18 20 371 https://staging.drfop.org/files/original/a4f59375f598279295c7fa943e156114.pdf 38aeeeab3d42cf740c3e04155a23deb3 https://staging.drfop.org/files/original/e9b5c21d0675e1f7f78eeae1cab0bf9b.jpg 4a5774b4db78fc684a6a1a7c148f1652 https://staging.drfop.org/files/original/179a4b1fdbe7af47f8671ad8dfc3b633.jpg 8d23f991b42aaa11f4865388aa37f444 https://staging.drfop.org/files/original/9e2dbd2dfdbf18308f14c16deffde187.jpg 516724a853eb79700fcc8b01fd9f4d84 https://staging.drfop.org/files/original/1ab8a3dcf922e1807accda3da54464e0.jpg 9a39560b010e50dd6076068288acd2a6 https://staging.drfop.org/files/original/8048c3cccd316e71ba2b766352368f1c.jpg e4881b396eb266d26e006c1872396510 https://staging.drfop.org/files/original/408763c312b92eca57665f96ace6e393.jpg f061728c01505d148eeca0704ad78939 https://staging.drfop.org/files/original/5539898a198c7a2106d020b39fbb42c9.jpg 7c5b6091748cc36c772f24eaec77668d https://staging.drfop.org/files/original/0fcd332e5c3c16557b9d2e6c049ab526.jpg 70ce52088e0c35f7c9c26b4762c38040 https://staging.drfop.org/files/original/4055a7a2c59d5a522d1e6cf32a0024af.jpg 64c5a270fedf2bd0199cd04498816491 https://staging.drfop.org/files/original/3ae56f5fbb8bf7c542f880fa056513da.jpg 3870cc3795e9a198097bd24bce53b023 https://staging.drfop.org/files/original/315fe14538fad0ed846aa9c5779de2f4.jpg a38b7afdc54124fb2c4fdfaa676a7eb4 https://staging.drfop.org/files/original/f0655872a5389e27f34b64a4975e5f09.jpg 0324b1ddac21e26db1e4d683035350a4 https://staging.drfop.org/files/original/8dc1c46b125a02cfeaac768c7a8b3ff9.jpg 8d644d9b4b557aa4e149b1a298c9728d https://staging.drfop.org/files/original/bc33be62f16216b29a7eefb543073589.jpg eec0b67878c0c03d1f20ca9558e7d867 https://staging.drfop.org/files/original/6741c4989a97f0face9bfbec1b477e07.jpg 6ee4529dba31e6b50c907a3dd975d190 https://staging.drfop.org/files/original/9f8219b9d8441382f6dcedfb9b985f4e.jpg e45df92748138be34e0abfdcfa199ecd https://staging.drfop.org/files/original/4988df0c10cb9d476fd01c9cd3d02880.jpg f3a2809feeb174dec5bc561ff1952898 https://staging.drfop.org/files/original/8d2b6ba0f09f64fc07ef921be89bd5bb.jpg 07fd87bdc0fe603f9a655fd89e76b987 https://staging.drfop.org/files/original/0307da51d6e620c88a84df6a0b08adde.jpg 231b3dc0a2ed2ee57dfe1165c2a9a695 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_001.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 1 - 52 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_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>1970 Limb Prosthetics</h2> <h5>A. Bennet Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>Loss of limb has been a problem as long as man has been in existence. Even some prehistoric men must have survived crushing injuries resulting in amputation, and certainly some children were born with congenitally deformed limbs, with effects equivalent to those of amputation. In 1958 the Smithsonian Institution reported the discovery of a skull dating back about 45,000 years of a person who, it was deduced, must have been an arm amputee, because of the way his teeth had been used to compensate for lack of limb. Leg amputees must have compensated partly for their loss by the use of crude crutches and, in some instances, by the use of peg legs fashioned from forked sticks or tree branches (<b>Fig. 1</b> and <b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Mosaic from the Cathedral of Lescar, France, depicts an amputee supported at the knee by a wooden pylon. Some authorities place this in the Gallo-Roman era. From Putti, V., <i>Historic Artificial Limbs, </i>1930. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Pen drawing of a fragment of antique vase unearthed near Paris in 1862 which shows a figure whose missing limb is replaced by a pylon with a forked end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The earliest known record of a prosthesis being used by man was made by the famous Greek historian, Herodotus. His classic <i>History, </i>written about 484 B.C., contains the story of the Persian soldier, Hegesistratus, who, when imprisoned in stocks by the enemy, escaped by cutting off part of his foot, and replaced it later with a wooden version.</p> <p>A number of ancient prostheses have been displayed in museums in various parts of the world. The oldest known is an artificial leg unearthed from a tomb in Capua in 1858, thought to have been made about 300 B.C., the period of the Samnite Wars. Constructed of copper and wood, the Capua leg was destroyed when the Museum of the Royal College of Surgeons was bombed during World War II. The Alt-Ruppin hand (<b>Fig. 3</b>), recovered along the Rhine River in 1863, and other artificial limbs of the 15th century are on display at the Stibbert Museum in Florence. Most of these ancient devices were the work of armorers. Made of iron, these early prostheses were used by knights to conceal loss of limbs as a result of battle, and a number of the warriors are reported to have returned successfully to their former occupation. Effective as they werefor their intended use, these specialized devices could not have been of much use to any group other than the knights, and the civilian amputees for the most part must have had to rely upon the pylon and other makeshift prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Alt-Ruppin Hand (circa 