of the effort should be put into fundamental research into problems such as those I have indicated? Indeed, all of us already engaged in such work should devote sufficient time to discovering what the patient really needs, rather than to providing him with what we think he ought to need.</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>D. S. McKenzie, M.D. </b></td></tr><tr><td class="clsTextSmall">Director, Ministry of Health, Biomechanical Research and Development Unit, Roehamp-ton, London, S.W. 15, England.</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 Still a Long Way to Go Creator An entity primarily responsible for making the resource D. S. McKenzie, M.D. * https://staging.drfop.org/files/original/1af135b4046fb2db501ded967f727ab2.pdf a4ca54acbda5984b15304cd6f7f016f5 https://staging.drfop.org/files/original/228e86e9452aa08be3bd9351e6c31dd0.jpg 5ccce9aaa2c5fa279985a74d639717be https://staging.drfop.org/files/original/c3df5a9743aed351dd319f2fb7e5112b.jpg a6f33c8ff187dab14eaff25dfafeecc3 https://staging.drfop.org/files/original/d5917e7f85a5a4c742cd2881c5d8c622.jpg 7b428b86fa69aeaa6a00da502d9b8c5b https://staging.drfop.org/files/original/d7d878173bbf5ec95e330af715e05b3a.jpg 3fc75ef8e1cadc253917ec7678b04d21 https://staging.drfop.org/files/original/da2a87a3ffef9f0eaf6e00bce461aede.jpg b746ec00689aa36b9d45c21f1587efca https://staging.drfop.org/files/original/54cbbe5693ea9e29ee0aab4eeb74d355.jpg f68af07a7951cc4830b6396717efbbcb https://staging.drfop.org/files/original/c865c0387c4ee04978be8c5707188774.jpg b2accc827111018a5ac53834cf59ac5a https://staging.drfop.org/files/original/ec3a3830c510a3a5beeeceb61f8ec202.jpg 9ef1d7fba1b6d89801277060612ca699 https://staging.drfop.org/files/original/85aee9dd4f8c9ffb71f4f4f600f45426.jpg 3ba2d1b34f53dbd76ad7069fbc2847d3 https://staging.drfop.org/files/original/e9760a32a1177547755bd80d61b859d0.jpg 0e658181df75e5a68bafb70e7e89cb7a https://staging.drfop.org/files/original/e83bead762c305b477ce5472b0c2c660.jpg cfe681da6e99338852c5c85b9aa8a8cf https://staging.drfop.org/files/original/efcb14dbaa8a3571f79a5c522cbfc587.jpg b7a17d0b20c308b84db4cb71383ed647 https://staging.drfop.org/files/original/063f9cc82fc0b22d33d5afc3b26ab2f8.jpg c0c7f6254ff24cb2489895ad919e66c5 https://staging.drfop.org/files/original/d9aef5c99b9e68a90850d61c434ee8fb.jpg 302927b6d2390d85826ddc3c38ea28fc https://staging.drfop.org/files/original/d1a8faaf3cedc688656a9fdf13e1d6b1.jpg e86b096968e144fb105e347fca51cc98 https://staging.drfop.org/files/original/bae29461b9316b470b68481ef53c0e67.jpg 3a177550c19df8561c721d998a50b471 https://staging.drfop.org/files/original/cf3f68b62ba311b841de515c0ad9727c.jpg 378c97c7ad10e652d2a03009da51411b https://staging.drfop.org/files/original/1739de25d66a546b4f81d95b07a9cd81.jpg 74e052d9003c72e4bb39645dfb2f587f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_001.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 1 - 13 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Acceptance and Rejection of Prostheses by Children With Multiple Congenital Limb Deformities</h2> <h5>P. J. R. Nichols M.A., D.M. (Oxon), D.Phys.Med. <a style="text-decoration:none;">*</a><br />E. E. Rogers, M.A.O.T. <a style="text-decoration:none;">*</a><br />M. S. Clark, M.A.O.T. <a style="text-decoration:none;">*</a><br />W. G. Stamp, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Children with severe multiple congenital limb deformities associated with thalidomide are numerically few. <a></a> Because of the severity of this disability, the associated deformities, and the psychological trauma to both parents and child, the thalidomide tragedy has served as a catalyst to study the congenital amputee in depth. There is still controversy concerning the appropriate prosthetic and rehabilitation program for these children, but the attention this tragedy has focused on other less-involved children perhaps will reap benefits far beyond our expectations. <a></a></p> <p>The possible factors associated with acceptance or rejection of appliances may be inherent in the appliance, or they may arise from the child's own frustration, the parental reaction, <a></a> or other environmental factors. Retrospective studies of children who attend the Nuffield Orthopaedic Centre for prosthetic management and a review of the relevant literature have been carried out in an effort to establish a pattern of management and to delineate topics for future research.</p> <h3>Scope of the Study</h3> <p>During the past four years, 50 children with congenital amputations and limb deformities have attended the Disabled Living Research Unit at the Nuffield Orthopaedic Centre. Approximately half were deemed not to need prostheses or appliances at this time.</p> <p>This article reviews 21 children with multiple congenital limb deformities who have been under continuous care for prosthetic management and general rehabilitation for four years. All the deformities were presumed to be due to thalidomide, and the lesions were characteristically bilateral (<b>Table 1</b>). Thirteen of the children have been fitted with upper-limb prostheses only, four with lower-limb appliances only, and four with both upper-and lower-limb appliances (<b>Table 2</b>). Henkel's classification <a></a> was used; other classifications are used in various parts of the world. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Each child has been fitted with appliances on more than one occasion. In considering acceptance or rejection of prostheses, attention has been focused on the type of prosthesis provided rather than actual numbers. A satisfactory design may well be repeated in different sizes or, after rejection of one type, a different pattern may be tried. On average, each child has passed through three stages of prosthetic management, but the number of prostheses made and supplied is in considerable excess of this (<b>Table 2</b>). The classification of type of prosthesis fitted is given in <b>Table 3</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some children had only conventional prostheses, and others only powered upper-limb appliances. The majority, however, started with conventional appliances and then "graduated" to the powered ones.</p> <h3>Criteria for Prosthetic Management</h3> <h4>Upper-Limb Appliances</h4> <p>The fitting of upper-limb prostheses at the Disabled Living Research Unit was governed by various factors. In the early stages, the demands of the parents and the availability of materials and appliances were the most dominant factors. As this was a disability incurred by a man-made drug, the parents felt that they had the right to have the best treatment available. For the first year or so the Unit was dependent upon the availability of material and parts from within the United Kingdom, those imported from Germany, or what could be made locally.</p> <p>When the children's rudimentary arms were long enough to grasp objects bilaterally, to reach the mouth, and to be within the child's vision, then an appliance was not considered appropriate. <a></a> But when both arms were absent, or the rudimentary arms were so short that they could not achieve the basic function of feeding, artificial arms were fitted. However, these children were also deliberately encouraged to use their feet to enable them to acquire sensory perception of texture, temperature, etc., as well as dexterity in movement and achievement of toilet management. <a></a></p> <p>The fitting of the upper-limb appliances attempted to follow the normal behavioral patterns. A cosmetic appliance fitted during the first few months of life helped them to get used to wearing such appliances and learn sitting balance.</p> <p>In order to give the child some form of bilateral grasp, "pat-a-cake" appliances were fitted when the child was approximately one year old. These were the first type of appliances to be powered by compressed carbon dioxide, and were actuated bv body movement (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The first powered upper-limb appliances known as "pat-a-cakes" were fitted at the age of about one year. These are no longer issued. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The next stage was the introduction of wrist rotation and externally powered hooks or hands, fitted as the materials became available and the needs of the child demanded (<b>Fig. 2</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Child with bilateral amelia who was issued an appliance giving powered prehension and wrist rotation with passive elbow and shoulder movements. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Lower-Limb Appliances</h4> <p>A child's development is directly dependent on the vertical positioning of spine. Sitting, standing, and walking at the normal age are important for the child's normal development. Therefore, it is important that babies with amelia or short dysmelia of the lower extremity sit up at the normal age of sitting; that is, at the age of six months in a "flowerpot" (<b>Fig. 3</b>), and at about one year they should be given some form of legs for mobility (<b>Fig. 4</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Child with lower-extremity amelias placed in a "flower-pot" at the normal age of sitting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Some form of mobility should be provided during the child's second year. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The type and height of the lower-limb appliances issued to the children depended on the degree of competence and confidence in balance (<b>Fig. 5</b>). The children were supplied appliances with "shoes" as soon as was practicable; in any case, before they commenced formal schooling.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The type and height of a lower-limb appliance depend upon the child's competence and balance. Whenever possible, the height should be kept within the lower limits of normal growth. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Coping with appliances for all four limbs imposes a considerable physical and intellectual strain on small children. The physical maneuvers necessary to walk with bilateral lower-limb appliances are often considerably restricted by the presence of upper-limb appliances. The children's activities and needs should be balanced and the training program phased to allow the children to obtain practice with both sets of appliances separately and together. For some children, upper-limb appliances are an aid to balance, whereas for others these appliances are an impediment.</p> <h3>Method</h3> <p>The children and parents were interviewed, schools were visited, and all available records and reports were reviewed. These records include functional activities of daily living, simple objective tests of skill, and school reports. The extent of the activities covered included those featured in other simple follow-up studies. <a></a> All children were seen by a clinical psychologist.</p> <p>In the analysis, notation was made of:</p> <ol> <li>The children's preferences.</li><li>The parents' preferences.</li><li>The amount of cooperation from the child.</li><li>The amount of cooperation from the parent.</li><li>The amount of cooperation from the school and teachers.</li></ol> <p>Concerning mechanical aspects, comments were recorded concerning:</p> <ol> <li>The weight of the appliance.</li><li>Delay in supply of the appliance.</li><li>Delay in supply of spare parts.</li><li>Speed of response of the appliance.</li><li>Limitation of reach.</li><li>Limitation of other movements.</li></ol> <p>Physical reactions noted included heavy perspiration (associated with the weight of the appliance), skin rashes, soreness from the harness, and restriction of the child's body movement.</p> <h3>Definitions</h3> <h4>Appliances</h4> <p>The appliances have been grouped into: conventional upper limbs; powered upper limbs; lower limbs; and then classified according to their functional features (<b>Table 2</b> and <b>Table 3</b>).</p> <h4>Acceptance And Rejection</h4> <p>"Acceptance" of prostheses by children is often more passive than active. "Acceptance" of an appliance in this study means that the child uses the appliance for most of the day for various activities; for example, feeding, writing, or playing. "Acceptance" in this context does not necessarily indicate that the child prefers the appliance to his own limbs. Almost invariably, the children prefer to use their own body and residual limbs for most manipulative activities.</p> <p>"Total rejection" implies complete refusal to wear the appliance. Some children have to be persuaded to wear the appliances even for short periods each day, but will do so with encouragement; this usually means periods of half an hour. This condition is termed "partial rejection"; it could equally well be termed "partial acceptance."</p> <h3>Results</h3> <h4>Acceptance And Rejection Of Conventional Upper-limb Appliances</h4> <p>Undoubtedly, conventional appliances for this group of children have a poor record of acceptance. Of those fitted before the age of two years, 14 children fitted with 14 bilateral appliances rejected the appliances on nine occasions (64 per cent), whereas acceptance was recorded in five cases (36 per cent) (<b>Table 4</b>). But it is difficult to assess correctly whether a child of this age has accepted or rejected an appliance, as the observer's judgment is likely to be very subjective.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It was noted, however, that after the age of two years conventional appliances were totally rejected.</p> <h4>Acceptance And Rejection Of Powered Upper Limbs</h4> <p>Thirty-nine powered upper-limb appliances were fitted on 13 children, and were rejected on 27 occasions.</p> <p>The acceptance of the powered upper-limb appliances in this series is 25 per cent in children under four years of age and 38 per cent in those over four years (<b>Table 5</b>). Acceptance increased considerably when the powered hand was introduced.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>However, partial rejection (or partial acceptance) occurs for 50 per cent of appliances, and total rejection of powered appliances has not occurred in children over four years of age.</p> <h4>Acceptance And Rejection Of Lower-limb Appliances</h4> <p>Seventeen lower-limb prosthetic appliances have been fitted on eight children; 13 of these were accepted, one partially rejected, and only three totally rejected. Ultimately, <i>all </i>lower-extremity prostheses were accepted.</p> <p>One child rejected appliances during her second year, because any type of appliance restricted her mobility and she was able to progress well by crawling. One child rejected, when, at the age of five years, he was fitted with appliances and he found them cumbersome and restrictive. This child has now accepted caliper appliances. Another child preferred the ski-type of appliance rather than those with shoes, because the latter kept on breaking and she had little confidence in them.</p> <p>The swivel walkers were made according to the design principles described by Motloch and Elliott <a></a> (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Swivel walkers are a distinct improvement over previous lower-limb appliances. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>None of the swivel walkers fitted has been rejected. They are a distinct improvement over any previous appliance. The full details are given in <b>Table 6</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Acceptance And Rejection Of Appliances According To Age</h4> <p>Acceptance and partial acceptance are clearly related to increasing age (<b>Table 7</b> and <b>Table 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Major Reasons For Rejection Of Upper-limb Appliances</h4> <p>There were many recorded reasons for rejection or partial rejection, and for each child there were usually several contributory reasons.</p> <p>When these were grouped together and all the different appliances were considered, it was found that the commonest cause for rejection was the mechanical inefficiency of the prostheses (76 per cent); the next most common cause of rejection was the child's preference for using his or her own residual limbs. In a relatively few cases, the lack of cooperation of parents or child was a major reason for rejection (<b>Table 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Change From Rejection To Acceptance</h4> <p>It is even more interesting to analyze the major factors that lead from a rejection to an acceptance (<b>Table 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Family Environment</h4> <p>The problem of parental cooperation is partly reflected in the families' general environmental background. Although the numbers are small, the review indicates that the better-educated, middle-class families are more likely to help their children accept appliances (<b>Table 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Clinical Psychologists' Assessment</h4> <p>All the children in this series were of at least average intelligence, with three being distinctly above average. Two children of average intelligence developed aggressive tendencies and for a period would use their artificial arms almost entirely as weapons. Their aggression finally diminished after starting at normal primary schools.</p> <p>Psychological testing was unable to delineate specific features helpful in predicting acceptance or rejection of appliances. Perhaps if the testing had been more comprehensive and more frequent, trends might have been exposed. However, the simple clinical psychological appraisal reflected the acknowledged situation rather than helping to elucidate the underlying motivation toward acceptance or rejection of prostheses. <a></a></p> <h4>School</h4> <p>In this series, 13 children attended normal state schools, five attended day schools for the physically handicapped, and two were at residential schools for the physically disabled. One child was undergoing orthopaedic treatment during the period covered by this survey. From this small series, acceptance for upper-limb appliances was higher for children attending normal state schools than for children at special schools for the physically handicapped (<b>Table 12</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Discussion</h3> <p>The birth of a child with a congenital limb deformity is a domestic crisis and the parents need urgent help and advice on the total management of the child. The crisis intervention <a></a> is a critical function of the management team, but the personal approach and careful handling are also essential. <a></a></p> <p>That there should be complex factors interacting to produce acceptance or rejection of the appliances is understandable. Goldner and Titus <a></a> noted that they have been uniformly unsuccessful in the upper-extremity amelia and phocomelia, particularly when the condition occurred bilaterally. It was only when external power was added that they were able to make significant progress. This experience has been true of other authors. <a></a></p> <p>The outstanding findings in this study are that therapists, parents, and children partake in a mutual learning process, and very close cooperation between all concerned is essential for good rehabilitation. <a></a> Brooks <a></a> emphasizes the importance of recognizing situations which are known to produce adverse reaction and aptly refers to this as "crisis intervention." Each stage of the child's development must be watched, <a></a> and the value of the appliances should be frequently reassessed.</p> <p>Many children have deformities which at first do not seem to need surgical or prosthetic intervention. However, as the child develops, function and environmental features change, and there is a need for continuity of supervision and repeated clinical and functional reappraisal. The need for aids to daily living, special aids, or, indeed, surgical management may become relevant at any stage of the child's development. <a></a> Although surgery of the upper limbs should be approached with caution during infancy, arteriograms indicate that the blood supply, even in single-digit phocomelia, is likely to be adequate for major reconstructive surgery to be contemplated in later life. <a></a></p> <p>Objective records of activity, writing, and performing other prearranged tasks which can be timed, or for which some degree of accuracy can be charted, are of more value than a "clinical impression" or answers to a questionnaire. <a></a> This study has employed simple tests which can be timed, and from which "learning curves" can be constructed. <a></a></p> <p>The assessment of a child's function is more than simple assessment of activities of daily living in a therapeutic environment. Assessment must be in "real life" terms, and the children, the teachers, and the parents need to be integrated into the assessment and therapeutic team. This is well illustrated by the comprehensive evaluation of a functional cosmetic hand carried out by New York University. <a></a></p> <p>The teacher does not need to be particularly orientated toward the physically handicapped. The children in this study often appear to do better at normal schools than at special schools for the physically handicapped, unless they have all four limbs severely involved; and very often a normal school near home would seem to be more appropriate than a school for the physically handicapped that is located further away. Estimation of intelligence should be an accepted method of evaluation of all children prior to entrance into school, and psychological evaluation may be of significant help. <a></a></p> <p>However, it may be necessary to adapt the child's physical environment, so that he is not penalized by unsuitable classroom furniture or unduly physically fatigued. This can usually be overcome by relatively simple devices.</p> <p>Gouin-Decarie <a></a> compared thalidomide children to the average population and found the mean I.Q. to be 98. Along with a delay in speech, there was retardation in development of the child's perceptual concept of space and movement.</p> <p>The design and fitting of prosthetic devices for children with multiple limb deformities and the subsequent training and resettlement of the children at home and school are complex activities involving engineers, technicians, prosthetists, therapists, school teachers, social workers, and, not the least, the children and their parents. The establishment of objective and valid criteria for evaluating patient performance in the very young is difficult. The fact that the children are constantly changing as they grow and develop should emphasize the importance of reassessing goals of achievement as well as anticipated attainment.</p> <p>There are three major factors of influence: the personality of the child, the parental influences, and the therapeutic unit managing the child. <a></a></p> <p>Brooks and Shaperman <a></a> devised a "Prosthesis Adjustment Scale" based on the child's use of the prosthesis-the applied use, maintenance, and acceptance. In their experience with the below-elbow congenital amputee, acceptance was interrelated with wearing, use, and skill of applied use. Although they emphasize that the fitting of a unilateral congenital below-elbow amputee before the age of two tends to result in full-time wearing and good acceptance of the prostheses, they also note that the category most closely related to early fitting is full-time wearing. Although indoctrination for full-time wearing is possible for single amputees, it is much more difficult to accomplish for multiple amputees.</p> <p>The almost complete acceptance of lower-limb appliances from an early age reflects the point that if the appliance fulfills a real need, even if inefficiently, the appliance will be accepted.</p> <p>In the case of upper-extremity appliances, there is a definite improvement in partial acceptance and a dramatic improvement with the development of more reliable appliances, less subject to mechanical failure (note the change from P.3. to P.4. in <b>Table 5</b>).</p> <p>In this review, no differentiation has been made between mechanical failure, troubles with control mechanisms, or power packs. Interestingly enough, in this series there was no particular problem relating to the supply and recharging of the gas cylinders. As more function is derived from gas-powered appliances, the supply problem will increase and probably limit the use of this type of appliance. <a></a></p> <p>Brooks and Shaperman <a></a> also note that the acceptance of a prosthesis is closely related to the ability to communicate, and that good communication between parents and child (that is, good family relationships) is probably the major factor in establishing acceptance of appropriate prostheses. Thus the home environment is critical, and in certain circumstances this may be the determining factor. <a></a> In this series, the age of four appeared to be the "watershed." At this age, children can begin to understand the reasons for continuing to use appliances and become at least partially cooperative. They also tend to start to attend nursery school at this age. Children with severe multiple limb deformities may be educated in normal schools or special schools for the physically handicapped, depending upon their clinical or their social needs. <a></a></p> <p>The decision to remove the child to a residential school for the physically handicapped is a major one, and not necessarily associated with improvement in physical function or acceptance of suitable appliances. In this study, it has been noted that normal state schools have accepted these severely disabled children as a personal challenge and have usually gone to great lengths to encourage the children in their rehabilitation, collaborating closely with the hospital therapists and prosthetics departments. By treating the children in this way, they have been permitted, indeed encouraged, to face up to many of the normal challenges and experiences of school life. This seems to have helped the children to be integrated into community living.</p> <p>In this series, a small number of children with limb deformities in special schools for the physically handicapped are not so adapted to their disability as those at normal schools, and prosthesis acceptance is relatively poor. The atmosphere of the schools for the physically handicapped is often more protective and necessarily geared to the most incapacitated. Furthermore, some of these schools have many children who are on the borderline of being educationally subnormal. Appliance training in these schools is usually the responsibility of the physical therapist and not the teachers, and the teachers are reluctant to divert individual attention to appliance training in the presence of more disabled children who are unable to use appliances, for example, victims of cerebral palsy. However, children with severe mobility problems, as well as severe upper-limb dysmelia, may find the special equipment, adapted environment, slower tempo, and special staff of particular help.</p> <p>As a group, these children achieve remarkable levels of manipulative skills using their residual upper limbs, chin, shoulder tips, feet, and mouth. The wearing of an upper-limb prosthesis frequently hampers these skills while only providing a much cruder form of function. However, there has been no experience here in fitting a single multifunctional arm balanced with a cosmetic prosthesis, and there are certain advantages in this approach. <a></a> For children with absent or deformed legs, almost any form of lower-limb appliance gives them an immediate advantage in standing, achieving reasonable height, and—as a bonus—walking short distances.</p> <p>As a general experience, it can be said that patients must obtain an immediate advantage from the appliance for it to be accepted. It is the immediate postfitting phase which appears to be of greatest importance. If the appliance looks unfinished, if the technicians have to make numerous adjustments in the fittings, if it is uncomfortable or scratchy, if mother's face registers horror at the appearance—all these factors have a long-term effect out of proportion to their immediate import. If the antagonistic features even slightly outweigh the advantages, then acceptance is unlikely, or at best partial, and becomes more a matter of deference to authority, or, for children, part of a game rather than a true integration of the appliance into the body image. The immediate advantage gained must outweigh all the antagonistic factors. If this occurs, the patient will persist through further stages of fitting, training, and redevelopment.</p> <p>The swivel walkers are a striking example. These appliances were used experimentally at first because earlier caliper-type lower-limb appliances were breaking so frequently that the children were continually frustrated. The swivel walkers were both more reliable and more immediately efficient, and acceptance was immediate and universal.</p> <p>Cosmesis is often a motivating force in acceptance of any appliance. <a></a> In this series, there was a marked improvement in acceptance on the introduction of a powered hand in preference to a hook (<b>Table 5</b>) even though function might be less. The change from 25 per cent to 75 per cent acceptance associated with the use of a powered hand accentuates the urgent need for a sophisticated, cosmetically acceptable, functional terminal device. This confirms the experience of New York University. <a></a> Children were also pleased when ordinary shoes could be fitted to their lower-limb appliances.</p> <p>Frequently, however, it is the mothers' dominant influences which lead to cosmetic acceptance overriding function, whereas fathers are often more likely to be interested in function. In one instance, a powered prosthesis was frequently returned nonoperational because a father repeatedly attempted to improve its functions. Another father, often at home because of shift work or lack of work, spent many hours training his son to use his upper-limb prostheses.</p> <p>However, acceptance associated with cosmesis might occasionally extend to a pathological acceptance, and there is one child with bilateral upper-limb, unequal-length phocomelia, who insists on wearing a single upper-limb prosthesis in spite of the fact that it prevents him from undertaking many functions he could perform with his two phocomelic limbs. The initial supply was largely at the insistence of the parents, and in retrospect probably should have been refused.</p> <p>One problem that was very unsettling for both child and parents was the involvement of more than one clinical center. Usually, this was due to geographical circumstances. The clinicians near the child's home were unable to provide certain facilities; for example, experienced training, or appropriate surgery or prosthetic devices. Furthermore, in some instances, there was a separation between the provision of upper-limb appliances and lower-limb appliances. In all instances, this diversification of clinical control and lack of unified approach led to difficulties in management and was, not infrequently, a contributory factor in rejection of appliances.</p> <h3>Conclusions</h3> <p>The object of any critical reappraisal of clinical management is to improve the treatment of patients in the future. On the basis of this study, it is possible to lay down some broad general principles for the management of children with congenital limb deformities.</p> <p>In the initial stages, the parents' attitudes are dominant; therefore, early confident collaboration is essential. The parents should have faith in the doctors and should have a clear understanding of the individual responsibilities of the members of the pediatric and prosthetics team, which may vary according to local facilities. The child should be under frequent review by the same clinical team. Each member of the team—pediatrician, prosthetics consultant, therapist, technician, social worker, and psychologist-has contributions to make at all stages.</p> <p>For severely disabled children, introduction to adapted clothing, aids to daily living, and training activities must be tailored to fit the individual child's expected development, and independent activities should, wherever possible, match the accepted "stepping stones" of child development.</p> <p>Lower-limb deformities should be treated by appropriate surgery and prosthetics so that independent mobility is achieved as early and as efficiently as can be matched with normal progress. The size of the appliance should match natural growth as nearly as possible.</p> <p>Upper-limb appliances present a more complex problem. Most children will alternate between accepting and rejecting appliances, depending on their development and needs.</p> <p>Early fitting, at perhaps 12 to 18 months (or even earlier), has some relevance in that it accustoms the child to a somewhat uncomfortable appliance. But the child is unlikely to accept formal training in the use of a sophisticated appliance until more than four years of age. Once schooling starts, training in the use of an appropriate appliance should be part of formalized education, and this demands close collaboration between therapists and teachers, particularly in the school surroundings.</p> <p>The prosthetists and technicians must be prepared to adapt and redesign frequently as the child's needs change. They must accept the need for adequate cosmesis even at an early age. Rejection of appliances must never be regarded as "naughty" or "ungrateful," but as part of natural development. Gentle insistence on regular training sessions may well tide a child over until in later years he understands and appreciates the need for the appliance and can make a reasonable personal decision regarding design and use.</p> <p>There is an urgent need for the development of mechanically reliable, cosmetically acceptable, and functionally sophisticated upper-limb appliances.</p> <p>This development of an awareness of the most suitable design and the appropriate uses of upper-limb prostheses should be the outcome of close understanding between the child, parents, doctors, teachers, and therapists.</p> <h3>Summary</h3> <p>A group of 21 children with multiple limb deformities associated with thalidomide who have been supplied with various upper- and lower-limb prostheses is described. The acceptance and rejection of the appliances are analyzed according to age, family background, and the type of appliance.</p> <h3>Acknowledgments</h3> <p>The powered upper-limb appliances and the swivel walkers were designed and made in the Research Workshops at Mary Marlborough Lodge.</p> <p>Other appliances were made in the Orthopaedic Workshops of the Nuffield Orthopaedic Centre or supplied by the Ministry of Health in various limb-fitting centers.</p> <p><b>References:</b></p> <ol> <li>Aitken, G. T., and C. H. Frantz, <i>Management of the child amputee</i>, Instructional Course Lecture, Amer. Acad, of Orthopaedic Surgeons, 17:246-295, 1960.</li> <li>Brooks, M. B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, <i>Crisis intervention</i>, Inter-Clinic Information Bull., Vol. IV, No. 11, September 1965.</li> <li>Brooks, M. B., and J. Shaperman, <i>Infant prosthetic fitting</i>, Amer. J. Occup. Ther., 19:6, November and December 1965.</li> <li>Burtch, R. L., <i>A study of congenital skeletal limb deficiencies</i>, Inter-Clinic Information Bull., Vol. II, No. 7, May 1963.</li> <li>Buttrup, E., <i>Parents of child amputees</i>, Prosthetics International, Vol. 2, No. 1, 1964.</li> <li>Campbell, E. I., and J. C. Bansavage,<i> The psychological and social factors related to successful prosthetic training in juvenile amputees; a preliminary study</i>, Inter-Clinic Information Bull., Vol. III, No. 12, October 1964.</li> <li>Fishman, Sidney,<i> Studies of the upper-extremity amputee; VIII. Research implications</i>, Artif. Limbs, Autumn 1958, pp. 117-127.</li> <li>Fishman, Sidney,<i> Amputee needs, frustration and behavior</i>, Rehab. Lit., Vol. 20, 1959.</li> <li>Fishman, Sidney, and Hector W. Kay, <i>Acceptability of a functional-cosmetic artificial hand for young children, Part 1</i>, Artif. Limbs, Spring 1964, pp. 28-43.</li> <li>Frantz, C. H., and R. O'Rahilly,<i> Congenital skeletal limb deficiencies</i>, J. Bone Joint Surg. (Amer.), 43:1202-1224, December 1961.</li> <li>Friedmann, L.,<i> Special equipment and aids for the young bilateral upper-extremity amputee</i>, Inter-Clinic Information Bull., Vol. IV, No. 6, April 1965.</li> <li>Gesell, Arnold L., et al.,<i> Infant and child in the culture of today; the guidance of development in home and nursery school</i>, Harper, New York, 1943.</li> <li>Gillis, Leon,<i> Thalidomide babies; management of limb defects</i>, Brit. Med. J., September 8, 1962.</li> <li>Goldner, J. L., and Bert R. Titus,<i> An experience with externally powered prostheses for children</i>, Inter-Clinic Information Bull., Vol. VII, No. 2, November 1967.</li> <li>Gouin-Decarie, T., <i>The mental and emotional devel- opment of the thalidomide children and the psychological reactions of the mothers</i>, Inter-Clinic Information Bull., Vol. VII, No. 4, January 1968.</li> <li>Hall, C. B., M. B. Brooks, and M. F. Dennis, <i>Congenital skeletal deficiencies of the extremities</i>, J.A.M.A., 181:590 599, August 1962.</li> <li>Hall, C. B., <i>Corrective surgery for infant hands</i>, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</li> <li>Hall, C. B., <i>Recent concepts in the treatment of the limb-deficient child</i>, Artif. Limbs, Spring 1966, pp. 36-51.</li> <li>Haslam, E. T., Joan Hayden, and Jean Dutro, <i>The habituation of a congenital quadruple amputee</i>, Inter-Clinic Information Bull., Vol. VI, No. 9, June-July 1967.</li> <li>Hebert, B., <i>The psychologist and congenital physical anomalies, Inter-Clinic Information Bull.</i>, Vol. VI, No. 4, January 1967.</li> <li>Henkel, L.,<i> Das Fehlbildungsmuster der Dysmelie</i>, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 1968.</li> <li>Her Majesty's Stationery Office Publication, <i>Deformities caused by thalidomide</i>, 1964.</li> <li>Hunter, J. M., David Subin, and A. J. Plank, <i>Some observations on upper extremity prosthesis applications</i>, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</li> <li>Hutt, S., Private communication.</li> <li>Kay, Hector W., and Edward Peizer, <i>Studies of the upper-extremity amputee; VI. Prosthetic usefulness and wearer performance</i>, Artif. Limbs, Autumn 1958, pp. 31-87.</li> <li>Lamb, D. W., D. C. Simpson, W. H. Schutt, N. T. Spiers, G. Sunderland, and G. Baker,<i> The management of upper limb deficiencies in the thalidomide-type syndrome</i>, J. Roy. Coll. Surg. Edinb., pp. 102-108, Vol. 10, January 1965.</li> <li>McKenzie, D. S., <i>The clinical application of ex- ternally powered artificial arms</i>, J. Bone Joint Surg. (Brit.), 47B(3):399-410, August 1965.</li> <li>McLaurin, C. A., <i>External power in upper-extremity prosthetics and orthotics</i>, Inter-Clinic Information Bull., Vol. VI, No. 1, October 1966.</li> <li>MacNaughton, A., <i>The role of the occupational therapist in the training of the child arm amputee</i>, Physiotherapy, Vol. 52, No. 6, June 1966.</li> <li>Maier, W. A.,<i> Thalidomide embryopathy and limb defects</i>, Orth. Dis. Child, Vol. 40, 1965.</li> <li>Marquardt, E., <i>The Heidelberg pneumatic arm prostheses</i>, J. Bone Joint Surg. (Brit.), 47B(3):425-434, August 1965.</li> <li>Mendez, M. A., <i>Survey by the O.T. staff of the Children's Prosthetic Unit of Queen Mary's Hospital, Roehampton</i>, Occup. Therapy, Vol. 30, No. 5, May 1967.</li> <li>Motloch, W. M., and Jane Elliott,<i> Fitting and training children with swivel walkers</i>, Artif. Limbs, Autumn 1966, pp. 27-38.</li> <li>Nichols, P. J. R., <i>The development of powered limbs, Special Education</i>, Vol. 44, Winter Issue 1965.</li> <li>Nichols, P. J. R., E. H. Hollings, and M. C. Clarke, <i>Aids to daily living for children with severe multiple congenital limb deformities</i>, in preparation, 1968.</li> <li>Nickel, V. L., and Worden Waring, <i>Future develop- ments in externally powered orthotic and prosthetic devices</i>, J. Bone Joint Surg. (Brit.), 47B(3):469-471, August 1965.</li> <li>Pearson, F. A., and B. W. Spiers, <i>Teamwork in the management of dysmelic children</i>, Physiotherapy, Vol. 52, No. 6, June 1966.</li> <li>Proceedings of a Symposium on Powered Prostheses held at the Limb Fitting Centre, Roehampton, on October 29, 1965.</li> <li>Scott, Stevenson M., <i>Providing for their education</i>, Special Education, Vol. 44, Winter Issue 1965.</li> <li>Sheridan, M., <i>The developmental progress of infants and young children</i>, Ministry of Health Report No. 102, 1960.</li> <li>Siller, Jerome, and Sydelle Silverman, <i>Studies of the upper-extremity amputee; VII. Psychological factor</i>s, Artif. Limbs, Autumn 1958, pp. 88-116.</li> <li>Simpson, D. C, and D. W. Lamb,<i> A system of powered prostheses for severe bilateral upper limb deficiency</i>, J. Bone Joint Surg. (Brit.), 47B(3): 442-447, August 1965.</li> <li>Spock, B., and M. O. Lerrigo, <i>Caring for your handicapped child</i>, Macmillan Co., New York, 1965.</li> <li>Stamp, W. G., S. Mahon, and H. C. Morgan, <i>Problems of management of the child with multiple amputations</i>, Arch. Phys. Med., Vol. 46, May 1965.</li> <li>Swanson, A. B., <i>The Krukenberg procedure in the juvenile amputee</i>, J. Bone Joint Surg. (Amer.), 46A(7):1540-1548, October 1964.</li> <li>Swanson, A. B., <i>Phocomelia and congenital limb malformations; reconstruction and prosthetic limb replacement</i>, Amer. J. Surg., 109, March 1965.</li> <li>Swanson, A. B., <i>Classification of limb malformations on the basis of embryological failures</i>, Inter-Clinic Information Bull., Vol. VI, No. 3, December 1966.</li> <li>Taussig, Helen B., <i>The thalidomide syndrome</i>, Sci. Amer., Vol. 207, No. 2, August 1962.</li> <li>University of California at Los Angeles Staff, <i>Cosmesis: can it be defined?</i> Inter-Clinic Information Bull., Vol. V, No. 10, July 1966.</li> <li>Weiss, S. A., <i>Integrating the handicapped child into the community center</i>, Inter-Clinic Information Bull., Vol. V, No. 8, May 1966.</li> <li>Willert, H. G, <i>Eine Klassifikation Angeborener Armfehbildungen mit Rohrenknoch-endefkten</i>, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 1968.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, Part 1, Artif. Limbs, Spring 1964, pp. 28-43.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, Part 1, Artif. Limbs, Spring 1964, pp. 28-43.</td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">University of California at Los Angeles Staff, Cosmesis: can it be defined? Inter-Clinic Information Bull., Vol. V, No. 10, July 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Simpson, D. C, and D. W. Lamb, A system of powered prostheses for severe bilateral upper limb deficiency, J. Bone Joint Surg. (Brit.), 47B(3): 442-447, August 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Scott, Stevenson M., Providing for their education, Special Education, Vol. 44, Winter Issue 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Weiss, S. A., Integrating the handicapped child into the community center, Inter-Clinic Information Bull., Vol. V, No. 8, May 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Brooks, M. B., and J. Shaperman, Infant prosthetic fitting, Amer. J. Occup. Ther., 19:6, November and December 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">McLaurin, C. A., External power in upper-extremity prosthetics and orthotics, Inter-Clinic Information Bull., Vol. VI, No. 1, October 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Brooks, M. B., and J. Shaperman, Infant prosthetic fitting, Amer. J. Occup. Ther., 19:6, November and December 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Fishman, Sidney, Amputee needs, frustration and behavior, Rehab. Lit., Vol. 20, 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Gouin-Decarie, T., The mental and emotional devel- opment of the thalidomide children and the psychological reactions of the mothers, Inter-Clinic Information Bull., Vol. VII, No. 4, January 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Campbell, E. I., and J. C. Bansavage, The psychological and social factors related to successful prosthetic training in juvenile amputees; a preliminary study, Inter-Clinic Information Bull., Vol. III, No. 12, October 1964.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Siller, Jerome, and Sydelle Silverman, Studies of the upper-extremity amputee; VII. Psychological factors, Artif. Limbs, Autumn 1958, pp. 88-116.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, Acceptability of a functional-cosmetic artificial hand for young children, Part 1, Artif. Limbs, Spring 1964, pp. 28-43.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Hutt, S., Private communication.</td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Proceedings of a Symposium on Powered Prostheses held at the Limb Fitting Centre, Roehampton, on October 29, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Kay, Hector W., and Edward Peizer, Studies of the upper-extremity amputee; VI. Prosthetic usefulness and wearer performance, Artif. Limbs, Autumn 1958, pp. 31-87.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Maier, W. A., Thalidomide embryopathy and limb defects, Orth. Dis. Child, Vol. 40, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Friedmann, L., Special equipment and aids for the young bilateral upper-extremity amputee, Inter-Clinic Information Bull., Vol. IV, No. 6, April 1965.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Hall, C. B., Corrective surgery for infant hands, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Nichols, P. J. R., E. H. Hollings, and M. C. Clarke, Aids to daily living for children with severe multiple congenital limb deformities, in preparation, 1968.</td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Swanson, A. B., The Krukenberg procedure in the juvenile amputee, J. Bone Joint Surg. (Amer.), 46A(7):1540-1548, October 1964.</td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Swanson, A. B., Phocomelia and congenital limb malformations; reconstruction and prosthetic limb replacement, Amer. J. Surg., 109, March 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Gesell, Arnold L., et al., Infant and child in the culture of today; the guidance of development in home and nursery school, Harper, New York, 1943.</td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Sheridan, M., The developmental progress of infants and young children, Ministry of Health Report No. 102, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Brooks, M. B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Information Bull., Vol. IV, No. 11, September 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">MacNaughton, A., The role of the occupational therapist in the training of the child arm amputee, Physiotherapy, Vol. 52, No. 6, June 1966.</td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Pearson, F. A., and B. W. Spiers, Teamwork in the management of dysmelic children, Physiotherapy, Vol. 52, No. 6, June 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Buttrup, E., Parents of child amputees, Prosthetics International, Vol. 2, No. 1, 1964.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Haslam, E. T., Joan Hayden, and Jean Dutro, The habituation of a congenital quadruple amputee, Inter-Clinic Information Bull., Vol. VI, No. 9, June-July 1967.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">McKenzie, D. S., The clinical application of ex- ternally powered artificial arms, J. Bone Joint Surg. (Brit.), 47B(3):399-410, August 1965.</td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Nickel, V. L., and Worden Waring, Future develop- ments in externally powered orthotic and prosthetic devices, J. Bone Joint Surg. (Brit.), 47B(3):469-471, August 1965.</td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Stamp, W. G., S. Mahon, and H. C. Morgan, Problems of management of the child with multiple amputations, Arch. Phys. Med., Vol. 46, May 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Goldner, J. L., and Bert R. Titus, An experience with externally powered prostheses for children, Inter-Clinic Information Bull., Vol. VII, No. 2, November 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Buttrup, E., Parents of child amputees, Prosthetics International, Vol. 2, No. 1, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Brooks, M. B., Yoshio Setoguchi, Joan Thue, Lila L. Beal, and Doris Tom, Crisis intervention, Inter-Clinic Information Bull., Vol. IV, No. 11, September 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Fishman, Sidney, Studies of the upper-extremity amputee; VIII. Research implications, Artif. Limbs, Autumn 1958, pp. 117-127.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Motloch, W. M., and Jane Elliott, Fitting and training children with swivel walkers, Artif. Limbs, Autumn 1966, pp. 27-38.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Mendez, M. A., Survey by the O.T. staff of the Children's Prosthetic Unit of Queen Mary's Hospital, Roehampton, Occup. Therapy, Vol. 30, No. 5, May 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Her Majesty's Stationery Office Publication, Deformities caused by thalidomide, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Nichols, P. J. R., The development of powered limbs, Special Education, Vol. 44, Winter Issue 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Marquardt, E., The Heidelberg pneumatic arm prostheses, J. Bone Joint Surg. (Brit.), 47B(3):425-434, August 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Her Majesty's Stationery Office Publication, Deformities caused by thalidomide, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Burtch, R. L., A study of congenital skeletal limb deficiencies, Inter-Clinic Information Bull., Vol. II, No. 7, May 1963.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Frantz, C. H., and R. O'Rahilly, Congenital skeletal limb deficiencies, J. Bone Joint Surg. (Amer.), 43:1202-1224, December 1961.</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Hall, C. B., M. B. Brooks, and M. F. Dennis, Congenital skeletal deficiencies of the extremities, J.A.M.A., 181:590 599, August 1962.</td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Maier, W. A., Thalidomide embryopathy and limb defects, Orth. Dis. Child, Vol. 40, 1965.</td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Swanson, A. B., Classification of limb malformations on the basis of embryological failures, Inter-Clinic Information Bull., Vol. VI, No. 3, December 1966.</td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Willert, H. G, Eine Klassifikation Angeborener Armfehbildungen mit Rohrenknoch-endefkten, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Henkel, L., Das Fehlbildungsmuster der Dysmelie, 17 Tagung der Gesellschaft fur Orthopadie in der D.D.R., Postam-Babelsberg, 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Gouin-Decarie, T., The mental and emotional devel- opment of the thalidomide children and the psychological reactions of the mothers, Inter-Clinic Information Bull., Vol. VII, No. 4, January 1968.</td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Hebert, B., The psychologist and congenital physical anomalies, Inter-Clinic Information Bull., Vol. VI, No. 4, January 1967.</td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Spock, B., and M. O. Lerrigo, Caring for your handicapped child, Macmillan Co., New York, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, G. T., and C. H. Frantz, Management of the child amputee, Instructional Course Lecture, Amer. Acad, of Orthopaedic Surgeons, 17:246-295, 1960.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Gillis, Leon, Thalidomide babies; management of limb defects, Brit. Med. J., September 8, 1962.</td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Hall, C. B., Recent concepts in the treatment of the limb-deficient child, Artif. Limbs, Spring 1966, pp. 36-51.</td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Hunter, J. M., David Subin, and A. J. Plank, Some observations on upper extremity prosthesis applications, Inter-Clinic Information Bull., Vol. IV, No. 8, June 1965.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Lamb, D. W., D. C. Simpson, W. H. Schutt, N. T. Spiers, G. Sunderland, and G. Baker, The management of upper limb deficiencies in the thalidomide-type syndrome, J. Roy. Coll. Surg. Edinb., pp. 102-108, Vol. 10, January 1965.</td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Nickel, V. L., and Worden Waring, Future develop- ments in externally powered orthotic and prosthetic devices, J. Bone Joint Surg. (Brit.), 47B(3):469-471, August 1965.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Scott, Stevenson M., Providing for their education, Special Education, Vol. 44, Winter Issue 1965.</td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Simpson, D. C, and D. W. Lamb, A system of powered prostheses for severe bilateral upper limb deficiency, J. Bone Joint Surg. (Brit.), 47B(3): 442-447, August 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Her Majesty's Stationery Office Publication, Deformities caused by thalidomide, 1964.</td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Taussig, Helen B., The thalidomide syndrome, Sci. Amer., Vol. 207, No. 2, August 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>W. G. Stamp, M.D. </b></td></tr><tr><td class="clsTextSmall">Chairman, Department of Orthopaedics, University of Virginia School of Medicine, Charlottesville, Va. 22901; Visiting Professor to the Nuffield Department of Orthopaedic Surgery, University of Oxford, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>M. S. Clark, M.A.O.T. </b></td></tr><tr><td class="clsTextSmall">Mary Marlborough Lodge, Disabled Living Research Unit, Nuffield Orthopaedic Centre, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>E. E. Rogers, M.A.O.T. </b></td></tr><tr><td class="clsTextSmall">Research Assistant, Department of Engineering Science, University of Oxford, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>P. J. R. Nichols M.A., D.M. (Oxon), D.Phys.Med. </b></td></tr><tr><td class="clsTextSmall">Director, Mary Marlborough Lodge, Disabled Living Research Unit, Nuffield Orthopaedic Centre, Oxford, England.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1968_01_001/spring68a-18.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Acceptance and Rejection of Prostheses by Children With Multiple Congenital Limb Deformities Creator An entity primarily responsible for making the resource P. J. R. Nichols M.A., D.M. (Oxon), D.Phys.Med. * E. E. Rogers, M.A.O.T. * M. S. Clark, M.A.O.T. * W. G. Stamp, M.D. * https://staging.drfop.org/files/original/f922814d211b608a697466e29490333b.pdf e5a35d98b2c617e7f9ded283ff5dafa7 https://staging.drfop.org/files/original/48cf7ac67e217521f3acb7e40d6b2a38.jpg f5a6cea41ca17f732cb253daf7918897 https://staging.drfop.org/files/original/16410b5f62b683ff0be5f6a0ef4730a6.jpg d8aa785829781cb0896ecc82863c789c https://staging.drfop.org/files/original/433b014b1a43a6614856053945b2243c.jpg 2b4c04387bc7f8a8bdc413c6109662d3 https://staging.drfop.org/files/original/843d131b77b5dc6c8f18d58702881340.jpg 5f4eff514a08be3ae5daaa303dc0cf7d https://staging.drfop.org/files/original/e575b525f13cc42d25f865c4db4ecb9e.jpg fc78601c78357e69128fc5a5290b83fd https://staging.drfop.org/files/original/e6ca2fa5bfd699bce64bf63899c6d86a.jpg ce75e70e35780221d326a363fc1dc05e https://staging.drfop.org/files/original/d803b3cc574d377eee5137bfd10f9db9.jpg 29d55e95bcb3a6b15f4a6b98f2c189e0 https://staging.drfop.org/files/original/5bc2ecf5e9ba7ac10a96388a62f09100.jpg e82f3d9d247bb7790f21711a8885532f https://staging.drfop.org/files/original/4de87b8d2e769e4c1287a208354fc8dc.jpg 70855f2c86c26331cc6fba80045e7553 https://staging.drfop.org/files/original/197022ec795072639ae32d2c689f1dc8.jpg 3cfec86e35d1b3315dafa497908e73ac https://staging.drfop.org/files/original/b4962dbe7236d6656d2297e42960d167.jpg 0970a72bbd0016a1fd49b37ead35272e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_005.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 5 - 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/1967_02_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_005.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>External Power in Prosthetics and Orthotics, an Overview</h2> <h5>James B. Reswick, Sc.D. <a style="text-decoration:none;">*</a><br />Lojze Vodovnik, D.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p>The large number of persons who could be materially helped if highly developed orthotics and prosthetics systems were available is not generally appreciated. The conquest of infectious diseases has increased life expectancy to the point where disability caused by the failure of physiological systems is common in old age. The ever-increasing rate of injuries resulting from vehicle accidents adds to the numbers of paralyzed and maimed, and at the present time the Vietnam conflict is adding its toll.</p> <p>Detailed statistics are difficult to obtain, but it has been estimated that there are 25,000 to 30,000 amputations per year in the United States from all causes. The Veterans Administration reported 25,000 lower-extremity and 6,000 upper-extremity service-connected cases treated during 1967 (incomplete figures), resulting from several wars. There are no immediately available statistics related to the Vietnam conflict.</p> <p>Dr. Virginia Badger <a style="text-decoration:none;">*</a> has estimated the numbers of patients in the United States with various types of rheumatic, arthritic, and neurological disorders, including quadriplegia, as follows: <b>Table 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of these patients, Dr. Badger estimates that <i>2</i> million could benefit markedly from orthotic devices, provided that the difficult problems of patient acceptance could be overcome.</p> <p>Unfortunately, much remains to be done in defining the need more precisely. Many persons suffering from neurological disorders are not recorded in hospital statistics; and, if they are, the nature of their disability is not. The specific types and numbers of disabilities need to be codified in a way which could lead to the development of engineering specifications and decisions on priorities of effort and specific engineering designs.