1400). The thumb is rigid; the fingers move in pairs and are sprung by the buttons at the base of the palm; the wrist is hinged. From Putti, V., <i>Chir. d. org di movimento, </i>1924-25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the use of ligatures was set forth by Hippocrates, the practice was lost during the Dark Ages, and surgeons during that period and for centuries after stopped bleeding by either crushing the stump or dipping it in boiling oil. When Ambroise Pare, a surgeon in the French Army, reintroduced the use of ligatures in 1529, a new era for amputation surgery and prostheses began. Armed with a more successful technique, surgeons were more willing to employ amputation as a life-saving measure and, indeed, the rate of survival must have been much higher. The practice of amputation received another impetus with the introduction of the tourniquet by Morel in 1674, and removal of limbs is said to have become the most common surgical procedure in Europe. This in turn led to an increase in interest in artificial limbs. Pare, as well as contributing much in the way of surgical procedures, devised a number of Limb designs for his patients. His leg (<b>Fig. 4</b>) for amputation through the thigh is the first known to employ articulated joints. Another surgeon, Verduin, introduced in 1696 the first known limb for below-knee amputees that permitted freedom of the knee joint (<b>Fig. 5</b>), in concept much like the thigh-corset type of below-knee limb still used by many today. Yet, for reasons unknown, the Verduin prosthesis dropped from sight until it was reintroduced by Serre in 1826 and, until recently, was the most popular type of below-knee prosthesis used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Artificial leg invented by Ambroise Pare (middle sixteenth century). From Pare A., <i>Oeuvres Completes, </i>Paris, 1840. From the copy in the National Library of Medicine. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Verduin Leg (1696). From MacDonald, J., <i>Amer.J. Surg., </i>1905. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After Pare's above-knee prosthesis, which was constructed of heavy metals, the next real advance seems to be the use of wood, introduced in 1800 by James Potts of London. Consisting of a wooden shank and socket, a steel knee joint, and an articulated foot, the Potts invention (<b>Fig. 6</b>) was equipped with artificial tendons connecting the knee and the ankle, thereby coordinating toe lift with knee flexion. It was made famous partly because it was used by the Marquis of Anglesea after he lost a leg at the Battle of Waterloo. Thus it came to be known as the "Anglesea leg." With some modifications the Anglesea leg was introduced into the United States in 1839. Many refinements to the original design were incorporated by American limb fitters and in time the wooden above-knee leg became known as the "American leg."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anglesea Leg (1800). Below knee at left, above knee at right. Knee, ankle, and foot are articulated. From Bigg, H., <i>Orthopraxy, </i>1877. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The American Civil War produced large numbers of amputees and consequently created a great interest in artificial limbs, no doubt inspired partly by the fact that the federal and state governments paid for limbs for amputees who had seen war service.</p> <p>J. E. Hanger, one of the first Southerners to lose a leg in the Civil War, replaced the cords in the so-called American leg with rubber bumpers about the ankle joint, a design used almost universally until rather recently. Many patents on artificial limbs were issued between the time of the Civil War and the turn of the century, but few of the designs seem to have had must lasting impact.</p> <p>During this period, with the availability of chloroform and ether as anesthetics, surgical procedures were greatly improved, and more functional amputation stumps were produced by design rather than by fortuity.</p> <p>World War I stirred some interest in artificial limbs and amputation surgery but, because the American casualty list was relatively small, this interest soon waned and, because of the economic depression of the Thirties, some observers think, very little progress was made in the field of limb prosthetics between the two World Wars. Perhaps the most significant contributions were the doctrines set forth and emphasized by Thomas and Haddan,<a></a> a prosthetist-surgeon team from Denver-that fit and alignment of the prosthesis were the most critical factors in the success of any limb and that much better end results could be expected if prosthetists and physicians worked together.</p> <p>Early in 1945, the National Academy of Sciences, at the request of the Surgeon General of the Army, initiated a research program in prosthetics<a></a>. The initial reaction of the research personnel was that the development of a few mechanical contrivances would solve the problem. However, it soon became evident that much more must be known about biomechanics and other matters before real progress could be made.<a></a> Devices and techniques based on fundamental data have materially changed the practice of prosthetics during the past 15 years. However, the best conceivable prosthesis is but a poor substitute for a live limb of flesh and blood, and so the research program is still continuing. Fiscal support for research and development by some 30 laboratories is provided by the Veterans Administration, the Social and Rehabilitation Service, the National Institutes of Health, the Children's Bureau, the Department of the Army, and the Navy Department.</p> <p>The overall program is coordinated by the Committee on Prosthetics Research and Development of the National Academy of Sciences. The committee publishes twice a year the journal <i>Artificial Limbs</i> and serves as an information center, not only in limb prosthetics but for orthotics as well.</p> <p>In England and Europe, research in artificial limbs was resumed after World War II at Queen Mary's Hospital, Roe-hampton, London, by the Ministry of Health, and a new program was started in Russia. The "thalidomide tragedy" of 1959-60 gave incentive for governments to support research, and now there are effective programs in Canada, Denmark, Holland, Scotland, and Sweden, and the studies in England and Germany have been greatly expanded. Under Public Law 480, the United States supports prosthetics research in a number of foreign countries.</p> <p>Soon after the close of World War II, the Artificial Limb Manufacturers Association, which had been formed during World War I, engaged the services of a professional staff to coordinate more effectively the efforts of individual prosthetists. Known today as the American Orthotic and Prosthetic Association,<a style="text-decoration:none;">*</a> this organization consists of some 500 limb and brace shops, and plays a large part in keeping individual prosthetists and orthotists advised of the latest trends and developments in prosthetics and orthotics.</p> <p>In 1949, upon the recommendation of the association, the American Board for Certification in Orthotics and Prosthetics, Inc.,<a style="text-decoration:none;">*</a> was established to ensure that prosthetists and orthotists met certain standards of excellence, much in the manner that certain physicians' specialty associations are conducted. Examinations are held annually for those desiring to be certified. In addition to certifying individuals as being qualified to practice, the American Board for Certification approves individual shops, or facilities, as being satisfactory to serve the needs of amputees and other categories of the disabled requiring mechanical aids. Certified prosthetists wear badges and shops display the symbol of certification (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Symbol of certification by the American Board for Certification in Orthotics and Prosthetics, Inc. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The research program, with the cooperation of the prosthetists, has introduced a sufficient number of new devices and techniques to modify virtually every aspect of the practice of prosthetics. To reduce the time lag between research and widespread application, facilities have been established within the medical schools of three universities for short-term courses in special aspects of prosthetics. Courses are offered to each member of the prosthetics-clinic team-the physician, the therapist, and the prosthetist. Also, special courses are offered to vocational rehabilitation counselors and administrative personnel concerned with the welfare of amputees.</p> <p>Short-term, continuing-education courses are offered by the University of California, Los Angeles, Northwestern University, and New York University. Two-year courses in prosthetics are offered by Cerritos Junior College (Norwalk, Calif.) and Chicago City College, and a four-year course is available at New York University.</p> <p>Prior to 1957, medical schools offered little in the way of training in prosthetics to doctors and therapists. To encourage the inclusion of prosthetics in medical and paramedical curricula, the National Academy of Sciences organized the Committee on Prosthetics Education and Information, and as a result of the efforts of this group, many schools have adopted courses in prosthetics at both undergraduate and graduate levels.</p> <p>Today, there are more than 400 amputee-clinic teams in operation throughout the United States. Each state, with assistance from the Social and Rehabilitation Service, carries out programs that provide the devices and training required to return the amputee to gainful employment. The Children's Bureau, working through a number of states, has made it possible for child amputees to receive the benefit of the latest advances in prosthetics. The Veterans Administration provides all eligible veterans with artificial limbs. If the amputation is related to his military service, the beneficiary receives medical care and prostheses for the remainder of his life. The Public Health Service, through its hospitals, provides limbs and care to members of the Coast Guard and to qualified persons who have been engaged in the maritime service.</p> <p>In July 1965, the 89th Congress passed Public Law 89-97, the Medicare bill, which includes provision for artificial limbs at essentially no cost for persons 65 years of age and over. The bill also assists individual states in providing artificial limbs for persons who are medically indigent at any age. A number of states have enacted legislation to take advantage of the offer by the federal government.