</p> <h3>The Man-Machine System</h3> <p>The human being and his assistive device comprise a man-machine system. When the orthotics or prosthetics system uses external power and is operated by means of feedback control, the result is a cybernetic system in the true sense of the term. <b>Fig. 1</b> illustrates the possible information paths of an orthotics or a prosthetics system. The following important elements are depicted: I. Signal Sources; II. Transducers; III. Signal Processors; IV. Output Systems; V. Feedback Receptors; and VI. Local Feedback. In addition to these physically identifiable elements, an important element in the performance of the system is the capability of man to learn to use a complex assistive device (VII. Adaptive Learning). Here, age and motivation are important; for example, "thalidomide children" show tremendous learning capacity with complex prostheses, while many geriatric lower-extremity amputees are not able, or are not motivated, to use an artificial leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Elements of a prosthetics or an orthotics system. I. Signal Sources: muscle motion, electromyographic, electroneurographic, electroencephalographic, eyeball motion, sound. II . Transducers: direct connections, switches, valves, proportional analog, proportional digital, electrodes, radio transmitters. III. Signal Processors: on-off, electromyographic, coupled function devices, proportional or velocity control systems, adaptive computer. IV. Output Systems: communication devices, environment and tools designed to work with the orthotics or prosthetics system, vehicles controlled by the orthotics or prosthetics system. IV. A. Prosthetic: terminal devices, upper-extremity components, lower-extremity components. IV. B. Orthotic: splints and casts, implant bone supports, body-powered splints, externally controlled splints, externally powered splints, functional electrical stimulation. V. Feedback Receptors: vision, hearing, proprioception, touch, "stereo" vibration, "stereo" electrical stimulation. VI. Local Feedback: Pressure sensors, slippage sensors, position, velocity, force. VII. Adaptive Learning. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This article will discuss each of the elements of the prosthetics or orthotics system depicted in <b>Fig. 1</b>, briefly indicating the present levels of research activity and future possibilities.</p> <h4>I. Signal Sources</h4> <p>The human desire to initiate movement of an orthotics or a prosthetics system originates at some conscious level in the central nervous system, but it must take the form of some voluntary physical action if a result is to be achieved. This action may be, for example, a simple muscle movement resulting in the closing of a switch, the pressing of a key, or the very sophisticated use of the tongue (<b>Fig. 2</b>) to activate a keyboard of miniature switches.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The Rancho Los Amigos Hospital electric arm orthosis. The various degrees of freedom are actuated by a series of bidirectional microswitches placed in front of the patient's mouth and operated by his tongue. A number of these devices are in use. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Recently, electrical signals associated with muscle and neuron activity have been explored for use as control signals. Although electro-neurographic (ENG) signals seem attractive because of their proximity to the central nervous system<a></a>, the practical difficulty of maintaining electrodes proximal to nerves in human subjects over extended periods of time has not been overcome. Instead, the more accessible electromyographic (EMG) signals have been used as sources of control signals. Most practical to date has been the use of so-called surface EMG signals obtained by means of electrodes resting on the surface of the skin near a muscle whose electrical activity is to be detected.</p> <p>A number of prosthetic hands and some hand orthoses have been developed to operate from EMG signals picked up through surface skin electrodes.<a></a> More recently, interest has grown in obtaining EMG signals from within a muscle. Such intramuscular EMG signals exhibit a wider range (from single motor unit pulses to signals of many asynchronous pulse combinations) and are more free from "cross talk" resulting from the activity of neighboring muscles.<a></a> Practical use of intramuscular EMG signals requires either wire electrodes which penetrate the skin and which can exist for long periods of time without breaking or promoting infection (<b>Fig. 3</b>), or the development of implantable radio transmitters capable of long-term operation (<b>Fig. 4</b> and <b>Fig. 5</b>) <i>(35,37.) </i>Future research will undoubtedly press in both of these directions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. A monopolar, helically wound, percutaneous electrode. It is used to detect electrical activity within a muscle. The electrode is inserted into the proper muscle by a hypodermic needle which, when withdrawn, leaves the electrode comfortably implanted. A surface connector protects the electrode-skin interface. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Miniature FM radio transmitter used to obtain electromyographic signals by complete implantation. The signals are received externally and, after processing, can be used as control inputs in a control system. The transmitter shown will be encapsulated in epoxy and coated with medical grade silicone rubber. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Transmitters implanted in a human and attached to the trapezius muscles. The electromyographic signal obtained by lifting the shoulder ( a motion possessed by many quadriplegics) was used to drive a variable-speed motor, a bidirectional prehensile hand splint, and a multilevel selector. The transmitter was turned on by changing the state of a magnetic switch influenced by an external magnetic field. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Many other sources for voluntary signals from the human being have been suggested from time to time. The electroencephalogram (EEG) signal is often mentioned, but, to date, it has been used only as an on-off switch responding to the presence or absence of the alpha rhythm <i>. </i><a></a> Enticing as the idea may be, many years must pass before thoughts will will be transformed directly into meaningful electrical signals.</p> <p>The human voice, including whistles and the like, has been proposed and used as a signal source. Much research at present is devoted to machine recognition of human speech for voice-operated typewriters and for speaking directly to a computer <i>. </i><a></a> These efforts show promise, but they are probably far too complicated at present to be considered for use in a prosthetics or an orthotics system. The human eye has also been used to switch devices by means of ultrasonic and infrared reflections <i>. </i><a></a> Unfortunately, many such promising sources of control signals are involved in the normal activities of living, such as eating, looking around, speaking, and the like. This could be a disadvantage when the patient desired to control his orthotics or prosthetics system with a signal such as sound while he was talking or eating <i>.</i><a></a> </p> <h4>II. Transducers</h4> <p>Transducers are the devices used to change physiological phenomena into engineering signals that provide inputs to signal processors and output systems. A transducer may be as simple as an on-off switch or as complicated as an implantable FM radio transmitter. Some elements of orthotics and prosthetics systems are difficult to classify. Bowden cables used to transmit shoulder movements to an amputee's terminal device are an example. More recently, hydraulic systems which function as a wire cable have been demonstrated <i>. </i><a></a> Such systems combine the roles of transducer and actuator in a single unit.</p> <p>Electric switches and pneumatic-hydraulic control valves which convert body movements into changes in electric current or fluid flow are highly developed. Many types of reliable, very small electric switches have been easily adapted to prosthetics and orthotics systems, but, in the case of hydraulic and pneumatic control valves, it has been necessary to develop a number of appropriate special valves.</p> <p>Not so widely used in prosthetics and orthotics systems, but highly developed for general instrumentation purposes, is a wide range of proportional analog and digital transducers capable of converting pressure or movement into voltage or current changes. These devices range from analog potentiometers and capacitive and inductive devices which convert motion to smooth voltage changes, to linear transducers which produce pulse-coded signals proportional to incremental changes or absolute position. Also available are the very ingenious accelerometers and other motion transducers developed for space research and guidance control systems. Accelerometers have been used in at least one head-motion-activated control system <i>.</i><a></a> </p> <p>Generally speaking, the mechanical-to-electric transducers have been highly developed, but only limited use has been made of their capabilities in prosthetics and orthotics systems. This does not imply, however, that a number of mechanical - to - electric transducers are immediately available for use in prosthetics and orthotics systems. An actual application often requires either a major redesign or a new design to take into account the unique problems inherent in physiological-data transduction. It is appropriate to mention here the National Aeronautics and Space Administration's Space Technology Utilization Program, in which NASA is actively searching for ways to apply transducers developed for space applications in orthotics and prosthetics systems.</p> <p>The recent interest in electrophysiological signals for control of orthotics and prosthetics systems has focused attention on the development of electrodes. A large variety of surface electrodes used in electrocardiographic diagnosis and long-term monitoring systems is already available. From space technology come the "spray-on" electrodes and other surface electrodes used in telemetry and in obtaining physiological data from astronauts.</p> <p>Two main approaches exist for obtaining EMG signals from within a muscle, namely: percutaneous wires inserted by means of hypodermic needles; and surgically implanted radio-transmitting devices. In the first method, wires leading through the surface of the skin from inside the muscle must be capable of flexing as the muscle moves and maintaining contact with motor units for many months. Present indications are that tissue-reaction and infection at the point of exit from the skin are minimal. Some newly developed silastic-im-pregnated spiral electrodes show promise of solving the problem of mechanical reliability <i>. </i><a></a> Similar problems exist for the electrodes of surgically implanted devices. In fact, the electrodes may well prove to be the weakest link in a biotransmitting system. It is well known that electrode failures in heart pacers continue to be a vexing problem. Research will continue to find ways to prevent metal fatigue and to discover contact materials which produce no body-tissue reaction, and which do not corrode and weaken.</p> <p>In the foregoing paragraph, electrodes were discussed in the context of signal-sensing devices. Their importance is much more critical in transducers used for the electrical stimulation of muscle, as in the case of functional electrical stimulation to be described later on in this article, and in heart pacemakers and bladder stimulators, which have been excluded from this discussion of orthotics and prosthetics systems. The relatively higher currents associated with electrical stimulation, as compared with detection of electrophysiological signals, create problems. It is believed that the material, corrosion, and tissue-reaction problems associated with electrodes for picking up signals are not severe and can be easily overcome through present technology.</p> <p>Electrical powering, long-term body acceptance, and sealing of the package are the issues around the active transmitters used for detecting electrophysiological signals from within the body and the passive and active implantable transducers for electrical stimulation of muscles. At present, all such experimental devices are powered by mercury cell batteries. Much effort is being devoted to minimize total electrical power requirements and to obtain electrical energy from within the body through mechanical and chemical transformers.<a></a> Battery-powered biotransmitters of a total size of 0.1 cu. in. have operated continuously for 200 hr. and, intermittently, over a three-month period in dogs. An EMG transmitter was first implanted in a human being in Sweden in 1966 <i>. </i><a></a> More recently, one was implanted in a subject in Cleveland, Ohio <i>. </i><a></a> Many problems remain to be overcome before such transmitters can be used routinely in the clinical situation, but progress with packaging techniques which produce no tissue-reaction in animals over long periods of time, and with electrode designs which can survive mechanical and electrolytic effects, indicates that prototype systems will be evaluated in human subjects within the year.</p> <h4>III. Signal Processors</h4> <p>This discussion of signal processors is concerned primarily with the special electronic and computer-type systems used for converting low-level control signals containing noise and artifacts to useful, high-level input for orthotic or prosthetic devices.</p> <p>Although not specifically designed for signal processing, the mechanical and hydraulic characteristics of many systems may be viewed as signal processors. For example, the speed of response of a gas-powered orthotics or prosthetics system is often limited by the size of the valve openings and tubing used in the system. In this way, the on-off characteristic of the valve is converted inherently into a velocity output and is so observed by the patient. In fact, subjects are often very much aware of the noises and speeds of response associated with their control devices, and improve their skills with practice and knowledge of how the system will perform for given input operations.</p> <p>Signal processors designed specifically to alter electrical wave forms include a wide range of circuits used for processing EMG information. Most such circuits involve rectification, integration, and various nonlinear components used to reject noise and provide the smoothest possible electrical systems for operating the orthotic or prosthetic device. Since the EMG signal, especially when detected from within the muscle, consists of an asynchronous train of pulses, signal conditioners based upon digital - signal - handling theory are being developed. Some of these systems would "clean up" the pulse signals from within a muscle to the point where they might be used as direct signals into a digital computer.</p> <p>Under another kind of theory for signal processing, combined or patterned functions are produced from one or more inputs. Among body-powered orthotic devices, the linkage feeders widely used by quadriplegics are an example.<a></a> These mechanical linkage systems support the forearm and allow the patient to convert shoulder and trunk movement into controlled movement of his hand. When given a controlled prehensile function, patients often learn to feed themselves and perform many other useful tasks. Externally powered arm prostheses have been designed for children, with coupled movements such that the programmed movement of an eating implement is obtained by the child through a single input action.<a></a> The conversion of a single input action to interrelated movements of each part of the prosthesis may be regarded as a type of signal processing, especially when one considers the possibility of using an elecrical computer to do the same sort of thing. The sophisticated prosthetic hands built in France and, more recently, in Yugoslavia and Japan,<a></a> in which a simple set of input signals is mechanically converted to a smoothly closing movement of all fingers, constitute a type of signal processing.</p> <p>Another type of signal processing is found in the automatic control systems used in some orthotic and prosthetic devices (<b>Fig. 6</b>). Recently, interest has developed in systems possessing automatic proportional and velocity control. Such systems differ from so-called "open-loop" systems in that feedback position or force signals are fed back to the control system itself rather than the patient. The patient provides command signals, such as a new position, to which the control system automatically responds. Such techniques have not been widely used in orthotics and prosthetics systems to date, but they have been demonstrated in research prototypes and will probably find increasing application <i>.</i><a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. A prototype automatic prehension system developed at the Army Medical Biomechanical Research Laboratory. It includes miniaturized electronics, a motor-driven No. 4 hand, and a thumb sensor. A cosmetic glove is worn over the assembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Most human motor activity is a combination of direct conscious control and patterned movements which are coordinated at levels below the conscious nervous system. Many research projects are now concerned with using computers or high-speed data processors to perform for an advanced prosthetics or orthotics system what the lower motor neuron system does for the human being. The problem is essentially one of information-channel capacity, wherein much information may be required to control a complex device but only limited channels are available for converting the desires of the patient into electrical command signals.<a></a> </p> <p>One approach to this problem was the Case Research Arm Aid, Mark I (<b>Fig. 7</b>), <a></a> which used a computer with pre-programmed tapes for a number of activities of daily living. The quadriplegic patient was required to select the portion of tape appropriate for the action he wished to accomplish, but he did not need to be actively involved once the action had started. More recently, proposals have been made for using computers adaptively to learn to provide patterned functions. The idea would be to store within the computer patterns or subroutines for elementary body movements which combine to produce walking or upper-extremity movement. The subject would then provide only "coarse" information about where he wanted his limb to go, and the computer would calculate according to some pre-programmed strategy how best to move his limb most efficiently from one place to another. The tremendous progress in machine computation has opened unlimited possibilities for research in such systems which can be reduced practically to patient needs. One can visualize, for example, a paralyzed leg being electrically stimulated according to a patterned program stored in a solid-state, micrologic computer worn on the belt. Although such a system can be imagined, it will be many years before it is technically and economically feasible.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The Case Research Arm Aid, Mark I. The pneumatic system shown allowed five degrees of freedom through the shoulder, arm, and wrist. Modifications being made include conversion from a pre-programmed tape control to computer-calculated trajectories by means of myoelectric input control signals. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>IV. Output Systems</h4> <p>In the past, most of the research, development, and clinical application of orthotics and prosthetics systems has been concerned with the output systems, for these are the hardware devices which perform the functions required by the handicapped person. Through intuition, designers have shown awareness of control and feedback, but their attention has been primarily directed toward the powering and fitting of devices to improve the function of the handicapped.</p> <p>Almost all the elements in the man-machine systems are applicable to both orthotics and prosthetics; but, when output systems are considered, it is necessary to discuss orthoses and prostheses independently, except for certain communication devices which apply to both. For example, much effort has been devoted to modifying telephone, recorder, typewriter, radio and television equipment for easier use by handicapped persons. Touch dialing, alone, is an important asset. Tape-recording and typewriters operated through coded signals from the tongue or voice make it possible for the paralyzed person to carry on a business and communicate with friends.</p> <p>In addition to communication devices, attention has also been given to the development of special tools and machines so that the handicapped can perform useful work. Interestingly, much of the philosophy in the development of such tools is common with the development of special tools for astronauts to use in space. This occurs because the normal man in an alien environment is similar in many respects to the handicapped man in a normal environment. Vehicles for the transportation of handicapped persons, including powered wheelchairs (<b>Fig. 8</b>) and modified automobiles, must also be included in output systems for the handicapped.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Ampersand Research, Highland View Hospital, three-level electromyographic control of wheelchair and flexorhinge splint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prosthetics</i></p> <p>The term "prosthesis" brings to mind artificial hands, arms, and legs. The historical development of these artificial limbs is an extensive and fascinating study in itself. Although seemingly simple and perhaps crude, the cable-controlled, rubber-band hooks commonly used by below-elbow amputees are, in fact, quite sophisticated, and many amputees have developed remarkable dexterity with them. Probably many years will elapse before the users of EMG-controlled, electrically powered hands achieve the same level of reliability and dexterity now found in thousands of skilled hook-users around the world.</p> <p>The problem is much more severe for the above - elbow and shoulder - disarticulation amputee, especially the bilateral case. It is a fact that when a patient has one good arm the margin of increase in function provided by a prosthetic second arm is often too small to make it worth his while to learn to use it. Much effort is now under way to provide improved functions for high-level amputees, especially bilateral cases. The most successful systems to date are powered by gas or electricity.<a></a> Each clinical application represents a major engineering achievement, and each one is usually somewhat different from all others. This is the real limitation in the development of sophisticated upper-extremity systems, for the problem of fitting and the nature of disability are so different among the relatively limited numbers of amputee patients and congenitally deformed children that the sophisticated engineering required is often economically unjustified. However, the obvious challenge presented by the creation of an artificial human limb continues to fire the imagination of engineers throughout the world, and one may expect continued progress.</p> <p>The case for the lower-extremity prostheses is somewhat different, because a man cannot walk with just one leg. Much effort has been devoted to developing lower-extremity prostheses for both above-knee and below-knee amputees. A successful prosthetic application requires close collaboration between the orthopaedic surgeon and the prosthetist. Thoughtful planning concerning the nature of the stump to be produced can make a great difference in the effectiveness of the final prosthesis. Walking is one of the most sophisticated patterned functions in man. Many muscles are interrelated in producing a gait of minimum energy expenditure. One area of intensive research has been the study of human gait in order to improve the design of lower-extremity prosthetic and orthotic devices. Although considerable data have been gained through cinematography and EMG studies, there is still much to be learned, and one can expect continuing research in this area.<a></a> </p> <p>Lower-extremity prostheses are more complicated than one might imagine. The acceleration sequences required for normal human gait are not produced by a simple pendulum swing. Instead, one must build nonlinear damping devices into a lower-extremity prosthesis to control the swing phase so that it will approximate that of a normal human being. In the simplest versions, disks of leather are used to provide this friction. Recently, nonlinear and hydraulic devices have been built into artificial limbs. These hydraulic devices still suffer occasionally from seal and other failures, but they have been successfully used by amputees under a Veterans Administration evaluation program.</p> <p>The problem of socket design and fitting is still under investigation, for one must transfer considerable forces to the limb, both in direct compression and in torsion. Sockets providing total-surface contact, air cushions, "breathing effect" and special types of support have been developed. For a number of years, researchers have attempted to measure the pressure distributions occurring under dynamic conditions within lower-extremity sockets. In general, these attempts have not been successful, and this remains a challenging area for future research. Such pressure-distribution data are urgently needed for the intelligent design of lower-extremity prostheses and, in some cases, for upper-extremity devices.</p> <p><i>Orthotics</i></p> <p>The first orthoses were the splints used to support a fractured limb and the canes and crutches used by early man. Bracing of weakened limbs due to neurological disorders and the therapeutic appliances used to overcome deformities have been widely applied by the orthopaedic surgeon and his collaborating orthotist. Through surgical reconstruction and tendon transplants, the orthopaedic surgeon can provide concepts for rehabilitation which complement improved engineering systems.<a></a> The future possibilities of such combined surgical intervention and engineering systems development have been only hinted at and much research undoubtedly will be carried on between the engineer and the surgeon in this area.</p> <p>A number of new, externally powered, and controlled splint systems are being made available to paralyzed patients. A kind of race is now occurring between the proponents of gas-powered orthotics systems and electrically powered systems. Actually, these systems are highly competitive when one considers the energy-storage capacity and weight of motors and batteries as compared to gas actuators and storage containers. The gas-powered systems still provide the best force-to-weight capability, but electric motors are being improved continuously and the overall simplicity of an all-electric system has many advantages.<a></a> </p> <p>A number of prehensile splints to provide grasp to paralyzed patients have been applied routinely, and many new multiaxis powered splints are being applied.<a></a> As in the case of the complex prosthesis, the need for many different approaches to meet the many different types of disability in paralysis or neurological disorders has slowed down the broad development of externally powered orthotic systems. We believe, however, that engineering developments will soon reach the point where such systems will be widely applied to the very large number of patients who can benefit from increased functions, especially in old age. Expanded research and development in externally powered orthoses for both upper and lower extremities is certainly going to occur.</p> <p>A promising new approach is being investigated throughout the world. This approach suggests the use of electrical stimulation of muscles for functional activity. <a></a> While electrical stimulation of muscles has been used extensively for a number of years in diagnosis and in therapy, its use for functional action has only recently been studied. The increased sophistication of electronic systems and the possibility of passive and active implants suggest the realization of controlled muscle activity. Such systems would certainly operate in parallel with some sort of external functional bracing, for in the foreseeable future one can imagine only a limited number of agonist and antagonist muscles being functionally stimulated.</p> <p>There is much to be learned about whether denervated muscles can be kept in an active stimulatable condition for long periods of time and whether intact lower motor systems will respond to controlled stimulation without inducing spasticity and other aberrations. The progress to date, however, is exciting and it is urged that serious consideration be given to programs of electrical stimulation of the muscles of recent victims of neuron lesions so that the atrophy of involved muscles can be retarded awaiting the day that functional stimulation can be made available.</p> <p>Expanded research around the understanding of the process of functional stimulation and physiologic factors in muscle stimulation, both from a physiological and an engineering point of view, is to be expected.</p> <h4>V. and VI. Feedback Receptors and Local Feedback</h4> <p>A human being controlling either the most simple or the most complex assistive device must have feedback information. In normal human motor activity, feedback comes via sight, sound, touch (pressure), and proprioceptive senses. These normal feedback channels are always impaired to some degree in handicapped persons and may be altogether missing. The visual path is still the most important for control in most orthotics and prosthetics systems, but much research has been undertaken recently to relieve the patient of the need to keep his eyes consciously fastened on each part of an output task. The sounds of electric motors and gas-operated systems provide many cues for feedback control, some of which may not be consciously appreciated by the subject. Many amputees learn to interpret reflected forces and motions through Bowden cables and other body-powered components.</p> <p>Much interest in sensory feedback research has been shown throughout the world, but only minimal progress has been made to date. Stereo effects are also being investigated, including transducers which produce vibration of varying phase and intensity at two points on the surface of the skin from which a sensation of spatial position proportional to an actual position can be produced <i>. </i><a></a> The possibility of producing a similar spatial position sense through "stereo" electrical stimulation at two different points on the surface of the skin is also being investigated.</p> <p>Recently proposed orthotics and prosthetics systems, using data processes, may require local feedback which is not processed by the human. <b>Fig. 1</b> indicates some paths which are analogous to some afferent paths in lower motor neuron systems in the human. Systems to select the grasping pressure in terminal devices have been developed. A recent approach to the problem at the Army Medical Biomechanical Research Laboratory uses a sound pickup to detect incipient slip in lieu of pressure to modulate the force applied in an artificial hand <i>.</i><a></a> </p> <p>To date, feedback control of orthotics and prosthetics systems has been severely limited by the inability to provide effective artificial sensory feedback, and will constitute a major barrier to overall system effectiveness for some years to come. It seems clear that a maximum research effort should be made to develop effective pseudosensory feedback signals, not only for orthotics and prosthetics systems, but also for sensory aids to the blind and deaf- areas which are, of course, closely related.</p> <h4>VII. Adaptive Learning</h4> <p>The success of any orthotics or prosthetics system or device must depend on acceptance by a patient and his abilty to learn to use it effectively. If the device proves to be more trouble than it is worth, it will be rejected. Thousands of rejected devices now rest in closets and dark corners.</p> <p>An important element of an orthotics or prosthetics system is the capability of a patient, whether young or old, to learn to employ his device skillfully <i>.</i><a></a> </p> <p>As new systems become ever more complex with many degrees of freedom (moving elements), the problem of control becomes more difficult.<a></a> One may visualize a multi-axis orthosis controlled by EMG signals from six or more voluntarily excited muscles (<b>Fig. 9</b>). An unanswered question remains as to how well the patient can train the six or more muscles to perform the functions required, especially when the functions may be very different from those for which the muscle was naturally used. The authors have discussed this difference between so-called naturally conditioned communication channels (NCCC) and operant-conditioned communication channels (OCCC) (<b>Fig. 10</b>) <i>. </i><a></a> It appears intuitively correct to use the naturally conditioned channels wherever possible as signal sources for natural functions. The EMG-controlled artificial hands previously referred to use signals obtained from the prehensile extensors and flexors so that the amputee may open and close his artificial hand with the same muscles he would have used prior to the amputation. However, as degrees of freedom increase and the nature of the disability precludes naturally conditioned sources, one is forced to employ other muscles, such as the auriculares muscles behind the ears<a></a> or the trapezius muscles in the shoulders, as signal sources.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. A test of the feasibility of exercising three degrees of freedom by means of myoelectric control. Six muscle sites received percutaneous electrodes, all in the forearm. The six sites were then connected to a model hand trainer possessing three degrees of freedom. The motions of the trainer could be controlled to correspond with those of the control muscles. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Schematic representation of naturally conditioned communication channels (NCCC) and operant-conditioned communication channels (OCCC). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is clear that much research on these issues remains to be done. Age is certainly an important factor, for it is known that young children adapt very much more easily to orthotic and prosthetic devices than do older persons. Learning capability is closely related to the amount of information being received by the patient through his feedback channels and to the amount of patterning and programming that can be done at the signal-processing level. No doubt the future will bring clarification of these matters.</p> <h3>Evaluation</h3> <p>Before closing, a major problem which continues to face the American orthotics and proshetics research, development, and clinical application program should be mentioned. This is the important issue of effective <i>evaluation. </i>Evaluation does not stand alone as a specific activity. The theory that a prototype developed by one group can be taken over by a separate evaluation agency to determine if it "works," and if it works can then be taken over by a manufacturer for production, just does not often succeed in practice. Problems in the medical engineering field of prosthetics and orthotics development are immensely complicated, and often the true nature of the problem to be solved is not undertood until one or two attempts have been made at solution. A constant interplay between the needs of the patient, the requirements of the physician, and the technical development by the engineer must be maintained. It is the rule, rather than the exception, that most new developments brought to the prototype stage require continued research and redesign. It seldom happens that a first-prototype development can be picked up and replicated in quantity for the field.</p> <p>The implication of the foregoing remarks is that the evaluation process is a continuing and integral part of the overall design-development process and is perhaps the hardest and most expensive part. To date, inadequate funds have been allocated for its accomplishment in grant programs. The result has been that not nearly so many fruits have accrued from the research and development programs as might otherwise have been the case.</p> <p>The specific need could be met by providing an overall systems-management function for the broad spectrum of activities throughout the nation. This systems-management function would be a cooperative effort authorized by federal government agencies and their advising groups. The lessons learned by the National Aeronautics and Space Administration in the management of the space effort seem applicable here, and it is the strong recommendation of these authors that the need for systems management in the broad field of orthotics and prosthetics research and development be recognized.</p> <p><b>References:</b></p> <ol> <li>Alldredge, R. H., and E. F. Murphy, Prostheticsresearch and the amputation surgeon, Artificial Limbs, pp. 4-46, September 1954.</li> <li>Allen, J. R., A. Karchak, V. L. Nickel, and R.nelson, The Rancho electric arm, Proc. 3rd Annual Rocky Mountain Bioengineering Symposium, pp. 79-82, 1966.</li> <li>Alter, R., Bioelectric control of prostheses, MITechnical Report 446, Cambridge, Mass., December 1966.</li> <li>Basmajian, J. V., M. Baeza, and C. Fabrigar,Conscious control and training of individual spinal motor neurons in normal human subjects, J. of New Drugs, 5(2):78-85, March-April 1965.</li> <li>Battye, C. K., A. Nightingale, and J. Whillis,The use of myoelectric currents in the operation of prosthesis, J. Bone and Joint Surg., 37B:506, 1955.</li> <li>Bennett, Robert L., The evolution of the GeorgiaWarm Springs Foundation feeder, Artificial Limbs, Spring 1966.</li> <li>Bontrager, E., M.Sc. thesis, Case Institute ofechnology, Cleveland, 1965.</li> <li>Bottomley, A. H., Myoelectric control of poweredprostheses, J. Bone and Joint Surg., 47B:411-415, 1965.</li> <li>Bottomley, A. H., and T. K. Cowell, An artificialhand controlled by the nerves, New Scientist, pp. 668-671, March 12, 1964.</li> <li>Bottomley, A. H., A. B. Kinnier Wilson, and A.ightingale, Muscle substitutes and myoelectric control, J. Brit. Institution of Radio Engineers, 26(6), December 1963.</li> <li>Brejdo, M. G., V. S. Gurfinkle, A. Ye. Kobrinskii,. A. Sysiu, M. L. Celtin, and A. S. Jakobson, O biolektricskoj sisteme upravlenija, Problemy kybernetiki, Gs. izd., fizikomatematiceskoj, literatury, Moscow, 1959.</li> <li>Close, J. R., E. D. Nickel, and F. N. Todd, Motorunit action potential counts, J. Bone and Joint Surg., 42-A(7): 1207-1222, October 1960.</li> <li>Close, J. R., E. D. Nickel, and F. N. Todd, Singlemotor unit action potentials, Clinical Orthopaedics, 42:171-190, 1965.</li> <li>Corell, R., Research and development of the CaseResearch Arm Aid, Ph.D. thesis, Case Institute of Technology, 1964.</li> <li>Crochetiere, W. J., L. Vodovnik, and J. B. Reswick,Electrical stimulation of skeletal muscle: a study of muscle as an actuator, Med. and Biol. Eng., 5:111-125, 1967.</li> <li>Dewan, E. M., Communication by electroencephalog-raphy, Special Report No. 12, Air Force Research Laboratory, Cambridge, Mass., November 1964.</li> <li>Dimitrijevic, M. R., Use of physiological mechanismsin the electrical control of paralyzed extremities, International Symposium on External Control of Human Extremities, Dubrovnik, 1966.</li> <li>Dorcas, D. S., and R. N. Scott, A three-state myo-electric control, Med. and Biol. Eng., 4:367-370, Pergamon Press, 1966.</li> <li>Engen, T. J., Powered upper extremity orthoticdevelopment, Progress Report, Texas Institute for Rehabilitation and Research, September 1967.</li> <li>Freedy, A., and J. Lyman, An information theoryapproach to control of externally powered artificial arms, Paper read at combined meeting of Panel on Control of External Power and Panel on Upper-Extremity Orthotics, Subcommittee on Design and Development, Committee on Prosthetics Research and Development, New York, May 1967.</li> <li>Gracanin, F., and M. R. Dimitrijevic, Applicationof functional stimulation in rehabilitation of neurological patients, International Symposium on Rehabilitation in Neurology, Prague, September 1966.</li> <li>Grahn, E. C, Electrical actuators in prosthetics andorthotics, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 172-185, 1966.</li> <li>Groth, H., and J. Lyman, A functional evaluationof several surgical techniques for establishing prosthetic control sites, Biotechnology Laboratory Technical Report No. 2, University of California (Los Angeles), June 1959.</li> <li>Highland View Hospital, Ampersand report, Cleve-and, September 1966.</li> <li>Hirsch, C, E. Kaiser, and I. Petersen, Telemetry ofmyopotentials, Acta Orthop. Scand., 37:156-165, 1966.</li> <li>Horn, G. W., Muscle voltage moves artificial hand,lectronics, October 11, 1963.</li> <li>Inman, V. T., Human locomotion, Can. Med. Ass.., 94:1047-1054, 1966.</li> <li>Karchak, A., J. R. Allen, V. L. Nickel, and R.nelson, The electric hand splint, Orthop. and Prosth. Appliance J., pp. 135-136, June 1965.</li> <li>Kay, Hector W. Conclusions of a conference onlinkage feeders, Artificial Limbs, Spring 1966.</li> <li>Kay, Hector W., and Nancy V. Appoldt, Prelimi-nary design analysis of linkage feeders, Artificial Limbs, Spring 1966.</li> <li>Kestenback, H. J., A feasibility study of smallradioisotopic batteries for medical implants, Report SSG-67-32, Case Institute of Technology, 1967.</li> <li>Kiessling, E. A., Carbon dioxide as a source of ex-ternal power for prosthetic devices, The application of external power in prosthetics and orthotics, National Academy of Sciences-National Research Council, Publication 874, pp. 79-87, 1961.</li> <li>Kiessling, E. A., Pneumatic prosthetic components:rigid servo mechanisms and their control valves, The application of external power in prosthetics and orthotics, National Academy of Sciences- National Research Council, Publication 874, pp. 116-131, 1961.</li> <li>Kinnier Wilson, A. B., Design of a motorized elbowsplint, Proc. Int. Symposium on the Application of Automatic Control in Prosthetic Design, pp. 6-9, Belgrade, 1962.</li> <li>Ko, W., Progress in miniaturized biotelemetry, Bio-cience, 15(2):118-120, 1966.</li> <li>Ko, W., Piezoelectric energy converter for electronicimplants, Proc. 19th Conference on Engineering in Medicine and Biology, San Francisco, p. 67, 1966.</li> <li>Ko, W., and M. R. Neuman, Implant biotelemetryand microelectronics, Science, 156:351-360, April 21, 1967.</li> <li>Kobrinskii, A. Ye., Bioelectric control of prostheticdevices, Herald of the Academy of Sciences, USSR, 30(7):58-61, July 1960.</li> <li>Kralj, A., L. Vodovnik, and M. Borovsak, Elec-tronic circuits used to obtain some functional movements by means of electrical stimulation, 2nd European Symposium on Medical Electronics, London, 1967.</li> <li>Litton Systems (Canada) Ltd., Research on myo-electric devices, D.I.R. Project No. E-74, DRB 9301-02, Toronto, 1967.</li> <li>Long, C, and B. Ebskov, Research applications ofmyoelectric control, presented at the 43rd Annual Session of the American Congress of Physical Medicine and Rehabilitation, 1965.</li> <li>Long, C, and V. Masciarelli, An electrophysiologicsplint for the hand, Arch. Phys. Med. and Rehab., 44:499, 1963.</li> <li>Lucaccini, L., A. Freedy, and J. Lyman, Externallypowered upper extremity prosthetic systems: studies of sensory motor control, Dept. of Eng. Report 67-12, University of California (Los Angeles), March 1967.</li> <li>Lucaccini, L. F., P. K. Kaiser, and J. Lyman, TheFrench electric hand: some observations and conclusions, Bull, of Prosth. Research, Veterans Administration, BPR 10-6, pp. 30-51, Fall 1966.</li> <li>Lyman, J., Biotechnology Laboratory Progress Re-ort No. 61-76, University of California (Los Angeles), September 1961.</li> <li>Lyman, J., Biotechnology Laboratory Progresseport No. 62-F, University of California (Los Angeles), December 1961.</li> <li>McGhee, R. B., Finite state control of quadrupedlocomotion, Report USCE 186, University of Southern California, December 1966.</li> <li>McLaurin, C. A., Control of externally poweredprosthetic and orthotic devices by musculoskeletal movement, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 10-19, 1966.</li> <li>McLaurin, C. A., On the use of electricity in upperextremity prostheses, J. Bone and Joint Surg., <b>47B: </b>448, 1965.</li> <li>Marquardt, E., Biomechanical control of pneumaticprostheses with special consideration of the sequential control, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 20-31, 1966.</li> <li>Massie, H., Cardiac pacemaker without batteries, 18th Conference on Engineering in Medicine and Biology, Philadelphia, 1965.</li> <li>Mott, W. E., and L. Sagan, Bioengineering problemsof implantable radioisotopic powered heart devices, San Diego Biomedical Engineering Symposium, 1967.</li> <li>Murphy, E. F., The swing phase of walking withabove-knee prosthesis, Bull, of Prosth. Research, Veterans Administration, BPR 10-1, pp. 5-39, Spring 1964.</li> <li>National Academy of Sciences-National Researchouncil, The application of external power in prosthetics and orthotics, Publication 874, 1961.</li> <li>National Academy of Sciences-National Researchouncil, The control of external power in upper-extremity rehabilitation, Publication 1352, 1966.</li> <li>Olson, H. F., Speech processing systems, IEEEpectrum, pp. 90-102, February 1964.</li> <li>Pearson, J. R., Gas-power sources and actuators forprosthetic and orthotic devices, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 186-201, 1966.</li> <li>Rakic, M., An automatic hand prosthesis, Med.lectron. Biol. Eng., 2:47, 1964.</li> <li>Reynolds, L. W., Utilization of bioelectricity aspower supply, Aerospace Med., February 1964.</li> <li>Salisbury, L. L., and A. B. Colman, A mechanicalhand with automatic proportional control of prehension, Technical Report 6611, Army Medical Biomechanical Research Laboratory, Walter Reed Army Medical Center, May 1966.</li> <li>Scott, R. N., A method for inserting wire electrodesfor electromyography, IEEE Transactions on Bio-Medical Engineering, BME-12(l):46-47, January 1965.</li> <li>Scott, R. N., Myo-electric control, Science J., pp. 2-8, March 1966.</li> <li>Scott, R. N., Myoelectric control of prostheses, Arch. Phys. Med. and Rehab., 47:174-181, March 1966.</li> <li>Scott, R. N., Myo-electric control systems, Reporto. 5, University of New Brunswick Bio-Engineering Institute, December 1965; No. 6, January 1967.</li> <li>Selwyn, D., Head-mounted inertial servo control forhandicapped, 6th Annual Symposium of the Professional Group on Human Factors in Electronics, Boston, May 1965.</li> <li>Sherman, E. D., A. L. Lippay, and G. Gingras,Prosthesis given new perspectives by external power, Hospital Management, pp. 44-49, November 1965.</li> <li>Spaco, Inc., The sight switch, Huntsville, Ala.,pril 1965.</li> <li>Stanford Research Institute, Experiments in tactualperception, Technical Report AFAL-TR-65-75_rJuly 1965.</li> <li>Suzuki, R., An automatic hand prosthesis, Jap,lectron. Eng., 2(1):39-41, January 1965.</li> <li>Tomovic, R., and G. Boni, An adaptive artificialhand, IRE Trans. Auto. Control, pp. 3-10^ April 1962.</li> <li>Tomovic, R., and R. B. McGhee, A finite stateapproach to the synthesis of bioengineering control-systems, IEEE Trans. Human Factors, HFE-7,. No. 2, June 1966.</li> <li>Trombly, C. A., Principles of operant conditioningrelated to orthotic training of quadriplegic patients, Amer. J. Occup. Ther., 20:217-220, September-October 1966.</li> <li>Vodovnik, L., W. J. Crochetiere, and J. B. Reswick,Control of a skeletal joint by electrical stimulation of antagonists, Med. and Biol. Eng., 5:97-109,1967.</li> <li>Vodovnik, L., C. Long, J. B. Reswick, A. Lippay,nd D. Starbuck, Myoelectric control of paralyzed muscles, IEEE Trans., BME-12, pp. 169-172, 1965.</li> <li>Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 1967.</li> <li>Waring, W., and V. L. Nickel, Powered braces withmyoelectric controls, Orthop. and Prosth. Appliance J., pp. 228-230, September 1965.</li> <li>Wasserman, W. L., Human amplifiers, Sci. and Technol., October 1964.</li> <li>Weltman, G., H. Groth, and J. Lyman, An analysisof bioelectrical prosthesis control, Biotechnology Laboratory Technical Report No. 1, Dept. of Eng. Report No. 59-49, University of California (Los Angeles), July 1959.</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">Bontrager, E., M.Sc. thesis, Case Institute ofechnology, Cleveland, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Lyman, J., Biotechnology Laboratory Progress Re-ort No. 61-76, University of California (Los Angeles), September 1961.</td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Lyman, J., Biotechnology Laboratory Progresseport No. 62-F, University of California (Los Angeles), December 1961.</td></tr><tr><td class="clsTextSmall"><b>78.</b> </td><td class="clsTextSmall">Weltman, G., H. Groth, and J. Lyman, An analysisof bioelectrical prosthesis control, Biotechnology Laboratory Technical Report No. 1, Dept. of Eng. Report No. 59-49, University of California (Los Angeles), July 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Trombly, C. A., Principles of operant conditioningrelated to orthotic training of quadriplegic patients, Amer. J. Occup. Ther., 20:217-220, September-October 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Salisbury, L. L., and A. B. Colman, A mechanicalhand with automatic proportional control of prehension, Technical Report 6611, Army Medical Biomechanical Research Laboratory, Walter Reed Army Medical Center, May 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>68.</b> </td><td class="clsTextSmall">Stanford Research Institute, Experiments in tactualperception, Technical Report AFAL-TR-65-75r July 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Crochetiere, W. J., L. Vodovnik, and J. B. Reswick,Electrical stimulation of skeletal muscle: a study of muscle as an actuator, Med. and Biol. Eng., 5:111-125, 1967.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Dimitrijevic, M. R., Use of physiological mechanismsin the electrical control of paralyzed extremities, International Symposium on External Control of Human Extremities, Dubrovnik, 1966.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Gracanin, F., and M. R. Dimitrijevic, Applicationof functional stimulation in rehabilitation of neurological patients, International Symposium on Rehabilitation in Neurology, Prague, September 1966.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Kralj, A., L. Vodovnik, and M. Borovsak, Elec-tronic circuits used to obtain some functional movements by means of electrical stimulation, 2nd European Symposium on Medical Electronics, London, 1967.</td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Long, C, and V. Masciarelli, An electrophysiologicsplint for the hand, Arch. Phys. Med. and Rehab., 44:499, 1963.</td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">Vodovnik, L., W. J. Crochetiere, and J. B. Reswick,Control of a skeletal joint by electrical stimulation of antagonists, Med. and Biol. Eng., 5:97-109,1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Allen, J. R., A. Karchak, V. L. Nickel, and R.nelson, The Rancho electric arm, Proc. 3rd Annual Rocky Mountain Bioengineering Symposium, pp. 79-82, 1966.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Engen, T. J., Powered upper extremity orthoticdevelopment, Progress Report, Texas Institute for Rehabilitation and Research, September 1967.</td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Karchak, A., J. R. Allen, V. L. Nickel, and R.nelson, The electric hand splint, Orthop. and Prosth. Appliance J., pp. 135-136, June 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Grahn, E. C, Electrical actuators in prosthetics andorthotics, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 172-185, 1966.</td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Pearson, J. R., Gas-power sources and actuators forprosthetic and orthotic devices, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 186-201, 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, R. H., and E. F. Murphy, Prostheticsresearch and the amputation surgeon, Artificial Limbs, pp. 4-46, September 1954.</td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Groth, H., and J. Lyman, A functional evaluationof several surgical techniques for establishing prosthetic control sites, Biotechnology Laboratory Technical Report No. 2, University of California (Los Angeles), June 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Inman, V. T., Human locomotion, Can. Med. Ass.., 94:1047-1054, 1966.</td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Murphy, E. F., The swing phase of walking withabove-knee prosthesis, Bull, of Prosth. Research, Veterans Administration, BPR 10-1, pp. 5-39, Spring 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Allen, J. R., A. Karchak, V. L. Nickel, and R.nelson, The Rancho electric arm, Proc. 3rd Annual Rocky Mountain Bioengineering Symposium, pp. 79-82, 1966.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Engen, T. J., Powered upper extremity orthoticdevelopment, Progress Report, Texas Institute for Rehabilitation and Research, September 1967.</td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Karchak, A., J. R. Allen, V. L. Nickel, and R.nelson, The electric hand splint, Orthop. and Prosth. Appliance J., pp. 135-136, June 1965.</td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Kiessling, E. A., Carbon dioxide as a source of ex-ternal power for prosthetic devices, The application of external power in prosthetics and orthotics, National Academy of Sciences-National Research Council, Publication 874, pp. 79-87, 1961.</td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Kiessling, E. A., Pneumatic prosthetic components:rigid servo mechanisms and their control valves, The application of external power in prosthetics and orthotics, National Academy of Sciences- National Research Council, Publication 874, pp. 116-131, 1961.</td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Kinnier Wilson, A. B., Design of a motorized elbowsplint, Proc. Int. Symposium on the Application of Automatic Control in Prosthetic Design, pp. 6-9, Belgrade, 1962.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Marquardt, E., Biomechanical control of pneumaticprostheses with special consideration of the sequential control, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 20-31, 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">McGhee, R. B., Finite state control of quadrupedlocomotion, Report USCE 186, University of Southern California, December 1966.</td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Tomovic, R., and R. B. McGhee, A finite stateapproach to the synthesis of bioengineering control-systems, IEEE Trans. Human Factors, HFE-7,. No. 2, June 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Corell, R., Research and development of the CaseResearch Arm Aid, Ph.D. thesis, Case Institute of Technology, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Freedy, A., and J. Lyman, An information theoryapproach to control of externally powered artificial arms, Paper read at combined meeting of Panel on Control of External Power and Panel on Upper-Extremity Orthotics, Subcommittee on Design and Development, Committee on Prosthetics Research and Development, New York, May 1967.</td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Lucaccini, L., A. Freedy, and J. Lyman, Externallypowered upper extremity prosthetic systems: studies of sensory motor control, Dept. of Eng. Report 67-12, University of California (Los Angeles), March 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Salisbury, L. L., and A. B. Colman, A mechanicalhand with automatic proportional control of prehension, Technical Report 6611, Army Medical Biomechanical Research Laboratory, Walter Reed Army Medical Center, May 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Lucaccini, L. F., P. K. Kaiser, and J. Lyman, TheFrench electric hand: some observations and conclusions, Bull, of Prosth. Research, Veterans Administration, BPR 10-6, pp. 30-51, Fall 1966.</td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Lyman, J., Biotechnology Laboratory Progresseport No. 62-F, University of California (Los Angeles), December 1961.</td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Rakic, M., An automatic hand prosthesis, Med.lectron. Biol. Eng., 2:47, 1964.</td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">Suzuki, R., An automatic hand prosthesis, Jap,lectron. Eng., 2(1):39-41, January 1965.</td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Tomovic, R., and G. Boni, An adaptive artificialhand, IRE Trans. Auto. Control, pp. 3-10^ April 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>References</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">McLaurin, C. A., Control of externally poweredprosthetic and orthotic devices by musculoskeletal movement, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 10-19, 1966.</td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">McLaurin, C. A., On the use of electricity in upperextremity prostheses, J. Bone and Joint Surg., 47B: 448, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Bennett, Robert L., The evolution of the GeorgiaWarm Springs Foundation feeder, Artificial Limbs, Spring 1966.</td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Kay, Hector W. Conclusions of a conference onlinkage feeders, Artificial Limbs, Spring 1966.</td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Kay, Hector W., and Nancy V. Appoldt, Prelimi-nary design analysis of linkage feeders, Artificial Limbs, Spring 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Hirsch, C, E. Kaiser, and I. Petersen, Telemetry ofmyopotentials, Acta Orthop. Scand., 37:156-165, 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Kestenback, H. J., A feasibility study of smallradioisotopic batteries for medical implants, Report SSG-67-32, Case Institute of Technology, 1967.</td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Ko, W., Piezoelectric energy converter for electronicimplants, Proc. 19th Conference on Engineering in Medicine and Biology, San Francisco, p. 67, 1966.</td></tr><tr><td class="clsTextSmall"><b> 51.</b> </td><td class="clsTextSmall">Massie, H., Cardiac pacemaker without batteries, 18th Conference on Engineering in Medicine and Biology, Philadelphia, 1965.</td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Mott, W. E., and L. Sagan, Bioengineering problemsof implantable radioisotopic powered heart devices, San Diego Biomedical Engineering Symposium, 1967.</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Reynolds, L. W., Utilization of bioelectricity aspower supply, Aerospace Med., February 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Selwyn, D., Head-mounted inertial servo control forhandicapped, 6th Annual Symposium of the Professional Group on Human Factors in Electronics, Boston, May 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">National Academy of Sciences-National Researchouncil, The application of external power in prosthetics and orthotics, Publication 874, 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>14.</b> </td><td class="clsTextSmall">Corell, R., Research and development of the CaseResearch Arm Aid, Ph.D. thesis, Case Institute of Technology, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">Spaco, Inc., The sight switch, Huntsville, Ala.,pril 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Olson, H. F., Speech processing systems, IEEEpectrum, pp. 90-102, February 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Dewan, E. M., Communication by electroencephalog-raphy, Special Report No. 12, Air Force Research Laboratory, Cambridge, Mass., November 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Basmajian, J. V., M. Baeza, and C. Fabrigar,Conscious control and training of individual spinal motor neurons in normal human subjects, J. of New Drugs, 5(2):78-85, March-April 1965.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Close, J. R., E. D. Nickel, and F. N. Todd, Motorunit action potential counts, J. Bone and Joint Surg., 42-A(7): 1207-1222, October 1960.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Close, J. R., E. D. Nickel, and F. N. Todd, Singlemotor unit action potentials, Clinical Orthopaedics, 42:171-190, 1965.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Highland View Hospital, Ampersand report, Cleve-and, September 1966.</td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Scott, R. N., A method for inserting wire electrodesfor electromyography, IEEE Transactions on Bio-Medical Engineering, BME-12(l):46-47, January 1965.</td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Scott, R. N., Myo-electric control, Science J., pp. 2-8, March 1966.</td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Scott, R. N., Myoelectric control of prostheses, Arch. Phys. Med. and Rehab., 47:174-181, March 1966.</td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Scott, R. N., Myo-electric control systems, Reporto. 5, University of New Brunswick Bio-Engineering Institute, December 1965; No. 6, January 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Battye, C. K., A. Nightingale, and J. Whillis,The use of myoelectric currents in the operation of prosthesis, J. Bone and Joint Surg., 37B:506, 1955.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Bennett, Robert L., The evolution of the GeorgiaWarm Springs Foundation feeder, Artificial Limbs, Spring 1966.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Bottomley, A. H., Myoelectric control of poweredprostheses, J. Bone and Joint Surg., 47B:411-415, 1965.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Bottomley, A. H., and T. K. Cowell, An artificialhand controlled by the nerves, New Scientist, pp. 668-671, March 12, 1964.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Bottomley, A. H., A. B. Kinnier Wilson, and A.ightingale, Muscle substitutes and myoelectric control, J. Brit. Institution of Radio Engineers, 26(6), December 1963.</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Brejdo, M. G., V. S. Gurfinkle, A. Ye. Kobrinskii,. A. Sysiu, M. L. Celtin, and A. S. Jakobson, O biolektricskoj sisteme upravlenija, Problemy kybernetiki, Gs. izd., fizikomatematiceskoj, literatury, Moscow, 1959.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Close, J. R., E. D. Nickel, and F. N. Todd, Motorunit action potential counts, J. Bone and Joint Surg., 42-A(7): 1207-1222, October 1960.</td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Dorcas, D. S., and R. N. Scott, A three-state myo-electric control, Med. and Biol. Eng., 4:367-370, Pergamon Press, 1966.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Horn, G. W., Muscle voltage moves artificial hand,lectronics, October 11, 1963.</td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Kobrinskii, A. Ye., Bioelectric control of prostheticdevices, Herald of the Academy of Sciences, USSR, 30(7):58-61, July 1960.</td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Litton Systems (Canada) Ltd., Research on myo-electric devices, D.I.R. Project No. E-74, DRB 9301-02, Toronto, 1967.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Long, C, and B. Ebskov, Research applications ofmyoelectric control, presented at the 43rd Annual Session of the American Congress of Physical Medicine and Rehabilitation, 1965.</td></tr><tr><td class="clsTextSmall"><b> 66.</b> </td><td class="clsTextSmall">Sherman, E. D., A. L. Lippay, and G. Gingras,Prosthesis given new perspectives by external power, Hospital Management, pp. 44-49, November 1965.</td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">Waring, W., and V. L. Nickel, Powered braces withmyoelectric controls, Orthop. and Prosth. Appliance J., pp. 228-230, September 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alter, R., Bioelectric control of prostheses, MITechnical Report 446, Cambridge, Mass., December 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Instructor in Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Mo. Data has estimated the numbers of patients in the United States with presented at combined meeting of the Panel on Control of External Power and the Panel on Upper-Extremity Orthotics of the Subcommittee on Design and Development, Committee on Prosthetics Research and Development, in New York, N.Y., May 15-17, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Lojze Vodovnik, D.Sc. </b></td></tr><tr><td class="clsTextSmall">Assistant Professor of Engineering, Engineering Design Center, Case Western Reserve University, University Circle, Cleveland, Ohio 44106, and Associate Professor of Electrical Engineering, University of Ljubljana, Yugoslavia.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 B. Reswick, Sc.D. </b></td></tr><tr><td class="clsTextSmall">Leonard Case Professor of Engineering and Director of the Engineering Design Center, Case Western Reserve University, University Circle, Cleveland, Ohio 44106.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_02_005/aut67t-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_02_005/aut67-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1967_02_005/aut67-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1967_02_005/aut67-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1967_02_005/aut67-04.jpg Figure 6 http://www.oandplibrary.org/al/images/1967_02_005/aut67-05.jpg Figure 7 http://www.oandplibrary.org/al/images/1967_02_005/aut67-06.jpg Figure 8 http://www.oandplibrary.org/al/images/1967_02_005/aut67-07.jpg Figure 9 http://www.oandplibrary.org/al/images/1967_02_005/aut67-08.jpg Figure 10 http://www.oandplibrary.org/al/images/1967_02_005/aut67-09.jpg Figure 11 http://www.oandplibrary.org/al/images/1967_02_005/aut67-10.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 External Power in Prosthetics and Orthotics, an Overview Creator An entity primarily responsible for making the resource James B. Reswick, Sc.D. * Lojze Vodovnik, D.Sc. * https://staging.drfop.org/files/original/bf963a7989acad403aa943778ba020f1.pdf 409d60d0518157719847a792bbaa57d6 https://staging.drfop.org/files/original/0106990b6dd41f117c47cb5fdca17da6.jpg df6ba1aeb28f1c6a9d86a606fe572db8 https://staging.drfop.org/files/original/f2e96714d806c927c09ba51bb59036d1.jpg 40fd5b62c3ecd7ff81b859972eb1341c https://staging.drfop.org/files/original/62eca765fb8a28647e1f1e9858e762b3.jpg d87f8fadb9907c263d1a3fde50944103 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_014.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 14 - 16 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_01_014.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_014.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>Immediate Postsurgical Prosthetics Fitting in the Management of Upper-Extremity Amputees</h2> <h5>Augusto Sarmiento, M.D. <a style="text-decoration:none;">*</a><br />Newton C. McCollough, III, M.D. <a style="text-decoration:none;">*</a><br />Edward M. Williams, M.D. <a style="text-decoration:none;">*</a><br />William F. Sinclair, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>In the experience of the authors of this article, immediate postsurgical prosthetics fitting has been the most satisfactory means of managing lower-extremity amputees. <a></a> The procedure has allowed better control of postsurgical edema, reduced postoperative pain, permitted more rapid conditioning of the stump, and shortened the time between amputation surgery and definitive prosthetic fitting. These conclusions are based on the experiences gained with 200 below-knee amputations followed by immediate postsurgical fittings at Jackson Memorial Hospital, the main teaching hospital of the University of Miami School of Medicine. The underlying cause of amputation in 85 per cent of these patients was peripheral vascular disease, usually with diabetes.</p> <h3>Four Upper-Extremity Cases</h3> <p>On four occasions there have been opportunities to apply temporary prostheses to upper-extremity amputees immediately after surgery. The patients in this small series showed a considerable reduction in postoperative pain, rapidly began to use their prosthetic appliances, and were impressive in their psychological adjustment to their disabilities.</p> <p>Brief clinical and prosthetics histories of these four patients follow.</p> <ol> <li>L.M. is a 32-year-old male who was struck in the right hand by a rattlesnake in November 1966. Despite a vigorous therapeutic regimen, extensive damage was sustained. The patient underwent several surgical procedures in attempts to restore function to his hand. One year later, because of a functionless, partially anaesthetic, two-digit hand, a wrist disarticulation was performed, with immediate fitting of prosthesis (<b>Fig. 1</b>). Seventeen hours after surgery, with no instruction other than the preoperative demonstration of the harness and hook control, the patient was capable of operating the terminal device sufficiently well to feed and dress himself (<b>Fig. 2</b>). The patient was fitted with a permanent prosthesis three weeks after amputation. The surgical wound had healed <i>per primam </i>when the stump was first inspected two weeks after the surgical procedure.</li><li>A.S. is a 57-year-old male who severely injured his hand in a meat grinder, requiring a wrist disarticulation. Because of the nature of the injury, it was elected not to close the wound but to perform an open carpal disarticulation. One week later, in the absence of infection or other complications, a wrist disarticulation was performed by conventional means. The patient was fitted immediately postoperative with a below-elbow temporary prosthesis, complete with harness and controls. The patient left the hospital four days after surgery; when seen as an outpatient one week after surgery, he was capable of using the terminal device satisfactorily. He was fitted with the final prosthesis four weeks after surgical procedure.</li><li>L.D. is a 57-year-old male who underwent a right below-elbow amputation in December 1967 because of extensive metastases to the right radius from a hypernephroma (<b>Fig. 3</b>). The operation was performed by conventional methods and a temporary prosthesis, with harness and controls, was applied immediately after surgery. Convalescence was uneventful and the patient was discharged 22 days after surgery, at which time he was capable of controlling the elbow and terminal device in a relatively satisfactory manner. He was fitted with a permanent prosthesis 60 days after the surgical procedure.</li><li>F.M. is a 57-year-old male who sustained a severe sideswipe injury to the left upper extremity, with multiple fractures and extensive arterial and nerve injuries. After approximately nine months and many surgical procedures, the patient was left with a functionless and nearly anaesthetic extremity. An above-elbow amputation was carried out by conventional means, with immediate fitting of the temporary socket. The postoperative course was uneventful. Harness and controls were added one week postoperative. Upon discharge four weeks after surgery, the patient was using the terminal device and elbow lock in a satisfactory manner.</li></ol> <h3>Discussion</h3> <p>The absence of severe peripheral vascular disease in the upper extremities appears to increase the possibility of successful immediate postsurgical prosthetics fitting even above that seen in the lower extremities. Since weight-bearing is not a factor, the possibility of stump damage as a result of excessive pressures is minimized. In all four cases reported in this article, primary healing took place and there were no complications. Phantom pain was not encountered in any instance. The four patients were fitted with plaster temporary prostheses with conventional harness and controls and were instructed to operate the terminal device as early as the first postoperative day. The two wrist-disarticulation patients were allowed to move their elbows freely, and the two above-elbow patients were encouraged to move their shoulders as freely as possible. The psychological advantage of early rehabilitation has been apparent. Immediate postsurgical prosthetics fitting of the upper-extremity amputee appears to have significant advantages.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Preoperative view of a functionless and partially anaesthetic hand resulting from the bite of a rattlesnake. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Photograph taken 24 hours after wrist disarticulation and immediate postsurgical fitting of prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Metastatic lesion of right radius resulting from hypernephroma. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Berlemont, M., <i>Notre experience de I'appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck</i>, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec, 1961.</li> <li>Berlemont, M., <i>L'appareillage des ampulis des membres inferieurs sur le table d'operations, paper given at the International Congress of Physical Medicine</i>, Paris, 1964.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr.,<i> Management of lower-extremity amputees using immediate postsurgical Jilting techniques.</i> Prosthetic and Sensory Aids Service, U.S. Veterans Administration. 1967.</li> <li>Weiss, Marian, <i>Neurological implications of fitting artificial limbs immediately after amputation surgery</i>, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</li> <li>Wilson, A. Bennett, Jr., <i>New concepts in the management of lower-extremity amputees</i>, Artif. Limbs, Spring 1967, pp. 47-50.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Berlemont, M., Notre experience de I'appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec, 1961.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Berlemont, M., L'appareillage des ampulis des membres inferieurs sur le table d'operations, paper given at the International Congress of Physical Medicine, Paris, 1964.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Management of lower-extremity amputees using immediate postsurgical Jilting techniques. Prosthetic and Sensory Aids Service, U.S. Veterans Administration. 1967.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Weiss, Marian, Neurological implications of fitting artificial limbs immediately after amputation surgery, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., New concepts in the management of lower-extremity amputees, Artif. Limbs, Spring 1967, pp. 47-50.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>William F. Sinclair, C.P. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward M. Williams, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Newton C. McCollough, III, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Augusto Sarmiento, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_01_014/spring68b-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_01_014/spring68b-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_01_014/spring68b-03.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 Immediate Postsurgical Prosthetics Fitting in the Management of Upper-Extremity Amputees Creator An entity primarily responsible for making the resource Augusto Sarmiento, M.D. * Newton C. McCollough, III, M.D. * Edward M. Williams, M.D. * William F. Sinclair, C.P. * https://staging.drfop.org/files/original/7b8252c8f883f24af6692bb69c37688d.pdf 295a867a36ca94a6cf7d56daa6aa3e46 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_022.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 22 - 23 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/1967_02_022.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_022.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Need for Research in Surgical and Medical Considerations Dealing with Prosthetics and Orthotics</h2> <h5>George T. Aitken, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The discussion of the Panel on Surgical and Medical Considerations at a Conference on Prosthetics and Orthotics sponsored by the Committee on Prosthetics Research and Development was divided into two parts-those considerations dealing with prosthetics and those dealing with orthotics.</p> <h3>Prosthetics</h3> <p>Much fundamental work in the area of amputation surgery remains to be done, as briefly outlined in this article.</p> <h4>Indicators For Amputation</h4> <p>It is believed that the modern methods of amputee management may have made amputation a more desirable procedure now than some reconstructive procedures currently in use, and the entire field needs a comprehensive review.</p> <h4>Selection Of Level Of Amputation, Especially In Cases With Vascular Insufficiency</h4> <p>No reliable test for measurement of circulation in the extremities exists. As a result, it is the practice in many centers to amputate above the knee in virtually all cases with peripheral vascular disease. However, it has been shown that many times the knee joint can be saved even when standard tests indicate that the blood supply is apt to be insufficient. Objective tests of circulation coupled with surgical studies should result in more below-knee amputations and fewer above-knee amputations.</p> <h4>Sites Of Election Of Amputation</h4> <p>Although it is generally agreed that all length possible should be saved, a study should be made in which length of stump is correlated with function and comfort when current fitting practices are used.</p> <h4>Surgical Techniques</h4> <p>A comprehensive review of surgical techniques should be made. This should include special attention to the care of transected muscles.</p> <p>The advantages of end-bearing and how much should be carefully reviewed in order to determine whether different techniques, such as myoplasty, osteoplasty and nonviable implants, should be vigorously tested in order to obtain varying degrees of end-bearing. Muscles that must be transected may eventually be control points for externally powered devices and careful attention must be focused on the preservation of their optimal ability to provide control sources such as myoelectric signals or pure biomechanical motion.</p> <h4>Postsurgical Procedures</h4> <p><i>Rigid Postsurgical Dressing</i></p> <p>There was agreement that the application of a rigid dressing postsurgically is desirable. To achieve the best results consistently it is necessary to determine the range and distribution of pressures that bring about the best results. Techniques for achieving and maintaining proper pressure will then need to be developed. Included in this study, of course, will be the problems of suspension of the cast.</p> <p><i>Ambulation</i></p> <p>Studies of the effect of ambulation should be made. Included in such studies would be such factors as time to begin ambulation, the amount of weight-bearing that should be taken, and alignment.</p> <p><i>Effect of Immediate Postsurgical Fitting on Cases with Vascular Problems</i></p> <p>In the opinion of some, immediate postsurgical fitting permits amputation at a lower level than is the case with conventional procedures, but no data have been accumulated to substantiate this opinion. This should be investigated, because the presence of the "normal" knee joint permits meaningful function that cannot be approached with an artificial limb and provides a much better chance for rehabilitation measures to succeed.</p> <p><i>Immobilization of the Next Proximal Joint</i></p> <p>Although it is recognized that a study of the effect of immobilization of the next joint in the early stage of immediate postsurgical fitting is a part of the overall suspension problem, it was recommended that attention be given this matter.</p> <h4>The Phantom Sensation</h4> <p>Although a good deal of work has been carried out in the study of the phantom sensation, especially in reference to phantom pain, very little is understood about these phenomena. It is felt that attention should be continued in this area.</p> <h3>Orthotics</h3> <p>Out of a general discussion of the surgical and medical considerations in orthotics, three broad recommendations developed.</p> <ol> <li>There is an urgent need for the development of criteria for the design of bracing based on the biomechanical needs of patients. Perhaps a system of classification of disability based on biomechanics is not only the proper approach to criteria development but, when brace components are related to it, a sounder basis for prescription can be developed.</li><li>Little is known about the response of human tissues to the application of pressure, yet every function of an orthopaedic brace involves the application of pressure. Studies on the effect of pressure are needed before it is possible to determine the efficacy of certain treatment procedures, especially some of those for children.</li><li>Studies involving buried and partially buried implants for facilitating control of externally powered devices should be continued.</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>George T. Aitken, M.D. </b></td></tr><tr><td class="clsTextSmall">Orthopaedic surgeon, College Avenue Medical Building, 50 College Ave., S.E., Grand Rapids, Mich. 49503; Chairman, Subcommittee on Child Prosthetics Problems, Committee on Prosthetics Research and Development. Dr. Aitken served as Chairman of the Panel on Surgical and Medical Considerations of the Conference on Prosthetics and Orthotics.</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 Need for Research in Surgical and Medical Considerations Dealing with Prosthetics and Orthotics Creator An entity primarily responsible for making the resource George T. Aitken, M.D. * https://staging.drfop.org/files/original/fc94390daaecbf5fe0e515d25844a562.pdf addcea0ef5d054afe2d97b8b2ed7d402 https://staging.drfop.org/files/original/b63e79eeb63c71071d4e658053cf7453.jpg 7033f3a9ae76997cae29ba015bdf6e1a https://staging.drfop.org/files/original/c916255036e94916ce3f90294984788f.jpg ed7c60521a368679fe0866091d1ba7c5 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_017.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 17 - 19 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_01_017.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_017.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>Immediate Postsurgical Prosthetics Fitting of a Bilateral, Below-Elbow Amputee, a Report</h2> <h5>Edward Loughlin, M.D. <a style="text-decoration:none;">*</a><br />James W. Stanford, III, C.P. <a style="text-decoration:none;">*</a><br />Marcus Phelps, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The application of immediate postsurgical prosthetics fitting procedures in the management of lower-extremity amputees has been reported as providing a number of advantages, notably control of postsurgical edema, a marked reduction in pain, and a material reduction of the period of hospitalization. <a></a></p> <p>Although somewhat different considerations are involved in upper-extremity cases, immediate postsurgical prosthetics fitting of upper-extremity amputees is a logical progression in the application of these procedures. Upper-extremity amputations are considerably less frequent and are usually in a younger age group. Adequate wound healing is usually not a problem, local factors being the most important determinant. Still the application of a rigid dressing is a sound surgical concept.</p> <p>Unilateral amputees have a high rejection rate for actual use of their prostheses. It is believed that immediate postsurgical fitting of prostheses to upper-extremity amputees permits rehabilitation from the earliest possible moment and, hopefully, a higher acceptance rate. As used in this report, the term "immediate fitting" means the application of a rigid surgical dressing with terminal device at the time of surgery or in the immediate postoperative period. This is in contrast with "early fitting," which is applied at some time after the removal of sutures.</p> <p>During the past two years, the authors have had the opportunity to apply immediate prosthetics fittings to three patients, with four upper-extremity amputations. The case reported here is that of a bilateral, below-elbow amputee.</p> <h3>Case History</h3> <p>LMW, a 26-year-old employee of an electric power company, sustained electrical burns of both upper extremities on March 7, 1967, the result of receiving 19,000 volts of current through both wrists. One month later he was seen in the hospital by a consulting group (general surgeon, plastic surgeon, and orthopaedic surgeon) for consideration of possible reconstructive measures. It was the consensus of the group that no useful hand or part thereof could be salvaged (<b>Fig. 1</b>). As a result, on April 17, 1967, bilateral midforearm amputations were carried out. At the time of surgery extensive muscle necrosis was found-as expected- proximal to the apparent skin defect. This required loose closure of the amputations. Drains were placed in the wounds and compression dressings were applied. On April 20, 1967, the patient was returned to the operating room so that the wounds could be viewed, and they appeared to be clean. At this time rigid surgical dressings with terminal devices and harnessing were applied. From that time on, a marked improvement in the emotional status of the patient was noted (<b>Fig. 2</b>). The patient wore his temporary prostheses until May 26, 1967, when he was fitted with permanent prostheses. The patient made an excellent recovery, returning to full-time work in November 1967.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Neither the left nor the right hand was considered salvageable. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. From the time of the application of the rigid dressings and temporary prostheses, there was an upturn in the patient's emotional status. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Application of Temporary Prostheses</h3> <p>Some details in the application of the rigid dressings and temporary prostheses may be of interest.</p> <p>Autoclaved lamb's wool was applied over the suture lines, and Orion Spandex socks were then rolled into place and held under tension.</p> <p>To satisfy two somewhat conflicting considerations-that is, to ensure that the rigid surgical dressing would not be displaced when the patient flexed and extended his elbows, and to avoid immobilization of the elbow joint with plaster-Ace bandages were applied about 3 in. below the elbow and continued proximally to encase the elbow joint. Elastic plaster bandages were then applied, and the Ace bandages were incorporated into the plaster wrap. The plaster wrap extended to a point just below the condyles of the joint. Thus the rigid dressing was held in contact, and at the same time limited movement was permitted to the joint.</p> <p>Steel straps attached to WE-500 wrist units were then applied to the rigid dressing with regular plaster for reinforcement.</p> <p>A retainer plate riveted to an anchor plate was attached to the socket for cable attachment.</p> <p>A standard bilateral ring harness with plastic triceps pad and flexible leather hinges completed the setup.</p> <p>Two 5XA hooks were applied with one rubber band each.</p> <p>On April 25, 1967, sufficient atrophy had occurred to warrant new rigid dressings. The foregoing procedure was repeated. At this time, extra rubber bands were added to the terminal devices, and the patient demonstrated proficiency at a number of activities.</p> <p>On May 9, 1967, the second cast change was made, and a wrist-flexion unit was applied to the right side. Again, more rubber bands were applied.</p> <h3>Permanent Prostheses</h3> <p>"Definite prostheses" were prescribed for the patient on May 18, 1967. The prostheses were fabricated and subsequently fitted on May 26, 1967. The prescription included:</p> <ul> <li>Bilateral below-elbow plastic prostheses.</li> <li>Double-wall sockets.</li> <li>Flexible joints.</li> <li>5XA hooks.</li> <li>Dorrance No. 4 hands.</li> <li>Two wrist-flexion units.</li> <li>One driving ring.</li> <li>One button hook.</li> </ul> <p><b>References:</b></p> <ol> <li>Berlemont, M., <i>Notre experience de V appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck</i>, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec. 1961.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., <i>Management of lower-extremity amputees using immediate postsurgical fitting techniques</i>, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, 1967.</li> <li>Weiss, Marian, <i>Neurological implications of fitting artificial limbs immediately after amputation surgery</i>, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</li> <li>Wilson, A. Bennett, Jr., <i>New concepts in the management of lower-extremity amputees</i>, Artif. Limbs, Spring 1967, pp. 47-50.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Berlemont, M., Notre experience de V appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec. 1961.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Management of lower-extremity amputees using immediate postsurgical fitting techniques, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, 1967.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Weiss, Marian, Neurological implications of fitting artificial limbs immediately after amputation surgery, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., New concepts in the management of lower-extremity amputees, Artif. Limbs, Spring 1967, pp. 47-50.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Marcus Phelps, C.P. </b></td></tr><tr><td class="clsTextSmall">J. E. Hanger, Inc., of Georgia, 947 Juniper St., N.E., Atlanta, Ga. 30309.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 W. Stanford, III, C.P. </b></td></tr><tr><td class="clsTextSmall">J. E. Hanger, Inc., of Georgia, 947 Juniper St., N.E., Atlanta, Ga. 30309.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward Loughlin, M.D. </b></td></tr><tr><td class="clsTextSmall">Peachtree Orthopaedic Clinic, Atlanta, Ga. 30301</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_01_017/spring68c-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_01_017/spring68c-02.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 Immediate Postsurgical Prosthetics Fitting of a Bilateral, Below-Elbow Amputee, a Report Creator An entity primarily responsible for making the resource Edward Loughlin, M.D. * James W. Stanford, III, C.P. * Marcus Phelps, C.P. * https://staging.drfop.org/files/original/aee975bd01e173cadb6bd332d9927ed3.pdf d866aabd179e97ad8f259caadfd4f46d https://staging.drfop.org/files/original/cf7e5a1c10865c7a2f6801745802706f.jpg bfb079830381162d6ce2c95f6c3db913 https://staging.drfop.org/files/original/80177bdc2c6d01dcef1002642392393f.jpg b72fa1e2bc643d38e868474976fab946 https://staging.drfop.org/files/original/d61fadd50e79b7203cb643df570abb42.jpg 50e9ab54ca359ad9fdd2b19c36f7ff32 https://staging.drfop.org/files/original/cabb1a4acfdfba520a78a7dc281f59b0.jpg e6d1577d5fee57ef9520df78f3a2e50d https://staging.drfop.org/files/original/fa7e073d9826e1cc48df65128f65c987.jpg 4e64810dc51607824b7edfab6b000dba https://staging.drfop.org/files/original/cb3215048cf3a11c179f71432884353b.jpg 08d1ecaf1034507e7ae1bb4edb00e1dd https://staging.drfop.org/files/original/8cbb68c28d3f97aca81a578e0068b1b6.jpg 160e3c6521c277fc6bbfc22fb411ad60 https://staging.drfop.org/files/original/ed88f8904d06fe0b726da88a744ab157.jpg f6e276d8e77f1ef1a8b4164aea967c37 https://staging.drfop.org/files/original/499b2d14df818927c677e6ab81294bf3.jpg 8832e1d454749fcb34de722dc4763cd4 https://staging.drfop.org/files/original/f0db8d36bc5ab95237bdaf8b3f0774ad.jpg 00a77b4c33e9d587ebfb6657f4b2f634 https://staging.drfop.org/files/original/ffa5c106a3a94dc6f3ffba57275d427b.jpg 505850a92d9a616c370f7071f20a4962 https://staging.drfop.org/files/original/26a9bc87b04573a87b50af221f53a172.jpg 26d44ea9c02e9b1e215d3cc9777cbbe7 https://staging.drfop.org/files/original/83d1441b01dcdb73ab0174906f56b719.jpg f27a354f95c023f556c00e45b7da38c5 https://staging.drfop.org/files/original/f811aafb32502cadbb7ea0672580e37a.jpg 033ffb96764b132c3b786e618d38b8da https://staging.drfop.org/files/original/68652caa9997d995b4fa091cbbaff9f0.jpg fcf7b1acefad733dab4306d7139d21fc https://staging.drfop.org/files/original/6f10c8ec7cab2b8734bacc6b74dacf84.jpg e11fd3ddf35479f9b8a871e27886d182 https://staging.drfop.org/files/original/d8a9c69caa7a722e6c26cc46a47ca86f.jpg b59874d90b7c956ebbbb4b223045572b https://staging.drfop.org/files/original/78f9d8d11382034703a6765a230cd321.jpg 99cc18ad6bf2cc161fd7ec5e42b8b512 https://staging.drfop.org/files/original/557e4cce203fd0edcfa199807c18deef.jpg 6148afe4dbedeaeeeaefae592b2154bd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_02_001.pdf Year 1968 Volume 12 Issue 2 Page Number(s) 1 - 27 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_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_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>Recent Advances in Above-Knee Prosthetics</h2> <h5>A. Bennett Wilson, JR.. B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>During the past few years, many innovations have been introduced into the practice of above-knee prosthetics. Most of the literature on the new practices has been provided by the innovators, and therefore the reports and articles on the subject generally are limited to a single approach. It is the purpose of this article to survey past and present practices and to set forth, as accurately as possible, a perspective of procedures and devices available today for the management of the above-knee amputee.</p> <p>Amputation through the thigh results in distinct functional losses. The obvious ones are loss of support by the long bones and loss of joints, resulting in inability to stand and move extensively from place to place. In addition, the appearance of the patient becomes altered from the "normal" in both static and dynamic conditions.</p> <p>Lost support and mobility can be replaced to some extent by the use of a wheelchair or crutches or both, but it has been shown that use of an articulated prosthesis is the most effective means of compensating for these losses. An amputee with a functional prosthesis can negotiate stairs, ramps, and other obstacles and, therefore, can move through areas that would be impracticable if not impossible for a wheelchair. Crutches, properly used, offer a great deal of facility of movement but require the use of considerably more energy than a well-fitted and -aligned above-knee prosthesis, or even a peg leg. <a></a> Also, when crutches are used the hands are not free during ambulation. Another argument for the use of a functional prosthesis is that a fairly normal appearance can be achieved.</p> <p>The basic functional prosthesis for the above-knee amputee consists of a socket, a knee unit, a shank, and a foot-ankle unit. In cases where it is not deemed advisable to keep the socket in place by air pressure (suction socket), suspension must be provided by a belt about the pelvic area or by a shoulder harness.</p> <p>Not so many years ago it was common practice for the prosthetist to make in his shop nearly every part for a prosthesis from basic materials such as wood, steel, and leather. This practice was time-consuming and wasteful. To eliminate as much manual work as possible, the prosthetist today designs and fabricates the socket from basic materials to fit each patient individually, but uses prefabricated components, which he purchases from manufacturers, for the rest of the prosthesis. <a></a></p> <h3>Sockets</h3> <p> Until the introduction of the suction socket in the late 1940's. <a></a> it was common practice to provide the above-knee amputee with a so-called plug-fit socket suspended by a pelvic band connected to the socket by a metal "hip" joint (<b>Fig. 1</b>) <a></a> The plug fit did not provide for a very adequate distribution of forces between stump and socket. There was a tendency for the formation of an adductor roll, and the stability provided between stump and socket left much to be desired. The pelvic belt was heavy. The "hip" joint restricted motion essentially to flexion and extension, and was subject to frequent breakage. Most of the sockets were carved from willow wood and reinforced with rawhide, although sockets formed from aluminum sheet were not uncommon.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical prosthesis for above-knee amputees during the 1940's. Note pelvic band, mechanical "hip joint," carved wooden socket with a "plug fit," and pelvic-control knee joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The primary purpose of the suction socket (<b>Fig. 2</b>) was to provide increased function and comfort by eliminating the mechanical hip joint and pelvic belt. Pressures between the stump and socket were distributed over wider areas; stability and, therefore, control were improved materially. A socket of the quadrilateral shape <a></a> became standard whether or not suction was used for suspension. The waist belt and Silesian bandage were introduced as more comfortable suspension methods to supplant the pelvic belt and hip joint in some cases. Willow wood remained the material of choice, but plastic laminate (usually nylon stockinet impregnated with a polyester resin) replaced rawhide as a reinforcement material.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. An early version of the suction-socket prosthesis <i>(right), </i>shown in comparison to the so-called conventional above-knee prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Experience with problem cases, with the early versions of the suction socket in which a certain amount of air space is left below the distal end of the stump, led the University of California, Berkeley, to develop the modification now known as the total-contact above-knee socket (<b>Fig. 3</b>).<a></a> In a certain number of cases, edema developed in spite of most careful fitting with the "open-end" socket. It was found that the edema could be eliminated by providing a small amount of counter-pressure over the distal end. It was also found that the entire stump must be in contact with the socket in order to keep the circulatory system in balance. The introduction of counterpressure also reduced the unit pressures at the proximal region of the stump, and the contact over the end of the stump seemed to enhance proprioception.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. An above-knee prosthesis with a quadrilateral, total-contact socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To provide a well-fitting total-contact socket of wood requires a great deal of skill and is quite time-consuming compared with the use of plastic laminates. Plastic laminates, which had proven so useful in the fabrication and fitting of upper-extremity and below-knee prostheses, had not been used for above-knee sockets because of the difficulty encountered in obtaining an adequate cast for preparation of the positive model needed for molding the laminate. A few highly skilled prosthetists had been known to produce adequately formed casts using only their hands, but this achievement was exceptional. To solve this problem, several devices were developed so that casts of above-knee stumps that required a minimum amount of modification could be achieved.</p> <p>The UC-Berkeley device (<b>Fig. 4</b>) <a></a> uses a series of adjustable brims with which the cast is taken under weight-bearing conditions; the Veterans Administration Prosthetics Center device uses a three-part universal jig for holding the stump in position, also under weight-bearing conditions (<b>Fig. 5</b>); <a></a> the New York University casting fixture is a portable device that holds the cast in position but does not require the patient to be in a weight-bearing position (<b>Fig. 6</b>); <a></a> and Northwestern University has developed a modification of the UC-Berkeley technique in which a cast sock is used to suspend the stump and thus assist in forming the desired contours (<b>Fig. 7</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The fixture for the "brim-fitting" technique developed at the University of California Biomechanics Laboratory (San Francisco and Berkeley). Adjustable, easily interchangeable brims are available in a complete range of sizes. The view on the right shows attitude of patient in fixture; right leg is not shown for clarity. See <b>Fig. 7</b> for still another view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The fixture for casting the impression of an above-knee stump developed at the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anterior view of the New York University casting brim in use. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. A method, developed at Northwestern University, which uses the University of California casting fixture. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The object of each of these tools is exactly the same: to provide a cast of the above-knee stump that requires the least modification for the fabrication of a well-fitting, quadrilateral, total-contact socket. Each has its advantages and disadvantages. None is superior to the others in all aspects, and selection is based on the personal preferences of the prosthetist. Many facilities have two or even all three devices available for use as circumstances dictate.</p> <h4>Fitting And Alignment</h4> <p> The basic rationale of alignment as set forth by Radcliffe <a></a> in the early 1950's is essentially unchanged, although proper use of some of the hydraulic knee units demands some variations.</p> <p>In order to make it easier for the prosthetist to achieve optimum alignment, the University of California, Berkeley, developed the adjustable leg (<b>Fig. 8</b>) and alignment duplication jig (<b>Fig. 9</b>). <a></a> Dynamic alignment is obtained during amputee ambulation with the adjustable pylon, and the alignment obtained is transferred to the finished prosthesis during fabrication by use of the alignment duplication jig. This procedure proved to be highly satisfactory for use with single-axis, constant-mechanical-friction knee joints, since the adjustable leg also contained this type of joint. Because the functions of the Hydra-Cadence leg demanded that it be aligned somewhat differently, the STAROS-GARDNER coupling (<b>Fig. 10</b>) was designed. <a></a> When placed between the top of the knee block and the thigh piece or socket, the Staros-Gardner coupling provides all the adjustments permitted by the adjustable leg except mediolateral placement of the foot with respect to the knee axis, an adjustment not often used and, then, only to provide better cosmetic appearance. A technique was developed so that when final alignment was achieved a wooden block could be substituted for the coupling, thereby eliminating the need for the alignment duplication jig.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The adjustable above-knee leg developed by the University of California Biomechanics Laboratory (San Francisco and Berkeley). </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 alignment duplication jig developed by the University of California Biomechanics Laboratory (San Francisco and Berkeley) to be used in conjunction with the adjustable leg shown in <b>Fig. 8</b>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Staros-Gardner coupling being used to achieve alignment in an above-knee prosthesis. When the desired alignment has been achieved the coupling is replaced with a section of wood. A technique has been developed so that alignment can be maintained without need for the alignment duplication jig. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Components</h3> <p> Components for above-knee prostheses can be obtained from central manufacturers in a number of ways. The most common approach is to purchase "knee-shin set-ups" and foot-ankle units, and to connect these to each other and to the socket in the alignment best suited for the individual patient. The knee-shin set-up usually consists of a wooden knee block, the proximal portion of a hollow wooden shank, and a knee control mechanism (<b>Fig. 11</b>). Excess wood is provided so that the knee and shin can be individually contoured, and in the finished prosthesis the entire unit is reinforced structurally by the application of a plastic laminate over the exterior. Complete wooden set-ups are available, but are seldom used. However, when coordinated motion between knee and ankle is incorporated in the prosthesis, as in the Hydra-Cadence unit, a complete set-up is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical knee-shin wood set-up. <i>Courtesy U.S. Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of temporary, or preparatory prostheses, popularly known as "pylons," are available (<b>Fig. 12</b>). Usually these devices are used with an ordinary foot-ankle unit which can be incorporated into the final or definitive prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. "Pylons" for above-knee amputations. <i>Left, </i>U.S. Manufacturing Co.; <i>Center, </i>A. J. Hosmer Corp. unit based on the UCB adjustable leg; <i>Right, </i>VAPC unit designed to accommodate a variety of knee-control devices. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Knee Units</h3> <p> Probably no other component of artificial limbs has received as much attention from designers and "gadgeteers" as the knee joint. Several hundred patents have been issued for knee designs, and many types have been produced and offered to the public, but relatively few designs have been used widely.</p> <p>The primary functions of a knee unit for above-knee prostheses are control of the leg during standing and the stance phase of walking, and control of the shank during the swing phase of walking.</p> <p><i>Swing-Phase Control</i></p> <p>The articulated above-knee prosthesis functions as a compound pendulum. As the thigh stump is brought forward during the latter stages of stance phase, the knee begins to flex and the foot is lifted from the ground because of the effects of inertia. The force propelling the shank acts more or less horizontally through the knee joint, while the center of gravity of the shank is well below this level; thus a moment is created, resulting in rotation of the shank about the knee joint in a backward direction (<b>Fig. 13</b>). <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Forces developed during rotation of the shank about the knee joint during forward swing of the thigh. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The less friction there is in the joint, the higher will be the rise of the heel for any given acceleration. Therefore, when a nearly frictionless joint is used, the amputee must use very short steps at a low cadence, so that the shank and foot will return to the proper fully extended position to support him as stance phase is begun. If friction, or some other form of resistance, is introduced, rise of the heel is restrained and shank motion toward full extension is retarded, so that longer steps at higher cadences are possible. When the amount of friction is constant, only one best speed is available to the patient. To overcome this limitation, designers have turned to hydraulic and pneumatic devices to obtain desirable resistance.</p> <p>To guide the design of swing-phase control units, the University of California has plotted knee moments against time for the ideal prosthesis during swing phase (<b>Fig. 14</b>). <a></a> This diagram is based on data accumulated from four normal young males, allowances being made for weight and weight distribution between normal and artificial limbs. The values, of course, will change as cadence is varied and as the height and weight distribution are changed. However, the general pattern should not change.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Knee-moment pattern required for natural swing of an artificial leg. This curve was developed by the University of California Biomechanics Laboratory based on data collected during the study of human locomotion. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Constant Friction (Mechanical)</i></p> <p>Constant friction in a way is a misnomer, because the amount of friction or restraint can be controlled or set, but does not vary in accordance with the needs of the amputee during a given cycle. The amount of friction can be controlled in a number of ways, the most common being the application of a braking surface to the peripheral area of the knee bolt (<b>Fig. 15</b>). The typical knee-moment diagram for a constant-friction knee unit is shown in <b>Fig. 16</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. One type of constant-friction single-axis knee joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Knee-moment patterns of various swing-phase units in comparison with the ideal curve of <b>Fig. 14</b>. Data were taken at the Veterans Administration Prosthetics Center. The knee units were adjusted for intermediate resistance, and were subjected to 43 cycles per min. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Intermittent Friction</i></p> <p>To more closely approximate the ideal knee-moment diagram, several designs have been made to vary the amount of mechanical friction applied at predetermined points during the swing phase. The Northwestern University Intermittent-Friction Knee Unit (<b>Fig. 17</b>) is one such device that is available commercially. Mechanical friction is provided by pressure between three disks mounted concentrically with the long axis of the knee bolt. The resistance offered by each individual disk is brought into play at varying intervals during the swing phase. The knee-moment diagram of the Northwestern University unit is shown in <b>Fig. 16</b>. The unit is available in a wood set-up, and is delivered with three disks installed. Two additional disks of different configurations are provided for interchange with the regular disks, so that the pattern of resistance about the knee can be changed to suit the amputee on an individualized basis. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Intermittent-Friction Knee Unit developed at Northwestern University, installed in a wood set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Hydraulic Swing-Phase Control Units</i></p> <p>Because the resistance offered by an orifice to the flow of a fluid increases at a greater rate than the increase in velocity of the fluid, hydraulic systems are ideally suited for control of the shank during swing phase. Thus, heel rise and terminal deceleration can be controlled automatically over a wide range of cadences, giving the amputee much more flexibility in speed of ambulation. <a></a> The value to be obtained by applying these principles has been recognized for many years, but a good deal of engineering was required to develop units that met the exacting demands of limb prosthetics. <a></a></p> <p>The Henschke-Mauch Model "B" unit (<b>Fig. 18</b>) is a very sophisticated device available in a wood set-up to make its use compatible with standard components and practices. A number of orifices are so incorporated into the cylinder wall that the moving piston successively blocks off escape of the fluid and thus varies the resistance throughout the swing phase in order to approximate the ideal moment curve (<b>Fig. 16</b>). Resistance to flexion and to extension may be adjusted independently of each other by the wearer.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. The Henschke-Mauch "Hydraulik" Knee Unit. <i>Left, </i>Unit installed in a wood set-up; <i>Right, </i>cross-section of the Model "B" (Swing-Phase) Unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In a clinical evaluation program conducted by the Veterans Administration, involving more than 30 test subjects, the results were overwhelmingly in favor of the Henschke-Mauch unit in comparison with mechanical friction devices previously worn by the amputees in the study. <a></a></p> <p>The ability to vary gait easily and a reduction in effort required and fatigue produced were the advantages most frequently cited. The last two advantages are particularly noteworthy, since the experimental prostheses were heavier than the prostheses worn previously.</p> <p>The DuPaCo "Hermes" Knee (<b>Fig. 19</b>) is quite similar in design and function to the Henschke-Mauch Model "B" unit and is also available in a wood set-up. Resistance to flexion and to extension may be adjusted independently of each other by the amputee. A clinical study of the DuPaCo knee by the Veterans Administration resulted in very positive reactions, strikingly similar to those obtained in the study with the Henschke-Mauch Model "B" unit. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. DuPaCo "Hermes" Hydraulic Swing-Phase Control Unit mounted in a wood set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Unlike the Henschke-Mauch and DuPaCo units, the "Hydra-Cadence" hydraulic leg (<b>Fig. 20</b>) is an integrated system incorporating some ankle control as well as swing-phase control. This system is available only in a metal frame, with a specially designed foot-ankle assembly. For appearance, the metal frame that constitutes the shank is covered with a cosmetic cover of a relatively thin, semirigid plastic cast to resemble an average normal shank. The swing-phase unit is a relatively simple piston type and does not offer quite as precise control of function as the more sophisticated units. In addition to control of the shank during swing phase, resistance to plantar flexion is controlled hy-draulically, and motion between the ankle and knee are coordinated so that dorsi-flexion of the ankle takes place after the knee has been flexed 20 deg. The object of the coordinated motion feature was to provide additional toe clearance during the swing phase, but unfortunately the motion does not take place at the time when it is needed most. Nevertheless, as in many other instances, the side effects are highly useful. One advantage of coordinated motion appreciated by amputees is that during sitting dorsiflexion of the foot allows the wearer to draw his artificial foot comfortably under his knee, thus keeping it out of the way when he is seated in a theater or bus. In clinical tests conducted by the Veterans Administration, the overwhelming majority of test subjects preferred the "Hydra-Cadence" unit to their conventional limbs. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. "Hydra-Cadence" Artificial Leg with cosmetic cover removed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The swing-phase control system of the "Hydra-Cadence" unit is offered in a wood set-up or separately for use in a pylon as the "Hydra-Knee" (<b>Fig. 21</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. "Hydra-Knee" installed in a wood set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the problems of leakage and high maintenance costs have been overcome to a point where hydraulic devices are practical, pneumatic systems also have appeal since manufacturing costs should be materially lower. Pneumatic systems are not apt to produce a knee-moment curve as smooth as those obtained with hydraulic units, but many feel that they offer an excellent compromise suitable for many amputees.</p> <p>One such device nearly ready for commercial distribution is the University of California Pneumatic Swing-Phase Unit. <a></a> Like the Henschke-Mauch and DuPaCo units, the UCB device consists essentially of a moving piston in a cylinder (<b>Fig. 22</b>). It will be available initially in a pylon-type shank and wooden knee block.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Pneumatic Swing-Control Unit developed at the Biomechanics Laboratory, University of California (San Francisco and Berkeley). <i>Left, </i>Cutaway view; <i>Center, </i>complete unit; <i>Right, </i>pylon and cosmetic cover designed especially for the pneumatic unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Stance-phase Units</h3> <p>Increased understanding of fitting and alignment has alleviated many of the former problems of stability control of the leg during stance phase, especially for those patients with relatively strong stumps. Nevertheless, there appears to be a real need for knee units that provide assurance against buckling yet do not interfere with other functions of the leg. The increase in the number of "geriatric" patients in recent years has tended to highlight this need. Patents have been granted for many ways of stabilizing the knee, but few have been found practical. Doubtless the most widespread stance-phase control device in use today is the Otto Bock knee (<b>Fig. 23</b>). Purely mechanical in action, the Bock knee provides resistance to flexion by a friction braking action effected by weight-bearing. When weight is placed on the prosthesis, the knee block moves slightly toward the shank to engage a "V"-type brake. Swing-phase control consists of constant friction and a spring-biased extensor mechanism.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. The Otto Bock Safety Knee Unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Henschke-Mauch Model "A" unit (<b>Fig. 24</b>), currently in an advanced experimental stage, consists essentially of the Model "B" unit (<b>Fig. 18</b>) with provisions for stance-phase control added. Braking of the knee joint is controlled by the complex interaction of a pendulum and a counterweight suspended in hydraulic fluid. <a></a> The braking action is brought into play whenever required to arrest buckling action, and is removed only by the prolonged hyperextension moment typical of late stance phase, so theoretically there should be a smoother transition between stance phase and swing phase than that provided by other units. Moreover, for special tasks, the amputee can set the knee either in "freewheeling" or almost fully locked position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Henschke-Mauch "Hydraulik" Model "A" (Swing and Stance Control) Unit. <i>1, </i>Cylinder; <i>2. </i>piston; <i>3, </i>piston rod; <i>4, </i>hydraulic fluid; 5<i>, </i>accumulator piston; <i>6, </i>dashpot; 7, dashpot piston; <i>8, </i>control bushing; <i>9, </i>swing adjustment screw; <i>10 </i>and <i>11</i>. check valves; <i>12 </i>and <i>13. </i>channels: <i>14, </i>pendulum; <i>15, </i>valve; <i>16, </i>counterweight; <i>17, </i>spring; <i>18, </i>stance adjustment screw; <i>19, </i>selector switch. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A clinical evaluation by the Veterans Administration involving 50 units has nearly been completed. It is expected that the Henschke-Mauch Model "A" unit will be available for general use in the near future.</p> <h3>Foot-ankle Units</h3> <p> Many attempts have been made to develop foot-ankle units that offer more than the minimum function required, which is controlled plantar flexion. Through the years several designs have been manufactured and made available, but none has found widespread use, usually because the maintenance requirements of the units have outweighed any functional gain they offered. Thus, today, nearly every artificial leg (except the "Hydra-Cadence") incorporates either a SACH (solid-ankle cushion-heel) foot (<b>Fig. 25</b>) or a so-called conventional foot (<b>Fig. 26</b>). Both designs provide controlled resistance to plantar flexion, firm resistance to dorsi-flexion, and limited toe motion, but little else. Resistance to plantar flexion can be adjusted more easily in the conventional foot by introducing rubber bumpers of different densities. The absence of parts in the SACH foot which rotate or rub and its resistance to moisture make its use attractive. Since its introduction in 1958, the design of the SACH foot has been refined in a number of ways. Initially the SACH foot was made by laminating layers of foam rubber around a wooden keel. Later, techniques for molding the rubber were developed and most units are manufactured in this manner. However, the laminated type is available for special applications where shaping to unusual sizes and configurations is required.