</p> <p>In addition to the government agencies that are concerned with the amputee, there are several hundred rehabilitation centers throughout the United States that assist amputees, especially those advanced in age, in obtaining the services needed for them to return to a more normal life.</p> <p>Thus, through the cooperative efforts of government and private groups, considerable progress has been made in the practice of prosthetics, and there is little need for an amputee to go without a prosthesis.</p> <h3>Reasons for Amputation</h3> <p>Amputation may be the result of an accident, or may be necessary as a lifesaving measure to arrest a disease. A small but significant percentage of individuals are born without a limb or limbs, or with defective limbs that require amputation or fitting (like that of an amputee).</p> <p>In some accidents, a part or all of the limb may be completely removed; in other cases, the limb may be crushed to such an extent that it is impossible to restore sufficient blood supply necessary for healing. Sometimes, broken bones cannot be made to heal, and amputation is necessary. Accidents that cause a disruption in the nervous system and paralysis in a limb may also be cause for amputation, even though the limb itself is not injured. The object of amputation in such a case is to improve function by substituting an artificial limb for a completely useless though otherwise healthy member. Amputation of paralyzed limbs is not performed very often, but has in some cases proven to be very beneficial. Accidents involving automobiles, farm machinery, and firearms seem to account for most traumatic amputations. Freezing, electrical burns, and the misuse of power tools also account for many amputations.</p> <p>Improved medical and surgical procedures introduced in recent years have resulted in the preservation of many limbs that would have been amputated. Infection, once a cause of a high fraction of amputations, can usually be controlled with antibiotics. Newer methods of vessel and nerve suturing make it possible to save limbs that would have had to be amputated some years ago. Highly qualified surgical teams have demonstrated during the last few years that it is possible to replace a completely severed limb.</p> <p>Diseases that may make amputation necessary fall into one of three main categories: vascular, or circulatory, disorders, cancer, and infection. The diseases that cause circulatory problems most often are arteriosclerosis, or hardening of the arteries, diabetes mellitus, and Buerger's disease. In these cases, not enough blood circulates through the limb to permit body cells to replace themselves, and unless the limb or part of it is removed, the patient cannot be expected to live very long. In nearly all these cases, the leg is affected because it is the member of the body farthest from the heart and, in accordance with the principles of hydraulics, blood pressure in the leg is lower than in any other part of the body. Vascular disorders are, of course, much more prevalent among older persons. Considerable research is being undertaken to determine the cause of vascular disorders so that amputation for these reasons may at least be reduced if not eliminated, but at the present time vascular disorders are the cause of a large number of lower-extremity amputations.</p> <p>In many cases, amputation of part or all of a limb has arrested a malignant or cancerous condition. In view of present knowledge, the entire limb is usually removed. Malignancy may affect either the arms or legs. Much time and effort are being spent to develop cures for the various types of cancer.</p> <p>Since the introduction of antibiotic drugs, infection has been less and less the cause for amputation. Moreover, even though amputation may be necessary, control of the infection may allow the amputation to be performed at a lower level than would otherwise be the case.</p> <p>"Thalidomide babies" born between 1958 and 1961 have been given extensive press coverage; however, thalidomide is by no means the sole cause of congenital malformations. Absence of all or part of a limb at birth is not an uncommon occurrence. Many factors seem to be involved in such occurrences, but what these factors are is not clear. The most frequent case is absence of most of the left forearm, which occurs slightly more often in girls than in boys. However, all sorts of combinations occur, including complete absence of all four extremities. Sometimes intermediate parts such as the thigh or upper arm are missing, but the other parts of the extremity are present, usually somewhat malformed. In such cases, amputation may be indicated; however, even a weak, malformed part is sometimes worth preserving if sensation is present and the partial member is capable of controlling some part of the prosthesis. Extensive studies are being carried out to determine the reasons for congenital malformations.</p> <p>As far as it can be determined, there are approximately 311,000 amputees in the United States, exclusive of those patients residing in institutions. There are about six lower-extremity amputees for every upper-extremity amputee.