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. The SACH (solid-ankle, cushion-heel) Foot. <i>Upper, </i>Laminated type; <i>Lower, </i>molded type. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Cross-section of a typical "conventional" foot-ankle unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Very recently, a special SACH foot has been made available by Kingsley Manufacturing Co. for use in immediate postsurgical fitting procedures (<b>Fig. 27</b>). This version has a flat, wide sole designed for use without a shoe while the patient is in the hospital. This permits equal leg length when the natural foot of the patient is bare or is covered simply with a sock or slipper. It is also about 20 per cent lighter than the conventional SACH foot, and resistance to toe break is less.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Special SACH foot for use in immediate postsurgical fitting procedures. <i>Courtesy Kingsley Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Veterans Administration Prosthetics Center is responsible for updating the specifications for the SACH foot, and makes periodic checks of mass-produced units on a random basis.</p> <p>At the present time, development of a more functional foot-ankle unit using hydraulic principles is under way.</p> <table> <tbody><tr><td> <h3><i>Definitions</i></h3></td> </tr> <tr><td> <p><i>Preparatory Prosthesis</i></p> </td> </tr> <tr><td> <p>A cosmetically unfinished functional replacement for an amputated extremity, fitted and aligned in accordance with sound biomechanical principles, which is worn for a limited period of time to expedite prosthetic wear and use and to aid in the evaluation of amputee adjustment.</p> </td> </tr> <tr><td> <p><i>Pylon</i></p> </td> </tr> <tr><td> <p>A rigid supporting member, usually tubular, that is attached to the socket or knee unit of a prosthesis. The lower end of the pylon should be connected to a foot-ankle assembly.</p> </td> </tr> <tr><td> <p><i>Rigid Dressing</i></p> </td> </tr> <tr><td> <p>A plaster stump wrap, usually applied in the operating or recovery room immediately following operation, for the purpose of controlling edema and pain. It is preferably shaped in accordance with the basic patellar-tendon-bearing (PTB) or quadrilateral designs, but is not necessarily so.</p> </td> </tr> <tr><td> <p><i>Immediate Postsurgical Prosthetic Fitting</i></p> </td> </tr> <tr><td> <p>A procedure wherein a functional socket, designed for weight bearing and walking, is fitted to the patient immediately after operation in the operating or recovery room, or at some time prior to removal of sutures. As distinct from the rigid dressing, referred to above, this socket should be shaped in accordance with the basic PTB or quadrilateral design; it incorporates provision for easy attachment and detachment of a pylon and foot-ankle assembly.</p> </td> </tr> <tr><td> <p><i>Early Prosthetic Fitting</i></p> </td> </tr> <tr><td> <p>A procedure wherein a preparatory prosthesis, as defined above, is provided for the amputee immediately following removal of sutures.</p> </td> </tr> <tr><td> <p><i>Permanent Prosthesis</i></p> </td> </tr> <tr><td> <p>A replacement for a missing limb, which meets accepted checkout standards for comfort, fit, alignment, function, appearance, and durability.</p> </td> </tr> </tbody></table> <h3>Pylons</h3> <p> Recently a number of devices known as pylons have been developed to meet the requirements imposed by immediate and early postsurgical fitting, namely, functional devices that contain built-in alignment features but are light enough for use throughout the day. Also, devices used in fitting immediately postoperatively should be easily removable from the socket so that the device may be disconnected when the patient is sleeping. Provision for locking the knee joint manually is desirable for use with infirm patients.</p> <p>The Hosmer Above-Knee Temporary Leg (<b>Fig. 28</b>) is a modification of the adjustable leg originally designed by the University of California Biomechanics Laboratory for alignment adjustment during walking trials.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. The Hosmer Above-Knee Temporary Leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The U.S. Manufacturing Co. above-knee constant-friction pylon (<b>Fig. 29</b>) is simple, is light in weight, and provides all adjustments necessary in aligning a leg. However, the wedge disks used to change the adduction-abduction and flexion-extension attitudes of the socket require compensatory adjustments to maintain position in one while the other is changed. Hence some degree of skill in using this unit is required.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. The U.S. Manufacturing Co. Above-Knee Constant-Friction Pylon. The expanded metal straps at the top are provided for use with plaster-of-Paris sockets. <i>Courtesy U.S. Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The U.S. Manufacturing Co. also provides an above-knee temporary prosthesis with the "Hydra-Knee" unit installed (<b>Fig. 30</b>). Alignment adjustment is provided in the same manner as in the above-knee unit shown in <b>Fig. 29</b>. Cosmetic covers similar to those used with "Hydra-Cadence" units are available.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. The Hydra-Knee Pylon. <i>Courtesy U.S. Manufacturing Co.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To provide for independent adjustment in the adduction-abduction and flexion-extension planes, the Veterans Administration Prosthetics Center designed a unit (<b>Fig. 31</b>) in which threaded "disks" are used to provide a wedging action between two conical surfaces placed apex to apex. This device is incorporated in the VAPC "Standard" above-knee pylon which permits the interchange of several knee mechanisms including various constant friction knees, the DuPaCo swing-control unit, both of the Henschke-Mauch knee units, and the UCB pneumatic device. This very desirable interchangeability feature permits the patient to try out a number of swing-control devices at a minimum cost.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Pylon developed at the Veterans Administration Prosthetics Center. This unit will accommodate a number of different standard mechanisms for control of the knee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is feasible and practical to use any of these prostheses for indefinite periods. Thus, changes in alignment can be made if they are needed. A comparison of the major features and characteristics of the various pylons is given in <b>Table 1</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Use of the Prosthetics Research Study (Seattle) casting fixture to form socket in fitting above-knee case with prosthesis immediately after operation. <i>Courtesy Prosthetics Research Study, Seattle, Wash.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Time of Fitting</h3> <p> From time to time through the years, a few clinicians have argued for fitting new amputees with temporary or "training" limbs, either for acceleration of the rehabilitation process or to evaluate the patient's potential for use of a prosthesis if there is doubt about his ability to use one. No one argued against this approach provided the temporary limb was properly fitted and aligned. However, when fitting was done before the stump had stabilized the frequent socket changes that were necessary resulted in high costs. If poorly fitted and aligned prostheses were used, more harm than good could result.</p> <p>The introduction of improved casting methods, improved fabrication techniques, and adjustable pylons led the Orthopaedic Department at Duke University to conduct a series of experiments, beginning about 1960, in which it was demonstrated that it is feasible and, indeed, desirable to fit amputees as soon as the wound has healed. <a></a> In 1963, several groups in the United States began experimenting with the concept of fitting the patient immediately after operation and allowing some degree of ambulation very soon thereafter, a technique that had achieved some success in a rather crude way in France and Poland.<a></a></p> <p>By 1967 the technique had been developed in sufficient detail at the Prosthetics Research Study, Seattle, Washington, and experience with experimental cases was such that it seemed warranted to offer special courses in the Prosthetics Education Program in immediate postsurgical fitting of prostheses. The technique applies to all levels of lower-extremity amputation. Experience has shown that the formation of edema is materially reduced, postoperative pain is reduced, development of contractures is avoided, stump bandaging is unnecessary, and the general well-being of the patient is better than when he is treated in the conventional manner. The procedure obviously reduces both time of hospitalization and time required for rehabilitation, and it is appropriate for use in virtually all types of cases except where an open amputation is indicated. More time is required by the surgeon and prosthetist in the management of the patient during the first two weeks, but substantial savings are effected in the over-all treatment program.</p> <p>For the above-knee case, immediate postsurgical fitting consists essentially of providing the patient with a quadrilateral total-contact socket of plaster-of-Paris bandage (<b>Fig. 32</b>) and an easily detachable functional pylon, allowing him to begin weight-bearing about 24 hours after amputation (<b>Fig. 33</b>). No special surgical techniques are needed. Myoplasty, consisting of some method to ensure reattachment of the cut muscles about the thigh, is recommended in any case. <a></a> The cast-socket is left in place for 8 to 12 days, at which time the sutures can usually be removed. A new cast socket is applied immediately and is kept in place until measurements and a cast can be made for the definitive prosthesis, usually 10 to 12 days later. If some other condition precludes the patient from walking, a rigid dressing of plaster of Paris should be used, rather than conventional dressings, to keep formation of edema to a minimum and thus provide a stump that will cause the pros-thetist less trouble.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Above-knee amputation patient fitted with a prosthesis immediately after amputation. <i>Courtesy Prosthetics Research Study, Seattle, Wash.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Immediate postsurgical fitting and early fitting have been very successful in the hands of competent surgeon-prosthetist teams, and are routine procedures in many centers today. Research in this area is continuing in order to refine the methods still further.</p> <h3>Above-Knee Prosthetics for Children</h3> <p> Amputation in children can be classified as either acquired or congenital. The acquired amputation is the result of trauma or of disease, usually a malignant tumor. The congenital type is the result of a malformation occurring during embryonic development.</p> <p>Management of the acquired amputation in children is essentially the same as that for the adult. Because wounds in children tend to heal faster than they do in adults, immediate postsurgical fitting and early fitting techniques are most appropriate. Usually care must be taken to keep the child patient from being too active. The quadrilateral, total-contact, plastic, suction socket is nearly always indicated. A Silesian bandage may be used, but is usually not needed. For patients below the age of puberty, the only knee unit available is the constant-friction type. SACH and conventional feet are available in sizes suitable for children of all ages.</p> <p>Children with congenital malformations of the lower extremities usually offer a greater challenge. Many times the stump and proximal anatomy are abnormal in structure, and these features must be taken into account in design of the socket and suspension. For guidelines and suggestions for treatment of unusual and bizarre cases, the reader is referred to <i>The Limb-Deficient Child</i>. <a></a></p> <p>For the high, bilateral above-knee case where conventional above-knee or knee-disarticulation prostheses are not suitable, <i>i.e., </i>the patient is unable to use crutches, the use of the swivel walker is recommended (<b>Fig. 34</b> and <b>Fig. 35</b>). <a></a> Designed at the Ontario Crippled Children's Centre for use by patients with severe involvement of all four limbs, the swivel walker has met with success wherever it has been used. Motion is effected by displacement of the center of gravity of the body. Although movement is restricted to smooth, level surfaces, the swivel walker offers an effective means of mobility, and the psychological benefits to be gained from it are quite rewarding.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Principle of the "Swivel Walker" developed at the Ontario Crippled Children's Centre, Toronto, Canada, for very high, bilateral, lower-extremity cases. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. The OCCC swivel walker with articulated joints that permit a sitting position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Above-Knee Prosthetics for Geriatric Cases</h3> <p> At one time it was an almost universal rule to amputate through the thigh in cases of peripheral vascular disease when limb ablation was indicated. However, since it has been shown that many knee joints can be saved in spite of what appear to be overwhelming odds, the ratio of above-knee to below-knee amputations is decreasing. Unfortunately, however, there will always be a certain number of above-knee cases.</p> <p>Immediate postsurgical and early fitting practices should be used whenever possible. Proper use of these procedures reduces the mortality rate drastically and permits the fitting of definitive prostheses considered impossible, or at least impractical, only a few years ago. The use of provisional prostheses permits the clinic team to determine, without question, whether or not a definitive prosthesis is indicated. The VAPC "Standard" AK Pylon permits experimentation with several hydraulic units as well as with mechanical friction knee control.</p> <p>In spite of the many useful innovations that have been introduced into the practice of above-knee prosthetics through the years, there is still room for further improvement. Among the developments needed are more foolproof methods of obtaining optimum fit and alignment. Sockets that can be adjusted to meet the constantly changing cyclical demands of the amputee are certainly desirable and possible. Indeed, it might be feasible to provide a socket that is adjusted automatically to meet the needs of the patient constantly throughout the day. In any event, studies of the effect of pressure on human tissues must lead eventually to a better application of limb prostheses.</p> <p>Needed also are methods for fitting and fabrication of limbs in even less time than is presently required. Materials that can be formed at temperatures safe to human tissues are now becoming available, and it is hoped that a useful socket can be molded over the stump, eliminating the need for plaster of Paris in taking impressions and making models of the stump. Such a technique, when used with adjustable pylons that are cheap enough and light enough to leave as the "permanent" prosthesis, should permit fast, economical service.</p> <p>Concurrently with studies designed to point the way to more functional prostheses and more efficient service, a number of surgeons are studying and trying to devise methods for providing more functional stumps. In recent years the techniques of amputation have taken on more significance in the minds of surgeons and, consequently, prosthetists have been seeing stumps that are more functional than has been the case in the past. Further research and a continuation of educational programs should result in even more improvement.</p> <h3>Acknowledgment</h3> <p>Special appreciation is due the Prosthetic and Sensory Aids Service of the Veterans Administration for providing nearly all of the illustrations for this article.</p> <p><b>References:</b></p> <ol> <li>Anderson, M. H., J. J. Bray, and C. A. Hennessy,<i>The construction and fitting of lower-extremity prostheses</i>, Chap. 6 in Orthopaedicappliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 263-312.</li> <li>Bard, Gregory, and H. J. Ralston, <i>The measurment of energy expenditure during ambulation, with special reference to evaluation of assistive devices</i>, Arch. Phys. Med., 40:415-420, October 1959.</li> <li>Blakeslee, Berton, ed.,<i>The limb-deficient child</i>, University of California Press, Berkeley and San Francisco, 1963.</li> <li>Burgess, E. M., J. E. Traub, and A. B. Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower extremity amputees</i>, Veterans Administration, Washington, D.C., 1967.</li> <li>Foort, J.,<i> Adjustable-brim fitting of the total-contact above-knee socket</i>, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 50, March 1963.</li> <li>Foort, J., and N. C. Johnson, <i>Edema in lower-extremity amputees</i>, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 1962.</li> <li>Golbranson, F. L., Charles Asbelle, and Donald Strand,<i> Immediate postsurgical fitting and early ambulation</i>, Clin. Orth., 56:119-131, 1968.</li> <li>Goldner, J. Leonard, Frank W. Clippinger, Jr., and Bert R. Titus, <i>Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis</i>, Final Report of Project 1363 to (U.S.)</li> <li>Vocational Rehabilitation Administration by Duke University Medical Center, Durham, N.C., 1967. 9. Haddan, Chester C, and Atha Thomas,<i> Status of the above-knee suction socket in the United States</i>, Artif. Limbs, 1:2:29-39, May 1954.</li> <li>Hampton, Fred, <i>Suspension casting for below-knee, above-knee, and Syme's amputations</i>, Artif. Limbs, 10:2:5-26, Autumn 1966.</li> <li>Hanger, H. B.,<i>Above-knee socket shape and clinical considerations</i>, Committee on Pros-thetic-Orthotic Education, National Research Council, August 1964.</li> <li>Kay, Hector W., K. A. Cody, and H. E. Kramer, <i>Total contact above-knee socket studies</i>, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, June 1966.</li> <li>Lewis, Earl A., <i>Fluid controlled knee mechanisms, clinical considerations</i>, Bull. Pros. Res., 10:3:24-56, Spring 1965.</li> <li>Motloch, W. M., and Jane Elliott, <i>Fitting and training children with swivel walkers</i>, Artif. Limbs, 10:2:27-38, Autumn 1966.</li> <li>Murphy, E. F., <i>The swing phase of walking with above-knee prostheses</i>, Bull. Pros. Res., 10:1:5-39, Spring 1964.</li> <li>Murphy, Eugene F., <i>Lower-extremity components</i>, Chap. 5 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</li> <li>Radcliffe, C. W., <i>Functional considerations in the fitting of above-knee prostheses</i>, Artif. Limbs, 2:1:35-60, January 1955.</li> <li>Radcliffe, C. W.,<i> Biomechanical design of an improved leg prosthesis</i>, Biomechanics Laboratory, University of California, Berkeley, Ser. 11, Issue 33, October 1957.</li> <li>Radcliffe, C. W., and H. J. Ralston, <i>Performance characteristics of fluid-controlled prosthetic knee mechanisms</i>, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 49, February 1963.</li> <li>Staros, Anthony, <i>Dynamic alignment of artificial legs with the adjustable coupling</i>, Artif. Limbs, 7:1:31-43, Spring 1963.</li> <li>Staros, Anthony, and Eugene F. Murphy, <i>Properties of fluid flow applied to above-knee prostheses</i>, Bull. Pros. Res., 10:1:40-65, Spring 1964.</li> <li>Staros, Anthony, and Edward Peizer, <i>Northwestern University intermittent mechanical friction system (disk-type)</i>, Artif. Limbs, 9:1:45-52, Spring 1965.</li> <li>Thomas, Atha, and C. C. Haddan, <i>Amputation prosthesis</i>, Lippincott, Philadelphia, Pa., 1945.</li> <li>Veterans Administration, Prosthetic and Sensory Aids Service, <i>Clinical application study of the Hydra-cadence above-knee prosthesis</i>, TR-2, Nov. 1, 1963.</li> <li>Veterans Administration, Prosthetic and Sensory Aids Service, <i>Clinical application study of the Henschke-Mauch "Hydraulik" swing control system</i>, TR-3, Dec. 1, 1964.</li> <li>Veterans Administration, Prosthetic and Sensory Aids Service, <i>Clinical application study of the DuPaCo "Hermes" hydraulic control unit</i>, TR-4, Jan. 4,1965.</li> <li>Wilson, A. Bennett, Jr., <i>New concepts in the management of lower-extremity amputees</i>, Artif. Limbs, 11:1:47-50, Spring 1967.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Motloch, W. M., and Jane Elliott, Fitting and training children with swivel walkers, Artif. Limbs, 10:2:27-38, Autumn 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Blakeslee, Berton, ed.,The limb-deficient child, University of California Press, Berkeley and San Francisco, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Burgess, E. M., J. E. Traub, and A. B. Wilson, Jr., Immediate postsurgical prosthetics in the management of lower extremity amputees, Veterans Administration, Washington, D.C., 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Burgess, E. M., J. E. Traub, and A. B. Wilson, Jr., Immediate postsurgical prosthetics in the management of lower extremity amputees, Veterans Administration, Washington, D.C., 1967.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Golbranson, F. L., Charles Asbelle, and Donald Strand, Immediate postsurgical fitting and early ambulation, Clin. Orth., 56:119-131, 1968.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., New concepts in the management of lower-extremity amputees, Artif. Limbs, 11:1:47-50, Spring 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Goldner, J. Leonard, Frank W. Clippinger, Jr., and Bert R. Titus, Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis, Final Report of Project 1363 to (U.S.)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Murphy, E. F., The swing phase of walking with above-knee prostheses, Bull. Pros. Res., 10:1:5-39, Spring 1964.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Staros, Anthony, and Eugene F. Murphy, Properties of fluid flow applied to above-knee prostheses, Bull. Pros. Res., 10:1:40-65, Spring 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Veterans Administration, Prosthetic and Sensory Aids Service, Clinical application study of the Hydra-cadence above-knee prosthesis, TR-2, Nov. 1, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Veterans Administration, Prosthetic and Sensory Aids Service, Clinical application study of the DuPaCo 'Hermes' hydraulic control unit, TR-4, Jan. 4,1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Veterans Administration, Prosthetic and Sensory Aids Service, Clinical application study of the Henschke-Mauch 'Hydraulik' swing control system, TR-3, Dec. 1, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Lewis, Earl A., Fluid controlled knee mechanisms, clinical considerations, Bull. Pros. Res., 10:3:24-56, Spring 1965.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Staros, Anthony, and Eugene F. Murphy, Properties of fluid flow applied to above-knee prostheses, Bull. Pros. Res., 10:1:40-65, Spring 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and H. J. Ralston, Performance characteristics of fluid-controlled prosthetic knee mechanisms, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 49, February 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Staros, Anthony, and Edward Peizer, Northwestern University intermittent mechanical friction system (disk-type), Artif. Limbs, 9:1:45-52, Spring 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Biomechanical design of an improved leg prosthesis, Biomechanics Laboratory, University of California, Berkeley, Ser. 11, Issue 33, October 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Biomechanical design of an improved leg prosthesis, Biomechanics Laboratory, University of California, Berkeley, Ser. 11, Issue 33, October 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>15.</b> </td><td class="clsTextSmall">Murphy, E. F., The swing phase of walking with above-knee prostheses, Bull. Pros. Res., 10:1:5-39, Spring 1964.</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Staros, Anthony, Dynamic alignment of artificial legs with the adjustable coupling, Artif. Limbs, 7:1:31-43, Spring 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Staros, Anthony, Dynamic alignment of artificial legs with the adjustable coupling, Artif. Limbs, 7:1:31-43, Spring 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Functional considerations in the fitting of above-knee prostheses, Artif. Limbs, 2:1:35-60, January 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Hampton, Fred, Suspension casting for below-knee, above-knee, and Syme's amputations, Artif. Limbs, 10:2:5-26, Autumn 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Kay, Hector W., K. A. Cody, and H. E. Kramer, Total contact above-knee socket studies, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, June 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Kay, Hector W., K. A. Cody, and H. E. Kramer, Total contact above-knee socket studies, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, June 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 50, March 1963.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Kay, Hector W., K. A. Cody, and H. E. Kramer, Total contact above-knee socket studies, Prosthetic and Orthotic Studies, Research Division, NYU School of Engineering and Science, June 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 50, March 1963.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Foort, J., and N. C. Johnson, Edema in lower-extremity amputees, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hanger, H. B.,Above-knee socket shape and clinical considerations, Committee on Pros-thetic-Orthotic Education, National Research Council, August 1964.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Functional considerations in the fitting of above-knee prostheses, Artif. Limbs, 2:1:35-60, January 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Thomas, Atha, and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, Pa., 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Vocational Rehabilitation Administration by Duke University Medical Center, Durham, N.C., 1967. 9. Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artif. Limbs, 1:2:29-39, May 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Anderson, M. H., J. J. Bray, and C. A. Hennessy,The construction and fitting of lower-extremity prostheses, Chap. 6 in Orthopaedicappliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 263-312.</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960, pp. 129-261.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Bard, Gregory, and H. J. Ralston, The measurment of energy expenditure during ambulation, with special reference to evaluation of assistive devices, Arch. Phys. Med., 40:415-420, October 1959.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and H. J. Ralston, Performance characteristics of fluid-controlled prosthetic knee mechanisms, Biomechanics Laboratory, University of California, San Francisco and Berkeley, No. 49, February 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, JR.. B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Research Council, 2101 Constitution Ave., N.W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1968_02_001/autumn68-a-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Recent Advances in Above-Knee Prosthetics Creator An entity primarily responsible for making the resource A. Bennett Wilson, JR.. B.S.M.E. * https://staging.drfop.org/files/original/bc9523cd81a3db7e15e5978454317e7d.pdf 57089e6c60b72cafca746442fcb5429d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_024.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 24 - 27 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/1967_02_024.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_024.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>Need for Research in Fundamental Biomechanical Studies</h2> <h5>J. Raymond Pearson, M.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>The Subcommittee on Fundamental Studies of the Committee on Prosthetics Research and Development is interested in the promotion of scientific and technological investigations that are fundamental to applied research studies of prosthetic and orthotic devices. Hopefully, the results of the subcommittee's efforts will lead to the establishment and dissemination of knowledge that is of common interest to researchers and clinicians concerned with the design and development of assistive devices.</p> <p>Past experience with such research and its current state of development suggest that future studies should be made in the areas outlined in this article.</p> <h3>Concepts of Methodology</h3> <h4>Systems Analysis</h4> <p>It is believed that the application of modern techniques of systems analysis to discern and clearly define the needs of the disabled could lead to the establishment of appropriate specifications for use in the design of devices.</p> <h4>The Disabled Condition as it Affects Experimentation and Evaluation</h4> <p>Studies of the disabled condition should include investigation of psychological reactions to the use of prosthetic and orthotic devices. Thought should be given to the interplay of psychological and physiological reactions to the application of constraints and restraints. A study of the interactions of physiological systems might prove to be beneficial since it is apparent that there is an interplay of effects from one anatomical system to another.</p> <h4>Disability Evaluations</h4> <p>Corrective assistive devices alter the joint of the musculoskeletal system. Since positions, forces, kinematics, or stresses of the original condition may be changed by the therapeutic device, it is essential that the biomechanics of the normal, abnormal, and treated condition be well understood. This information is necessary for the proper use of such devices and the design of improved devices.</p> <p>The biomechanical analysis of any system must necessarily be preceded by an adequate, accurate description of the system. If forces are involved, it is essential to know the points of application of the forces and the direction of forces applied either by muscles or by constraining passive tissues such as ligaments.</p> <p>The addition of an assistive device to any part of the anatomy results in a hybrid mechanical-anatomical system. Complete understanding of the effect of such assistive devices rests upon the proper analysis of the hybrid system as a whole.</p> <p>Analysis rests upon quantitative data which can be secured only by measurement. Taking</p> <p>such measurements often involves the design and development of the experiment and instruments. This subject in itself is a worthwhile area of investigation.</p> <h3>Specific Research Areas</h3> <h4>Fundamental Physiology Of Muscle</h4> <p>Inconvenience, negative psychological reactions, and the complexity of design of exo-skeletal devices all lead to the hope that one day it may be possible in appropriate cases to stimulate muscles which have been denervated by trauma or disease. Some research in this area has been conducted, but very little is known about the optimum type of stimulation, the response characteristic of stimulated muscle in the disabled condition, and the ultimate possibility of using electromyographic signals of one muscle to control stimulation of another.</p> <p>Since muscles represent the actuators of the musculoskeletal system, it would be helpful to know more about the mechanical characteristics of muscle in terms of its strength, endurance, and efficiency. Hopefully, modern methods of measurements would permit the accumulation of quantitative data <i>in vivo </i>if research were pursued in this direction.</p> <p>While upper and lower motor neuron lesions usually lead to atrophy of associated muscles, it has been shown that exogenous stimulation of muscle counteracts atrophy to some degree. If research should lead to solutions of this type, it will be necessary to know more about stimulative hypertrophy of muscle.</p> <h4>Body and Device Mechanics</h4> <p>Data for proper design of orthotic and prosthetic devices require a knowledge of existing force capacity and range of motion for both normal and various selected abnormal conditions of frequent occurrence. It would be of much benefit to the designers to have such data assembled in a convenient reference volume.</p> <p>More knowledge of the kinematics and kinetics of the upper extremity, comparable to that of the ambulation cycle in the lower extremity, would also represent essential and valuable data for the design of devices. The existence of accelerometers and potentiometers for measurement of inertia forces and position facilitates the gathering of such information by experimental means.</p> <p>Recent advances in the art of simulation of linkages in engineering suggest that the musculoskeletal system of the upper extremity can be treated in a manner that will permit study of the effects of constraints or supplemental power to upper-extremity orthoses. It may prove to be possible to optimize designs with regard to various possible constraints to meet the needs of common motion patterns.</p> <h4>Comparison Of Mechanical Work and Physiological Energy Consumption of Natural As Well As Pathological Movements</h4> <p>Since one of the important criteria of evaluation of assistive and prosthetic devices is the conservation of the energy of the patient, it would be most helpful to devise ways and means of measurement of physiological energy consumption of discrete muscles or muscle systems for a determinable quantity of mechanical work output in the performance of needed tasks. While total oxygen-consumption measurements have been made for subjects with and without assistive devices in ambulation, very little has been done with regard to the upper extremity, particularly for discrete activities.</p> <h4>Control Modes and Locations on Patients</h4> <p>Underlying the problem of control of external power by electromyographic signals is the problem of proper association of biological signal and motion to be executed. In the case of amputation, the existence of the electromyographic signal of a remote muscle might be used as a control signal. However, this involves a retraining procedure for the subject. The improper or irrational selection of a control site may lead to an excessively complex learning procedure that would defeat the purpose of the design. The effects of paralysis may bring about a similar situation where the cause is a pathologic condition other than amputation. In any event, the success of any external power system controlled by electromyographic signals is highly dependent upon the rational selection of the site from which the biological signal is taken. The pursuit of such knowledge is highly important to the success of electromyographic control.</p> <p>Recent investigations of the feasibility of single motor units of muscles as a source of biological signal for controlled purposes indicate the value of pursuing this idea as an eventual method of associating thought processes with limb action. Such solutions should lead to utilizing a portion of the muscle signal without impairing the usefulness of the muscle for its original intended purpose. As this study is in its infancy, considerably more information is needed in order to evaluate its potential.</p> <h4>Rheology of Human Tissue</h4> <p>In the study of the biomechanics of joints, it becomes evident that the forces applied through bones find their reactions in the soft, passive tissues of constraint. Relative displacements of the bones of the joint are then a function of the mechanical characteristics of these tissues. The stress-strain ratio of the collagen tissue of tendon has been shown to be rate dependent for low and moderate rates of loading. Also, strain is a function of time; the tissue shows a recovery capacity when unloaded, demonstrating that viscosity plays a role in the mechanism of response. Investigations of some of the factors of some discrete tissues are examples of what can and should be done in the future by way of establishing factual knowledge of the response of component tissues and joints as a whole to the types of loading brought to bear by corrective devices.</p> <p>Past achievements have demonstrated that this kind of information is also useful in detecting the reasons for certain types of deformities. Such understanding leads to better therapy and to devices designed to counteract the system of forces causing the deformity.</p> <p>It is hoped that future research in this area will bring more knowledge of the factors involved. Investigation of more of the tissues involved is also essential.</p> <p>Further studies of the mechanical characteristics of bone, especially under loadings of the type encountered in orthoses and prostheses, are, of course, part of this picture.</p> <h4>Phyiological and Rheological Characteristics of the Stump</h4> <p>In addition to knowledge of the rheological characteristics of the tissues of the stump, which is needed for the determination of pressure and tension on skin and subcutaneous tissue, knowledge of tissue compartitions and the interplay of effects of forces thereon is also necessary. Interference with the flow of blood brings deleterious effects to the health of the tissue, and faulty distribution of pressure or skin tension can affect nerves and bring pain, Knowledge of the type proposed here would assist in avoiding these dangers.</p> <p>One of the problems encountered in the fitting of prostheses is that of edema. Measurement of the pressure encountered and the deformations involved should permit compensatory procedures providing better design.</p> <p>Since rheological experimentation has shown that the stress-strain ratios are rate dependent and load dependent, it seems that special studies of the properties of compressed and deformed tissues should prove to be beneficial.</p> <h4>Response of Bone and Connective Tissue to External Loads</h4> <p>Knowledge of the nature of the distribution of stress and strain in bone as a response to the implantation of pins in the marrow, such as those encountered in endoprosthetic joints and transcutaneous pylons, will be essential if these experimental methods are to develop into practical, clinical therapies.</p> <p>The tolerance of the tissues to implantation and to the magnitudes and types of loading will also be an important factor in this research.</p> <h4>Implantation of Artificial Organs of the Musculoskeletal System</h4> <p>Another aspect of the possibility of utilizing as much as possible of the natural anatomical system instead of exoskeletal devices is the use of implanted artificial muscles. It is envisioned that plastics capable of contraction excited by external signal will become available. Study of the materials and the tolerance of biological tissues for them will be required to realize this possibility.</p> <p>The effects of implantation on endoprostheses and endoorthoses need more comprehension if materials are to be developed to make approaches practicable. This will include the chemical and physiological reactions as well as the biomechanics of the arrangements.</p> <p>Of vital importance is knowledge of the tissue reactions to implants if methods of this type are to succeed.</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>J. Raymond Pearson, M.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Professor of Mechanical Engineering, University of Michigan, Ann Arbor, Mich. 48104; Chairman, Subcommittee on Fundamental Studies, Committee on Prosthetics Research and Development. Professor Pearson served as Chairman of the Panel on Fundamental Studies of the Conference on Prosthetics and Orthotics.</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 Need for Research in Fundamental Biomechanical Studies Creator An entity primarily responsible for making the resource J. Raymond Pearson, M.S.M.E. * https://staging.drfop.org/files/original/c79f3f5c06fbbad81bc534504137ea3e.pdf 56cedf7cb099c7fc851bdff7afeb1c91 https://staging.drfop.org/files/original/a7ac4b8b00ef3f5830653ebc22e659b2.jpg 335d2e274b5821d0d91ccc0338e156c0 https://staging.drfop.org/files/original/33504c7b98ac0853055ccefc9bc6b9c8.jpg 1a330b00bafa9bb15ec2d099bb159f06 https://staging.drfop.org/files/original/e71bdbc6078fbbac96e8b81e5d6678d2.jpg e1943727ad52b90951b681daddfdda85 https://staging.drfop.org/files/original/9408796397f1cbfaa3f48fa88b387d62.jpg 6bf9efb5b675a3eab952bd92fc036d38 https://staging.drfop.org/files/original/6e93d0f1a716dd100e308fbf39a5cd4b.jpg df5d4bd7e85ebc7852ce93f8010a48f7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_028.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 28 - 32 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/1967_02_028.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_028.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Application of Prosthetics-Orthotics Principles to Treatment of Fractures</h2> <h5>Augusto Sarmiento, M.D. <a style="text-decoration:none;">*</a><br />William F. Sinclair, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>Greater knowledge and understanding of bioengineering by the prosthetics and orthotics industries during the past twenty years have resulted in the development of highly functional and sophisticated appliances. For example, modern prostheses for lower- and upper-extremity amputees are now designed with proper attention given to energy expenditures and other physiological factors based on scientific information obtained from laboratory and clinical studies. Close liaison between medical and engineering disciplines has contributed enormously to the revolutionary changes that prosthetics and orthotics have undergone during the past two decades.</p> <p>Experience in the management of amputees has given the authors the opportunity to study the possibilities of utilizing prosthetics principles in the management of orthopaedic conditions. The first of these came as a result of clinical work with below-knee amputees. Prior to the development of the patellar-tendon-bearing (PTB) prosthesis in 1957, the below-knee amputee ambulated with an appliance which required a thigh corset to provide stability and to assist in the distribution of weight-bearing forces. The PTB prosthesis proved that the below-knee stump could take the pressures necessary for weight-bearing during ordinary activities without assistance from a thigh corset. The snug, total-contact fit and the firm contouring of the tibial flare and patellar tendon make possible weight-bearing ambulation without undue pressure being exerted over small areas or appreciable telescoping of the stump in the prosthesis.</p> <p>The traditional belief in orthopaedic circles has been that fractures of the tibia require the joints above and below the fracture site to be immobilized, the knee joint to be held in flexion to increase rotational stability, and weight-bearing to be avoided until fracture healing is complete. Some reports have appeared in the literature where ambulation on the fractured extremity is encouraged while the injured limb is stabilized in a groin-to-toe cast. This method, however, makes motion of the knee and ankle joints impossible <a></a>.</p> <p>Convinced that the patellar-tendon-bearing prosthesis can adequately stabilize the stump without excessive piston action or rotation, the senior author applied the principles of this appliance to the treatment of tibial fractures. Three and a half years ago, he constructed a total-contact, below-knee cast firmly molded over the entire leg and contoured over the proximal tibia in a.manner identical to that of the patellar-tendon-bearing prosthesis (<b>Fig. 1</b>). The results were encouraging, since the fracture united without loss of the reduction originally obtained and without additional shortening, angulation, or rotation of the fragments. Since then we have treated 200 patients with various fractures of the tibia, malleoli, or os calcis <a></a>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Short-leg total-contact PTB-like cast for tibial fractures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The impossibility of providing flexion in the proximal segment of the cast, as in the case of the PTB prosthesis, soon convinced the authors that the patellar tendon was not a major contributor to the distribution of weight-bearing pressures. In most cases, we do provide the patellar-tendon indentation and high condylar wings because they appear to be valuable in enhancing rotational stability, particularly in cases of high tibial fractures.</p> <p>With this short-leg, total-contact PTB-like cast, weight-bearing forces are transmitted from the ground to the proximal tibia, virtually bypassing the fracture site. At first glance, such a method of treatment appears to conflict with orthopaedic principles. It is the authors' belief, however, that it utilizes to a fuller degree the knowledge of basic principles governing osteogenesis and fracture repair. The active use of the extremity in a near-normal manner seems to place the fractured limb in a physiological environment more conducive to uneventful healing.</p> <p>Experience with the first 200 cases and the addition to the staff of the University of Miami School of Medicine of the junior author of this paper made it possible to attempt elimination of the foot and ankle portion of the cast, the object being the transmission of weight-bearing forces from the ground to the proximal tibia by means of metallic uprights attached distally to the patient's shoe and proximally to the cast (<b>Fig. 2</b> and <b>Fig. 3</b>). We have treated 40 tibial fractures with this cast-brace with encouraging results.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Short-leg total-contact cast-brace used in the treatment of tibial fractures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Bilateral short-leg total-contact cast-braces used in delayed union of tibial fractures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In order to utilize the benefits of a near-normal physiological environment in fractured limbs, we have used short-leg, total-contact casts with or without the orthotic components in many instances of delayed unions with or without associated chronic osteomyelitis. A complete report on these cases will be published in the near future.</p> <p>In the same manner that the patellar-tendon-bearing prosthesis led to the development of the short-leg, total-contact cast, we have introduced the principles of the quadrilateral, ischial weight-bearing prosthesis to the treatment of fractured femurs. We have constructed a cast-brace that stabilizes the fractured femur but permits freedom of motion of the hip, knee, and ankle joints (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Ischial weight-bearing cast-brace for femoral fractures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This cast-brace is applied with the patient standing on his normal limb while the ischium on the affected side rests on the platform of an above-knee casting stand. Ambulation results in transmission of weight-bearing pressures from the ground to the ischium, thus preventing shortening of the fractured fragments, angulation, and rotation. Our experience has been limited, and so we are in no position at this time to state whether or not this cast-brace will earn a place in the armamentarium of the orthopaedic surgeon.</p> <p>We have utilized the basic construction design of the Munster prosthesis as applied to the very short below-elbow amputee, and have constructed a cast in a manner similar to that of this prosthesis. To prevent rotation of the forearm, the cast is molded in such a manner that its anteroposterior diameter is as narrow as possible. The high condylar wings firmly contoured over and around the bony prominences of the forearm and humerus enhance rotational stability. A metal joint makes possible freedom of motion of the wrist joint (<b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Cast-brace with articulated wrist joint for forearm fractures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The possible applications of these cast-braces may be numerous in the everyday practice of orthopaedics. Additional investigations should be conducted before arriving at any final conclusions regarding the value of these approaches.</p> <h3>Conclusion</h3> <p>Familiarity with prosthetic appliances has resulted in the application of their basic principles to the management of orthopaedic conditions of the upper and lower extremities.</p> <p>A functional short-leg, total-contact cast based on the patellar-tendon-bearing (PTB) prosthesis was developed and used in 200 cases of tibial, malleolar, and os calcis fractures. In addition, a short-leg, total-contact cast-brace which permits motion of the knee and ankle joint has been utilized in 40 cases of fresh and old tibial fractures.</p> <p>Attempts have also been made to stabilize femoral and forearm fractures with cast-brace appliances. These cast-braces are constructed with features resembling those of the ischial weight-bearing quadrilateral socket and the Munster prostheses used by above-knee and below-elbow amputees, respectively.</p> <p>There are many clinical situations in orthopaedics which provide opportunities for further study of the utilization of prosthetics-orthotics principles.</p> <p><b>References:</b></p> <ol> <li>Dehne, Ernest, C. W. Metz, P. A. Deffer, and R. M. Hall, Nonoperative treatment of the fractured tibia by immediate weight bearing, J. Trauma, 1:514-535, 1961.</li> <li>Sarmiento, Augusto, A functional below-the-knee cast for tibial fractures, J. Bone and Joint Surg., 49A:5, July 1967.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, A functional below-the-knee cast for tibial fractures, J. Bone and Joint Surg., 49A:5, July 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Dehne, Ernest, C. W. Metz, P. A. Deffer, and R. M. Hall, Nonoperative treatment of the fractured tibia by immediate weight bearing, J. Trauma, 1:514-535, 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>William F. Sinclair, C.P. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Augusto Sarmiento, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_02_028/aut67-11.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_02_028/aut67-12.jpg Figure 3 http://www.oandplibrary.org/al/images/1967_02_028/aut67-13.jpg Figure 4 http://www.oandplibrary.org/al/images/1967_02_028/aut67-14.jpg Figure 5 http://www.oandplibrary.org/al/images/1967_02_028/aut67-15.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 Application of Prosthetics-Orthotics Principles to Treatment of Fractures Creator An entity primarily responsible for making the resource Augusto Sarmiento, M.D. * William F. Sinclair, C.P. * https://staging.drfop.org/files/original/d6ec4f4cef4fe2b96b5552ee4bba10a9.pdf 8f92cb1131cf047459895a5704ecc878 https://staging.drfop.org/files/original/998b11fabd198c71f6abd4bf6b516e92.jpg 315bfea7ae8512dca9b0928e26cca16c https://staging.drfop.org/files/original/a791344928dd5ce06a9dafb331b696fb.jpg 79ef2482afd24d2c7b2c8dd1b65284ec https://staging.drfop.org/files/original/4134d8561dbb4b9e1a573017e6502b8b.jpg 800248e585502a10a8018e210a065fa7 https://staging.drfop.org/files/original/9954f37265beca7bc0641bc84005faec.jpg a22bede040881a6d70bf53010ced6d35 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_020.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 20 - 24 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_01_020.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_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>Experience with the Münster-Type Below-Elbow Prosthesis, a Preliminary Report</h2> <h5>Charles H. Epps, Jr., M.D. <a style="text-decoration:none;">*</a><br />John H. Hile <a style="text-decoration:none;">*</a><br /></h5> <p>The Münster technique, an attempt to obviate the traditional problems associated with fitting short and very short below-elbow amputees with split sockets and step-up hinges, has been described in some detail. <a></a> However, individual clinic experience in fitting Münster-type prostheses to patients has not been well documented. Following publication of a manual of instruction for the Münster-type below-elbow prosthesis by New York University in 1965, <a></a> the Juvenile Amputee Clinic of the District of Columbia General Hospital undertook the routine fitting of short below-elbow cases with these prostheses. The principles of construction and fitting outlined in the New York University manual were followed very closely. This article presents an analysis of patients fitted with the Münster-type prosthesis at the Juvenile Amputee Clinic.</p> <h3>Scope of the Study</h3> <p>Fourteen patients were fitted with a total of 24 Münster-type below-elbow prostheses between 1965 and 1967. The group comprised eight female and six male patients. The right upper extremity was involved in eight patients, the left in six. There were no bilateral cases. One ten-year-old boy had an amputation of traumatic etiology; the remaining 13 patients had congenital deficiencies. An 11-month-old infant is not included in the analysis because her family moved to another city shortly after her fitting, and no long-term follow-up data could be obtained. Stump length ranged from 1 1/4 in. to 7 in., with all but two stumps measuring less than 4 in. The distribution was as follows:</p> <table> <tbody><tr> <th> <p>Number of Patients  </p> </th> <th> <p>Stump Length (in.)</p> </th></tr> <tr> <td> <p>1</p> </td> <td> <p>1 1/4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>1 1/2</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>1 7/8</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>2</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>2 1/2</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>2 3/4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>3 1/4</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>3 3/4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>7</p> </td> </tr> <tr> <td> <p><b>Total: 13</b></p> </td> <td> <p> </p> </td> </tr></tbody></table> <p>Seven of the patients had been previously fitted by conventional means, and seven had never worn a prosthesis. It is interesting to note that only one of the previous prostheses had been of the split-socket type, the others being preflexed.</p> <p>During the study period, two patients received three prostheses, six received two prostheses, and six had single fittings. In the multiple fittings, the shortest period before replacement was five months, and the longest 26 months. The average for the entire 13 patients on whom adequate follow-up information was obtained was 11.8 months. The three patients requiring replacement at five to six months gained weight rapidly or experienced spurts in growth.</p> <h3>Fabrication and Fitting Procedures</h3> <p>Taking the wrap cast is one of the most critical steps in the preparation of Münster-type prostheses. Use of a proper molding grip is essential to the success of the technique. It was found that the stump of an infant is more difficult to cast than that of an older child because of the discrepancy between the size of the infant's stump and the hands of the prosthetist. Accentuation of the groove for the patient's ulna formed by the thenar and the hypothenar eminences of the pros-thetist's hand seems to be less critical in casting the infant's stump than in casting the stump of the older child or adult. The difference is probably due to the generous layer of subcutaneous fat so characteristic of infancy. No special efforts were made to relieve the olecranon during casting, but a buildup was added to the positive model of the stump. Important factors during casting are pressure at the posterior distal surface of the humerus above the epicondyle level and the two-fingered pressure on either side of the biceps tendon. On small patients, the prosthetist's middle finger is slightly bent because of the different lengths of the index and middle fingers (<b>Fig. 1</b>). A symmetrical socket brim which provides overall fit is the goal (<b>Fig. 2</b>). Aside from these minor differences, the casting and all the construction procedures followed the Xew York University manual exactly.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Molding grip. Note slight flexion of middle finger. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. End view of symmetrical socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The simplified harness system commonly referred to as the figure-nine harness, with the cable reaction point located on the proximal posterior portion of the socket, was used in the series. For the nine-month-old patient a small triceps pad with conventional figure-eight harness was used, in order to make the prosthesis more secure (<b>Fig. 3</b>). It was believed that the nine-month-old patient might be able to remove the prosthesis without the additional suspension provided by the triceps pad and the anterior forked strap.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Nine-month-old female infant (P.M.) with short below-elbow stump fitted with triceps pad and figure-eight harness for additional suspension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Evaluation</h3> <p>The value of the prosthesis was judged on two bases. First, the reactions of the patient and his parents were considered. Second, patient response and performance were compared with the checkout criteria published in the New York University manual.</p> <p>All patients and parents were pleased with the Minister-type prosthesis. The simplified harness and light weight were consistently mentioned as favorable features. It was interesting to note that the seven patients who had previously worn other types definitely preferred the Münster-type. The patient who had worn the split socket was even more emphatic in his approval, as were his parents.</p> <p>Standard checkout forms were used in the clinic. However, for purposes of this study, special attention was given to certain specific items: range of motion with and without prosthesis, stability, and control-system efficiency. These data are summarized in <b>Table 1</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Terminal-device openings were recorded for all patients within the limits of 30 deg. and 90 deg. of elbow flexion and were considered acceptable. The number of rubber bands varied between one-half a band to three, depending upon the functional requirements of the patients.</p> <p>The recorded ranges of elbow motion without the prosthesis illustrate the hyperextension so characteristic of upper-extremity terminal transverse partial hemimelia. Maximum flexion varied from 80 deg. to 100 deg. with the prostheses for most patients. In all instances, full terminal-device opening was obtained at maximum forearm flexion. The test of full terminal-device opening at the mouth did not apply, because the terminal device could not be brought to the mouth. However, since all the patients were unilateral amputees, the flexion ranges were considered acceptable.