</p> <h3>Losses Incurred</h3> <p>Many of the limitations resulting from amputation are obvious, others less so. An amputation through the lower extremity makes standing and locomotion without the use of an artificial leg or crutches difficult and impracticable except for very short periods. Even when an artificial leg is used, the loss of joints and the surrounding tissues, and consequently loss of the ability to sense position, is felt keenly. The sense of touch of the absent portion is also lost, but in the case of the lower-extremity amputee, this is not quite as important as it might seem, because the varying pressure occurring between the stump and the socket indicates external loading. In the upper-extremity amputee, sense of touch is more important.</p> <p>Most lower-extremity amputees cannot bear the total weight of the body on the end of the stump, and other parts of the anatomy must be found for support.</p> <p>Muscles attached at each end to bones are responsible for movement of the arms and legs. Upon a signal from the nervous system, muscle tissue will contract, thus producing a force which can move a bone about its joint (<b>Fig. 8</b>). Because muscle force can be produced only by contraction, each muscle group has an opposing muscle group so that movement in two directions can take place. This arrangement also permits a joint to be held stable in any one of a vast number of positions for relatively long periods of time. How much a muscle can contract is dependent upon its length, and the amount of force that can be generated is dependent upon its circumference.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Schematic drawing of muscular action on skeletal system. The motion shown here is flexion, or bending, of the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Muscles that activate the limbs must of course pass over at least one joint to provide a sort of pulley action; some pass over two. Thus, some muscles are known as one-joint muscles, others as two-joint muscles. When muscles are severed completely, they can no longer transmit force to the bone and, when not used, wither away or atrophy. It will be seen later that these facts are very important in the rehabilitation of amputees.</p> <h3>Types of Amputation</h3> <p>Amputations are generally classified according to the level at which they are performed (<b>Fig. 9</b>). Some amputations levels are referred to by the name of the surgeon credited with developing the amputation technique used. The general rule in selecting the site of amputation is to save all length that is medically possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Classification of amputation by level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>LOWER-EXTREMITY AMPUTATIONS</h4> <p><i>Syme's Amputation</i></p> <p>Developed about 1842 by James Syme, a leading Scottish surgeon, the Syme amputation leaves the long bones of the shank (the tibia and fibula) virtually intact, only a small portion at the very end being removed (<b>Fig. 10</b>)<a></a> (The tissues of the heel, which are ideally suited to withstand high pressures, are preserved, and this, in combination with the long bones, usually permits the patient to bear the full weight of his body on the end of the stump. Because the amputation stump is nearly as long as the unaffected limb, a person with Syme's amputation can usually get about the house without a prosthesis, even though normal foot and ankle action has been lost. Atrophy of the severed muscles that were formerly attached to bones in the foot to provide ankle action results in a stump with a bulbous end which, though not of the most pleasing appearance, is quite an advantage in holding the prosthesis in place.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Excellent Syme stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since its introduction, Syme's operation has been looked upon with both favor and disfavor by surgeons. It seems to be the consensus now that "the Syme" should be performed in preference to an amputation at a higher level, if possible. In the case of most women, though, "the Syme" is undesirable because of the difficulty of providing a prosthesis that matches the shape of the other leg.</p> <p><i>Below-Knee Amputations</i></p> <p>Any amputation above the Syme level and below the knee joint is known as a below-knee amputation. Because circulatory troubles have often developed in long below-knee stumps, and because the muscles that activate the shank are attached at a level close to the knee joint, the below-knee amputation is usually performed at the junction of the upper and middle third sections (<b>Fig. 11</b>). Thus, nearly full use of the knee is retained-an important factor in obtaining a gait of nearly normal appearance. However, it is rare for a below-knee amputee to bear a significant amount of weight on the end of the stump; therefore, the design of prostheses must provide for weight-bearing through other areas. Several types of surgical procedures have been employed to obtain weight-bearing through the end of the below-knee stump, but none has found widespread use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical, well-formed, right below-knee stump. <i>Courtesy Veterans Administration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Knee-Bearing Amputations</i></p> <p>Complete removal of the lower leg, or shank, is known as a knee disarticulation. When the operation is performed properly, the result is an efficient, though bulbous, stump (<b>Fig. 12</b>), capable of carrying the weight-bearing forces through the end.