</p> <p>Retention of the prosthesis under axial load testing revealed suspension stability to be excellent, as most prostheses tolerated one-third of the child's weight without excursion of the socket. The greatest slippage recorded was one-half in.</p> <p>Control-system efficiency was better than 80 per cent in one-half of the prostheses, and in no instance was the percentage less than the 71 per cent recorded in one case.</p> <p>Perspiration has not been a problem even during humid summer days. All patients used cotton stockinette stump socks for insertion of the stump, with the ends tucked back into the forearm shell after donning. It is believed that the opening provided in the medial socket wall for this purpose may have been a significant factor in heat regulation.</p> <h3>Summary</h3> <p>An analysis of experience in fitting a total of 23 Münster-type prostheses to 13 patients has been presented. The prostheses were fitted, with very minor modifications in casting technique, according to the New York University fabrication manual. Actually, the differences were more quantitative than qualitative.</p> <p>It should be mentioned that the clinic prosthetist attended the pilot course in Münster-type fabrication technique at New York University. This technique is best acquired through firsthand instruction rather than by reading a manual.</p> <p>The results have been gratifying. The parents and patients found the prcsthesis acceptable, and in seven cases preferred it to other types that had been previously worn.</p> <p>Although the range of motion in the prosthesis did not always equal the expected 70 deg. of active flexion, function was acceptable. The stability achieved was excellent. In no case was there more than 1/2-in. displacement of socket on the stump with one-third of body weight in axial pull.</p> <p>The control-system efficiency was within acceptable limits in all cases, with one-half checking out at 80 per cent or better.</p> <p>On the basis of this limited experience, it is believed that the Münster-type prosthesis is the fitting of choice for the child with a unilateral short or very short below-elbow amputation.</p> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector W. Kay, <i>The Münster-type below-elbow socket, an evaluation</i>, Artif. Limbs, Autumn 1964, pp. 4-14.</li> <li>Kay, Hector W., Kevin A. Cody, George Hartmann,and Dominick E. Casella, <i>The Münster-type below-elbow socket, a fabrication technique</i>, Artif. Limbs, Autumn 1965, pp. 4-25.</li> <li>New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, <i>The "Münster" type fabrication technique for below-elbow prostheses</i>, June 1964.</li> <li>New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science,<i> A fabrication manual for the "Muenster" type below-elbow prosthesis</i>, April 1965.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the 'Muenster' type below-elbow prosthesis, April 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Münster-type below-elbow socket, an evaluation, Artif. Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Kay, Hector W., Kevin A. Cody, George Hartmann,and Dominick E. Casella, The Münster-type below-elbow socket, a fabrication technique, Artif. Limbs, Autumn 1965, pp. 4-25.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Münster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the 'Muenster' type below-elbow prosthesis, April 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>John H. Hile </b></td></tr><tr><td class="clsTextSmall">Clinic Prosthetist, Juvenile Amputee Clinic, District of Columbia General Hospital, Washington, D.C. 20003.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles H. Epps, Jr., M.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Juvenile Amputee Clinic, District of Columbia General Hospital, Washington, D.C. 20003; Chief, Division of Orthopaedic Surgery, Howard University College of Medicine, 520 W St., N.W., Washington, D.C. 20001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 2 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-04.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experience with the Münster-Type Below-Elbow Prosthesis, a Preliminary Report Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * John H. Hile * https://staging.drfop.org/files/original/900c406bee3adcda50bf8b6267359ead.pdf df82042fb3ac474e9dedb922d4912194 https://staging.drfop.org/files/original/fe114a930bf052972f072f3dceff189a.jpg baf11ca27502acca8baaf54e3ca55687 https://staging.drfop.org/files/original/2bea6a4071dcb885ee29cf80b031c21d.jpg 495cb08e3d3b7f57cf3c08c8ab99bd81 https://staging.drfop.org/files/original/6ce3fbdbe8f4750a79fc8b18340555b4.jpg 863124825991da3ae0b5ba0c515a41e1 https://staging.drfop.org/files/original/022c06bc2eadf40c0f1e04c53578a7a1.jpg b890e5d134886cf5f9630c735ed31b4d https://staging.drfop.org/files/original/488da4aeb82fd8a32ad0e2ca277a641f.jpg bce900c1fcc880b0989b617b2ee94ea5 https://staging.drfop.org/files/original/3bf5f22ba09b4acc4594ca080bb9a838.jpg 95b37754f135d90549bda9247fbc0e23 https://staging.drfop.org/files/original/3d8f97204bb2bb16ed9d02d6d9f40501.jpg 03284aa41c6c0b02c4a6f995614ac73b https://staging.drfop.org/files/original/d634c2d774e6dd2826a9839c7f153913.jpg d5757b210e0771bb37226bdf6cc6bbe1 https://staging.drfop.org/files/original/362e4848532095e03dc40255afdfc1f2.jpg 42bc04ccce92bc21e883090f6981081a https://staging.drfop.org/files/original/bd7d7e55042feb7315cc9b240e582e1a.jpg 5cebe71dc1c91759df3936df3c824f98 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_025.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 25 - 34 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_01_025.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_025.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Army Medical Biomechanical Research Laboratory Porous Laminate Patellar-Tendon-Bearing Prosthesis</h2> <h5>Clyde M. E. Dolan, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p>In warm or humid climates, the problem of heat and perspiration within a nonporous plastic laminate prosthesis covering a substantial area of the body is particularly troublesome. The accumulation of sweat in a patellar-tendon-bearing (PTB) socket or a shoulder cap, combined with the inability of the laminate to permit evaporation or diffusion of water vapor, frequently causes mild to severe discomfort and even skin lesions sufficiently severe to require that the use of the prosthesis be suspended. Moreover, when a rubber (Kemblo) and leather liner is used, the sweat may cause it to deteriorate.</p> <p>Initial efforts of the U.S. Army Medical Biomechanical Research Laboratory (AMBRL) to produce porous plastic laminates for prosthetic applications were well received when applied to upper-extremity devices; <a></a> but, when the same technique was applied to PTB prostheses, the strength and durability of the material proved to be inadequate <a></a> In addition, problems of low porosity, nonreproducibility, and increased fabrication time were cited as serious deficiencies in the technique. <a></a></p> <p>In 1966, AMBRL reported on the development of an epoxy porous laminate which when fabricated according to the instruction manual <a></a> offered the following claimed advantages over prior techniques utilizing polyester resins:</p> <ol> <li>The new laminates were two and one-half times stronger under laboratory test conditions.</li><li>The new technique produced laminates which were twice as porous as prior versions.</li><li>The fabrication procedure was simpler, required only one curing temperature, and could be reproduced more reliably.</li></ol> <h3>Description of the Technique</h3> <h4>Stump-Casting Procedures</h4> <p>The stump-casting and cast-modification procedures are essentially the same as those taught in the various prosthetics educational programs. However, the positive stump model is prepared for a suction lamination. This technique, which involves the use of a vacuum pump to make the PVA bag conform to the socket contours, is familiar to many pros-thetists but is not a routine procedure in the fabrication of a PTB socket with soft insert.</p> <h4>Fabrications Procdedures</h4> <p>The procedures for fabricating a porous epoxy laminate PTB socket with a soft distal end differ from those used in the polyester lamination system as follows: the utilization of Silastic Elastomer 385 and Foam Elastomer 386 to form the soft distal end, and the procedure of impregnating the Banlon and nylon stockinette with a predetermined quantity of resin mixture consisting of epoxy EPON, Versamid, pigment, and methylene chloride.</p> <p>Preimpregnation of the stockinette and evaporation of the solvent prior to layup result in a stronger, more porous socket.</p> <h3>Finishing Procedures</h3> <p>Standard finishing procedures are not used because they would reduce the porosity of the socket. A procedure in which indexing pins are used to align the porous shank with the socket is detailed in the 1963 AMBRL instruction manual <a></a> and is incorporated in the NYU revision of the 1966 AMBRL manual. <a></a></p> <p>The one variation from the AMBRL procedure that was introduced in the finishing process by NYU was the use of polyurethane as a buildup material over the socket instead of A.C. polyethylene wax (steps 51 and 52 in the 1966 AMBRL manual). Polyurethane foam was believed to offer the prosthetist a faster method for accomplishing the external buildup over the socket. The foam also permits the use of power equipment for shaping, which the wax does not.</p> <h3>Preliminary Evaluation</h3> <p>A preliminary evaluation completed at NYU in March 1967 <a></a> critically considered the epoxy porous laminate procedure in the following respects on the basis of four fittings on below-knee amputees: the fabrication process, amputee reactions, durability, and laboratory tests. The fittings were carried out in the New York metropolitan area during a period of very hot, humid weather in the summer of 1966, which afforded ideal conditions for investigation of amputee reactions to socket porosity.</p> <p>In summary, the conclusions of the preliminary evaluation were:</p> <p>That the May 1966 AMBRL instruction manual was generally clear and easy to follow. However, the finishing procedures lacked the completeness of those set forth in the June 1963 AMBRL manual. A revision of the former was prepared, incorporating details of this part of the technique. The procedures were consistent with accepted prosthetics practice, and no unusual equipment was necessary.</p> <p>That the actual time required for fabrication was approximately one and a quarter hours longer than that required for fabrication of the conventional PTB prosthesis. The bench time can be reduced somewhat if the suction hose is inserted into the oven, eliminating the necessity of setting up the undercut areas of the stump model prior to placement of the socket in the oven for curing.</p> <p>That the coloring and the finish of the experimental prostheses were uniform, and the porosity was highly acceptable. Since no socket liner is used in this procedure, but rather a soft distal end, the amputee's tolerance to a "hard" socket was incidentally investigated. None of the amputee subjects in this preliminary evaluation noted any adverse reaction to the lack of a soft insert. All reported a significant reduction in discomfort associated with perspiration during the period of wear, remarking that the stump socks were much less saturated at the end of the day.</p> <p>That the experimental prostheses were significantly lighter in weight, with an average reduction of 32 per cent. The prostheses showed no signs of breakdown or clogging of the pores over a six- to 12-month period of wear, and showed excellent retention of original conformation. All are still being worn satisfactorily after 18 months.</p> <p>On the basis of this preliminary evaluation, the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development recommended that a field study be initiated to evaluate the porous laminate technique on a broad sample of juvenile subjects.</p> <h3>Scope and Objectives of the Field Study</h3> <p>Six clinics (Atlanta, Birmingham, Durham, Memphis, New Orleans, and Orlando), all located in hot, humid climates in the southern and southeastern sections of the United States, were invited to send a prosthetist representative to a three-day course in the fabrication of the AMBRL porous laminate PTB prosthesis, conducted at New York University in May 1967. Each clinic agreed to fit five subjects during the summer of 1967 with porous PTB prostheses fabricated by or directly under the supervision of the prosthetist attending the course.</p> <p>The field study was designed to evaluate the AMBRL porous laminate used in the following respects:</p> <ol> <li>Fabrication procedures.</li><li>Subjective reactions (comfort and cosmesis).</li><li>Medical considerations (stump hygiene and skin condition).</li><li>Durability and adjustments.</li></ol> <h3>The Sample</h3> <p>The sample consisted of 20 subjects-11 males and nine females between four and 20 years of age. Five were from Atlanta, three from Birmingham, three from Durham, two from Memphis, and seven from New Orleans. There were seven right and ten left below-knee amputees, two bilateral amputees (one right below-knee and left Syme's; one bilateral below-knee), and one unspecified. Eleven of the amputations were congenital, ten acquired, and one unspecified. All subjects were experienced prosthesis wearers, the prior prosthesis having been worn for seven months to three years.</p> <p>The types of prostheses worn by these subjects prior to the study are listed as follows:</p> <table> <tbody><tr> <td> <p><b>PTB sockets</b></p> </td> </tr> <tr> <td> <p>With side joints and lacer, without liner</p> </td> <td> <p>   3</p> </td> </tr> <tr> <td> <p>With supracondylar cuff, with liner</p> </td> <td> <p>   8</p> </td> </tr> <tr> <td> <p>With supracondylar cuff, without liner</p> </td> <td> <p>   6</p> </td> </tr> <tr> <td> <p>Syme's prosthesis</p> </td> <td> <p>   2</p> </td> </tr> <tr> <td> <p>Other or unspecified</p> </td> <td> <p>   3</p> </td> </tr> <tr> <td> <p> </p> </td> <td> <p> </p> </td> </tr> <tr> <td> <p><b>TOTAL: </b></p> </td> <td> <p><b>  22</b></p> </td> </tr></tbody></table> <h3>Methodology</h3> <p>At least, five clinic visits by each amputee subject were required for the appropriate evaluations. An outline of the procedures follows.</p> <h4>First Visit (Screening and Prescription)</h4> <p>At the first visit, clinic personnel discussed the purpose of the study with patient and parents, indicating the type of data that would be requested. A porous laminate PTB prosthesis was to be prescribed at this time. For purposes of uniformity, all experimental limbs were to use supracondylar suspension. General biographical information was recorded, as well as subjective comments concerning the previously worn prosthesis.</p> <h4>Second Visit (Delivery)</h4> <p>The porous laminate prosthesis was delivered at the second visit, and initial reactions of the subject and the clinic team were recorded. The prosthetist's report was initiated and retained by the prosthetist for submission at the termination of the study, as a means of recording fabrication and maintenance problems.</p> <h4>Third Visit (One Month Postdelivery)</h4> <p>The child's stump was examined to ascertain if any dermatological changes had occurred which might be attributable to the porous socket. Subjective reactions to the experimental prosthesis and reactions of the subject to the prosthesis as compared with the previously worn prosthesis were recorded.</p> <p>At this time the experimental prosthesis was rendered nonporous by the application of Saran Wrap, duplicating the procedure used in the preliminary evaluation at NYU. The prosthesis was then worn under these conditions for a two-week period of hot weather.</p> <h4>Fourth Visit (After Wear with Saran Wrap)</h4> <p>The stump was examined for dermatological changes. Any differences reported by the subjects as a result of eliminating socket porosity were assessed. The Saran Wrap was then removed.</p> <h4>Fifth Visit (After Six Weeks' Wear of the Porous Prosthesis without Saran Wrap)</h4> <p>Subjective and comparative reaction were once more elicited. The prosthetist's report was submitted.</p> <h3>Field Study Results</h3> <p>During the NYU course of instruction in this technique, one prosthetist was adversely affected by the epoxy resin. The difficulty had been noted occasionally in earlier studies. The developer has recognized the potential hazard, and appropriate handling precautions must be carefully observed. <a style="text-decoration:none;">*</a></p> <p>The epoxy resins (EPON 815) and curing agents (T-l) and, to a lesser extent, Versamid 140, are primary skin irritants. When in contact with the skin for a sufficient period of time, these materials are capable of producing a contact dermatitis in most individuals. In a relatively few hypersensitive workers, they can produce an allergic type of dermatitis in a relatively short period of time.</p> <p>Intermittent skin contact with these materials will not usually cause a dermatitis among normal workers; however, because of the occasional hypersensitive individual who cannot always be identified in advance, the precautionary measures suggested above should be used at all times.</p> <p>In addition to the foregoing precautions, good general ventilation is highly recommended.</p> <p>The first case of dermatitis usually indicates that proper handling procedures are not being observed, although in a very hypersensitive individual this is not necessarily true. The dermatitis should be treated promptly, and the source of contact should be ascertained and eliminated. The rash may be alleviated in most instances by soaking with warm Burow's Solution for 15-30 min., three or four times daily. Rashes that do not respond to treatment should be seen by a physician</p> <p><i>Based upon Handling Precautions for the Resin-Solvent System Used for Preparing Porous Laminates, an intramural memorandum issued by AMBRL in May 1967.</i></p> <h4>Fabrication Procedures</h4> <p>Telephone contacts with the participating prosthetics facilities during the course of the field study indicated that, with one exception, the fabrication procedures posed no serious problems. One facility was unable to duplicate the procedures because of difficulties with equipment. (Adequate temperature control is mandatory for successful preparation; this facility's oven temperature could not be reliably maintained for precuring the layup material.) Prosthetists' fabrication reports were received from five of the participating clinics.</p> <p>All reports indicated that two or three additional hours were required to fabricate a porous PTB prosthesis. Phases of the process cited as time-consuming were the weighing, processing, and curing; breakouts and reassembly; finishing; and the preparation of the soft distal end.</p> <p>No criticisms were made of the instructions contained in the manual. The process, however, was evidently more demanding than the conventional technique. Close attention to accuracy and detail is essential for successful preparation of the porous laminate.</p> <p>The increased fabrication time and effort, the need for some special materials, and the necessity for adequately ventilated work areas may result in some cost increases. One clinic expressed concern about the attitude of the local state agency in this respect, and one prosthetist suggested that the increased cost be borne in mind when the prescription is written.</p> <h4>Reactions of Subjects and Clinic Personnel</h4> <p>The experimental limbs were generally considered superior to the previously worn prostheses in several respects. Initial reactions to the porous prostheses, elicited immediately after delivery, are shown in <b>Table 1</b> and <b>Table 2</b>. After a one-month period of wear, corresponding reactions of the subjects and the clinics were recorded; these results appear in <b>Table 3</b> and <b>Table 4</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Examination of <b>Table 2</b> and <b>Table 4</b> (comparative reactions) indicates few changes from the positive first impression as wear increased, with a trend toward more emphatic positive comments.</p> <p>One month after delivery, the patient, his parents, and the clinic were asked their preference between the previously worn prosthesis and the experimental prosthesis. The results are shown in <b>Table 5</b>. In addition, the clinics were asked if they would prescribe a porous laminate prosthesis for other patients. Three clinics said "Yes," one said "No," and one said "Probably."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After four weeks of wear, the prostheses were covered with Saran Wrap to eliminate the porosity of the sockets while leaving the prostheses intact. No change was made in fit, weight, alignment, or other factors that might affect reactions. The subjects were asked to wear the experimental limbs under these conditions for a two-week period of hot weather. Seventeen subjects reported data for this test period. The majority indicated that perceived heat within the socket increased and that perspiration became a problem (introducing dermatological problems and discomfort). <b>Table 6</b> lists the reactions of the subjects regarding the test period utilizing the Saran Wrap.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Comparison of <b>Table 6</b> with <b>Table 2</b> shows a significant change in the perception of heat within the socket. Of those subjects offering opinions, 90 per cent considered the experimental prosthesis very satisfactory or satisfactory prior to the application of Saran Wrap, and 10 per cent considered it unsatisfactory. With the Saran Wrap, only 27 per cent reported the prosthesis satisfactory, and 73 per cent considered it unsatisfactory or very unsatisfactory-certainly a very dramatic reversal of reactions on the part of the wearers.</p> <p>Since no changes were introduced in fit, weight, or alignment, it was not expected that perception of socket comfort would change significantly under the test conditions, except to the extent that comfort might be affected by heat in the socket. Prior to the test period 95 per cent reported satisfactory reactions to comfort, while 5 per cent considered the prosthesis unsatisfactory; with the use of Saran Wrap, 83 per cent considered the experimental limb satisfactory and 17 per cent unsatisfactory.</p> <p>An uninterrupted six-week wear period followed the study of the effects of the Saran Wrap covering. At this time, subjects and clinic teams were asked to submit a non-comparative assessment of the experimental prosthesis and a separate questionnaire comparing the experimental prosthesis to the one worn before the field study. The results appear in <b>Table 7</b> and <b>Table 8</b>. These data were received regarding 17 experimental prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After a three-month period of wear, subjects and clinics were asked to indicate preferences as to the type of prosthesis to be worn in the future (<b>Table 9</b>). When clinics were asked if they would recommend the porous laminate prosthesis for other patients, three said "Yes," one said "No," and one said "Possibly."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Medical Considerations</h4> <p>A definite decrease in stump hygiene difficulties was specifically reported for two subjects in the study, leading to a recommendation by one clinic that the porous laminate be considered in cases presenting dermato-logical problems. There were no instances of deterioration of stump condition that could be related to the porous laminate, although socket adjustments were required in some cases.</p> <h4>Durability and Adjustments</h4> <p>Two clinic chiefs and their prosthetists expressed doubt that the porous laminate prosthesis would be sufficiently durable for patients who give their prostheses extremely heavy use. No such problems were encountered in an 18-month follow-up of the adult patients participating in the original NYU study of the epoxy porous prosthesis. The developer implies that adequate strength can be provided with this technique, even for heavy subjects, although only limited supporting data for this contention are available.</p> <p>One prosthesis fitted with side joints and thigh corset, which compromised the requested supracondylar suspension, showed repeated breakdown. If side joints are to be provided, the porosity of a substantial socket area must be sacrificed in order to provide adequate strength. Consequently, porous lamination may not offer as significant an advantage for these patients. In view of this problem, reservation of the porous laminate procedure for the PTB-type of fitting without side joints may be indicated. This point merits further investigation.</p> <p>One prosthesis was reported to have de-laminated between the insert and the outer wall. However, it appears that this complaint referred to a failure of the bond between socket and shell and not to delamination <i>per se. </i>Two other prostheses showed marked wear during the period of study, although no functional problems were encountered.</p> <p>Adjustments are more difficult to perform on the porous laminate socket, since it is impossible to fill in an area without sacrificing porosity. It is also more difficult to relieve an area. Because the finished laminate is so much thinner than conventional products, reducing the area may render it too weak for normal use.</p> <h4>Discussion</h4> <p>The high level of acceptance of the experimental prosthesis is supported by repeated references to three principal factors.</p> <p>"Increased comfort" is a broad term which encompasses, both directly and indirectly, the decreased weight of the porous limbs compared to the previously worn prostheses, decreased perspiration (with concomitant dermatological improvement) and reduction of heat within the socket, and the added comfort of the soft distal end.</p> <h4>Weight</h4> <p>To confirm the subjective impression of lighter weight, the weights of previously worn prostheses and experimental prostheses were compared. <b>Table 10</b> indicates the percentage of weight reduction for the 14 prostheses where such data were available. It can be seen that the average reduction is approximately 25 per cent.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Perspiration and Heat</h4> <p>Approximately one-third of the reasons cited for the preference of the porous laminate for future use related to the diminution of perspiration and the perception of the experimental limb as cooler. The results of the two-week test period (experimental socket covered with Saran Wrap) dramatically illustrate the importance of socket porosity in this regard.</p> <h4>Soft Distal End</h4> <p>In their preliminary testing, both the developer and New York University found no serious problems occasioned by the change from an insert to a hard socket with soft distal end. The observation was borne out in the field study during which the incidental investigation of the soft distal end elicited several positive comments (one clinic, although recommending a standard laminate in the future fitting of a patient to provide greater durability, would recommend that the new prosthesis incorporate the soft distal end procedure).</p> <h4>Amputee and Clinic Reactions</h4> <p>Patients and their parents were almost unanimous in their acceptance of the porous prosthesis (nearly 95 per cent of the patients and their parents preferred the experimental technique), whereas the clinics exhibited much less enthusiasm. At the close of the study, only two of the five clinics would definitely prefer the porous laminate for future use. It is important to note that the two clinics which recommended the porous laminate for future use accounted for the fitting of 11 of the 17 subjects who completed this phase of the study. Reluctance to prescribe the porous laminate resulted in extremely limited samples from the three clinics who preferred the standard technique.</p> <p>Two of the clinics rejecting the porous laminate for the future use of the patients fitted in the study might, however, recommend the porous prosthesis for <i>other </i>patients. Therefore, only one clinic categorically rejected the experimental prosthesis.</p> <p>Several suggestions may be advanced to help resolve this apparent discrepancy of opinion. During the study, as early as one month postdelivery, four reports were received which indicated dissatisfaction with the appearance of the experimental limbs. The poor appearance was specifically related to difficulties in keeping the comparatively rough surface clean. It was noted that the porous prostheses tended to appear dirty after only a short period of use, with one experimental prosthesis being rejected for this reason. Interrogation cf adult patients involved in the preliminary laboratory study showed that the prostheses are in fact difficult to clean and that they gather varying amounts of dirt, but none of the patients spontaneously complained of this problem. It might be expected that children would be less sensitive to this problem than adults.</p> <p>A further explanation for the clinics' less emphatic endorsement may lie in the increased cost factors (due to two to three hours' increase in fabrication time and materials), the need for some specialized equipment, and the occasional allergenic reactions of shop personnel to the uncured resin-solvent system. Therefore, the prosthetists' reluctance to utilize the technique may have been transmitted to the clinics.</p> <h3>Summary</h3> <p>The AMBRL porous laminate technique as applied to the PTB prosthesis was evaluated over a three-month period on 20 children at five juvenile amputee clinics in the southern section of the country. Essential aspects investigated were the fabrication process, subjective reactions, medical considerations, adjustments, and durability.</p> <p>The data indicated that porous laminate PTB prostheses were generally well accepted by patients and parents but less so by clinic personnel. The developer's claims of reduced perspiration, added comfort, decreased der-matological problems, and lighter weight were generally corroborated; weight reduction was the most consistently reported advantage.</p> <p>Increased fabrication time and some increase in the complexity of the fabrication process were cited as problems. Cosmetic characteristics elicited both favorable and unfavorable remarks; the propensity of the porous laminate to collect and trap dirt particles caused some dissatisfaction, while the textured appearance of the porous laminate was preferred in some instances.</p> <p>Concern was expressed regarding the durability of the porous laminate, particularly when applied to a prosthesis which was subjected to arduous use, although the experimental evidence was apparently insufficient for such concern.</p> <p>Based upon patients' and parents' preference for the experimental limbs, including instances of improvement in stump condition, it appears that the porous laminate PTB is a significant and worthwhile addition to prosthetics technology. Other applications of the porous laminate may also be recommended, particularly for those patients with substantial body areas enclcsed within a socket, with severe perspiration problems, or where a lightweight prosthesis is indicated. Shoulder caps, transthoracic sockets, above- and below-elbow sockets, or hip-disarticulation and hemipelvectomy applications may be considered. Informal observations of several upper-extremity fittings have again indicated that the porous laminate offers distinct advantages in terms of decreased perspiration and weight.</p> <p><b>References:</b></p> <ol> <li>Dolan, Clyde M. E., <i>The AMBRL porous laminatepatellar-tendon-bearing prosthesis</i>, New York University, Prosthetics and Orthotics, Post-Graduate Medical School, March 1968.</li> <li>Hill, James T.,<i>A manual for the preparation of above and below elbow porous prostheses</i>, TechnicalReport 6204, Army Prosthetics Research Laboratory, Washington, D.C., January 1962.</li> <li>Hill, James T., and Fred Leonard, <i>Porous plasticlaminates for upper-extremity prostheses</i>, Artif. Limbs, Spring 1963, pp. 17-30.</li> <li>Plumb, Robert E., and Fred Leonard,<i> Patella-tendon-bearing below-knee porous socket with soft Silastic distal end</i>, Technical Report 6311, Army Medical Biomechanical Research Laboratory, Washington, D.C., June 1963.</li> <li>Plumb, Robert E., and John J. Urban, <i>Patella-tendon-bearing below-knee porous socket with soft Silastic distal end</i>, MR-62-62, Army Prosthetics Research Laboratory, Washington, D.C., November 1962.</li> <li>Plumb, Robert E., James T. Hill, and HenryMouhot, <i>Instruction manual for preparing a porous epoxy PTB socket with soft distal end</i>,Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 1966.</li> <li>Plumb, Robert E., James T. Hill, and HenryMouhot,<i> Instruction manual for preparing a porous epoxy PTB socket with soft distal end</i>, Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 1966 (as amended by New York University).</li> <li>New York University, Prosthetic and OrthoticStudies, School of Engineering and Science, <i>Preliminary evaluation of AMBRL porous laminate patellar tendon-bearing prosthesis</i>, May 1965.</li> <li>New York University, Prosthetic and OrthoticStudies, Post-Graduate Medical School,<i>Preliminary evaluation: AMBRL porous laminate PTB prosthesis</i>, March 1967.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Disposable gloves should be worn when handling all resins and solvents. Face shield or goggles are advisable when pouring or mixing the resins.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">New York University, Prosthetic and OrthoticStudies, Post-Graduate Medical School,Preliminary evaluation: AMBRL porous laminate PTB prosthesis, March 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Plumb, Robert E., James T. Hill, and HenryMouhot, Instruction manual for preparing a porous epoxy PTB socket with soft distal end, Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 1966 (as amended by New York University).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Technical Report 6311, Army Medical Biomechanical Research Laboratory, Washington, D.C., June 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Plumb, Robert E., James T. Hill, and HenryMouhot, Instruction manual for preparing a porous epoxy PTB socket with soft distal end,Technical Report 6609, Army Medical Biomechanical Research Laboratory, Washington, D.C., May 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">New York University, Prosthetic and OrthoticStudies, School of Engineering and Science, Preliminary evaluation of AMBRL porous laminate patellar tendon-bearing prosthesis, May 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Technical Report 6311, Army Medical Biomechanical Research Laboratory, Washington, D.C., June 1963.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Plumb, Robert E., and John J. Urban, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, MR-62-62, Army Prosthetics Research Laboratory, Washington, D.C., November 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>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Hill, James T.,A manual for the preparation of above and below elbow porous prostheses, TechnicalReport 6204, Army Prosthetics Research Laboratory, Washington, D.C., January 1962.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Hill, James T., and Fred Leonard, Porous plasticlaminates for upper-extremity prostheses, Artif. Limbs, Spring 1963, pp. 17-30.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Clyde M. E. Dolan, M.S. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic and Orthotic Studies, NYU Post-Graduate Medical School, 317 East 34th St., New York, NY. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 2 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-04.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-05.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-06.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-07.jpg Figure 9 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-08.jpg Figure 10 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-09.jpg Figure 11 http://www.oandplibrary.org/al/images/1968_01_025/spring68e-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 Army Medical Biomechanical Research Laboratory Porous Laminate Patellar-Tendon-Bearing Prosthesis Creator An entity primarily responsible for making the resource Clyde M. E. Dolan, M.S. * 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/3dc12ac74d007b30cd9ac2192ac0215c.pdf 5d7beccc83e107ade0d0749486469958 https://staging.drfop.org/files/original/a0a401a9b25d17513105126cb0e22659.jpg 0fcc33c1d8a6f3816a522919abb35777 https://staging.drfop.org/files/original/44c99f5d58723ecaa4e79eaf87cf3981.jpg 892fb6ec39817908bb4edc85e61acf13 https://staging.drfop.org/files/original/3ef2a0fe19537ad158c472f2949df71b.jpg 55a4929f1a78ab78e33373d5ea6ce3f9 https://staging.drfop.org/files/original/3612577ff647fd7ecd02f0df52948026.jpg 08f3fa9b0f6f0385168f6e324ceda5a0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_02_028.pdf Year 1968 Volume 12 Issue 2 Page Number(s) 28 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_02_028.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_02_028.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Considerations in Management of the Above-Knee Geriatric Amputee</h2> <h5>Newton C. McCollough, III, M.D. <a style="text-decoration:none;">*</a><br />Augusto Sarmiento. M.D. <a style="text-decoration:none;">*</a><br />Edward M. Williams, M.D. <a style="text-decoration:none;">*</a><br />William F. Sinclair, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The gradual increase in the life span of people in the developed countries of the world has resulted in a tremendous increase in the number of amputees in the older age, or "geriatric," group. A survey by Glattly in 1962 <a></a> showed that approximately 52 per cent of all amputees fitted with prostheses for the first time were over 50 years of age. Of these patients, 82 per cent had had amputations as a result of disease, 2 per cent because of tumor, and 16 per cent because of trauma. Most of these, of course, were lower-extremity cases.</p> <p>As short a time as 10 years ago, only a relatively few geriatric amputees were provided with limbs, and not much attention was given to the special problems of older patients. However, it has now been demonstrated that, with expert care, older amputees can be fitted with functional prostheses and that the results obtained are well worth the extra efforts required. The below-knee case obviously presents fewer problems as a rule than does the above-knee case, but though surgeons are now saving more and more knee joints there will always be a certain number of above-knee cases that require attention.</p> <p>Just as in the case of younger amputees, geriatric patients should be fitted as soon as possible. The longer the patient goes without a prosthesis, the greater the possibility for the development of contractures, edema, and other undesirable conditions. If the patient is not provided with a prosthesis immediately after the amputation, he should be fitted with a preparatory prosthesis as soon as he is seen by the clinic team.</p> <p>When treating the geriatric amputee, the clinic team must keep in mind constantly that the patient's potential is far from that of an otherwise healthy person, and certain compromises must be made if optimum results are to be achieved. The primary factors to be considered are condition of the skin, muscle tone and strength, coordination and balance, and energy potential.</p> <h3>Anatomical and Physiological Factors</h3> <p>Skin loses its turgor and becomes more fragile as age increases, and although it does not necessarily become more sensitive to the touch it does become more subject to abrasion and breakdown. This is true especially for the below-knee amputee but also demands special consideration when fitting and training the above-knee patient, and every effort is made to limit relative motion and pressure between the socket and stump.</p> <p>The older a person becomes the more likely he is to collect a fair number of scars, some of which may become supersensitive. The patient who has had an amputation secondary to vascular occlusion may well have scars present in the femoral triangle or abdominal scars from previous sympathectomies (<b>Fig. 1</b>). Particular care must be given to socket fit and suspension in order to avoid undue pressure and abrasion of these scarred areas. The presence of abdominal or inguinal hernias must likewise be taken into consideration and appropriate relief given if necessary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Sensitive scars in the inguinal area secondary to vascular reconstruction may require modifications in the quadrilateral socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Subcutaneous atrophy occurs in the elderly patient and may present difficulties with socket fitting. The loss of fatty tissue padding often gives rise to complaints of extreme discomfort in areas subjected to high pressure, such as the ischial tuberosity and the laterodistal end of the femur. It may also complicate socket fitting, because flabby tissues tend to roll and therefore provide less stability. Muscles also tend to atrophy with age and, in addition to becoming weaker, have correspondingly less tone and less bulk, as any surgeon knows who has operated through the muscles of an elderly patient. Loss of muscle tone and bulk further decreases the soft tissue padding over bony prominences and may contribute to socket discomfort. Loss of definition of muscle groups leads to loss of stump contour and hence less stability between socket and stump. The decrease in muscular strength which accompanies atrophy results in less strength for actuating the prosthesis; hence, the weight of the artificial limb becomes an extremely important factor.</p> <p>Coordination and balance definitely are affected by the process of aging and rapidly become impaired when any degree of cerebral arteriosclerosis is present. Studies have shown that vestibular function decreases steadily after 50 years of age and, in addition, there is a general slowing of reflex motor action to proprioceptive stimuli which is irreversible. <a></a> The prosthesis, therefore, must be modified frequently to provide increased stability.</p> <p>The energy expenditure in the elderly above-knee amputee has been studied only recently, and is highly significant in the management of this class of patient. Miiller and Hettinger showed that energy expenditure was 25 per cent greater in above-knee amputees than in normal people. <a></a> Bard and Ralston gave a figure of 20 per cent greater energy expenditure in the above-knee amputee over the normal person. <a></a> Later, Ralston studied 17 above-knee amputees, all over 50 years of age, and found that the average energy expenditure was 55 per cent greater than for a normal elderly person. <a></a> He further demonstrated that a normal subject walking at a comfortable speed consumed 580 cc. of oxygen per min., whereas the same subject at maximum walking speed consumed 715 cc. of oxygen per min. This figure coincided almost exactly with the figure of 700 cc. of oxygen per min. consumed by above-knee amputees walking at a slow speed. The average pulse rate in these elderly amputees walking at slow speed was 110 per min. From these studies it is obvious that energy expenditure is greatly increased when an elderly person must use an artificial limb instead of his own.</p> <p>The use of crutches without a prosthesis has been used in the past as a criterion for prescribing prostheses for the elderly. However, this not only demands more energy from the patient than the prosthesis itself, but also demands more balance and coordination, and therefore the use of this criterion has been discontinued. Many patients who are not able to use crutches without a prosthesis can achieve some functional activity with a prosthesis. Use of a temporary, or preparatory, prosthesis (<b>Fig. 2</b>) offers the best index to future function. <a></a> This is to be distinguished from a pylon, which has no articulated knee joint and no prosthetic foot. The temporary, or preparatory, prosthesis has a completely formed, quadrilateral, total-contact socket on an adjustable knee with a positive knee lock, an aluminum shank, and an articulated SACH (solid-ankle, cushion-heel) foot.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. A typical temporary above-knee prosthesis for determining the feasibility of a permanent prosthesis for the elderly amputee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Socket Design</h3> <p>Hall has reviewed the principles which led to the development of the quadrilateral socket as we know it today: <a></a></p> <ol> <li>Actively functioning muscles should have relief.</li><li>Stabilization forces should be applied where no functioning muscles exist.</li><li>Functioning muscles should be placed at slightly greater than rest length for maximum power.</li><li>Properly applied pressure is well tolerated by neurovascular structures.</li><li>Force is best tolerated if it is distributed over the largest available area.</li></ol> <p>For these reasons, the quadrilateral socket is relieved anterolaterally for the functioning rectus muscles and postero-laterally for the functioning gluteus maxi-mus muscle; it is flattened along the lateral wall to provide the greatest surface area for the forces of abduction and along the posterior wall to provide a similar large area for the forces of extension, and is molded snugly into Scarpa's triangle to keep the ischial tuberosity displaced posteriorly on the ischial seat.</p> <p>Although it may seem like fitting a round peg into a square hole, the quadrilateral socket has provided the most satisfactory union between stump and prosthesis ever achieved for the above-knee amputee, because its shape permits proper function of the muscles which move the stump. At the same time, the forces generated by this muscular activity are distributed over relatively large areas.</p> <p>This is in contradistinction to the "plug-fit" socket which was used formerly and which did not take properly into consideration muscle action and the forces generated. The plug-fit socket, seemingly more compatible because it provides a round hole for a round peg, allows the ischium to slide inside the socket brim and the weight to be borne chiefly on the gluteal muscle mass and adductor region. Because the weight is borne chiefly by the soft tissues and because the socket is of a conical shape, there is a wedging effect of the stump in the socket and the distal tissues are pulled tightly over the end of the femur, frequently causing pain or stump breakdown. Stability about the long axis is poor because of its round cross section. In addition, the forces of abduction are distributed over relatively small areas as the femur is pushed out against the lateral wall.</p> <p>The use of the plug-fit socket has been largely abandoned today, but some of its features are useful at times for the geriatric amputee, particularly when pressure is to be avoided over Scarpa's triangle because of a femoral bypass graft or because of inadequate circulation. In some geriatric patients there is justification for modifying the quadrilateral shape in the direction of a rounded or plug-fit shape, retaining, however, certain characteristics of the quadrilateral socket.</p> <p>The quadrilateral socket is not made to a rigid pattern but is modified from a typical pattern in various ways to accommodate individual stumps. If the rectus femoris is unusually large, it may be accommodated by further relief. The same is true for the hamstring and gluteal groups. If the gluteal muscles are underdeveloped or atrophied, less relief can be given. In the elderly, because of tissue atrophy, ischial weight bearing is often uncomfortable and the posterior wall may be modified to distribute the load over the gluteal group. If it is necessary to have the Scarpa's-triangle area free from pressure, this can be accomplished by relief in this area, allowing the ischium to slide into the socket over a properly contoured posterior brim.</p> <p>We must also reconcile ourselves to the fact that, as much as we delight in rehabilitating the geriatric amputee to an ambulatory status, he will, nevertheless, spend much of his time sitting, and certain socket modifications must be made to provide comfort during prolonged periods of sitting. The thickness of the posterior wall may be decreased so that pressure neuropathy of the sciatic nerve does not develop, and the anterior brim may be lowered so that excessive pressure does not develop in the region of the femoral neurovascular bundle or the anterior superior iliac spine.</p> <p>There appear to be no contraindications to the fitting of total-contact sockets to the elderly above-knee amputee. With total contact, not only are the tissues supported evenly and edema and skin breakdown prevented, but a greater proprioceptive and kinesthetic sense is developed, a condition of even more importance to the geriatric amputee than it is to his younger counterpart. Total contact, however, is not as important with pelvic suspension as it is with suction suspension, and it is difficult to maintain, particularly when stump socks are used.</p> <h3>Suspension</h3> <p>There is uniform agreement that suction provides the best suspension available. Suction suspension, however, has a limited use in the geriatric amputee because of the exertion required in donning the prosthesis and the fact that many elderly patients have a limited ability to bend forward.</p> <p>The pelvic band is in wide use, but it has disadvantages. It is apt to create excessive pressure about the lower abdomen when the patient is sitting. It must be well padded to prevent the development of excessive pressure over the iliac crest and over any scarred areas on the abdomen. The location at the hip joint is critical.</p> <p>The preferred method of suspension in the elderly above-knee amputee is the Silesian bandage or one of its modifications. When used with the quadrilateral total-contact socket, it provides comfortable suspension and gives good stability. It may be modified to include a shoulder strap, or may be modified further to incorporate an elastic webbing band from the posterior portion of the belt to the posterior wall of the socket to act as a hip-extensor aid. <a></a></p> <p>The inability of most elderly above-knee amputees to don a suction socket properly has led to the development of a split-socket type of appliance at the University of Miami Prosthetic Laboratory (<b>Fig. 3</b>). In this type of prosthesis the intimate fit of the suction-type socket is obtained, yet it is donned easily by the geriatric amputee. [A complete description of the split-socket type of appliance will be published in the Spring 1969 issue of <i>Artificial Limbs.</i>-Ed.]</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The double-wall above-knee suction socket with anterior opening developed by the University of Miami Prosthetic Laboratory for easy application in the older amputee. The flexible inner socket is jointed to the outer by a lateral Velcro strap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Alignment</h3> <p>The above-knee socket, in general, is adducted at least 5-10 deg. to restore the normal position of the femur and place the abductor muscles at their optimum functional length. Adduction of the socket also has the effect of narrowing the base of gait, an important factor in energy conservation. <a></a> If the abductor muscles are not placed in their optimum position of function, if the socket is abducted too far, or if the prosthetic foot is located too far laterally, the center of gravity of the body must shift over the supporting leg in order to gain sufficient stability during walking. Conversely, if the adduction of the socket is sufficient to hold the femur in a normal position of adduction and to keep the abductor muscles at their optimum length, these muscles will act to stabilize the pelvis with a minimum amount of contraction while dissipating the force of stabilization by femoral pressure against the lateral wall of the socket. This ideal cannot always be achieved in the elderly patient and the socket sometimes has to be aligned in the neutral or slightly abducted position in order to gain the required stability, at the expense of increased energy consumption.</p> <p>Aligning the socket in some degree of flexion increases the power of hip extension and voluntary knee stability. In general, the above-knee socket should be aligned in some degree of flexion, usually by 5 deg. in excess of the maximum amount of hip extension that can be obtained by the amputee while standing on his good leg without producing excessive lordosis. The amount of flexion will vary from 5 to 35 deg., depending on the length of the stump and the amount of hip-flexion contracture present. Alignment of the socket in flexion is limited by the length of the stump, and in the longer stump is minimal. As socket flexion is increased, the knee bolt must be moved somewhat more posteriorly in order to retain the same alignment stability at the knee. <a></a></p> <p>Although adduction of the socket is quite efficient because there is very little excursion of the femur outward toward the lateral wall of the socket in walking, flexion is not nearly so efficient because the large posterior muscle mass allows considerable backward shift of the femur in the soft tissues prior to its exerting significant pressure on the posterior wall. This has been documented by the senior author in a cineradiography movie of above-knee stumps in sockets (<b>Fig. 4</b>). Because of this backward excursion of the femur in the soft tissues as the thigh is extended, it is felt that the femur should be set in the maximum amount of flexion consistent with cosmesis to give greater voluntary control of extension to the knee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Frames from a cineradiography film of an above-knee stump in the socket. <i>Left, </i>The femur displaces posteriorly in the soft tissues a considerable distance before effective force can be transmitted to the posterior socket wall to stabilize the knee. <i>Right, </i>The limb is at heel strike prior to hip-extensor thrust. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the elderly patient with less voluntary control and deficiencies of balance and coordination, even a long stump may require the alignment characteristics of the medium or short stump.</p> <h3>Stability of the Knee Joint</h3> <p>Knee stability is usually achieved by a combination of voluntary control by the hip extensors and alignment of the knee axis so that it is posterior to the weight-bearing line (so-called alignment stability), or by a lock or brake. Voluntary control of knee extension is usually diminished in the geriatric amputee because of muscular weakness and poor coordination, and often an increased amount of alignment stability is necessary. This alignment stability, in combination with a single-axis constant-friction knee, the most standard type, is generally sufficient. However, there may be instances in which additional stability during weight bearing is necessary, and this can be provided by the use of a unit, such as the Bock Safety Knee, which gives a braking action during weight bearing. The chief disadvantage of this type of unit is the added weight of the mechanism.</p> <p>For the elderly amputee with extreme instability and insecurity, such as a bilateral amputee, or one in whom there is a severe flexion contracture, some type of positive knee lock is usually necessary. The knee is locked in extension throughout all phases of gait, producing obvious gait deviation, but as someone once said, "an abnormal gait is better than no gait at all," which would otherwise be the case.</p> <p>Hydraulic knee units can be used successfully by the elderly above-knee amputee, and offer many advantages when the amputee has sufficient muscle power to handle these necessarily heavier limbs. The chief advantage of the hydraulic unit in geriatric patients is that it allows more anterior placement of the knee joint without sacrificing stability, and less energy is consumed in hip flexion to initiate the swing phase of gait. The other primary advantage of the hydraulic knee unit, that of permitting rapid walking by faster and more reliable knee extension, is frequently lost on geriatric amputees as they usually walk with a slow, purposeful gait.</p> <p>Until recently it has been a most difficult task to provide the knee-disarticula-tion and long above-knee stumps with adequate swing-phase control. DuPaCo recently introduced a set up so that the DuPaCo "Hermes" unit can be used with these long stumps.</p> <p>Stability at heel strike is extremely important to prevent buckling of the knee or jack-knifing, which may occur in the elderly above-knee amputee with insufficient hip-extensor power. The less resistance to plantar flexion, the more stability there is at heel contact and shortly thereafter. Locating the foot anteriorly with respect to the knee also increases stability during the period just after heel contact.</p> <p>The SACH foot is generally satisfactory for use by geriatric amputees, although in cases where weight is a real consideration a wooden foot with an aluminum ankle joint can be lighter than the SACH feet available commercially. For the elderly amputee the heel should be relatively soft in order to act as a shock absorber and enhance stability of the knee at heel contact. A single-axis wooden foot in which the softness of the plantar bumper can be varied can give greater stability than even the softest SACH heel available. However, excessive stability results in unnecessary expenditure of energy.</p> <p>The foot must occasionally be outset more than usual to enhance lateral stability in the elderly. This again is another example of obtaining stability at the expense of increased energy consumption, for outset of the foot requires a greater lateral shift of the center of gravity in walking.</p> <h3>Ambulation</h3> <p>While it is desirable to return all elderly above-knee amputees to an ambulatory status, it is often not practicable. Nearly all bilateral above-knee amputees over 50 years of age will find the wheelchair an easier and more practical means of locomotion than the use of prostheses. One must carefully evaluate the patient in terms of strength, endurance, balance, and coordination prior to prescribing a prosthesis. The patient and his family or, more likely, the government will be saved unnecessary expenditure by proper selection of patients for fitting. Often, one must accommodate the patient's own desire to find out for himself whether or not he should be relegated to the wheelchair permanently. In the true geriatric amputee, once ambulation has been achieved it is best to continue the use of some type of external support, depending upon the patient. Usually a cane or single crutch on the opposite side will be sufficient support for the elderly amputee. In some extreme cases a walker may be used, which admittedly makes for poor gait pattern, but this is preferable to no gait at all. The use of external support not only gives increased mechanical stability but also provides the amputee with additional proprioceptive feedback from the terrain on which he is walking, thus leading to better balance. In determining the functional capacity of the bilateral amputee in the older age group, the use of "stubbies" is strongly recommended and the patient should graduate to nonarticulated pylons with increasing height, to a preparatory prosthesis, and, finally, to a permanent prosthesis. Needless to say, the bilateral above-knee patient must always use external support when walking, and a wheelchair should be considered the primary mode of locomotion.</p> <h3>Summary</h3> <p>In order to provide optimum function in the elderly above-knee amputee, one must consider thoroughly certain anatomical and physiological characteristics of the patient which may indicate the necessity for modifications of the standard prosthesis. The characteristics are individual and vary greatly from one elderly amputee to another, but include skin condition, condition of the subcutaneous tissue, muscle strength and tone, coordination, and general factors relating to energy consumption. Modifications based on these factors may then be made in the prosthesis to ensure optimum functional performance. These modifications may include changes in socket shape and alignment, changes in the suspensory apparatus, provisions for increased stability at the knee, and provisions in the ankle to ensure over-all stability. In every instance an attempt should be made to provide the amputee with a minimum prosthetic weight. The future level at which the amputee will function can best be anticipated by the initial use of a temporary, or preparatory, prosthesis.</p> <p><b>References:</b></p> <ol> <li>Anderson, M. H., John J. Bray, and C. A. Hennessy, <i>Prosthetic principles-above knee amputations</i>, Charles C Thomas, Springfield, El., 1960.</li> <li>Bard, Gregory, and H. J. Ralston, <i>Measurementof energy expenditure during ambulation, with special reference to evaluation of assistive devices</i>, Arch. Phys. Med., 40, October 1959.</li> <li>Birren, J. E., <i>Age changes in speed of simple responses and perception and their significance for complex behavior</i>, Old age in the modern world, E. and S. Livingstone, London, 1955, pp. 235-247.</li> <li>Glattly, Harold W., <i>A preliminary report on theamputee census</i>, Artif. Limbs, 7:1:5-10, Spring 1963.</li> <li>Hall, Cameron B., <i>Prosthetic socket shape as related to anatomy in lower extremity amputees</i>, Clin. Orthop., 37:32-46, November-December 1964.</li> <li>Muller, E. A., and T. Hettinger, <i>Arbeitsphysiologische Untersuchungen verschiedener Ober-shenkel-Kunstbeine</i>, Ztschr. f. Orthop., 81: 525, 1952.</li> <li>Radcliffe, Charles W., <i>Functional considerationsin the fitting of above-knee prostheses</i>, Artif. Limbs, 2:1:35-60, January 1955.</li> <li>Radcliffe, Charles W., Norman C. Johnson, and James Foort, <i>Some experience with prosthetic problems of above-knee amputee</i>, Artif. Limbs, 4:1:41-75, Spring 1957.</li> <li>Ralston, H. J., <i>Some observations on energy expenditure and work tolerance of the geriatric subject during locomotion</i>, in <i>The geriatric amputee</i>, NAS Publication 919, 1961.</li> <li>Staros, Anthony, <i>The temporary prosthesis for the above-knee amputee</i>, in <i>The geriatric amputee</i>, NAS Publication 919, 1961.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Functional considerationsin the fitting of above-knee prostheses, Artif. Limbs, 2:1:35-60, January 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Anderson, M. H., John J. Bray, and C. A. Hennessy, Prosthetic principles-above knee amputations, Charles C Thomas, Springfield, El., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Norman C. Johnson, and James Foort, Some experience with prosthetic problems of above-knee amputee, Artif. Limbs, 4:1:41-75, Spring 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Hall, Cameron B., Prosthetic socket shape as related to anatomy in lower extremity amputees, Clin. Orthop., 37:32-46, November-December 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Staros, Anthony, The temporary prosthesis for the above-knee amputee, in The geriatric amputee, NAS Publication 919, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Ralston, H. J., Some observations on energy expenditure and work tolerance of the geriatric subject during locomotion, in The geriatric amputee, NAS Publication 919, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bard, Gregory, and H. J. Ralston, Measurementof energy expenditure during ambulation, with special reference to evaluation of assistive devices, Arch. Phys. Med., 40, October 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Muller, E. A., and T. Hettinger, Arbeitsphysiologische Untersuchungen verschiedener Ober-shenkel-Kunstbeine, Ztschr. f. Orthop., 81: 525, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Birren, J. E., Age changes in speed of simple responses and perception and their significance for complex behavior, Old age in the modern world, E. and S. Livingstone, London, 1955, pp. 235-247.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Glattly, Harold W., A preliminary report on theamputee census, Artif. Limbs, 7:1:5-10, Spring 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>William F. Sinclair, C.P. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward M. Williams, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Augusto Sarmiento. M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Newton C. McCollough, III, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_02_028/1968_02_028-04.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Some Considerations in Management of the Above-Knee Geriatric Amputee Creator An entity primarily responsible for making the resource Newton C. McCollough, III, M.D. * Augusto Sarmiento. M.D. * Edward M. Williams, M.D. * William F. Sinclair, C.P. * https://staging.drfop.org/files/original/9278e2810ea9f78e2de4c8bba8abbd72.pdf a774a49fa86c90712363d0801131e532 https://staging.drfop.org/files/original/08588a42be997361ba8f0142b7823983.jpg bee92071ff1c11bb2d2ceb61ca93b3df https://staging.drfop.org/files/original/9c17baf3b9691a8d9a37cdce7212e703.jpg feecd87d738ea94d1b39cc924df85985 https://staging.drfop.org/files/original/3d034d5f3443f358031dab6eba679d06.jpg 1f5e08192e9e7ef11a3299d1f9749209 https://staging.drfop.org/files/original/451f37e9c36d349733b74e0af0e323d3.jpg 232044070b13d5921ba696566e6e560e https://staging.drfop.org/files/original/efaaeec0404c6bfdb706ef31a7cc8773.jpg 31daf4bc27bde9e0a78a2d1ffc3a261f https://staging.drfop.org/files/original/11ccde34591e33f4bf94ae477a409147.jpg 32fd97e2284084e280a5a3c40bc68e12 https://staging.drfop.org/files/original/b9380eca06f68f68dc024f24e35ce0fa.jpg bf40832a2704e549a6292d2e59bc98bb https://staging.drfop.org/files/original/c7b17c455f05352581a7c7a67769c333.jpg 7c8cbab28c7a54a0495778bcbf11af86 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_02_036.pdf Year 1968 Volume 12 Issue 2 Page Number(s) 36 - 41 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_036.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_02_036.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>Toronto Orthosis for Legg-Perthes Disease</h2> <h5>W. P. Bobechko, M.D., F.R.C.S.(C.) <a style="text-decoration:none;">*</a><br />C. A. McLaurin, B.A.Sc, P.Eng <a style="text-decoration:none;">*</a><br />W. M. Motloch <a style="text-decoration:none;">*</a><br /></h5> <p>The treatment of Legg-Perthes disease has been given considerable attention at the Hospital for Sick Children in Toronto during the last few years. It is now known that certain types of Legg-Perthes disease have a good prognosis regardless of the type of treatment used, whereas other types tend to have a poor prognosis. Proper prescription of treatment must, therefore, recognize this difference in prognosis.</p> <p>Attempts have been made to assess the outcome of the disease on the basis of age at onset and the degree of involvement of the ossific nucleus of the femoral head.</p> <p>In children who develop Legg-Perthes disease prior to the age of five years, the prognosis tends to be better than in a child who develops the condition at an older age. This difference is probably related to the total mass of bone that has to be re-ossified, since it has been noted that in a smaller femoral head the time for re-ossification is often shorter, being in the vicinity of 12 to 18 months compared to several years for an older child.</p> <p>The degree of involvement also plays a most important part, and attempts have been made here to differentiate between cases where the entire femoral head is involved, with avascular necrosis of the entire ossific nucleus, and those where merely a portion is involved. The partial-head-type of Legg-Perthes disease carries a much better prognosis and is less liable to deformity, since a part of the femoral head remains uninvolved.</p> <p>If there is any tendency towards the formation of a metaphyseal cyst, the possibility of a poor long-term result is increased.</p> <p>The stage at which the patient is first seen is of the utmost importance. If the child is seen early in the course of the disease, before joint deformity has occurred, proper management, if instituted quickly, can often result in a congruous joint. If, however, there is already considerable flattening and subluxation when the child is first seen, then the result, of course, cannot be as good. If the entire process of reossification has already occurred by the time the child is first seen, the golden opportunity has passed, and at this stage only secondary reconstructive procedures can be carried out, with even less satisfactory results.</p> <p>Certain selected cases are suitable for innominate osteotomy, in which the femoral head is covered and seated just as if the hip were held in abduction and internal rotation. At present, innominate osteotomy is restricted to the child who carries an unusually bad prognosis; that is, a child over the age of six years with total involvement of the femoral head. In addition, an arthrogram must be made to be certain that a significant joint deformity is not already present. If a deformity is present, innominate osteotomy is contraindicated. In addition, prior to the use of an innominate osteotomy, full joint movement must be obtained, which sometimes will require traction or soft tissue release of contracted structures, such as the psoas tendon.</p> <p>In the very young child with only a part of the head of the femur involved, often no treatment is indicated, provided that no soft tissue contractures have occurred. If soft tissue contractures are present, then soft tissue release may suffice, with or without a short period of traction.</p> <p>This leaves a small group of children for whom bracing may be used to advantage. These children would typically be in the under-six age group, with partial or total head involvement and with free joint movement, before deformity has set in.</p> <p>In the past, ischial weight-bearing braces have been used in the treatment of Legg-Perthes disease with little regard for the various forms and severity of the disease process. Cineradiography has revealed that as the patient walks with an ischial-bearing brace the involved hip tends to move medially and laterally, a condition which may contribute to subluxation and further flattening in the form of a coxa plana; therefore, use of such braces has been discontinued at the Hospital for Sick Children.</p> <p>In 1957, Dr. William Craig<a style="text-decoration:none;">*</a> of Los Angeles first reported <a></a> the use of the abduction and internal rotation method of treatment of Legg-Perthes disease, a procedure which has been modified by Dr. Gordon Petrie<a style="text-decoration:none;">*</a> of Montreal. <a></a> When a child was allowed to bear weight on the legs in the abducted cast, it was found that a remodeled femoral head would, in fact, develop in a spherical fashion in its round and uninvolved acetabulum. This method has proved satisfactory in many instances, but there are certain disadvantages. Because the child's legs must be kept in abduction for a period of several years, cast changes must be made at 8-to 12-week intervals. Considerable stiffness develops about the knees and ankles and, in some instances, there has been a suggestion of flattening of the femoral condyles because of the continuous pressure that is applied to the knee as it is held in one position over a prolonged period of time. In addition, prolonged plaster immobilization encourages the development of osteoporosis, atrophy of muscle, pressure sores, and other problems.</p> <p>To eliminate some of the problems encountered with the use of abduction casts, a new type of articulated experimental brace has been designed. Known as the "Toronto Legg-Perthes Brace," it provides for 90-deg. abduction and slight internal rotation, yet allows hip and knee movements so that the child may ambulate and sit (<b>Fig. 1</b> and <b>Fig. 2</b>). With the brace, the child is encouraged to walk as much as possible, for it is the weight-bearing movement with the hips centered in a safe position that encourages successful remodeling of the femoral head during growth. The brace is removed easily, but the child, of course, must not be allowed to walk without the brace. It is emphasized that at present (1968) this brace has been used on an experimental basis for the past 18 months, and we do not yet have any indications as to whether any problems will develop, such as those that were produced by ischial weight-bearing braces which, in fact, produced a coxa plana and probably did more harm than good. Cineradiography on one patient has indicated that the femoral head does stay within the acetabulum during loading and unloading of the joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Front and rear views of the Toronto brace for Legg-Perthes disease. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The Toronto brace for Legg-Perthes disease in use. <i>Left, </i>Three-quarter view in the standing position; <i>Right, </i>side view in the sitting position. Note that the thighs are maintained in the abducted position at all times. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Sixteen patients are presently using the Toronto brace and, in our present state of knowledge, this new type of brace appears to fulfill all the criteria set forth.</p> <h3>Biomechanics</h3> <p>The Toronto brace holds the legs in 90-deg. abduction with respect to each other, with the feet rotated internally. The body weight, when the patient stands erect, is distributed axially through each leg to each foot. The shoes are fastened to blocks of wood with the plantar surface at an angle of 45 deg. to the floor. The foot blocks are tied together by rods which are rigidly attached to the blocks but articulated at the sagittal plane. The force diagram is shown in <b>Fig. 3</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Resolution of forces being applied to patient using the Toronto brace for Legg-Perthes disease. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Each tie rod is connected by a ball joint to a rigid frame that supports the two thigh cuffs. The thigh cuffs take no load when the patient stands with knees extended, yet the hips are held in abduction as the knees are flexed. The geometry permits each knee to flex independently of the other (<b>Fig. 4</b>) and, because ball joints are used, accurate alignment is not necessary. The ball joints also allow dorsi-plantar flexion of the foot block (<b>Fig. 5</b>). Because the plantar surface of the shoe and foot is at 45 deg. to the floor, plantar flexion of the foot itself is accompanied by toe-in and dorsiflexion of the foot is accompanied by toe-out. Otherwise, toe-in and toe-out are securely held to the appropriate angle (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Schematic view from the front of the Toronto brace for Legg-Perthes disease to show the geometry of the system. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Location of the shoe with respect to the foot block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Schematic view from the top of the Toronto brace, showing angular position of the sole of the shoe. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fitting and Fabrication</h3> <p>The first step in fitting and fabrication of the Toronto orthosis is to make a tracing of the patient's legs and pelvis when he is supine with each leg abducted 45 deg. from the center line of the body. (If this cannot be accomplished, traction or soft tissue release is indicated before fitting can proceed.) The shoes are put on the patient's feet so that the edge of the sole is traced rather than the edge of the foot itself, because the shoes are a part of the total structure. The following information should be indicated on the tracing (<b>Fig. 7</b>):</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Typical tracing needed for fabrication of the Toronto brace for Legg-Perthes disease. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The position of the thigh cuffs, which should be 1 in. above the patella and 2 in. below the groin.</li><li>The position of the shoe, when the sole of the shoe is placed at a 90-deg. angle to the long axis of the leg.</li><li>The position of the knee axis.</li><li> Measurements of the lower (LC) and upper (UC) circumferences of the thigh cuffs.</li></ol> <p>The frame, joint block, tie rods, foot blocks, and thigh cuffs are outlined on the tracing to facilitate fabrication.</p> <h3>Frame</h3> <p>The frame, which supports the thigh cuffs and joint block, is made from 1 in. X 1/4<i> </i>in. 24ST-4 aluminum bar, bent cold into a more or less diamond shape to conform to the tracing, and attached to the upper sides. The joint block is attached to the lower apex.</p> <h3>Joint Block</h3> <p>The purpose of the joint block is to provide a firm mounting for the ball joints to which the tie rods are attached. The block is assembled from five sections cut from 3 in. X 3 in. X 1/2 in. 65 ST (or equivalent) aluminum angle. Two automotive-type tie rods and joints are used for the ball joints,<a style="text-decoration:none;">*</a> which are located in the block so that they are in line with the knee axis. The threaded shank of the socket is bent to a 45-deg. angle before being brazed to the tie rod (<b>Fig. 8</b>). The tapered shank (Morse taper no. 1) on the ball of the joint is fitted to a hole in the joint block when the Chevy II part is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Method of bending threaded shank of the ball joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Tie Rods</h3> <p>The tie rods which connect the joint block with the foot blocks are made from chrome molybdenum tubing, 3/4 in. O.D. X .056 in. wall thickness. Tubing of this strength is required to resist damage that may be encountered with curbs, steps, etc. One end of the tie rod is brazed to a foot-block plate and the other end to the threaded shank of the joint.</p> <h3>Foot Blocks</h3> <p>The foot blocks are used to secure the shoes to the rods and support the shoes at the correct angle. Each foot block consists of a metal plate and a triangular block of wood. The metal plate is brazed to the distal end of the tie rod, and the wooden block is fastened to the plate with epoxy resin and wood screws. The shoes are fastened to the sloping surface of the wood block with rubber cement and wood screws. Note that the shoes are aligned on the block with approximately 15 deg. to 20 deg. internal rotation, as shown in <b>Fig. 6</b>. The bottom surface of the blocks should be covered with a tough soling material. A section of automobile tire is very serviceable, but tends to mark floors. It can be fastened on with rubber cement and wood screws. Frequent replacement is usually necessary.</p> <h3>Thigh Cuffs</h3> <p>The thigh cuffs should fit from 2 in. below the groin to 1 in. above the proximal border of the patella. The distal posterior edge should be flared to minimize discomfort in the popliteal area when the knees are flexed. The cuffs should be made to fit (not too tightly) over the trousers. They should be made from a semi-flexible material with a lateral opening so that the brace can be put on and taken off readily. Velcro straps provide a convenient method of adjustment. Cuffs made at the Centre were formed from a thermoplastic material from Smith and Nephew called "San Splint." A similar material, "Orthoplast," is marketed by Johnson and Johnson. The thigh cuffs and Velcro straps have required frequent replacement in active patients.</p> <h3>Gait Training</h3> <p>Usually about three days of intensive training by a physiotherapist are required for the child to learn to walk in the brace. Two crutches are used. They are usually held in front of the body, although the occasional child keeps one crutch behind. Stairs and curbs can be negotiated with little difficulty, and some patients learn to walk without crutches for short distances.</p> <p>The braces are removed for bathing, swimming, and sleeping, but the child must never be allowed to stand, kneel, crawl, or walk without the brace.</p> <p><b>References:</b></p> <ol> <li>Craig, William, Personal communication, 1967.</li> <li>Petrie, Gordon, Personal communication, 1968.</li> <li>Salter, Robert B., <i>Innominate osteotomy in the treatment of congenital dislocation and subluxation of the hip</i>, J. Bone Joint Surg. (Brit.), 43B:3:5l8-539, August 1961.</li> <li>Salter, Robert B., Personal communication, 1968.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Joints from a 1965 Chevy II have been used satisfactorily.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Petrie, Gordon, Personal communication, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Dr. James A. Petrie, Orthopaedic Surgeon, Royal Victoria Hospital, Montreal, P.Q., Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Craig, William, Personal communication, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Dr. William Craig, 328 W. 23rd St., Los Angeles, Calif. 90007.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>W. M. Motloch </b></td></tr><tr><td class="clsTextSmall">Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Road, Toronto 17, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>C. A. McLaurin, B.A.Sc, P.Eng </b></td></tr><tr><td class="clsTextSmall">Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Road, Toronto 17, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>W. P. Bobechko, M.D., F.R.C.S.(C.) </b></td></tr><tr><td class="clsTextSmall">Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Road, Toronto 17, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1968_02_036/1968_02_036-08.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 Toronto Orthosis for Legg-Perthes Disease Creator An entity primarily responsible for making the resource W. P. Bobechko, M.D., F.R.C.S.(C.) * C. A. McLaurin, B.A.Sc, P.Eng * W. M. Motloch * https://staging.drfop.org/files/original/b4f40bca2c90d2cb7aaabe73acdc9755.pdf 93f307630ba83bd52f500cbae4929830 https://staging.drfop.org/files/original/6ade0b441b483cc9f3804c0eb907cef2.jpg 510989eb599f892c8b2e8c055704eb08 https://staging.drfop.org/files/original/f992d6f159add6551a5927ffdad104a4.jpg 2b3059782381c1b405945cc1df2a65e4 https://staging.drfop.org/files/original/97cfb5d939b20b09ce8eef3379376ff5.jpg 3159b4335f45fb7d187f4e230713fe30 https://staging.drfop.org/files/original/e71107f0f952e070fd0f18a250c50c5e.jpg 3187980e5eb0db54e1fd157d75985aef https://staging.drfop.org/files/original/9f5149248ae20c875ebc879851fc505d.jpg 7975ed4b11b397c330fbd73d34711061 https://staging.drfop.org/files/original/95f314b39e2ef9df0a3d3e113c78841d.jpg 20023369bfd507d6c8b1eaf7c139ccad https://staging.drfop.org/files/original/1e75d8d603b0a37b68c5d88f571954d8.jpg 06838a7e96d784457010a04ffb0d4939 https://staging.drfop.org/files/original/47657fbbbf25bb2870775a5111f1ae16.jpg c6bf99f27ce81525ce4a3c18d6a22984 https://staging.drfop.org/files/original/e2a1a8f0badea8e1360e71eacea7e5ae.jpg 1f9b134869c49e1a7594c8a28780e58c https://staging.drfop.org/files/original/62d143747db0eb1a6cec876a190f8120.jpg 85a7f0afcba88084e4cdc1a630c7606a https://staging.drfop.org/files/original/78e31cec1089a104b5192b24ccb1c522.jpg b7a478f3d3152aeafe4cbc46b503926f https://staging.drfop.org/files/original/a78e4e9e46e8d715eca8b5ddc28d10d1.jpg 63281a59efb08f181a317a6aae358edd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_001.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 1 - 12 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Amputations Below the Knee</h2> <h5>Ernest M. Burgess. M.D. <a style="text-decoration:none;">*</a><br />Joseph H. Zettl, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The elective amputation must be considered plastic and reconstructive in nature. The need to create a dynamic and sensory motor end-organ should be foremost in the surgeon's mind in planning an amputation, and is emphasized here once more. The below-knee stump no longer hangs suspended in an open-end socket. The variable degrees of pressure and weight-bearing over the entire stump surface afforded by the total-contact patellar-tendon-bearing prosthesis enhance the surgeon's opportunity to fashion a functional terminal end-organ. Stump strength created by surgical muscle stabilization; pliable, sensitive, but nontender skin and scar; adequate soft tissue coverage of bone ends and other pressure-sensitive areas; high ligation and division of nerves to remove neuromata from pressure zones; meticulous rounding and tailoring of bone surfaces; all contribute to an ideal organ for substitute limb application. The atrophic, wasted, bony, below-knee stump so commonly encountered in years past is no longer acceptable. Stump-muscle stabilization, <i>i.e., </i>the attachment of sectioned muscles under appropriate tension to bone (myodesis) and to opposing muscles (myoplasty), is a prime requisite for dynamic stump activity. Muscle stabilization is especially needed in the through-knee and the above-knee amputee. Our experience also justifies its routine use in below-knee amputation. Muscle-to-bone suture does add operative handling of tissues and encircling sutures carry the potential of local muscle constriction. For these reasons myodesis is not recommended for use in the below-knee amputation for vascular disease. The new technique developed by the Prosthetics Research Study utilizes the long posterior myofascial flap sewn anteriorly to anterolateral deep fascia and tibial periosteum and provides a reasonable degree of muscle fixation without risk of strangulation. Muscle-to-bone suture is reserved for the nonischemic patient.</p> <h3>Nonischemic Patients</h3> <p>The optimum level for a below-knee amputation in the presence of adequate blood supply is at the junction of the middle and lower third of the leg. However, the level of amputation will often be determined by the causal pathology, including infection, the degree of scarring of the tissues, and related factors. The surgeon should save all effective length down to optimum level, consistent with providing a comfortable, nontender stump.</p> <p>A cylindrical stump shape is desired. The surgeon should think in terms of producing a "foot-like" organ at the below-knee level. The total-contact socket is the "shoe on the foot." Just as plastic surgical techniques are required in operating on the hand and foot, the same techniques of gentleness in skin and other tissue handling are applicable to amputation surgery. When viewed in this light, the amputation becomes a surgical challenge instead of a distressing surgical exercise. Immediate postsurgical prosthetic fitting not only supports and augments the dynamic approach to rehabilitation, it offers certain physical advantages, <i>i.e., </i>immobilization, appropriate continuous pressure relationships, and comfort. These benefits further justify its incorporation into the over-all management of the below-knee amputee.</p> <h4>Amputation Technique For The Nonishemic Patient</h4> <p>The patient is prepared for surgery in the usual manner. A pneumatic tourniquet is used. Short, broad fishmouth skin flaps are outlined to provide a mediolateral closure. In the nonischemic patient the flaps are fashioned approximately equal in length. It is advisable to cut the flaps long, then trim them at the time of closure to provide correct skin tension without puckering or undue tension. Skin and fascia are reflected together.</p> <p>Scarring, infection, deformity, or other unusual circumstances may necessitate modification of the skin closure. Flaps can be outlined to permit closure in any plane or direction provided the resulting scar is nonadherent, nontender, and able to withstand properly and comfortably wearing of a total-contact socket. Anterior location of the scar, condemned in the past, actually is well tolerated even in elderly patients. The application of principles of plastic surgery in skin management must prevail.</p> <p>In the average adult the tibia is transected 2 1/2 to 3 in. above the distal level of the skin incision. The fibula is divided 3/8 to 1/2<i> </i>in. higher. A reciprocating power saw facilitates clean bone section. The tibial periosteum is elevated about 3/4 in. above the cut end of the tibia and the an-teromedial angle beveled to provide a larger radius on the anteromedial aspect. Careful <i>rounding </i>of the edges with a sharp, fine-tooth file is now done. Bone surfaces must be smooth so as to eliminate the possibility of high unit pressures.</p> <p>When the muscles are to be reattached to bone, a procedure recommended where it is physiologically feasible, 4 to 6 holes not more than 7/64 in. in diameter are drilled through the lateral and posterior periphery of the tibia about 3/8 in. proximal to the distal end. Muscles are sectioned long, the gastrocnemius-soleus is left as a myofascial flap sufficiently long to bring it around the end of the tibia to the anterior surface, and nerves and blood vessels are ligated and divided, the former well above amputation level, the latter at the level of tibial section. The nerves are ligated high, as indicated, but are not pulled down so forcibly that traction-avulsion injury results proximal to ligation.</p> <p>Muscles are now sutured to the bone through the drill holes with medium braided polyester suture and tying the knots within the medullary cavity of the tibia. The loop sutures pass through the body of the major muscle groups and through deep fascia. They should be attached under moderate tension, slightly greater than rest length and therefore capable of providing maximum function. Muscle groups are now sectioned just beyond the end of the tibia except for the gastrocnemius-soleus flap which is left long, beveled, and brought over the end of the tibia as a thinned myofascial flap and sutured to anterior deep fascia and anterior periosteum. Good muscle stability and stump contour are provided by this technique. The moderately bulbous stump will rapidly contour to an ideal cylindrical shape in the rigid postsurgical dressing.</p> <p>The skin flaps are trimmed and closed with interrupted fine polyester sutures in such a manner that no tension is present, yet a firm stump without redundant tissue is provided (<b>Fig. 1</b>). Drainage of the stump is optional. We prefer a through-and-through Penrose drain; however, suction drainage is convenient and some wounds will not require any drainage.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Below-knee stump of nonischemic patient immediately after closure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Rigid Dressing</h4> <p>The wound is covered with a saline-dampened nonadherent silk or nylon dressing and a small amount of fluffed gauze (2 to 3) is placed over the distal stump end. A sterile three-ply Orion Lycra stump sock is rolled carefully over the stump to avoid damage to the suture lines. The superior portion of the stump sock is held firmly suspended anteriorly and in a proximal direction by an assistant. A simple adjustable shoulder-suspension harness which is interchangeable for right and left can be substituted to achieve the same result.</p> <p>Relief pads of felt or polyurethane are glued to appropriate locations on the stump sock to provide relief for bony prominences. Prefabricated pads are available in a standard size, right and left, but must be trimmed, skived, and beveled in appropriate areas to suit individual requirements. The pads are designed and located to provide relief of pressures over the patella, the tibial tubercle including the tibial crest, and the distal-anterior (bevel) aspect of the tibia. Dow Corning medical adhesive is used to secure the felt relief pads in place while the polyurethane relief pads are provided with an adhesive backing. A sterile reticulated polyurethane distal pad of the proper size is selected and applied to the distal stump end over the tibial relief pads (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Application of distal polyurethane pad. Other relief pads are already in place. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For the initial part of the rigid dressing, elastic plaster bandage is used because, when pulled within limits of its elasticity, this bandage provides safe and beneficial compression to the stump while conforming well to its contours, providing a smooth, effective, rigid dressing.</p> <p>Before the wrap is started, the tibial relief and distal relief pads are secured in place with one-and-three-quarter turns of elastic plaster bandage (<b>Fig. 3</b>). Firm tension is applied to the distal portion of the stump from a posterior-to-anterior direction, while the plaster bandage is pulled almost to the limit of its elasticity. By supporting the posterior skin flap, tension on the suture line is reduced and the soft tissues are immobilized. The wrap is then started on the distal end and carried prox-imally to a level slightly past mid-thigh while tension is maintained in the bandage. A minimum of two layers is required. Circumferential wrapping is carried out from the lateral to the medial aspect, when viewed from the front, in order to avoid anterior displacement of the gastrocnemius (<b>Fig. 4</b>). Tension in the wrap decreases progressively as the application proceeds proximally to the level of the knee joint where it is simply rolled on up to slightly past mid-thigh. It is important to apply the dressing with firm tension to the distal portion of the stump and to avoid proximal constriction to blood flow. The knee is held in 5 to 15 deg. of flexion controlled by longitudinal tension applied to the stump sock from the proximal end. Owing to the inherent structural weakness of elastic plaster bandage, the initial wrap must be reinforced with conventional plaster bandage and splints. Two splints are applied over the distal portion of the rigid dressing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Beginning the rigid dressing by securing the tibial relief and distal relief pads in place with elastic plaster bandage. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Application of the first layers of the rigid dressing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A minimum of two layers of conventional plaster bandage is applied starting at the distal third and wrapping proximally with even, overlapping circular wraps (<b>Fig. 5</b>). At the proximal border of the cast a suspension strap is incorporated anteriorly. For an obese patient with excessive soft tissue over the thigh, a second suspension strap is applied posterolaterally. With the plaster of Paris still wet, the cast is gently compressed with the base of each hand just proximal to the femoral condyles to provide an effective built-in suspension mechanism.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Completed rigid dressing. Note alignment reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the plaster has hardened sufficiently, the contoured waistbelt is applied to the patient and connected to the strap or straps of the rigid dressing. The prosthetic unit is located and attached to the cast with a roll of conventional plaster bandage (<b>Fig. 6</b>). The pylon is sized and cut to correspond to the length of the sound extremity. A window is cut out of the plaster over the patella to insure complete relief in this area (<b>Fig. 7</b>). The prosthetic unit is then disconnected from the cast socket before the patient is taken to the recovery room.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Attachment of upper portion of prosthetic unit to the rigid dressing. Note alignment reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Window in rigid dressing to provide complete relief over patella, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Postsurgical Care</h4> <p>As a rule, a minimum amount of pain is experienced by patients that have been provided with a rigid dressing. It is unusual for drugs stronger than mild opiates and sedatives to be required for relief. A slight degree of weight-bearing on the stump will usually tend to reduce any discomfort that might be present.</p> <p>The patient should be encouraged to stand up and bear some weight on the prosthesis as soon after the first 24-hour period postoperatively as is practicable.</p> <p>The time and extent of ambulation must be determined by the responsible surgeon. Walking training should be carried out only under the direction of a physical therapist or other qualified personnel. Activity should be increased daily as the patient's condition permits. Parallel bars, walkerettes, crutches, and canes are used as aids in ambulation. Two bathroom scales may be used to determine the degree of weight-bearing that is taken on the amputated side. These measurements provide a good guide to the clinic team concerning the progress being made by the patient. The patient should never be allowed to ambulate without supervision. Furthermore, ambulation should not be permitted without the prosthesis because in this case the effect of gravity tends to pull the socket away from the stump, thereby reducing the pressure between stump and socket.</p> <p>On the second postoperative day (48 hours after surgery) the drain is removed. If there does not appear to be any reason for removing the cast, such as elevated body temperature, extreme discomfort, or excessive looseness of fit, the cast is kept in place up to 14 days. If for any reason the cast is removed, whether intentionally or unintentionally, it is mandatory that, if a new cast is indicated, it be applied immediately. During the first two postoperative weeks edema will form rapidly upon removal of the cast and, unless a new cast is reapplied within a very short period, the patient will have to be treated in the conventional manner. The old cast should never be reapplied because of the trauma that is apt to result. When the socket is removed purposely, a cast cutter is used. Often the sutures can be taken out at the time of removal of the first cast, 10 to 14 days after surgery. Sometimes it is necessary to wait until removal of the second cast, 15 to 20 days postoperatively.</p> <p>In many instances the stump will be sufficiently mature and stable for use of a definitive prosthesis at the time the second cast is removed. When this is so, a cast of the stump is taken and appropriate measurements are recorded so that fabrication of a permanent prosthesis can proceed immediately. When the definitive prosthesis is delivered, a light plaster socket mobilizing the knee joint is provided for use when the definitive prosthesis is removed. Use of a plaster socket has proven to be superior to elastic bandages to prevent edema. If delays are anticipated in providing the patient with a definitive prosthesis, the prosthetic unit, pylon, and foot are applied to the short cast to continue ambulation activities.</p> <h3>The Ischemic Patient</h3> <p>Throughout the United States and Canada an estimated 80 per cent of all major, elective, civilian amputations result from ischemia. All but a relatively few involve the lower extremity. Significant advances in surgical and postsurgical management coupled with the use of improved prostheses now allow amputation below the knee in the great majority of these patients.</p> <p>It is difficult to overestimate the importance of the knee in amputee rehabilitation, especially in the older, classical ischemic patient. Debility, impaired vision, poor balance, neuropathy, compromised circulation and joint function in the remaining lower limb, and chronic systemic illness, all emphasize the critical need to save the knee. The older bilateral leg amputee, especially, needs his knees to approach the rehabilitation goal that permits a reasonable degree of ambulation and self-sufficiency. In a consecutive series of 128 unselected major lower-extremity amputations for peripheral vascular disease (1964 through 1968), we have been able to obtain primary healing at below-knee level in 86 per cent. Once healed, the stumps remain healed. With adequate prosthetic care, secondary breakdown will seldom occur. These patients were among the approximately 300 cases requiring amputation of the lower extremity that were used in studying and developing the techniques of fitting prostheses immediately after surgery. As a result of these experiences, separate surgical techniques have been developed for the ischemic patient and for the nonischemic patient.</p> <h4>Level Of Amputation</h4> <p>The great achievements in surgical reconstruction of the peripheral vascular system represent a leading chapter in medical progress during the past two decades. Continuing basic and clinical research throughout the world supports the hope that an even higher percentage of limb salvage can be expected in the years ahead. However, despite the practical effectiveness of modern vascular reconstructive surgery, statistics indicate that amputations for ischemia are increasing both relatively and absolutely in relation to population throughout the western world.</p> <p>When acute or chronic compromise of arterial blood supply reaches a level insufficient to support tissue viability and when reconstructive surgery and nonsurgical supportive measures fail, amputation will be required.</p> <p>Patients requiring amputation are entitled to comparable medical and surgical consideration, comparable team effort, and the same high-level rehabilitation management attending similar patients whose ischemic limbs are treated by vascular reconstruction. Too often, ablative surgery does not command this high estate.</p> <p>Decision to amputate may be simple and evident. Gross necrosis of tissue with demarcation, uncontrollable infection, pain, irreversible neuropathy, alone or in combination, and with results of specific tests to assay circulation, will establish the need to amputate. When all available information poses a serious question as to the possibility of limb salvage by reconstructive surgery rather than amputation, it has been common practice to attempt such surgery, even though extensive. Before questionable extensive reconstructive arterial surgery is carried out, the surgeon should consider critically the overriding probability of its failure with mandatory subsequent amputation. Will the proposed surgery compromise the level of amputation? Will amputee rehabilitation be additionally complicated by further deterioration of general health incident to the extensive surgical attempt at limb salvage? On a number of occasions, below-knee amputations have been performed in ischemic patients who were being considered for possible vascular surgical treatment but in whom, after review of all available information, such surgery might well have damaged the existing blood supply to a degree that an above-knee amputation would then have been required. It is important that the responsible surgeon understand the great rehabilitation value of the knee and weigh all facts relevant to the rehabilitation potential.</p> <p>There is no single test or combination of tests now available that will demonstrate specifically the lowest effective amputation level. Successful below-knee amputations have been obtained repeatedly in patients whose arteriograms indicated complete occlusion of the superficial femoral artery.</p> <p>A careful physical examination is the first requisite in determination of the level of amputation. Appearance of the soft tissues, temperature of the skin, the presence or absence of edema after elevation, growth of hair, level of sensation and acuity, together with palpation of pulses, are all important and cannot be supplanted by laboratory data. Arteriography, plethysmography, thermography, and a number of other objective techniques are useful. These include skin mapping with interar-terial fluorescein, the use of radioactive Xenon #133, and transcutaneous ultrasonic Doppler recordings. Each adds to the available information and assists in level determination. Old established guidelines for determining amputation level are not valid when weighed against recent experience.</p> <p>Unless it is <i>clearly evident </i>that a through-knee or above-knee amputation will be required, the surgeon should prepare the leg for both below-knee and above-knee amputation. Incisions through the skin and muscle preparatory to belowknee surgery can then be carried out quickly.</p> <p>Bleeding and tissue viability can be observed directly and the final decision can now be made as to the level of amputation. Only a few minutes are added to the operative time should one elect the above-knee or through-knee level.</p> <h4>Amputation Technique For The Ischemic Patient</h4> <p>No tourniquet is used. The leg is draped free with the patient supine. Open and infected areas are walled off and shielded by sterile adherent plastic drapes prior to skin preparation. The level of amputation is 3-1/2 to 5 in. below the knee, <i>i.e., </i>a short below-knee stump (<b>Fig. 8</b>). It has been recognized for many years that skin over the posterior leg has better blood supply than that anterior and anterolateral, and a long posterior and a short anterior skin flap are now used routinely. A long anterior flap, or even equal anterior and posterior flaps, should be avoided. The anterior scar resulting from use of a long posterior flap poses no problem in fitting the prosthesis. The modern total-contact below-knee prosthetic socket can accept a stump with scar placement in any position, provided it is nonadherent, well-healed, and nontender, and it is now standard policy in the Prosthetics Research Study to place the scar wherever it will heal most advantageously.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Left, stump of 33-year-old patient on 26th day after amputation because of infection owing to nonunion of the tibia. Right, permanent prosthesis provided same patient on 26th day postoperative. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The anterior skin flap is fashioned approximately at the level of anticipated tibial section. The posterior flap must then be 5 to 6 in. longer to provide proper skin coverage without undue tension (<b>Fig. 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Outline of skin flaps for below-knee amputation on typical ischemic patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After outlining the skin flaps, dissection is carried down through the deep fascia to the tibia. The periosteum is incised and stripped proximally 1 in. The anterolateral muscles are divided down to the intermuscular septum; blood vessels and nerves are ligated appropriately and severed; and then the tibia and fibula are sectioned, preferably with a power saw. The fibula is cut no more than 3/8 to 1/2 in. above the level of the tibia. Soft tissues are dissected from the posterior aspect of the tibia and fibula down to the level of the posterior transverse division of skin. The leg is then separated and removed. The tibia is very carefully rounded with a short bevel over its anterior and medial aspects. It is important that no rough bone areas or ridges remain. A long bevel is specifically avoided. Nerves are pulled down and sectioned high with a sharp knife. They are not injected, crushed, or cauterized. The major nerves are ligated with a fine suture just above the site of division before the division is made. Encircling suture controls oozing from the blood supply that accompanies the nerve, and it also appears to localize neuroma formation and to lessen overgrowth and adherence to adjacent structures. The posterior muscle mass consisting of the gastrocnemius-soleus and deep flexor group is now beveled and tailored to permit the entire muscle flap to come forward and be sewn anteriorly to the deep fascia of the anterolateral muscle group and to the reflected periosteum over the anterior tibia. Contouring and trimming of the gastrocnemius medially and laterally gives a smooth musculofascial flap stabilized over the end of the bones. The skin is then brought up and closed without subcutaneous suture (<b>Fig. 10</b>). Medial and lateral "dog ears" are contoured moderately. They should not be taken back sufficiently to disturb skin circulation. The immediate postsurgical socket rapidly shapes the stump including moderate skin irregularity at the medial and lateral angles. The wound is drained deep to the muscle flap, <i>i.e., </i>to bone. Through-and-through drain or suction drainage may be used. An immediate postsurgical rigid dressing and prosthesis are then applied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Below-knee stump of typical ischemic patient showing position of suture line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Postsurgical Care</h4> <p>Drains are removed 48 hours after surgery. If the patient's general condition permits, ambulation with guarded weight-bearing is begun 24 to 48 hours following surgery. The advantages of upright activity with limited stance and gait are obvious. However, only touch-down weight-bearing not exceeding 25 lb. is allowed until the initial cast is changed. Personnel in charge of the patient should be instructed carefully as to their responsibility in preventing the patient from bearing excessive weight or from falling.</p> <p>The postsurgical management with an immediate prosthesis has resulted in much less pain than previously encountered. Postoperative pain is generally of a diffuse aching type. Complaint of localized pain almost always indicates abnormal pressure and requires inspection of the stump and change of the socket. Unless complications develop, <i>i.e., </i>evidence of infection, excessive loosening of the socket, or severe pain, the initial rigid dressing should be left intact until the time of anticipated suture removal, usually two to two-and-one-half weeks following surgery. The cast is then removed, with the patient under sedation but not anesthesia, the wound is inspected, sutures are removed if indicated, and a new temporary prosthesis is applied. By this time the patient is usually ready for unsupported crutch ambulation and discharge from the hospital. A temporary prosthesis is worn continuously until a definitive limb is provided. Ordinarily the final limb can be fabricated, fitted, and worn four to five weeks following below-knee amputation. Typical ischemic patients are shown in <b>Fig. 11</b> and <b>Fig. 12</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. A 69-year-old, white male had multiple difficulties consisting of arteriosclerosis obliterans with complete right superficial femoral occlusion, diabetes mellitus, arteriosclerotic heart disease with mitral insufficiency, and coronary occlusion. No reconstructive vascular surgery was considered to be feasible. The preoperative condition of his foot is indicated on the left. Good stump healing was achieved by the 25th postoperative day, center. The definitive prosthesis was applied on the 28th postoperative day, right. </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 73-year-old, white female with severe chronic peripheral vascular disease without diabetes. Two attempts at femoral popliteal bypass graft had been made in the three weeks prior to "breakdown" of the graft operative sites. Progressive gangrene of the foot had ensued with demarcation just above the ankle level. Figure in upper left shows the appearance of the leg prior to amputation. A short below-knee level of amputation was selected and a long posterior musculocutaneous flap developed, upper right. The appearance of the below-knee stump at 19 and 29 days following surgery is indicated in the lower figures. The definitive prosthesis was fitted on the 32nd postoperative day. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Necrosis of skin flaps can result from either inadequate blood supply or undue pressure. If the level of amputation is so low that the blood supply is insufficient to support a below-knee amputation, it will be evident at the initial cast change. The decision then to amputate at a higher level should be made promptly. Re-amputation rate in the PRS series to through-knee or above-knee over the four-year period has been 9.4 per cent. As experience and techniques have improved, the re-amputation rate for below-knee cases with ischemia has continued to decrease. The surgeon, of course, likes to avoid all re-amputations. However, salvage of the knee is of such paramount importance that an occasional re-amputation may be required if we are to save all knee joints possible in view of our inadequate means for determining the best level for amputation.</p> <h3>Summary and Conclusions</h3> <p>Below-knee amputation is statistically by far the most important major amputation used today. The vast majority of major lower-extremity amputations performed for ischemia will heal primarily and remain healed at below-knee level. The below-knee amputation for ischemia is short in length, the posterior skin and myofascial flaps are fashioned long, and the technique is precise. The resulting stump is cylindrical in shape, well-padded, comfortable, and easily fitted with modern below-knee prostheses of the total-contact type. An immediate postsurgical prosthesis is an integral part of the over-all below-knee amputee management in both the ischemic and nonischemic patient. Restoration of function and rehabilitation of the below-knee amputee, both unilateral and bilateral, have improved in almost spectacular fashion when the guidelines and management which have been outlined are followed.</p> <p><b>References:</b></p> <ol> <li>Baddeley, R. M., and J. C. Fulford, <i>The use of arteriography in conservative amputations forlesions of the feet in diabetes mellitus</i>, Brit. J. Surg., 51:633-658, September 1964.</li> <li>Berlemont, M., <i>Notre experience de I'appareillageprecoce des amputes des membres inferieursaux Etablissements Helio-Marinsde Berck</i>, Ann. Med. 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Torres, <i>Evaluation of below-the-knee amputation in the treatment of diabetic gangrene</i>, New Eng. J. Med., 266: 440-443, March 1962.</li> <li>Jansen, Knud, <i>Amputation, a manual of principles and methods</i>, World Veterans Federation, Paris, 1965.</li> <li>Kelly, P. J., and J. M. Janes, <i>Criteria for determining the proper level of amputation in occlusive vascular disease: A review of 232 amputations</i>, J. Bone Joint Surg., 39A:833-891, July 1957.</li> <li>Kendrick, R. R., <i>Below knee amputation in arteriosclerotic gangrene</i>, Brit. J. Surg., 44:13-17, July 1956.</li> <li>Loon, Henry E., <i>Below-knee amputation surgery</i>, Artif. Limbs, 6:1:86-99, June 1962.</li> <li>Loon, Henry E., <i>Biological and biomechanical principles in amputation surgery</i>, Prosthetics International, Committee on Prostheses, Braces, and Technical Aids, International Society for the Welfare of Cripples,Copenhagen, 1960.</li> <li>Mondry, F., <i>Der Muskelkraftige Ober-und Unterschenkelstumpf</i>, Chirurg, 23:517-519, November 1952.</li> <li>Murphy, Eugene F., and A. Bennett Wilson, Jr., <i>Anatomical and physiological considerations in below-knee prosthetics</i>, Artif. Limbs, 6:2:4-15, 1962.</li> <li>Pedersen, Herbert E., <i>Lower extremity amputations for gangrene</i>, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 15:262, 1958.</li> <li>Pedersen, H. E., R. L. LaMont, and R. H. Ramsey, <i>Below-knee amputation for gangrene</i>, Southern Med. J., July 1964. Reprinted in Orthop. Pros. Appl. J., 18:281- 287, December 1964.</li> <li>Radcliffe, C. W., and James Foort, <i>The patellar tendon-bearing below-knee prosthesis</i>, Biomechanics Laboratory, University of California. Berkeley and San Francisco, 1961.</li> <li>Robb, H. J., L. F. Jacobsen, and B. Jordan, <i>Midcalf amputation in the ischemic extremity: Use of lateral and medial flap</i>, Arch. Surg., 91:506-508, September 1965.</li> <li>Rosenberg, N., <i>Midleg amputation in patients with necrotic leg muscles</i>, Arch. Surg., 81:614-617, October 1960.</li> <li>Silbert, Samuel, <i>Mid-leg amputations for gangrene in the diabetic</i>, Ann. Surg., 127:503, 1948.</li> <li>Slocum, D. B., <i>An atlas of amputations</i>, C. V. Mosby, St. Louis, 1959.</li> <li>Smith, B. C,<i> Amputation through lower third of leg for diabetic and arteriosclerotic gangrene</i>, Arch. Surg., 27:267, 1933.</li> <li>Tillgren, C., <i>Obliterative arterial disease of the lower limbs: A study of the course of the disease</i>, Acta Med. Scand., 178:103-119, July 1965.</li> <li><i>Manual of below-knee prosthetics</i>, University of California, San Francisco, Biomechanics Laboratory, November 1959.</li> <li>Weiss, Marian, personal communication and demonstration, Konstancin Rehabilitation Hospital, Poland, 1964.</li> <li>Weiss, Marian,<i> Neurological implications of fitting artificial limbs immediately after amputation surgery</i>. Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</li> <li>Weiss, Marian, <i>Myoplasty—immediate fitting—ambulation, paper presented at the Sessions of the World Commission on Research in Rehabilitation</i>, Tenth World Congress of the International Society, Wiesbaden, Germany, September, 1966.</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>Joseph H. Zettl, C.P. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetics Research Study, Seattle, Wash.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Ernest M. Burgess. M.D. </b></td></tr><tr><td class="clsTextSmall">Principal Investigator, Prosthetics Research Study, Seattle, Wash., and Director of Amputations and Congenital Defects Service, Children's Orthopedic Hospital, Seattle, Wash. This study was conducted under Contract V5261P-438 with the Veterans Administration.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_001/spring69-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_001/spring69-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_001/spring69-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_001/spring69-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_001/spring69-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_001/spring69-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_001/spring69-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_001/spring69-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_01_001/spring69-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_01_001/spring69-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_01_001/spring69-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_01_001/spring69-12.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 Amputations Below the Knee Creator An entity primarily responsible for making the resource Ernest M. Burgess. M.D. * Joseph H. Zettl, C.P. * https://staging.drfop.org/files/original/563b7e3d5e654828605f04deb909797d.pdf bdd8ac1d4ea751b6467591119d581c32 https://staging.drfop.org/files/original/06192bdad0f19b8b8f1a62b6de034970.jpg b1d165ad8953da55d9ae82c37eb333fa https://staging.drfop.org/files/original/11faed39014403a6dc246e19447a1e04.jpg e053bf6273abb66dfc3e4b534d6f0ef2 https://staging.drfop.org/files/original/ab3f22ae3bf0b961414fc0148beb8ad2.jpg c8cc8b308e2f932c66508ebcb3918fe5 https://staging.drfop.org/files/original/a98488decd50e21af69363b9e67475e2.jpg 8ae2865195228b7aca7c75f753e4584b https://staging.drfop.org/files/original/3104c38e2e1fdde67ea076415c929bf7.jpg ce62f98c13cdfb73a43c7b2f673348df https://staging.drfop.org/files/original/1bfb3db8f0a4653731d81faa29559635.jpg bc64124b91d9ba11eef6f8356c5d0319 https://staging.drfop.org/files/original/1a846b2a0fe0a6fddc0540823690ccff.jpg d1f0c1cb1a48e93b1be62020126a530d https://staging.drfop.org/files/original/54f4c041c313324c6dd89aba4c7335e8.jpg 1a38657457516471793399d4f2ade79f https://staging.drfop.org/files/original/c5555a3c031f1ad854aeee2c5fbd1376.jpg 836517a1021bc3d397aab93236925ba2 https://staging.drfop.org/files/original/ddd6cf419da77ba7ed5f5f1bcf7c62b3.jpg adca9e2f32b00a97ee7de032d4c3efc4 https://staging.drfop.org/files/original/8a780fa990993d128a1889acb02fe387.jpg a021a16bcf45de281a02a47e05ebe5a8 https://staging.drfop.org/files/original/1657876e7ff4af53ca8144dee7ddb077.jpg 9dd2ddab021621e602392a91ed65eae6 https://staging.drfop.org/files/original/7da95365c1b01ff987fb41f4868ee168.jpg e09de561d7cb9a7fe09ddbb9766aafe6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_001.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 1 - 12 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_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>Recent Advances in Below-Knee Prosthetics</h2> <h5>A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>The concept of constructing a below-knee prosthesis with side joints and a thigh lacer was set forth by the Dutch surgeon Verduin in 1696 (<b>Fig. 1</b>) and followed universally until the advent of the patellar-tendon-bearing prosthesis in the late 1950's. <a></a> Although other innovations such as contact over the distal end of the stump, suction suspension, and "muley" sockets were introduced from time to time, they were never widely used, possibly because principles governing their use were not set forth in a systematic manner.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Verduin leg (1696). From MacDonald, J., Amer.J. Surg., 1905. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In 1957, the predecessor of CPRD, the Advisory Committee on Artificial Limbs, encouraged the University of California at Berkeley to study the problems of the below-knee amputee and to improve the then current management practices. As a result, some of the leading prosthetists in this country were invited to Berkeley later in 1957 for the express purpose of examining in detail the prosthetics practices for BK amputees and rationales for those practices. <a></a> An analysis of the findings of that conference led to the development of the patellar-tendon-bearing prosthesis, known now as the PTB prosthesis.</p> <p>The original version of the PTB prosthesis was a plastic laminate socket which was formed over a modified plaster-of-Paris model of the stump, and which contained a soft inner liner that contacted the entire surface of the stump. <a></a> The major weight was borne by the medial flares of the tibia and the patellar tendon. No knee joints or thigh corsets were used, suspension being effected by a fabric strap around the thigh just above the femoral condyles (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Cutaway view of the original patellar-tendon-bearing (PTB) prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The PTB concept was offered in formal education programs in this country and gradually gained acceptance, so that by 1961 slightly more than half of the below-knee prostheses provided in the United States were of that type. <a></a> The concept also has been accepted widely in other countries, and the PTB now is generally considered to be the standard prosthesis for below-knee amputations.</p> <p>In recent years, research groups and individual prosthetists have introduced improvements to the basic concept. <a></a> This article describes the advanced practices in the management of the below-knee amputee that have been developed since the introduction of the PTB prosthesis.</p> <h3>The Hard Socket</h3> <p>The original PTB socket design called for a lining of leather or Naugahyde backed by sponge rubber. Perspiration caused problems in many instances, however, because Naugahyde does not "breathe" and leather deteriorates rapidly in the presence of sweat. This problem prompted some prosthetists to eliminate the liner, and the "hard" PTB socket has become increasingly popular.</p> <h3>The PTS Socket</h3> <p>The suspension strap for the PTB prosthesis, as designed originally, was usually satisfactory, but there were enough dissatisfied amputees to prompt a number of prosthetists to seek improved suspension methods. In addition to developing different strap designs (<b>Fig. 3</b>) <a></a>, several groups experimented with new configurations for the proximal border of the socket. The research team at Nancy, France, introduced the "prothese tibiale a emboitage supracondylien," popularly known as the PTS, in which the proximal border extends above the patella and the femoral condyles (<b>Fig. 4</b>), <a></a> thus holding the socket on the stump. This concept was introduced into the United States by Nitschke and Marschall <a></a> and the PTS prosthesis is being used at an increasing rate in the United States. The technique may be used with or without a liner. Hamontree <a></a>, in reporting his experiences with 94 cases, noted that, although he believed that the majority of the patients could have been satisfied with the original version of the PTB, a certain percentage could have been successfully fitted only with the PTS version.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Left, continuous-strap suspension arranged in a figure eight with Velcro for adjustment; right, anterior view of two inverted V-straps looped through a ring and attached inside a hard socket close to the brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. A right, below-knee stump and the amputee wearing a PTS-socket prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Wedge Suspension Socket</h3> <p>Another attempt to improve upon the strap type of suspension resulted in the KBM (Kondylen Bettung Munster) prosthesis <a></a>, in which a small wedge is inserted between the proximal area of the socket and the area of the stump along the medial condyles of the femur (<b>Fig. 5</b>). Developed at the University of Munster, this concept was introduced into the United States by Fillauer <a></a> and is now known as the supracondylar-wedge suspension system. The wedge system may be used with or without a socket liner, but generally no liner is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The supracondylar-wedge suspension method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Air-Cushion Socket</h3> <p>In an effort to develop a socket that would permit the stump to bear the optimum amount of the weight load over its distal end, Wilson and his associates <a></a> designed and developed the "air-cushion socket" (<b>Fig. 6</b>), which reduces the magnitude of the vertical components of weight-bearing forces at other points on the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Cutaway view of the air-cushion socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The air-cushion PTB consists of an elastic inner sleeve (stockinet impregnated with silicone rubber) suspended from the level of the tibial tubercle in a rigid outer shell that is closed distally. Stump support is provided by the tension of the sleeve itself and by the compression of the air in the chamber between the inner sleeve and outer cap.</p> <p>Trials in the United States, Denmark, and Yugoslavia <a></a> have shown that the air-cushion version of the PTB is particularly useful for patients with very sensitive stumps. In fact, there appear to be few, if any, contraindications to the use of the air-cushion socket, the only disadvantages being that slightly more time is required to fabricate the socket and that few modifications can be made after it has been fabricated.</p> <h3>Porous Socket</h3> <p>In seeking ways to alleviate the problems caused by perspiration, the U. S. Army Medical Biomechanical Research Laboratory developed a porous plastic laminate. <a></a> Conventional epoxy resins and filler materials are used in the fabrication, but special care must be taken in controlling the proportions of the ingredients and in curing. The first porous laminates developed by AMBRL were satisfactory for upper-extremity sockets, but they were not strong enough for routine use in lower-extremity sockets. Subsequently, the technicians developed a fabrication technique using epoxy resins that overcame the major shortcomings of the earlier laminates. <a></a> New York University, after studying 20 children and young adults, reported that the porous-laminate socket appeared to be a "significant and worthwhile addition" to below-knee prosthetics specifically and to limb prosthetics generally. <a></a> There were fewer problems with perspiration, and skin eruptions were ameliorated. In addition, the prostheses with porous-laminate sockets weighed less. When perspiration was a major problem, the two disadvantages cited-slightly increased fabrication time and greater difficulty in maintaining socket cleanliness-were far outweighed by the advantages.</p> <p>Because most of the innovations to the original PTB design are not mutually exclusive, it was possible to develop a chart showing the combinations of features that can be used to devise a below-knee prosthesis that best meets the needs of the individual patient (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Casting Methods</h3> <p>The method for obtaining a model of the stump for fabrication of the PTB socket, as described in the original manuals, consisted of wrapping the stump with plaster-of-Paris bandages, shaping the wrap with the fingers, and subsequently modifying the male mold produced from the female cast, or wrap. Any number of attempts have been made to devise a procedure that would require less skill. One such method that has been accepted by many prosthetists is the sling-casting, or suspension-casting, technique developed by Hampton <a></a> (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Ring and sock for suspension casting of the below-knee stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the suspension-casting technique, the stump is wrapped while it is held in a vertical position that simulates weight-bearing during standing. Felt patches to provide relief for sensitive areas of the stump can be applied directly to the stump, and a minimum amount of modification is necessary, although the need for modification is not eliminated entirely.</p> <p>Research workers and clinicians have been searching for years for a material that will enable the prosthetist to form a socket directly over the stump, thereby eliminating the need for plaster wraps and male molds. Experience with a synthetic rubber, Polysar<a style="text-decoration:none;">*</a> X-414, has shown that this material definitely has a place in the fabrication of sockets. <a></a> Temporary, or provisional, below-knee prostheses consisting of a synthetic-balata socket and pylon-type components are proving to be useful. Because it becomes pliable at temperatures easily tolerated by the skin, synthetic balata can be applied directly over the stump. Extruded tubing of various diameters with walls 1/4-in. thick is available. A piece of tubing slightly smaller in diameter than the stump is heated in water to about 160 deg F, then forced over the stump, which has been padded in appropriate areas (<b>Fig. 9</b>). To give proper shape to the socket, a length of pressure-sensitive tape, 1 in. wide, is wrapped over the outside, and final forming is carried out manually. To provide total contact, the distal end is filled with "foam-in-place" silicone. The socket is easily mounted on a pylon unit for use as a temporary prosthesis, or a more permanent one if desired. The prosthesis can be given a natural appearance by applying and shaping semirigid blocks of Koroseal "Spongex"<a style="text-decoration:none;">*</a> (<b>Fig. 10</b>). Contours of the socket can be changed at any time by heating the area with a heat gun and reshaping it manually.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Top, application of socket tube to the stump; bottom, trimming of socket brim prior to final molding. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Foam blocks for fitting over pylon and socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Time of Fitting</h3> <p>During the past decade, the advantages of fitting a prosthesis as soon after amputation as possible have been demonstrated repeatedly. Goldner and his associates <a></a> demonstrated that "early" fitting-that is, providing the patient with a temporary prosthesis as soon as the wound has healed rather than waiting for a maximum amount of shrinkage to take place-could drastically reduce time and costs of rehabilitation. Even more dramatic results have been obtained by fitting artificial limbs immediately after surgery, especially with below-knee amputees <a></a> (<b>Fig. 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Schematic cross section showing the major elements of a prosthesis as applied immediately following surgery to a below-knee amputee. The suture line, silk dressing, and drain are not shown. The fluffed gauze does not extend beyond the area indicated in "A." Inset: A below-knee amputee fitted with the immediate postsurgical prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The technique of immediate postsurgical fitting was originated in France by Berlemont, was carried further by Weiss in Poland, and, after a considerable experimentation period in the United States, is now being taught routinely in the prosthetics education programs in this country. <a></a> The technique consists of applying a rigid dressing over the stump and attaching an adjustable pylon and foot. Standing and ambulation is begun as soon as the patient's condition permits. For young, otherwise healthy patients, some ambulation can begin on the day following amputation.</p> <p>Usually the rigid dressing is left in place until the wound has healed and the sutures can be removed-about 10-14 days postoperatively. A second rigid dressing is provided for another 10- to 14-day period, at which time a "permanent," or definitive, limb can be provided. The advantages of immediate postsurgical fitting include reduction of edema, less pain, shorter periods of hospitalization and therapy, and fewer contractures. The technique has become standard practice in many centers with trained teams. <a></a></p> <h3>Hardware</h3> <p>To make early fitting and immediate postsurgical fitting easier, a number of adjustable pylons have been developed. Those currently available are shown in <b>Fig. 12</b>. Some of their characteristics are given in <b>Table 1</b>. These units are strong enough and light enough for extended usage with or without some sort of cosmetic cover. A number of approaches to cosmetic treatment such as the use of Spongex, mentioned above, have been offered, but none have been accepted widely by prosthetists. Work on this problem is continuing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Below-knee pylon-type prostheses that can be used for fitting immediately after surgery. A, Hosmer Postoperative Pylon; B, Northwestern Pylon (Hosmer); C, Veterans Administration Prosthetics Center (VAPC) "Standard" Pylon; D, Canadian "Instant" Prosthesis (Hosmer); E, United States Manufacturing Co. Pylon; F, Finnie-Jig (Arthur Finnieston Co.). Metal straps for attachment to a plaster-of-Paris socket are available, but not shown. Courtesy of Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Education and Research Needs</h3> <p>At the December 1968 "Symposium on Below-Knee Prosthetics", <a></a> sponsored by the Committee on Prosthetics Research and Development, a number of suggestions for improving prosthetics education and practice were offered.</p> <ol> <li>The body of knowledge about BK prosthetics that has been developed in recent years should be made available to practicing prosthetists and other clinicians.</li><li>All institutions offering prosthetics-education courses should include the information presented at the symposium in their curricula.</li><li>Opportunities for continuing education, such as postgraduate-type courses for clinic teams in the latest prosthetics techniques, should be provided.</li><li>Additional manuals and other instructional materials should be prepared. In addition, a central group that would be responsible for the orderly preparation and dissemination of technical information is needed.</li><li>Current research efforts in BK prosthetics should be continued, but with emphasis placed on the development of a truly refined theory of fitting.</li></ol> <p>Because most of the recent improvements to the design of the below-knee socket, especially in suspension techniques, have been accomplished by practicing prosthetists, there is little need for the research centers to devote their time to developing additional improvements. On the other hand, there is very little knowledge about the basic principles underlying optimum fitting of prostheses. Therefore, the research centers should be encouraged to obtain basic information about the effects of pressure and shear forces on tissues, and to more clearly indicate the biomechanical forces required in the various phases of walking. Following that work, methods by which those principles could be put into practice should be developed, including the use of hydrostatic sockets and other methods that might provide automatic adjustment.</p> <p>As a result of these suggestions, a pilot course in advanced below-knee prosthetics practices was held at Northwestern University (see "News and Notes") on August 4-13, 1969, for prosthetist instructors from the University of California at Los Angeles, New York University, and Northwestern University. The University Council on Prosthetics Education is now developing a curriculum for short-term postgraduate courses in below-knee prosthetics. The advanced techniques will also be offered in regular courses in below-knee prosthetics.</p> <p><b>References:</b></p> <ol> <li>The American Academy of Orthopaedic Surgeons, Inc.,<i> Historical development of artificial limbs</i>, Chap. 1 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Burgess, Ernest M., <i>The below-knee amputation</i>, Inter-Clinic Inform. Bull., 8:4:1-22, January 1969.</li> <li>Burgess, Ernest M., and Joseph H. Zettl, <i>Amputations below the knee</i>, Artif. Limbs, 13:1:1-12, Spring 1969.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower extremity amputees</i>, TR 10-5, Prosthetic and Sensory Aids Service, Veterans Administration, Washington, D. C, April 1967.</li> <li>Caldwell, Jack L., <i>Inverted V-strap suspension for PTB prosthesis</i>, Artif. Limbs, 9:1:23-26, Spring 1965.</li> <li>Committee on Prosthetics Research and Development, <i>Below-knee prosthetics</i>, A report of a symposium, National Academy of Sciences, Washington, D. C, December 1968.</li> <li>Committee on Prosthetics Research and Development, <i>Immediate postsurgical fitting of prostheses</i>, A report of a workshop, National Academy of Sciences, Washington, D. C, May 1968.</li> <li>Compere, Clinton L., <i>Early fitting of prostheses following amputation</i>, Surg. Clin. N. Amer., 48:1:215-226, February 1968.</li> <li>Dolan, Clyde M. E., <i>The Army Medical Biomechanical Research Laboratory porous laminate patellar-tendon-bearing prosthesis</i>, Artif. Limbs, 12:1:25-34, Spring 1968.</li> <li>Fillauer, Carlton, <i>Supracondylar wedge suspension of the P T.B. prosthesis</i>, Orth. and Pros., 22:2:39-44, June 1968.</li> <li>Goldner, J. Leonard, Frank W. Clippinger, and Bert R. Titus, <i>Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis</i>, Final Report of Project RD-1363-M, Duke University Medical Center, Durham, N. C, circa 1967.</li> <li>Hamontree, Sam E., Howard J. Tyo, and Snowdon Smith, <i>Twenty months experience with the "PTS"</i>, Orth. and Pros., 22:1:33-39, March 1968.</li> <li>Hampton, Fred, <i>Suspension casting for below knee, above-knee, and Syme's amputations</i>, Artif. Limbs, 10:2:5-26, Autumn 1966.</li> <li>Hill, James T., Henry Mouhot, and Robert E. Plumb, <i>Manual for preparation of a porous PTB socket with soft distal end</i>, Tech. Rep. 6804, U. S. Army Medical Biomechanical Research Laboratory, Washington, D. C, May 1968.</li> <li>Kuhn, G. G., S. Burger, R. Schettler, and G. Fajal, <i>Kondylen Bettung Munster am Unter-schenkel Stumpf</i>, "KBM-Prothese," Atlas d'Appareillage Prothetique et Orthopedique, No. 14, 1966.</li> <li>Litt, Bertram D., and LeRoy Wm. Nattress, Jr., <i>Prosthetic services USA-1961</i>, American Orthotics and Prosthetics Association, Washington, D. C, October 1961.</li> <li>Lower-Extremity Amputee Research Project, Minutes of symposium on BK prosthetics, University of California, Berkeley, April 1957.</li> <li>Marschall, Kurt, and Robert Nitschke, <i>Principles of the patellar tendon supra-condylar prosthesis</i>, Orthop. Pros. Appl. J., 21:1:33-38, March 1967.</li> <li>Marschall, Kurt, and Robert Nitschke, <i>The P.T.S. prosthesis (Complete enclosure of patella and femoral condyles in below knee fittings)</i>, Orthop. Pros. Appl. J., 20:2:123-126, June 1966.</li> <li>Pierquin, L., G. Fajal, and J. M. Paquin, <i>Prothese tibiale a emboitage supracondylien</i>, Atlas d'Appareillage Prothetique et Orthopedique, No. 1, January 1964.</li> <li>Plumb, Robert E., and Fred Leonard, <i>Patella-tendon-bearing below-knee porous socket with soft Silastic distal end</i>, Tech. Rep. 6311, U S. Army Medical Biomechanical Research Laboratory, Washington, D. C, June 1963.</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> <li>The Staff of the Prosthetics Research Group, Biomechanics Laboratory-University of California, <i>Manual of below knee prosthetics</i>, The Regents of the University of California, November 1959.</li> <li>The Staff, Veterans Administration Prosthetics Center, <i>Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material</i>, Orth. and Pros., 23:1:36-61, March 1969.</li> <li>Wilson, L. A., E. Lyquist, and C. W. Radcliffe, <i>Air-cushion socket for patellar-tendon-bearing below-knee prosthesis</i>, Tech. Rep. 55, Department of Medicine and Surgery, Veterans Administration, Washington, D. C, May 1968.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Below-knee prosthetics, A report of a symposium, National Academy of Sciences, Washington, D. C, December 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>7.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Immediate postsurgical fitting of prostheses, A report of a workshop, National Academy of Sciences, Washington, D. C, May 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>7.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Immediate postsurgical fitting of prostheses, A report of a workshop, National Academy of Sciences, Washington, D. C, May 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Burgess, Ernest M., The below-knee amputation, Inter-Clinic Inform. Bull., 8:4:1-22, January 1969.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Burgess, Ernest M., and Joseph H. Zettl, Amputations below the knee, Artif. Limbs, 13:1:1-12, Spring 1969.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Immediate postsurgical prosthetics in the management of lower extremity amputees, TR 10-5, Prosthetic and Sensory Aids Service, Veterans Administration, Washington, D. C, April 1967.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Compere, Clinton L., Early fitting of prostheses following amputation, Surg. Clin. N. Amer., 48:1:215-226, February 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>11.</b> </td><td class="clsTextSmall">Goldner, J. Leonard, Frank W. Clippinger, and Bert R. Titus, Use of temporary plaster or plastic pylons preparatory to fitting a permanent above knee or below knee prosthesis, Final Report of Project RD-1363-M, Duke University Medical Center, Durham, N. C, circa 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Sockets of this material should not be left near radiators or in an abnormally warm environment, such as the interior of a closed automobile parked in sunlight on a warm day, because synthetic balata becomes pliable at temperatures as low as 120 deg F.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">B. F. Goodrich Co.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">The Staff, Veterans Administration Prosthetics Center, Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material, Orth. and Pros., 23:1:36-61, March 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Registered trademark of Polymer Corporation Limited.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Hampton, Fred, Suspension casting for below knee, above-knee, and Syme's amputations, Artif. Limbs, 10:2:5-26, Autumn 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Dolan, Clyde M. E., The Army Medical Biomechanical Research Laboratory porous laminate patellar-tendon-bearing prosthesis, Artif. Limbs, 12:1:25-34, Spring 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Tech. Rep. 6311, U S. Army Medical Biomechanical Research Laboratory, Washington, D. C, June 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Dolan, Clyde M. E., The Army Medical Biomechanical Research Laboratory porous laminate patellar-tendon-bearing prosthesis, Artif. Limbs, 12:1:25-34, Spring 1968.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Hill, James T., Henry Mouhot, and Robert E. Plumb, Manual for preparation of a porous PTB socket with soft distal end, Tech. Rep. 6804, U. S. Army Medical Biomechanical Research Laboratory, Washington, D. C, May 1968.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Plumb, Robert E., and Fred Leonard, Patella-tendon-bearing below-knee porous socket with soft Silastic distal end, Tech. Rep. 6311, U S. Army Medical Biomechanical Research Laboratory, Washington, D. C, June 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Below-knee prosthetics, A report of a symposium, National Academy of Sciences, Washington, D. C, December 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>25.</b> </td><td class="clsTextSmall">Wilson, L. A., E. Lyquist, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, Tech. Rep. 55, Department of Medicine and Surgery, Veterans Administration, Washington, D. C, May 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>10.</b> </td><td class="clsTextSmall">Fillauer, Carlton, Supracondylar wedge suspension of the P T.B. prosthesis, Orth. and Pros., 22:2:39-44, June 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>15.</b> </td><td class="clsTextSmall">Kuhn, G. G., S. Burger, R. Schettler, and G. Fajal, Kondylen Bettung Munster am Unter-schenkel Stumpf, 'KBM-Prothese,' Atlas d'Appareillage Prothetique et Orthopedique, No. 14, 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hamontree, Sam E., Howard J. Tyo, and Snowdon Smith, Twenty months experience with the 'PTS', Orth. and Pros., 22:1:33-39, March 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Marschall, Kurt, and Robert Nitschke, Principles of the patellar tendon supra-condylar prosthesis, Orthop. Pros. Appl. J., 21:1:33-38, March 1967.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Marschall, Kurt, and Robert Nitschke, The P.T.S. prosthesis (Complete enclosure of patella and femoral condyles in below knee fittings), Orthop. Pros. Appl. J., 20:2:123-126, June 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Pierquin, L., G. Fajal, and J. M. Paquin, Prothese tibiale a emboitage supracondylien, Atlas d'Appareillage Prothetique et Orthopedique, No. 1, January 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Caldwell, Jack L., Inverted V-strap suspension for PTB prosthesis, Artif. Limbs, 9:1:23-26, Spring 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Below-knee prosthetics, A report of a symposium, National Academy of Sciences, Washington, D. C, December 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>16.</b> </td><td class="clsTextSmall">Litt, Bertram D., and LeRoy Wm. Nattress, Jr., Prosthetic services USA-1961, American Orthotics and Prosthetics Association, Washington, D. C, October 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>References</b></td></tr><tr><td class="clsTextSmall"><b>22.</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><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">The Staff of the Prosthetics Research Group, Biomechanics Laboratory-University of California, Manual of below knee prosthetics, The Regents of the University of California, November 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Lower-Extremity Amputee Research Project, Minutes of symposium on BK prosthetics, University of California, Berkeley, April 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">The American Academy of Orthopaedic Surgeons, Inc., Historical development of artificial limbs, Chap. 1 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Research Council, 2101 Constitution Ave., N. W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1969_02_001/69autumn-13.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Recent Advances in Below-Knee Prosthetics Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/211972ac2450f7c379e75a6afbeee2dc.pdf ae8db5d5134f237d958bbd2b68be6d08 https://staging.drfop.org/files/original/520946adfb02dd1afbd9b4c67af73f08.jpg 61cd9ff898171a3445f27886c90a2493 https://staging.drfop.org/files/original/9170dd45d7ca4e14488f584a811dd23e.jpg fe5833e8ce6bc7bdf61f5f73baf816e3 https://staging.drfop.org/files/original/3b0777a43f09e4e4ee2114768fb56d30.jpg d22944087f7c13edf9ac4ccc260893d8 https://staging.drfop.org/files/original/fe459c0ecfb645ab7220642b51f9c593.jpg f2423f9a630bfe7e433bda250a03a58c https://staging.drfop.org/files/original/7cfdf4864b7be4044c17cc555926b0e2.jpg 05467aefe472260562820f5c91fb6f4c https://staging.drfop.org/files/original/54b46adc00046b649185688bcfa06ed8.jpg d9288be7f7a62533a8e62cb9e56ac3e8 https://staging.drfop.org/files/original/e21b7388fdb6d845283dd747b9618c11.jpg dfe82d1c37e1a9669c31bcfda7e97869 https://staging.drfop.org/files/original/c228c40b5262dd433fd295410cdae1e4.jpg 6f2c4233f38372d631252e490f83e18f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_013.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 13 - 26 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_01_013.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_013.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Clinical Evaluation of the Engen Plastic Hand Orthosis</h2> <h5>Hector W. Kay, M Ed. <a style="text-decoration:none;">*</a><br /></h5> <p>A primary function of the hand is prehension, the ability to grasp an object. While the hand can perform numerous types of grasp, of major importance is the type involving flexion of the index and middle fingers towards or against the opposing thumb to provide what is sometimes referred to as "three-jaw-chuck" prehension.</p> <p>Temporary or permanent paralysis can impair or completely inhibit the function of hand, wrist, or entire upper extremity, and the ability to oppose the thumb to the flexing fingers may be lost. In these instances, various types of orthotic systems have been designed to achieve the goals of prevention or correction of deformities, or restoration of function, or both. A key feature of these systems is the stabilization of the thumb in opposition to the fingers.</p> <p>Pioneering efforts in the area of hand-splinting were undertaken at the Georgia Warm Springs Foundation where many types of assistive devices were developed to meet the needs of a large patient population having residuals of poliomyelitis. Although the number of polio patients has decreased in recent years, rehabilitative medicine has expanded to include patients with many other types of neuromuscular and skeletal disorders. A systematic method of hand splinting to meet the needs of these patients has continued to be of paramount importance. On-going efforts in this regard have been maintained not only at GWSF but also at Rancho Los Amigos Hospital and other institutions. <a></a></p> <p>As part of Research Project VRA RD-1564, Thorkild J. Engen, Project Director, Baylor University College of Medicine, Houston, Texas, in 1959 initiated the development of a plastic hand orthosis having the basic configuration shown in <b>Fig. 1</b>. <a></a> Based on the premise that preservation of hand posture is best maintained by support, rather than suspension, the device is designed to hold the thumb in the opposed position and simultaneously support the metacarpal arch. The aim has been to develop a standardized item shaped to conform to the natural contours of the hand which could then be adapted to meet individual needs. The Engen orthosis is made in four sizes: large, medium-large, medium, and small; and for both right and left hands. Because the orthosis is fabricated of polyester resins, it can be remolded upon application of heat.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Basic Engen plastic hand orthosis being prepared for individual application. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the early stages of redevelopment, the Engen orthoses were fabricated of epoxy resins with and without fiberglass reinforcement. Ultimately these models were discarded because of breakage problems. The plastic shells originally submitted to New York University for a laboratory evaluation program were made of fiberglass and polyester resins. <a></a> The current shell is a polyester resin and nylon laminate prepared by means of a vacuum-molding technique. With the new materials, the fitting technique is essentially unchanged; the orthosis is molded and modified by the orthotist as necessary to provide a custom fit.</p> <p>In the course of development, attachments were devised or adapted to provide wrist support and to provide prehension.</p> <p>Three versions or adaptations of the Engen plastic hand orthosis were selected as the subject of the field evaluation: the short opponens orthosis, the long oppo-nens orthosis, and the reciprocal wrist-extension, finger-flexion unit. Additional modifications of the basic concept involving the use of external power were specifically not included in the study.</p> <h3>Short Opponens Orthosis</h3> <p>The so-called short opponens orthosis is the simplest application or adaptation of the Engen equipment. <a></a> It consists essentially of the basic hand shell with a retaining strap (<b>Fig. 2</b>). The prime purpose of this device is to maintain the thumb in apposition to the index and long fingers and to support the metacarpal arch. The functional goal is the achievement of "three-jaw-chuck" prehension as distinct from "lateral" grasp. Patients said to benefit from this orthosis are those with neuromuscular disorders resulting in various degrees of muscle imbalance of the intrinsic and opponens muscle groups. Such patients would typically have spinal cord injuries at the C-7, C-8, and T-l levels, peripheral neuropathy (ulnar and median nerves), or hemiplegia.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Two views of the short opponens orthosis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Long Opponens Orthosis</h3> <p>This adaptation <a></a> consists essentially of the basic plastic hand shell with an attached extension arm which is stabilized on the forearm by appropriate straps (<b>Fig. 3</b>). Like the short opponens orthosis, this device is designed to prevent deformity and achieve "three-jaw-chuck" prehension if the necessary residual muscle movements are present and can be controlled. Patients with spinal lesions at the C-5, C-6 levels, peripheral neuropathy involving the median or ulnar nerves, or both, and the radial nerve, or hemiplegia, are said to be suitable candidates for this device.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Two views of the long opponens orthosis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Reciprocal Wrist-Extension Finger-Flexion Orthosis</h3> <p>This adaptation, which is the most complex of those studied, is designed to provide prehension when voluntary wrist-extension power is available (<b>Fig. 4</b>). Quadriplegic patients who retained innervation to the wrist-extensor muscles are said to be appropriate subjects for this type of functional orthosis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Two views of the reciprocal orthosis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Procedures</h3> <h4>Participating Clinics and Personnel</h4> <p>As an initial step in the activation of the proposed field study, the Committee on Prosthetics Research and Development, through its staff and Subcommittee on Evaluation, selected five treatment centers known to be active and interested in the application of hand splints. These clinics were approached and each agreed to participate in the study. The institutions and personnel involved were:</p> <ol> <li>Duke University Medical Center, Durham, N. C. (Frank W. Clippinger, Jr., M.D.; Bert R. Titus; Felton Elliott).</li><li>Georgia Warm Springs Foundation, Warm Springs, Ga. (Edward Haak, M.D.; H. G. Bowden).</li><li>Highland View Hospital, <a style="text-decoration:none;">*</a> Cleveland, Ohio (Al-vin A. Freehafer, M.D.; Arthur Guilford, Jr., G. A. Guilford and Sons).</li><li>Ohio State University, Columbus, Ohio (Marvin H. Spiegel, M.D.; Lawrence Czap; Charles W. Rosenquist, Columbus Orthopaedic Appliance Co.).</li><li>Veterans Administration Hospital, Hines, Ill. (James F. Kurtz, M.D.; Vladimir T. Liberson, M.D.; Walter J. Piotrowicz, CO.).</li></ol> <h4>Instruction In Fabrication Procedures</h4> <p>The study of the Engen devices was initiated by an instructional course in the three applications to be evaluated. This course was conducted by the developer and his staff at the Texas Institute for Rehabilitation and Research, Houston, Tex., from Dec. 5 to 8, 1966 (orthotists, four days; physicians, one day). Instructional material and fitting check lists were prepared by the developer, <a></a> and used as the basis for the course. A special training session for Mr. Sigars was conducted December 4-6, 1967, after he joined the Rancho Los Amigos Hospital team.</p> <h4>The Study Plan</h4> <p>Concurrent with the recruitment and training of participating clinic personnel, the CPRD staff, in collaboration with the developer, and under the guidance of its Subcommittee on Evaluation, prepared the schedule and data-recording forms for the study. <a></a></p> <p>Essentially, each clinic was requested to seek patients appropriate for applications of the Engen devices. Data related to the fittings would be recorded on the forms developed by the Committee on Prosthetics Research and Development. Each patient fitted was to be followed for a period of 12 months unless treatment was terminated prior to that time. The CPRD staff was to provide liaison with the field clinics as necessary during the course of the study.</p> <h3>Results</h3> <h4>Technique Transferability</h4> <p>With a new fabrication or fitting technique which is said to yield excellent results in the hands of the developer, an important consideration is whether or not the skill and "know-how" involved in the applications can be successfully transferred to others.</p> <p>In the present study the means of achieving this transfer were: (1) Written instructional material prepared by the developer; (2) A course of instruction which included practice in the fabrication of devices; and (3) Follow-up visits made by the developer to each participating facility. Problems encountered locally were analyzed and supplementary instruction given.</p> <p>It was the consensus of the evaluation team as well as that of the participants that the fabrication techniques for the three EPHO adaptations under study were successfully transmitted by these procedures. Moreover, while the orthotists participating in the evaluation were selected and highly skilled, indications were that less skilled technicians could be satisfactorily taught by the same methods.</p> <h4>Patient Fittings</h4> <p><i>The Sample</i></p> <p>During the period of the evaluation program, 22 patients were fitted with the Engen Plastic Hand Orthosis. Distribution in terms of the three adaptations under study were: short opponens orthosis, 7; long opponens orthosis, 3; and reciprocal units, 12.</p> <p>Moreover, data was available on an additional 48 patients distributed as follows: short opponens orthosis, 11; long opponens orthosis, 7; and wrist-driven reciprocal units, 30. These patients were fitted at Hines VA Hospital following the closure of the official phase of the study. Some findings of interest from these additional fittings are included.</p> <p>In the total of 70 fittings reported, 18 were with short opponens, 10 with long opponens, and 42 with reciprocal units, roughly a 2:1:4 ratio. Whether this ratio could be extrapolated to the general population is not known.</p> <p>Typical conditions for which the three versions of the EPHO<a style="text-decoration:none;">*</a> were applied were: (1) short opponens orthosis: rheumatoid arthritis of the hands (<b>Fig. 5</b>); quadriplegia (to prevent deformities and support the hand in a position of function pending fitting of reciprocal units); contraction deformity of the wrist; (2) long opponens orthosis: quadriplegia (as a stabilizing device pending reduction of contractures and fitting with a reciprocal unit) (<b>Fig. 6</b>); or as a base for the addition of self-help devices (<b>Fig. 7</b>); reciprocal units: quadriplegia (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Left, palmar and dorsal views of patient's arthritic hands. Above, left hand fitted Engen short opponens orthosis and Thomas outrigger splint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Patient fitted with Engen long opponens orthosis as stabilizing device. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Patient fitted with Engen long opponens orthosis with attachment for self-help devices. Note atrophy of thenar cleft. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Patient fitted with reciprocal unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Outcomes</i></p> <p>Results of the fittings in the five participating clinics were variable, success or failure being related primarily to three factors:</p> <ol> <li>Proper selection of patients. In several of the clinics patients were selected under somewhat experimental circumstances, that is, either the motivation of the patients was less than optimal or the anticipated benefit to be derived from the Engen device was marginal. In these instances, the fittings typically proved to be failures.</li><li>Objectivity in the evaluation of outcomes. Two of the clinics participating in the study had devices of their own design which were "competitive" with the Engen items. Personnel of these clinics were of the opinion that the Engen devices provided no features superior to their own devices other than perhaps the telescoping rod on the reciprocal unit application.</li><li>Meticulous care in application and follow-up. Although the Engen Plastic Hand Orthosis is essentially a prefabricated shelf item, it must be carefully tailored to the needs of the individual patient. This tailoring may involve: (a) some reshaping of the plastic shell to accommodate atrophy or size discrepancy in the patient's hand; (b) the addition of accessory finger pieces and other equipment to the basic Engen shell.</li></ol> <p>Moreover, since the condition of the patient's hand changes with time and with the use of the Engen splint, follow-up to maintain fit of the device is essential. This follow-up is obviously best accomplished when the patient is being treated on an in-patient basis, in-house orthotic facilities are available, and there is close cooperation between the disciplines involved in the care of the patient.</p> <p>Where the foregoing conditions were satisfactorily met, excellent success was achieved in the fittings of the Engen devices. Selected cases which illustrate the applications and outcomes of the three EPHO modifications under study are presented below.</p> <h3>Case Presentations</h3> <h4>Short Opponens Orthosis</h4> <p><i>Case No. 1</i></p> <p>A. M. was a 40-year-old male with a diagnosis of quadriplegia resulting from a physiologically incomplete lesion of the spinal cord at the C-5 level. A short op-ponens orthosis was prescribed for his right, dominant hand with a view to aiding in the restoration of function, and the prevention and correction of deformities. It was hoped that eventually Mr. M. would be a candidate for a right reciprocal unit. The patient was described as having a motivational level of fair and a tolerance to pain that was average.</p> <p>Mr. M. was fitted with a medium-sized orthosis. The suitability of the preformed size and shape was rated as good and the ease of customizing and the clarity and completeness of the instructions for doing so were also rated as good. No special modifications of the shell were necessary for this patient.</p> <p>A. M. was reevaluated at 1, 3, 6, 9, and 12 months following the initial fitting. The efficacy of the splint in achieving the objectives of the fitting was rated as good in all respects. The patient's performance in such activities as turning pages in a book and writing was rated as fair. The performance in feeding and using a toothbrush was cited as being poor. The patient's reactions to the orthosis were good with respect to fit, comfort, and cosmesis, and fair as regards function. During the course of his treatment the patient was given physical and occupational therapy and special instruction in the use of the Engen device. He was also given medication for spasticity which did not involve the hands.</p> <p>The evaluation of the device with regard to this patient remained remarkably consistent throughout the entire 12 months of the test period except that the patient's own reactions to the functional assistance provided by the device declined from fair to poor from the third month on.</p> <p>The outcome in this instance was considered to be excellent, but two other patients, D. R. and J. A., whose initial conditions were remarkably similar, withdrew from the study one and four months, respectively, after the initial fitting. In these two instances the restoration of function achieved with the orthosis was minimal and this factor, combined with low levels of motivation, resulted in the withdrawals.</p> <p><i>Case No. 2</i></p> <p>Patient N. E. was a 60-year-old male with a diagnosis of rheumatoid arthritis of some eight years' duration. He was prescribed an EPHO short opponens orthosis for his right, dominant hand, the objectives being assistance in the restoration of function and the prevention and correction of deformities. His tolerance to pain was described as average, and his skin condition as thin, and his motivational level was said to be good.</p> <p>N. E. was fitted with the large-sized EPHO shell. With regard to the fitting, the suitability of the preform size and shape was rated as good, as were the ease of customizing and the clarity and completeness of instructions. No special modification was necessary initially, but some five weeks later a Thomas outrigger suspension was applied to prevent further subluxation of the metacarpophalangeal (MCP) joints (<b>Fig. 5</b>). Mr. E. was reevaluated at 1, 3, 6, 9, and 12 months following fitting and then left the clinic area taking the provided splint with him.</p> <p>Initially the achievement of objectives involving the prevention and correction of deformities was rated as good, but the restoration of function as poor. Mr. E.'s performance in typical activities of daily living were all rated as poor. The patient's reactions to the device were good with respect to fit, comfort, and cosmesis, but poor as regards function.</p> <p>As Mr. E. continued to wear the experimental device his ratings in all performance activities were raised to fair, and finally to good in such activities as page-turning, writing, and feeding. The patient's rating of the functionality of the device gradually improved until finally it was reported as good.</p> <p>In this fitting the outcomes appeared to be positive from the beginning with respect to the prevention and correction of deformities with gradually increasing benefit in the area of function.</p> <h4>Long Opponens Orthosis</h4> <p><i>Case No. 3</i></p> <p>Patient J. K. was a 21-year-old male. His primary diagnosis was quadriplegia with a spinal-cord injury at the C-5, C-6 levels which was incurred some nine months prior to his inclusion in the evaluation program. He was fitted with an EPHO long opponens orthosis, medium-size, to the right hand which was less impaired than the left. His hands were atrophied, especially in the thenar-cleft area, and he had a slight lateral palmar drift on the (right) hand fitted. The patient's motivational level was said to be good and his pain tolerance average. The objectives of the fitting were restoration of function, and prevention and correction of deformities in the hope that he might eventually be fitted with a reciprocal orthosis.</p> <p>The application of the device proceeded without difficulty except that the device was somewhat too large for the patient's atrophied thenar-cleft area. The splint tended to displace itself into this area. Three weeks after the initial fitting a reduction in the cock-up angulation was recommended by the developer, together with the addition of a T-bar to abduct the thumb and a dorsal strap for better retention.</p> <p>The patient preferred the EPHO splint to his previously worn Royalite device and requested that the EPHO be modified to include the self-aid attachments worn on the earlier splint. The device was subsequently reinforced with a Monel metal piece and has held up well since that time. The patient's flexed lateral palmar drift was held in proper position by the orthosis.</p> <p>At the one-month follow-up of this patient the ratings of outcomes were generally poor to fair with only the patient's reaction to the cosmesis of the device being designated as good. However, steady improvement occurred throughout the follow-up period, and by 9 months after initial fitting the device was rated as good in all characteristics specified in the evaluation program. Thus, in this instance, the outcomes of fitting the Engen plastic hand orthosis must be considered as excellent.</p> <p><i>Case No. 4</i></p> <p>On another patient, F. G., with a somewhat similar disability, the results of the fitting were considerably less positive. This patient was a 40-year-old male with complete transverse severance of the spinal cord at the C-6, C-7 levels. The injury to this patient had occurred some six and a half years prior to the present study and he had had a surgical transfer of the brachioradialis tendon to the wrist extensors on his left hand several years previously. The hand tended to go into marked radial deviation on voluntary extension of the wrist. He could raise his elbows and shoulders bilaterally. He had muscle spasms.</p> <p>F. G. was fitted with a medium-sized long opponens orthosis and it was immediately noticeable that the splint would not hold the patient's marked radial deviation. At the developer's suggestion the cock-up angle of the splint was reduced to prevent creeping and a plastic clip added on the proximal medial side. A lateral Velcro strap was added to pull the ulnar side of the wrist toward the radial side, and an elastic sling was added to correct the flexion of the interphalan-geal (IP) joint of the thumb. The patient was to be considered for a reciprocal orthosis if his contractures could be reduced. The patient's motivational level was rated as poor with respect to any type of splinting.</p> <p>The outcomes of this fitting initially were also mixed and failed to show appreciable improvement, particularly with regard to function, over a 6-month follow-up period. The patient was then taken off the program at his own request.</p> <h4>Reciprocal Wrist-Extension Finger-Flexion Orthosis</h4> <p><i>Case No. 5</i></p> <p>Patient V. C. was a 42-year-old male who had sustained a spinal-cord injury at age 26. His primary diagnosis was "dislocation and compression of the spinal cord at the C-5, C-6 levels with complete paralysis." With no prior experience with orthotic devices, he was fitted with a reciprocal unit on his right, dominant hand. His motivational level was rated as good, but his pain tolerance was given as low. The objectives of the fitting were restoration of function and prevention and correction of deformities.</p> <p>The fitting utilized a large reciprocal orthosis and finger pieces but a medium-sized forearm piece. The component sizes were considered to be good for this patient. However, the shape of the plastic shell did not provide good support for the arch of the hand or conform well to the thenar-cleft area. A thumb sling and a middle-finger IP stabilizer were added. A later review of this case indicated that the MCP and the wrist joints were incorrectly placed. With these conditions the patient had no desire to try and use the splint and did not wish to keep it. Replacement of the malpositioned joints effected a marked improvement in the function of the device and the patient's acceptance of it. This high level of performance and acceptance was maintained throughout the remainder of the patient's 12-month participation in the study. In this case, obviously the difference between success and failure hinged on the proper joint positioning, emphasizing the importance of this aspect of the fitting. This type of experience was repeated with a number of other patients in the evaluation.</p> <p><i>Case No. 6</i></p> <p>Patient W. M. was a 47-year-old male who sustained a spinal-cord injury approximately one year prior to being fitted with the Engen orthosis. His diagnosis was given as "compression of cord, level C-5, C-6 incomplete, C-7 complete." Mr. M.'s motivational level was said to be good, but his pain tolerance was given as low. He was fitted with a reciprocal orthosis on his right, dominant hand, the objectives being restoration of function, and prevention and correction of deformities.</p> <p>The initial application of the device seemed to proceed satisfactorily, the component parts being a large plastic shell, a larger finger unit, and a large forearm piece. The sizes and shapes of the various components seemed to be appropriate. Three days later a "knuckle bender" was added because of tightness of the MCP joints and a modified Oppenheimer splint was fitted to increase the limited range of wrist extension and thumb abduction.</p> <p>A later review of this case indicated that the joint hinges had been incorrectly positioned and this deficiency was corrected. Again a dramatic improvement in the achievement of fitting objectives, functional level and patient acceptance, was evident, although this subject's function was not as good as that of the previous patient. This case again illustrates the importance of joint positioning and indicates the use of the Engen basic equipment as a module to which other accessories might be added.</p> <h3>Summary and Recommendations</h3> <p>In the present study it would appear evident that orthotists with prior experience and skill in the fabrication of hand splints can be taught to apply the EPHO variations successfully. In this connection the instructional manual and fitting checkout sheets developed in conjunction with the field study provided an excellent basis for the transfer of techniques from developer to field orthotists. However, this written material is not regarded as an adequate substitute for direct person-to-person instruction. Moreover, a follow-up visit to each of the clinics following initial fittings helps to insure that the techniques taught are being properly applied and assists in the solution of specific local problems.</p> <p>The outcomes of the field fittings of the Engen equipment were mixed, positive results being related primarily to three factors: (1) proper selection of patients, including consideration of motivational factors; (2) meticulous care in application and follow-up of the devices; and (3) objectivity in evaluating outcomes. Where these considerations were observed, the successful outcomes achieved support the developer's claims for the device.</p> <p>Fitting results for each subject in the study showed no significant changes after 6 months' wear of the Engen device. Hence, consideration might be given to reducing the follow-up period in similar future studies from 12 to 6 months.</p> <h4>The Devices</h4> <p><i>Prescription Criteria</i></p> <p>The criteria for prescription of the Engen adaptations as set forth above were re-affirmed by the results of the field study. The following additional comments also emerged:</p> <ol> <li>Short Opponens Orthosis <ul><li>a. has been found useful as a stabilizing splint in several instances of postsurgical management;</li> <li>b. has been used in providing patients with various self-help devices as attachments to the basic shell;</li> <li>c. with special modifications has been used in rheumatoid arthritic cases to help prevent ulnar and radial finger drift and align the fingers in proper position for finger prehension;</li> <li>d. has been used as the stabilizing splint pending evaluation for application of a reciprocal unit.</li></ul></li><li>Long Opponens Splint with Extension Arm Support <ul><li>a. has also been utilized for the same applications as the short opponens orthosis above.</li></ul></li></ol> <h4>Specific Findings</h4> <p>Specific findings relating to the design and applications of the EPHO devices were:</p> <ol> <li>Although the Engen Plastic Hand Orthosis is ostensibly a prefabricated shelf item, it must be carefully tailored to the needs of the individual patient. This tailoring may involve: <ul> <li>a. some reshaping of the plastic hand shell to accommodate atrophy or size discrepancy in the patient's hand;</li> <li>b. the addition of accessory finger pieces and other equipment to the basic Engen shell.</li></ul></li><li>In the installation of the EPHO reciprocal orthosis, great care must be exercised in the location of the joint axes.</li><li>Since the condition of the patient's hand changes with use of the Engen splint, follow-up to maintain fit of the device is essential. This follow-up is best accomplished when the patient is being treated on an in-patient basis, in-house orthotic facilities are available, and there is close cooperation between the disciplines involved in patient care.</li><li>The telescopic rod feature of the reciprocal unit was frequently cited as a most significant new characteristic of this type of orthosis.</li><li>Although definitely related to the level of experience gained in the application of the EPHO devices, saving of the orthotist's time was a significant feature of the system.</li><li>Some deficiencies in the design and materials of the EPHO were noted: <ul> <li>a. The range of three sizes provided initially were considered inadequate but the addition of the fourth (medium-large) size virtually eliminated this problem.</li> <li>b. A very common problem was that of fitting the hand shell to atrophied thenar-cleft musculature. The likelihood that this problem would be encountered and measures for adapting the shell to meet it should be emphasized in the instructional material.</li> <li>c. Some problems were encountered with stripping and bending of the telescopic rods.</li> <li>d. Some tendency for the shells to revert to their original shape after heating and modification was reported. However, in general, the physical properties of the splints were considered adequate to last an indefinite period with proper care and maintenance.</li></ul></li></ol> <p>In conclusion, the field evaluation of the EPHO adaptations clearly revealed that the devices are useful additions to the armamentarium of orthotic items available for the treatment of patients with disabilities of the hand. It is recommended that the outcomes of this study be forwarded to the prosthetics-orthotics schools with a view to the possible inclusion of instruction in this system as part of the orthotics curriculum.</p> <p><b>References:</b></p> <ol> <li>Anderson, Miles H, <i>Upper extremities orthotics</i>, Charles C Thomas, Springfield, Ill., 1965.</li> <li>Bisgrove, J. G., <i>A new functional dynamic wrist extension-finger flexion hand splint, a preliminary report</i>, J. Assoc. Phys. Ment. Rehab., 8:5:162-163, September-October 1954.</li> <li>Engen, Thorkild J., <i>A plastic hand orthosis</i>, Orthop. Pros. Appl. J., 13:2, September 1959.</li> <li>Engen, Thorkild J., <i>A "modification" of a reciprocal wrist extension-finger flexion orthosis</i>, Or-thop. Pros. Appl. J., 14:1, March 1960.</li> <li>Engen, Thorkild J., <i>Instructional manual for a reciprocal wrist extension-finger flexion orthosis</i>, Baylor University, Houston, Tex., 1: April 1968.</li> <li>Engen, Thorkild J., <i>Fabrication instructions, long opponens orthosis,</i> unpublished.</li> <li>Engen, Thorkild J., <i>Fabrication instructions, short opponens orthosis</i>, unpublished.</li> <li>Kay, Hector W., and A. Bennett Wilson, Jr., <i>Clinical evaluation of prosthetic and orthotic devices and techniques</i>, Committee on Prosthetics Research and Development, National Academy of Sciences, Washington, D.C., 1969.</li> <li>Vorchheimer, Heidi, <i> Summary of fittings - Engen hand orthoses</i>, Prosthetic and Orthotic Studies, New York University, June 1966.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall"> Utilizing the basic Engen items as modules to which accessory equipment was added if indicated by the needs of the patient.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical evaluation of prosthetic and orthotic devices and techniques, Committee on Prosthetics Research and Development, National Academy of Sciences, Washington, D.C., 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>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Engen, Thorkild J., Instructional manual for a reciprocal wrist extension-finger flexion orthosis, Baylor University, Houston, Tex., 1: April 1968.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Engen, Thorkild J., Fabrication instructions, long opponens orthosis, unpublished.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Engen, Thorkild J., Fabrication instructions, short opponens orthosis, unpublished.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical evaluation of prosthetic and orthotic devices and techniques, Committee on Prosthetics Research and Development, National Academy of Sciences, Washington, D.C., 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Unfortunately, the Highland View Hospital team had to withdraw prior to the commencement of the study. It was replaced by a team from Rancho Los Amigos Hospital consisting of E. Shannon Stauffer, M.D., and Dale Fries, orthotist. In the course of the study, Mr. Fries transferred to another position and was replaced by Mr. Charles Sigars.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Engen, Thorkild J., A plastic hand orthosis, Orthop. Pros. Appl. J., 13:2, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Engen, Thorkild J., A plastic hand orthosis, Orthop. Pros. Appl. J., 13:2, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Vorchheimer, Heidi, Summary of fittings - Engen hand orthoses, Prosthetic and Orthotic Studies, New York University, June 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Engen, Thorkild J., A plastic hand orthosis, Orthop. Pros. Appl. J., 13:2, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Anderson, Miles H, Upper extremities orthotics, Charles C Thomas, Springfield, Ill., 1965.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bisgrove, J. G., A new functional dynamic wrist extension-finger flexion hand splint, a preliminary report, J. Assoc. Phys. Ment. Rehab., 8:5:162-163, September-October 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>Hector W. Kay, M Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Research Council, 2101 Constitution Ave., N.W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_013/spring69-13.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_013/spring69-14.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_013/spring69-15.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_013/spring69-16.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_013/spring69_17.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_013/spring69_18.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_013/spring69-19.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_013/spring69-20.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 Clinical Evaluation of the Engen Plastic Hand Orthosis Creator An entity primarily responsible for making the resource Hector W. Kay, M Ed. * https://staging.drfop.org/files/original/10c1e9153313406ba4f5bb6316536cb0.pdf f021c880f280590c0b2349861906bbcb https://staging.drfop.org/files/original/dc11864cea6523c87bf2d8df4550c001.jpg 13279d0e9cb832a37dc538a352203e0b https://staging.drfop.org/files/original/2002e46ffabbd7a8026db85c3669de1f.jpg 74ffcd886b527321c2f9d37afc60ab20 https://staging.drfop.org/files/original/9dc4487b2acddd05e4f0f442510b35b9.jpg d5f724d51a1e6ba2b8a1d03c305f1774 https://staging.drfop.org/files/original/3a68d5d8a5f6b3952661c4bbd46eefa7.jpg 89904eeb58e41489800af4cb2a49a63e https://staging.drfop.org/files/original/77c9d3c2d4a941dc2c53cdf6f0a49971.jpg fc10f1203fdabd37b416196d917e1a9b https://staging.drfop.org/files/original/1ba9f329202448af3fa4efbfd9070888.jpg 2f146206c850edfddfda674098294ccb https://staging.drfop.org/files/original/35727e9c9abf2b58afcb30a82a68b630.jpg 6e3ea0d5ebea2f60d1d2cf5edb70215a https://staging.drfop.org/files/original/7880f6b348c16563637e568b84221d13.jpg 1b1a6610e78623175fbdc6336c343ba5 https://staging.drfop.org/files/original/bda95fea38a30663bb14a54fdd0bf252.jpg 003b6c53652ab72a46888a097359d477 https://staging.drfop.org/files/original/1c9248ec6e5c79bd34a6b0e521ddc916.jpg d08a866941e3cec5031a61f6feb966fa https://staging.drfop.org/files/original/c604af9b9225d4ffc11d1b6d9f2b0fdf.jpg db1f4c9447ff9977f7a3c7a7cbc0d8ac https://staging.drfop.org/files/original/d289c21c42aa9f609743bcb0fe52e10a.jpg 5cee6ff75cd02de689a5b21010742089 https://staging.drfop.org/files/original/ee73aa307cf4e9cc566ca1852eb9efa2.jpg 386ce91b1d4443ce1250cd660c0715ab https://staging.drfop.org/files/original/4a3d7f3112ca91a59eaf1ff5a9a5a204.jpg ee3ea0c538854c55e5170f52570aba84 https://staging.drfop.org/files/original/b830cc45412e5424f35cc65c231b8d5b.jpg 0fcd7e975fb49b493c0e6d7c0191bc84 https://staging.drfop.org/files/original/b2e854fc9a5e33325ed8ec746dda8ae0.jpg 2f339c44ea64b52504a784b6443b4a77 https://staging.drfop.org/files/original/6de37e945a0e41d8484dc77c16bc3cd6.jpg 04bdad71e4b68a0386a544b9b4121882 https://staging.drfop.org/files/original/febbd73f2648976234d696c9b757b7ae.jpg d7658aff6e0000e75444773e217cde8e https://staging.drfop.org/files/original/d5b7a908de158673aff7c895d77eba42.jpg fe328b7b8ee047f1d66414ae1226bf7e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_013.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 13 - 30 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_02_013.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_02_013.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The NYU Transparent Socket Fabrication Procedure</h2> <h5>Thomas Grille <a style="text-decoration:none;">*</a><br />Ronald Lipskin <a style="text-decoration:none;">*</a><br />Richard Hanak <br /></h5> <p>It has been recognized for a long time that a transparent socket that could be made to fit the stump would be a useful tool in studying the relationship between the amputation stump and the socket of a prosthesis. Early attempts by a number of investigators to devise sockets of acrylics such as Plexiglas and Lucite were abandoned because of the difficulty encountered in controlling the contours and because of the inordinate amount of time required for fabrication of a single socket.</p> <p>In 1966, the New York University Prosthetics and Orthotics group undertook a comprehensive study to develop a practical method of fabricating a transparent socket using newer materials and fabrication techniques.</p> <p>The criteria for the selection of the transparent material to be utilized for the socket were that it be water-clear with good transparency, have adequate strength and fracture resistance, and be non-toxic. The method of fabrication was to be reasonably simple and was not to require an excessive amount of actual working time or sophisticated equipment; the materials and equipment were to be readily available.</p> <p>Two basic approaches were explored: vacuum forming and casting.<a style="text-decoration:none;">*</a> Transparent polycarbonate sheet material was used in the attempts to make a socket using the vacuum forming method. Below-knee sockets were made by this method, but it was necessary to form the socket in two parts and to bond them together, a procedure which was time-consuming and which required extreme care if accuracy was to be obtained.</p> <p>Both epoxy and polyester resins were tried for casting transparent sockets. Satisfactory results could be obtained with epoxy resins, but excellent results were obtained consistently with polyester casting resins when RTV silicone rubber was used on the outer surface of a male plaster slush mold and the casting surfaces were covered with polyvinyl chloride film. This article describes the procedures, in a step-by-step fashion, for fabrication of a transparent socket using polyester casting resins.</p> <h4>Silicone Male Mold</h4> <p>A conventional hard socket is supported on a wood attachment block during the fabrication of the silicone rubber male mold. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>1. Using approximately five layers of plaster bandage, the proximal trim line of the conventional socket is built up to the level that existed prior to trimming (about 1 in. above the proximal end of the socket with the interior surface made reasonably flat). After the plaster bandage has hardened, any rough interior areas are sanded smooth, and any plaster that interferes with the interior contour is removed.</p> <p>2. To facilitate separation of the silicone shell from the hard socket, the interior surface of the hard socket is sprayed with Dow Corning Silastic RTV Mold Release. <b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>3. In order to retain the liquid silicone rubber in the hard socket, masking tape is used to form a V2-in.-wide rim around the proximal edge of the plaster-bandage buildup.</p> <p>4. Dow Corning Silastic D RTV Silicone Rubber is mixed with 5% by weight of Silastic D RTV thinner. One-half to one lb of silicone is used for BK sockets and 1-1/2 to 2 lb are used for AK sockets, depending upon socket size.</p> <p>5. Stannous octoate catalyst is added in a ratio of 100 drops or 2.2 gm to 1 lb of silicone rubber. This provides a 10-min working and a 1-hr curing time, which is the optimum for this procedure. The working time can be changed by varying the amount of catalyst. (Although this catalyst recommendation differs from the product-use instructions, its use is suggested because it has been found to be more convenient.) If stannous octoate is not available, a proportion of one part of standard catalyst to five parts of silicone rubber is used. <b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>6. The mixture is poured into the hard socket, then the socket is rotated by hand so that the entire inner surface is covered. After this has been accomplished, the socket is rotated only in one direction to insure an even distribution of the mixture to a uniform thickness of approximately % in. The rotation (in one direction) is continued until the mixture is set (10-15 min); the mixture is then allowed to cure at room temperature for 45 min. <b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A uniform wall thickness of approximately 1/8 in. is important in order to provide adequate shock absorption during break-out and to avoid the formation of an undersized socket. <b>Fig. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>7. The silicone-rubber shell is pulled away from the medial wall, and a slit is made down the medial side of the socket. The slit will simplify the removal of the completed male mold by permitting the hard socket to be spread open. The slit is started 1/2 in. below the proximal brim and ended 2 in. short of the distal edge. (A wooden tongue blade and a clamp can be used to keep the silicone shell away from the medial wall while cutting the socket.) <b>Fig. 6</b> - <b>Fig. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>8. The male mold will be fabricated with a hollow core in order to simplify breaking it out of the transparent socket. With the silicone shell in the hard socket, a plaster slush mold is poured to a 3/4-in. thickness, except at the distal end, where the thickness should be approximately 1-1/2 in. The plaster is allowed to set. <b>Fig. 8</b> - <b>Fig. 9</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>9. A pipe drilled with a few vacuum holes is inserted as a mandrel into the slush mold, and secured at its distal end with additional plaster. The middle section of the mold is filled with paper, and plaster is added at the proximal end of the mold to secure the mandrel. The plaster is allowed to set. <b>Fig. 10</b> - <b>Fig. 11</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>10. To separate the completed male mold from the hard socket, the plaster-bandage buildup is removed, the socket is opened along the slit, and the socket is slipped off. <b>Fig. 12</b> - <b>Fig. 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>11. To permit the application of vacuum to the undercut areas, 1/8-in. holes are punched through the silicone shell and 1/8-in. holes are drilled through the underlying plaster. The holes must be cut through to the void space in the male mold. <b>Fig. 14</b> - <b>Fig. 15</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Female Mold</h4> <p>12. An alignment pin is used to insure correct alignment of the distal ends of the male and female molds during casting of the transparent socket. A hole 1/2 in. in diameter is punched in the silicone shell, and one 1/2 in. in diameter and 3/4 in. deep is drilled into the distal aspect of the male mold. An alignment pin, cut 1/2<i> </i>in. in diameter by 3 in. long of nonferrous metal rod. is inserted into the distal hole. <b>Fig. 16</b> - <b>Fig. 17</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>13. In order to provide a 1/4-in. wall thickness for the transparent socket, a 1/4-in. Dacron felt sleeve, a 1/8-in. Dacron felt sleeve, and a cotton stockinette sleeve are prepared, all to fit over the male mold. Compression eventually will reduce the thickness of the sleeves to the desired 1/4 in. Holes 1/2 in. in diameter are cut in the ends of the sleeves to permit clearance of the alignment pin. The two felt sleeves are pulled over the male mold and trimmed even with the proximal edge of the mold. <b>Fig. 18</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>AK Sockets Only</i></p> <p>To reinforce the proximal-lateral wall, a 5-in. x 7-in. strip of 1/8-in. felt is attached to the outer sleeve with Barge cement (<i>a</i>).</p> <p>Because of limited space between the male and female molds for AK sockets, a means for pouring the polyester resin into the completed female mold must be provided by creating a lip, or inlet, at its proximal anterior brim (<i>b</i>). A triangular piece of 1/4-in. felt is rolled to form a funnel and fastened with Barge cement to the anterior brim of the outer sleeve so that the top of the funnel is even with the top surface of the mold. (The funnel is not needed in the below-knee socket fabrication, because in that case there is adequate space between the male and female molds.)</p> <p>14. To facilitate alignment of the male and female molds, and to insure a uniform wall thickness of the transparent socket, the felt is cut away in the region above the posterior socket trim line as illustrated. The female mold will be contoured so that a proximal surface of this mold will contact the corresponding surface of the male mold. <b>Fig. 19</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>BK Sockets Only</i></p> <p>The felt layers are cut out in the region above the popliteal trim line. The cutout should not cross the popliteal trim line. <b>Fig. 20</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>AK Sockets Only</i></p> <p>The Dacron layers are trimmed in the flat areas above the posterior and medial brims, leaving approximately 1 in. of uncut material above the socket trim lines. <b>Fig. 21</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>15. The stockinette sleeve is now pulled over the felt on the male mold and tied to the mandrel. <b>Fig. 22</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>16. To provide for the transparent socket pedestal, a piece of 1/32-in.-thick plastic sheet is wrapped around the distal end of the male mold, over the sleeve, beginning at the point where the male mold starts to slope in and extending to the distal end of the alignment pin. The vertical seam and horizontal juncture line are sealed with tape. <b>Fig. 23</b> - <b>Fig. 24</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>17. Plaster is poured into the cylindrical cavity formed by the plastic sheet, leaving 1/2<i> </i>in. of the alignment pin exposed above the plaster level. The plaster is allowed to set, and the plastic sheet is removed. <b>Fig. 25</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>18. An inflated balloon is inverted over the lay-up and pushed downward as the air is slowly released. The distal end of the balloon is tied off around the alignment pin, and the proximal end around the mandrel. The balloon is then covered with a coat of silicone spray. <b>Fig. 26</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>19. To fabricate the female mold, 4-in. plaster bandage is wrapped around the balloon-covered male mold, starting at the distal end and overlapping each previous wrap by approximately 3 in. until a 4- to 6-layer thickness is achieved. Care is taken to avoid using excessive tension while applying the plaster bandage so as to prevent compression of the felt and reduction of the wall thickness of the transparent socket. In addition, the undercuts (<i>e.g., </i>the patellar region in BK sockets) are minimized or reduced by bridging the bandage in that area. <b>Fig. 27</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To provide a good receptacle for the exposed length of the alignment pin, it is covered with additional plaster, and the plaster is allowed to set. <b>Fig. 28</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>20. The balloon and stockinette are trimmed off to expose the proximal end of the mold. <b>Fig. 29</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>21. Using a combination square or a strip of metal bent to 90 deg as a guide, orientation lines are drawn on the proximal ends of the molds to provide references for their realignment. Two lines on each of the four sides are sufficient. <b>Fig. 30</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>22. The molds are separated, and the felt and stockinette lay-up is removed from the inside of the female mold.</p> <p>23. The plaster pedestal is broken out of the female mold, and the balloon and the alignment pin are removed without breaking the pin's receptacle.</p> <p>24. At this point, a slit is made in the female mold to simplify its removal from the transparent socket after casting. Starting 1 in. below the proximal rim on the medial side, a cut is made vertically along three-quarters of the socket length. The cut is covered with two vertical layers of plaster bandage on the exterior surface. The interior surface is smoothed where necessary. <b>Fig. 31</b> - <b>Fig. 32</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>25. To complete the mold, 1/16-in.-dia vacuum holes are drilled in the undercut area of the female mold to insure the correct surface contour on the transparent socket. <b>Fig. 33</b> - <b>Fig. 34</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Alignment Of The Molds And Casting</h4> <p>26. The outer surface of the female mold is covered with a 1/4-in. felt sleeve. A PVA bag is pulled over this sleeve, and both covers are trimmed even with the proximal edge. A vacuum tube is attached to the distal end of the PVA bag and secured with plastic tape.</p> <p>27. A heavy coating of Vaseline petroleum jelly is applied to the inside surface of the female mold. <b>Fig. 35</b> - <b>Fig. 36</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>28. The end of a second PVA bag is fastened to the alignment pin with a rubber band and then both are inserted (glossy side in) into the alignment pin receptacle in the female mold. The interior PVA bag is lapped over the exterior PVA bag and sealed with pressure-sensitive tape. At least 4-in. overlaps must be provided because this PVA bag will later be fastened to the male mold mandrel. <b>Fig. 37</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>29. Vacuum is applied and the wrinkles are smoothed out on the interior PVA bag. This lining provides the smooth exterior surface of the transparent socket. <b>Fig. 38</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>30. A PVA sheet (glossy side out) is pulled over the male mold and fastened to the mandrel with plastic tape. The sheet is reinforced around the alignment pin with plastic tape, and a 1/2-in. hole is cut through the tape and the PVA bag for the alignment pin. Vacuum is applied and the wrinkles in the PVA sheet are smoothed out. <b>Fig. 39</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>AK Sockets Only</i></p> <p>The valve body may be placed before or after casting. If placement is done before casting, the valve body is filled with beeswax and glued with Barge cement to the PVA sheet on the male mold in the appropriate location. The valve body must be so located that it will not subsequently contact the wall of the female mold during the casting procedure. <b>Fig. 40</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>31. The female mold is placed in a bench vise or other supporting device, with the proximal end up and proximal edges horizontal. The male mold is oriented in the female mold by means of the alignment pin and placed all the way down on the pin. <b>Fig. 41</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>BK Sockets Only</i></p> <p>The posterior surfaces of the molds are butted in the region superior to the popliteal trim lines, and the orientation marks are aligned. The molds are taped together securely to maintain the alignment.</p> <p><i>AK Sockets Only</i></p> <p>The surfaces superior to the posterior and medial brims are butted and the orientation marks aligned. The molds are secured with tape. <b>Fig. 42</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>32. One to 1-1/2 qt of polyester casting resin for below-knee or 2 to 3 qt for above-knee sockets (depending on the size) are combined with the catalyst, with constant stirring. The manufacturer's instructions are followed regarding the amount of catalyst required to obtain a "slow setting time." Ideally, the resin should have a 1/2-hr gel time, which is adequate time for pouring. The resin is poured slowly and continuously while the female mold is simultaneously tapped to prevent any air bubbles being entrapped in the casting. <b>Fig. 43</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>33. After the resin has set to a soft gel (about 30 min), the tape around the PVA bags is removed, and the outer PVA bag and Dacron sleeve are removed. The male mold PVA bag is punctured around the pipe, and the female mold PVA bag is pulled secure and tied to the mandrel. <b>Fig. 44</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>34. After the resin has set to a firm gel (about 1 hr after pouring), the plaster strips are peeled off the slit in the female mold. The female mold is then removed by spreading the slit open, with care being taken not to tear the PVA bag on the transparent socket. The resin is allowed to cure for an additional hour at room temperature. <b>Fig. 45</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>35. The vacuum equipment is removed. The transparent socket (on the male mold) is heated in the oven at 165 deg F for 4 hours. The oven is turned off, and the socket is left until the oven cools to 125 deg F. This heat-treating helps to eliminate any internal stresses that may have developed during the curing phase. <b>Fig. 46</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Finishing The Socket</h4> <p>36. The PVA bags are cut along the proximal edge of the male mold. To protect the transparent socket surfaces from scarring, the PVA bags are left in place. The plaster slush mold is carefully chiseled away, and the mandrel and silicone shell are removed. <b>Fig. 47</b> - <b>Fig. 48</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>37. The socket is cut down to the proximal trim lines, using a band saw and electric sander. The rough edges are smoothed by hand-rubbing with fine-grade sandpaper. The transparency can be restored to these edges by applying a surface coating of resin to the area, covering with a PVA sheet, and allowing to cure.</p> <p>38. Any flashing on the interior surface around the alignment pin is removed, and the bottom of the hole is sealed with tape. The hole is filled with resin and allowed to cure.</p> <p><i>AK Sockets Only</i></p> <p>If the valve body was placed before the casting, a hole saw of the same size as the valve body diameter is now used to bore through to the valve body. To improve the boring angle, the distal corner of the socket pedestal is sawed and ground down. <b>Fig. 49</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the valve body has not yet been placed, the anteromedial corner of the socket pedestal is sawed and ground off to provide a flat surface. Then, using a hole saw of the same size as the valve body diameter, a hole is bored through the socket wall. The valve body is carefully secured in place with either polyester resin or epoxy cement so that the inner surface of the valve body is flush with the inner surface of the socket. <b>Fig. 50</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>39. Before the socket is attached to an adjustable leg, the pedestal base is sanded flat and to the proper alignment angulation, using a disk sander. <b>Fig. 51</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>BK Sockets Only</i></p> <p>Suspension-strap retainers are attached to the below-knee socket with #8-32 flat-head machine screws. The holes may be countersunk by using an inside countersink tool. <b>Fig. 52</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>40. The socket attachment plate is fastened to the transparent socket by drilling and tapping eight holes in the pedestal base and securing with flat-head machine screws. <b>Fig. 53</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>41. The PVA bags are removed, and the completed transparent socket is polished with silicone spray and a soft cloth. (This spray is also a good lubricant to facilitate donning the socket.) <b>Fig. 54</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Completed above-knee socket mounted on an adjustable leg. <b>Fig. 55</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Completed below-knee socket.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">R. Lipskin and T. Grille, The Development of the NYU Transparent Socket Fabrication Technique, November 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Ronald Lipskin </b></td></tr><tr><td class="clsTextSmall">Present address: Prosthetics Center, Bioengi-neering Research Service, 252 Seventh Ave., New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Thomas Grille </b></td></tr><tr><td class="clsTextSmall">Now with Key Mfg. Co., Brooklyn, N. Y. 11207.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1969_02_013/69autumn-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The NYU Transparent Socket Fabrication Procedure Creator An entity primarily responsible for making the resource Thomas Grille * Ronald Lipskin * Richard Hanak  https://staging.drfop.org/files/original/4699d64d3df5994ef8f7e1b85cd99959.pdf b3917f4e00ca2ab8d8c25b3f49862b6e https://staging.drfop.org/files/original/e5ce76adfd45dd6f57b618d54dde10ad.jpg 73269599a0739d162dabc155d43ed468 https://staging.drfop.org/files/original/743b5e834a6bd64136a8729f21c07d13.jpg 94ba2e4204849d17989659f400598a78 https://staging.drfop.org/files/original/36ae3ca908bc73b7f24e244440dda104.jpg f928a27eaaee312841c942cf30496ae1 https://staging.drfop.org/files/original/b65a0390d93c0160d55cc411ff05f1d9.jpg a2f12631b5934dca4d2cffbe177994eb https://staging.drfop.org/files/original/a366ac4453ec47ff2c58896dcaaeed9f.jpg 4d4b69bb9323ba6d1e82d72ee69e7b11 https://staging.drfop.org/files/original/404e9dfeeaf0ddf28ee6cc9724a164be.jpg b7cf2d1829b06c77f60ad53a56ea1532 https://staging.drfop.org/files/original/1b6b21650828332a841575640ebd49c2.jpg b97764b21b3f5e2eb36440de368b7a9e https://staging.drfop.org/files/original/69921ae973886707c7f19d0b0ad8d958.jpg 11567fa8743e3ca28c329197914c2b13 https://staging.drfop.org/files/original/cb3f332ee038c22ea975988c0684ce58.jpg 069149801aa269a87db508949da51d8f https://staging.drfop.org/files/original/924b2334c44029327c1b7924cb3fe7ac.jpg ffebb08a2dd20782db4a706e97eb0c18 https://staging.drfop.org/files/original/667fb5c153d80c36866d27fd5fd55700.jpg 6682288306bc4940fe68f83b9b600f51 https://staging.drfop.org/files/original/f078c25d734e44df7cc68fc2991aaa1e.jpg a46a3f90736de24584111c8e3b4dd414 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_027.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 27 - 36 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_01_027.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_027.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>Causes of Death in a Series of 4738 Finnish War Amputees</h2> <h5>Georg Bakalim <a style="text-decoration:none;">*</a><br /></h5> <p>The loss of a limb and its replacement by a prosthesis create conditions deviating from the normal. Walking is always more difficult. Loon <a></a> found that the energy consumption of amputees increases with the level of amputation. In the case of an above-knee amputation the effort of walking is greater than in a be-low-knee amputation and, in cases of hemipelvectomy and disarticulation of the hip, energy requirements are still greater. In the same investigation, it was found that walking with crutches, without a prosthesis, requires more energy than walking with a prosthesis. In addition, it appeared that in the presence of disturbances in the stump that affect walking, the consumption of energy increases. A poorly fitted prosthesis has the same effect. During walking, the center of gravity should shift smoothly, not in a jerky way that makes it more difficult to maintain balance. Almost all amputees experience excessive sweating not only of the stump but in general. The tightly fitted socket and the thigh corset used in connection with the old, conventional type of below-knee prosthesis are contributory causes of sweating.</p> <p>Owing to the loss of the weight and accompanying movements of the amputated limb, upper-extremity amputees find it more difficult to keep their balance in walking after amputation. Similarly, the strain on the remaining upper limb in lifting and carrying is greater than before. The increased consumption of energy taxes the circulation and the heart. In this connection, no further attention will be paid to the secondary changes in the weight-bearing structures, particularly the joints and spine, that result from the altered static conditions due to the loss of a limb <a></a>.</p> <p>The health of amputees has been the subject of many previous studies, <i>e.g., </i>those of Rausche, <a></a> Schneider, <a></a> Schulze, <a></a> and Bodechtel <a></a>. Meyer-ingh, Stefani, and Cimbal <a></a> reported a higher rate of hypertension in obese amputees than in amputees of average weight. In an electrocardiographic investigation of 1033 amputees, performed by the same authors, no differences were observed as compared with a normal series. Likewise, in a series of 1128 amputees obesity was not more frequent than in a corresponding group of the general population. <a></a> Loos <a></a> reported similar findings in a series of 647 cases. Solonen, Rinne, Viikeri, and Karvinen <a></a> observed no noteworthy increase in cardiac and vascular diseases in amputees.</p> <p>The purpose of this study was to find out whether death from degenerative cardiac and vascular diseases is more common among amputees than in the general population. At the same time tuberculosis, cancer, accidents, suicide, and miscellaneous causes of death were surveyed from the same standpoint.</p> <h3>Material</h3> <p>The series consists of 4782 war amputees. Data was collected from the files of the State Insurance Department. Finger, hand, toe, and foot amputations have been omitted since these cause no major problems. Before the end of 1944, <i>i.e., </i>during the war, 44 amputees died. These cases are also considered in this study. The age distribution in this group was the same as in the remaining 4738 cases which have been followed up from 1945 till the end of 1965. The causes of death were obtained from the death certificates. During the last 10 years a steadily increasing number of cases have been examined postmortem. In case of a casualty, or when the cause of death is unknown, autopsy is invariably performed. As a rule, the autopsy records contain more than one diagnosis, but in this study only the main diagnoses have been utilized. Although many of the second diagnoses might have been of interest, taking them into account would have implied considerable technical problems and would have rendered the statistical treatment more difficult. Since 1945, 643 subjects have died. During the period 1940-1965 the total mortality was thus 687/4782 (14.4 per cent). The number of mortalities during each year is shown in <b>Fig. 1</b>. A steady rise is seen from 1960 onward. This increased mortality is not surprising, considering that more than 20 years have elapsed since the war and the mean age of the war veterans is about 50. However, this curve alone permits no conclusions to be drawn. In order to form an opinion concerning the mortality of the war amputees, the figures have to be compared to the death rates for the corresponding age groups of the general population.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Annual mortality of war amputees in 1940-1965. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Age And Occupation</h4> <p>For the main causes of death the distribution of the dead war amputees by 5-year age groups is given in <b>Table 1</b>. Mostly, the age groups 40-50 years show the highest mortality. However, for conclusions to be drawn concerning the health of the group under review, comparable data for a "normal" group is required. The occupations of the dead, differentiated mainly on the basis of training, are given in <b>Table 2</b>. In this connection the main interest attaches to the proportion of heavy laborers.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Farmers (177) and unskilled workers (230) constitute the largest groups. Heavy labor is represented by 72.6 per cent, light occupations by 27.4 per cent. The handicraftsmen number 74 (10.8 per cent). There are as many as 31 shoemakers, which is accounted for by the fact that training for this occupation was offered after the war.</p> <h4>Level Of Amputation</h4> <p>The level of amputation appears in <b>Table 3</b>. Finger, hand, toe, and foot amputations were not included in this series because the trouble caused by them is considered to be so slight that it cannot lead to vascular disease. Two amputees in the present series had Chopart stumps, one had a Pirogoff stump, and in six cases disarticulation of the wrist had been performed. The ratio of above-knee to be-low-knee amputations is 1:2.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Method of Comparison</h3> <p>The age distribution of the series followed up, exclusive of those who died before 1945, and the percentage figures for the corresponding age groups of the general Finnish male population are shown in <b>Table 4</b>. As may be seen in the table, the age distribution of the amputees differs widely from the age distribution of the general Finnish male population as obtained from the Statistical Yearbook of Finland. <a></a> For this reason, the death rates for the general Finnish male population could not be used as such for comparison with the mortality rate of amputees. It was necessary therefore to construct an equivalent, theoretical population with an age distribution corresponding to that of the amputees. The data required was obtained in part directly from the Statistical Yearbook, and in part by calculation based on the death rates for men and women and the sex ratio, or for the earlier years, on the total mortality and the age distribution of the dead, as indicated in the Statistical Yearbook. In the comparisons, it was deemed most appropriate to consider only the period from 1945 till the end of 1964. The amputees who died before 1945 numbered 44, and 71 died in 1965. When these 115 cases were subtracted from the total number of dead in the present series (687), 572 cases remained for the comparative analysis of mortality.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Mortality</h4> <p>As mentioned above, the total mortality for the period under review was 687/ 4782 (14.4 per cent). The causes of death are listed in detail in <b>Table 5</b>. The distribution according to the cause of death has been given in summary form in <b>Table 1</b>. Degenerative vascular diseases of the central nervous system and degenerative cardiac and vascular diseases have the same etiology but each forms a separate entity, and the Statistical Yearbook of Finland provides figures for comparison precisely on this basis. In addition, death rates were available for pulmonary tuberculosis, malignant diseases, accidents, and suicide, other causes falling into a miscellaneous group consisting of cases for which no comparative figures were found in the Statistical Yearbook. Many cases of poisoning and drowning were recorded under accidents. Alcohol abuse was a major etiological factor. It was sometimes difficult to decide whether the cause of death was an accident or suicide.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Comparison of Mortality of the Amputees and the General Population</h3> <p>In what follows, the total mortality is analyzed first and then the mortality in the various groups listed above is analyzed, except for the miscellaneous group for which no comparable data was available.</p> <h4>Total Mortality</h4> <p>On comparing the total number of deaths during the period January 1, 1945, to December 31, 1964, <i>i.e., </i>572, to the mortality of the general Finnish male population, the age distribution was taken into account in two different ways. In both methods, consideration was given to the fact that during the period under review the subjects passed into age groups with a lower expectation of life.</p> <p><i>Method I</i></p> <p>For each 5-year age group of amputees in <b>Table 4</b> (age distribution at the beginning of 1945), the expected losses for the 5-year periods 1945-1949, etc., until the beginning of 1965, were calculated on the basis of the expectations of life indicated in the Statistical Yearbook of Finland, that figure being used which pertains to the mean age of the age group during the period in question. To exemplify, for those who were aged 20-24 years at the beginning of 1945, the expectation of life at 25 years was considered as the relevant figure for the period 1945-1949, since the youngest in the group had survived for 20-24 years and the oldest for 24-29 years. Correspondingly, the expectation of life at 30 years was applied to the period 1950-1955, etc. The 5-year losses were calculated on the basis of the total number of survivors. In <b>Fig. 2</b>, the cumulative curve for the calculated losses from the level of 1945 is compared to the cumulative curve for the actual losses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Cumulative death rates-calculated for 5-year periods compared to cumulative expected death rates. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The recorded death rates for the <i>5-year age groups </i>are slightly lower than the expected figures, but the difference is statistically insignificant. The same obtains to the death rates as expressed by <i>5-year periods </i>(<b>Table 6</b>). The differences between the recorded and the expected figures are of the order of 10 per cent. The greatest differences relate to the periods 1950-1954 and 1955-1959, while for the periods 1945-1949 and 1960-1964, the recorded figures fall below the expected ones by about 2 per cent only.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Method II</i></p> <p>In the Statistical Yearbook of Finland, the number of survivors among 100,000 men of the same age is indicated. On the basis of these figures, the numbers of expected survivors in all age classes represented in this series at the beginning of 1945 were calculated for the end of the age periods 20-24 years, 25-29 years, etc., and the expected death rates in the various age groups were expressed as percentages. The expected total mortality by the end of 1964, <i>i.e., </i>549, is in very good agreement with the actual figure of 572. All the 687 deaths considered, the percentile distribution between the age groups corresponds fairly well to the expected distribution (<b>Table 7</b>, <b>Fig. 3</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Death rates for the different age groups compared to the expected death rates. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the causes of death are disregarded, it may be stated that the mortality in the present series corresponds very closely to the mortality in the corresponding general population. This obtains to the figures for the various 5-year periods and the total mortality as well as to the figures for the age groups. There seems to be a tendency toward a lower mortality for amputees than in the general population, and, with regard to the age at death, it appears that among the amputees there may be a trend toward a lower age, though only by one or two years at the most.</p> <h4>Degenerative Egenerative Vascular Diseases of the Central Nervous System</h4> <p>The mortality in degenerative vascular diseases of the central nervous system was 64/687 (9.3 per cent). Traumatic cerebral hemorrhages of course do not belong to this group. Comparable data relating to the general population was obtained from the Statistical Yearbook of Finland, and expected figures were calculated for the period 1945-1964 in the same way with respect to the total mortality. The expected number of deaths in this group of disease was 37.4. The actual number (64) was 71.2 per cent higher. In the age groups 25-44 years the actual number of deaths was 130.9 per cent higher than the expected number; in the age groups 45-64 years it was 49.6 per cent higher; and in the age groups 65-74 it was 42.6 per cent higher (<b>Table 8</b>). No consistent trend is discernible with regard to the age at death.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Degenerative Cardiac And Vascular Diseases</h4> <p>This group includes cardiac infarction, pulmonary infarction, peripheral embolism, myodegeneration, cardiac insufficiency, and arteriosclerosis. The mortality in this group was 219/687 (31.9 per cent). The expected number of deaths in the general population was 134.3. The actual mortality was 63.1 per cent higher. As regards the different age groups, the actual mortality was 193.2 per cent higher than the expected in the group aged 25-44 years at death, 38.9 per cent higher in the group aged 45-64 years, and 28.6 per cent higher in the group aged 65-74 years (<b>Table 8</b>). One hundred and four amputees (47.5 per cent) died at an age of 45-54 years, 51 (23.3 per cent) at an age of 35-44 years, and 44 (20.1 per cent) at 55-64 years. The remaining 20 deaths (9.1 per cent) were evenly distributed between the age groups 25-34 and 65-84 years (<b>Table 1</b>).</p> <h4>Pulmonary Tuberculosis</h4> <p>The mortality in pulmonary tuberculosis was 70/687 (10.2 per cent). The actual mortality was found to be 24.9 per cent lower than the expected mortality (93.2 cases). In the group under 24 years of age the mortality was 172.7 per cent higher than the expected, while in the age groups 25-44 and 45-64 the actual mortality was 10.5 and 70.9 per cent lower, respectively, than the expected (<b>Table 8</b>).</p> <h4>Malignant Diseases</h4> <p>The mortality in malignant disease was 96/687 (14.0 per cent). The mortality was 19.6 per cent lower than the expected. In the age group 45-64 years the mortality was 21.1 per cent lower, and in the age group 65-74 it was also 21.1 per cent lower than the expected mortality. The frequency of malignant disease in different organs appears in <b>Table 5</b>. In none of the present cases was the disease a result of the amputation (<b>Table 8</b>).</p> <h4>Accidents</h4> <p>Accidents were the cause of death in 72/687 cases (10.5 per cent). The actual figures were in all age groups lower than the expected. In the age group under 24, the recorded number of deaths was 78.3 per cent lower than the expected mortality; in the group 25-44 years it was 36.2 per cent lower; in the group 45-64 years it was 24.1 per cent lower. The actual total mortality was 34.2 per cent lower than the expected. This group includes 17 (2.5 per cent) traffic accidents, but these could not be separately analyzed, because traffic accidents are not treated as a separate group in the Statistical Yearbook (<b>Table 8</b>).</p> <p>It thus appears that the mortality from accidents was markedly lower among the amputees than in the general population. It might have been expected that amputees would be more accident-prone both at work and in the traffic, owing to their poorer mobility. The small proportion of traffic accidents among the total number of cases is also striking. Obviously, the amputees move about less than the general population, work at less dangerous places, and are, perhaps, employed to a lesser extent owing to their reduced working capacity.</p> <h4>Suicides</h4> <p>Since about 80 per cent of the suicides are committed by men, it seemed reasonable to use this age distribution as a basis when the expected mortality was calculated in the same way as for the other causes of death. The actual figures for the periods 1955-1959 and 1960-1964 are 68.1 and 36.0 per cent higher than the expected figures. The total number of suicides (63) for the period 1945-1964 is 37.3 per cent greater than the expected number. The greatest difference is noted for the period 1945-1949, the recorded frequency of suicides being 3.6 times higher (260.0 per cent) than the expected (<b>Table 8</b>). By contrast, the figure for 1950-1954 is 73.4 per cent lower than the expected mortality. If these two 5-year groups are added together the difference by which the actual frequency of suicides exceeds the expected has changed to a decrease (-13.8 per cent).</p> <p>It appears that among amputees under 25 years of age, suicides were 300.0 per cent higher, and in the age group 25-44 years 53.8 per cent higher than was to be expected on the basis of the statistics for the general population. By contrast, the number of suicides committed by amputees aged 65-74 years was within 0.2 per cent of the expected figure. The total actual number of suicides exceeds the expected figure by a difference of 37.3 per cent (<b>Table 8</b>).</p> <p>In addition, the rate of suicides among the dead amputees with the same occupation has been calculated. In this respect there is no major difference between heavy labor and other occupations. Technicians have the lowest rate of suicide, those with unknown occupations the highest. With regard to the former, it may be pointed out that their occupation is highly suitable for amputees, while the latter group includes subjects without regular employment, who lived in poor social conditions.</p> <p>The possible relationship between the rate of suicides and the level and site of the amputation is analyzed in <b>Table 9</b>. Among lower-limb amputees the frequency of suicide was twice the frequency among upper-limb amputees. However, when the whole series is taken into account, the difference is not very great, the number of lower-limb amputees being double the number of upper-limb amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The methods of suicide appear in <b>Table 5</b>. Alcohol abuse was known to have played a part in 11 cases, and 6 subjects had used barbiturates in addition. This group of 63 consists of only sure cases of suicide. In the group of accidents, at least a slight suspicion of suicide was present in many cases.</p> <h3>Summary and Discussion</h3> <p>In a series of 4782 war amputees, the total mortality was 687 (14.4 per cent). The period covered by the present study is from 1945 till the end of 1965. In 1960, the mortality of the war amputees began to rise abruptly, and was one of the causes for undertaking this study. This mortality was compared to the mortality in the general Finnish male population. A theoretical, equivalent male population was constructed on the basis of data obtained from the Statistical Yearbook of Finland.</p> <p>When the causes of death were not differentiated, the mortality of the amputees was found to be in good agreement with the mortality of the general population. This obtains to both the whole series and the different 5-year periods. There was even a tendency towards slightly lower figures for the amputees.</p> <p>On the other hand, when the causes of death were differentiated, certain features of interest emerged. The recorded death rates were higher than the expected figures with regard to degenerative diseases of the central nervous system ( + 71.2 per cent), degenerative cardiac and vascular diseases ( + 63.1 per cent), and suicide (+37.3 per cent). These were the causes of death in half the cases. One-fourth of the deaths were due to pulmonary tuberculosis or malignant disease. In both these groups the actual death rate was lower than the expected ( - 24.9 per cent and - 19.6 per cent). In the age group under 25, the mortality in pulmonary tuberculosis was 2.7 times higher than in the corresponding group of the general population, but in all other age groups it was lower than the expected death rate. The number of deaths due to accidents (72) fell below the expected mortality by 34.2 per cent. Obviously, amputees move about considerably less than the general population, and they are less exposed to accidents owing to their limited working capacity.</p> <p>In order to give a general survey of the findings, the main causes of death are listed in <b>Table 8</b>. In addition to the number of deaths, the mortality in each group is expressed as a percentage. Likewise, the expected mortality is given both in absolute figures and as percentages, and the differences between the actual and expected figures are indicated in percentages. In this connection, it has been assumed that the total expected mortality is the same as the actual mortality, as was also suggested by the analysis of the total mortality carried out at the beginning of this study. The amputees seem to be more afflicted with fatal degenerative diseases of the central nervous system and fatal degenerative cardiac and vascular diseases, and suicides seem to be more common among them, as compared with the general population. On the other hand, the mortality from pulmonary tuberculosis, accidents, and a large group of miscellaneous diseases <i>(e.g., </i>various diseases of the lungs and abdominal disorders), was lower among the amputees than in the general population.</p> <p>It may be assumed that the higher frequency of suicides among the amputees is due in part to psychological causes connected with the loss of a limb. Also, a postwar depression may have become more pronounced with the lapse of time. Economic problems and poor social conditions may be regarded as contributory causes.</p> <p>In the care of amputees, the factors of importance are: a satisfactory prosthesis, good condition of the stump, rehabilitation, suitable employment, and judiciously administered subvention. The question arises as to whether all that could have been done for the war amputees was done. Perhaps something had been neglected that could have prolonged the lives in some cases.</p> <p><b>References:</b></p> <ol> <li>Bodechtel, G., <i>Klinik des veget</i>. Nervensystems, Verh. Deutsch. Ges. Inn. Med., 57: 1948.</li> <li>Loon, H. E., <i>Biological and biomechanical principles in amputation surgery</i>, Prosthetics international, Copenhagen, 1960.</li> <li>Loos, H. M., <i>Klinische und statistiche Ergebnesse des Blutdruckuerhaltens bei Amputierten</i>, Medizinische, 29:1050, 1957.</li> <li>Meyeringh, H., and H. Stefani, <i>Besteht nach einer Amputation des Oberschenkels eine Neigung zur Adipositas und zur Hyperextension</i>? Deutsch. Med. Wschr., 81:10, 1956.</li> <li>Meyeringh, H., H. Stefani, and G. Cimbal, <i>Herz und Amputation: Eine klinische EKG Studie</i>, Deutsch. Med. Wschr., 85:9, 1960.</li> <li>Rausche, C, <i>Uber den Zusammenhang zwischen Amputation und arteriellem Hochdruck</i>, Med. Klin., 35:1418, 1939.</li> <li>Schneider, K. W., according to G. Schletter, in A. W. Fischer, R. Herget, and G. Molineus, <i>Das artzliche Gutachten im Versicherungs-wesen</i>, Johann Ambrosius Barth, Munchen, 1955.</li> <li>Schulze, K., according to G. Schletter, in A. W. Fischer, R. Herget, and G. Molineus, <i>Das drtzliche Gutachten im Versicherungswesen</i>, Johann Ambrosius Barth, Munchen, 1955.</li> <li>Solonen, K. A., H. J. Rinne, M. Viikeri, and E. Karvinen, <i>Late sequelae of amputation: The health of Finnish war veterans</i>. Ann. Chir. Gynaec. Fenn., Supplementum 138, 1965.</li> <li>Statistical Yearbook of Finland, 1945-1965, Central statistical office.</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>10.</b> </td><td class="clsTextSmall">Statistical Yearbook of Finland, 1945-1965, Central statistical office.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Solonen, K. A., H. J. Rinne, M. Viikeri, and E. Karvinen, Late sequelae of amputation: The health of Finnish war veterans. Ann. Chir. Gynaec. Fenn., Supplementum 138, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Loos, H. M., Klinische und statistiche Ergebnesse des Blutdruckuerhaltens bei Amputierten, Medizinische, 29:1050, 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Meyeringh, H., H. Stefani, and G. Cimbal, Herz und Amputation: Eine klinische EKG Studie, Deutsch. Med. Wschr., 85:9, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Meyeringh, H., H. Stefani, and G. Cimbal, Herz und Amputation: Eine klinische EKG Studie, Deutsch. Med. Wschr., 85:9, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bodechtel, G., Klinik des veget. Nervensystems, Verh. Deutsch. Ges. Inn. Med., 57: 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>8.</b> </td><td class="clsTextSmall">Schulze, K., according to G. Schletter, in A. W. Fischer, R. Herget, and G. Molineus, Das drtzliche Gutachten im Versicherungswesen, Johann Ambrosius Barth, Munchen, 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>7.</b> </td><td class="clsTextSmall">Schneider, K. W., according to G. Schletter, in A. W. Fischer, R. Herget, and G. Molineus, Das artzliche Gutachten im Versicherungs-wesen, Johann Ambrosius Barth, Munchen, 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>6.</b> </td><td class="clsTextSmall">Rausche, C, Uber den Zusammenhang zwischen Amputation und arteriellem Hochdruck, Med. Klin., 35:1418, 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>9.</b> </td><td class="clsTextSmall">Solonen, K. A., H. J. Rinne, M. Viikeri, and E. Karvinen, Late sequelae of amputation: The health of Finnish war veterans. Ann. Chir. Gynaec. Fenn., Supplementum 138, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Loon, H. E., Biological and biomechanical principles in amputation surgery, Prosthetics international, Copenhagen, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Georg Bakalim </b></td></tr><tr><td class="clsTextSmall">State Supervisor of Prosthetic Services, Ministry of Social Affairs, Helsinki, Finland.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_027/spring69-21.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_027/spring69-22.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_027/spring69-23.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_027/spring69-24.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_027/spring69-25.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_027/spring69-26.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_027/spring69-27.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_027/spring69-28.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_01_027/spring69-29.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_01_027/spring69-30.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_01_027/spring69-31.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_01_027/spring69-32.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Causes of Death in a Series of 4738 Finnish War Amputees Creator An entity primarily responsible for making the resource Georg Bakalim *