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Typical knee-disarticulation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Unfortunately, the length causes some problems in providing an efficient prosthesis because the space used normally to house the mechanism needed to control the artificial shank properly is occupied by the end of the stump. Nevertheless, excellent prostheses can be provided the knee-disarticulation case.</p> <p>Several amputation techniques have been devised in an attempt to overcome the problems posed by the length and shape of the true knee-disarticulation stump. The Gritti-Stokes procedure entails placing the kneecap, or patella, directly over the end of the femur after it has been cut off about two inches above the end. When the operation is performed properly, excellent results are obtained, but extreme skill and expert postsurgical care are required. Variations of the Gritti-Stokes amputation have been introduced from time to time but have never been used widely.</p> <p><i>Above-Knee Amputations</i></p> <p>Amputations through the thigh are among the most common (<b>Fig. 13</b>). Because of the high pressures exerted on the soft tissues by the cut end of the bone, total body weight cannot be taken through the end of the stump but can be accommodated through the ischium, that part of the pelvis upon which a person normally sits.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical well-formed above-knee stump. <i>Courtesy Veterans Administration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Hip Disarticulation and Hemipelvectomy</i></p> <p>A true hip disarticulation (<b>Fig. 14</b>) involves removal of the entire femur, but, whenever feasible, the surgeon leaves as much of the upper portion of the femur as possible, in order to provide additional stabilization between the prosthesis and the wearer, even though no additional function can be expected over the true hip disarticulation.<a></a> Both types of stump are provided with the same type of prosthesis. With slight modification, the same type of prosthesis can be used by the hemipelvectomy patient, that is, when half of the pelvis has been removed. It is surprising how well hip-disarticulation and hemi-pelvectomy patients have been able to function when fitted with the newer type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Patient with true hip-disarticulation amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>UPPER-EXTREMITY AMPUTATIONS</h4> <p><i>Partial-Hand Amputations</i></p> <p>If sensation is present, the surgeon will save any functional part of the hand in lieu of disarticulation at the wrist. Any method of obtaining some form of grasp, or prehension, is preferable to the best prosthesis. If the result is unsightly, the stump can be covered with a plastic glove, lifelike in appearance, for those occasions when the wearer is willing to sacrifice function for appearance. Many prosthetists have developed special appliances for partial-hand amputations that permit more function than any of the artificial hands and hooks yet devised and, at the same time, permit the patient to make full use of the sensation remaining in the stump. Such devices are usually individually designed and fitted.</p> <p><i>Wrist Disarticulation</i></p> <p>Removal of the hand at the wrist joint was once condemned because it was thought to be too difficult to fit so as to yield more function than a shorter forearm stump. However, with plastic sockets based on anatomical and physiological principles, the wrist-disarticulation case can now be fitted so that most of the pronation-supination of the forearm-an important function of the upper extremity- can be used. In the case of the wrist disarticulation (<b>Fig. 15</b>), nearly all the normal forearm pronation-supination is present. Range of pronation-supination decreases rapidly as length of stump decreases; when 60 per cent of the forearm is lost, no pronation-supination is possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. A good wrist-disarticulation stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Amputations Through the Forearm</i></p> <p>Amputations through the forearm are commonly referred to as below-elbow amputations, and are classified as long, short, and very short, depending upon the length of stump (<b>Fig. 9</b>). Stumps longer than 55 per cent of total forearm length are considered long, between 35 and 55 per cent as short, and less than 35 per cent as very short.</p> <p>Long stumps retain the rotation function in proportion to length; long and short stumps without complications possess full range of elbow motion and full power about the elbow, but often very short stumps are limited in both power and motion about the elbow. Devices and techniques have been developed to make full use of all functions remaining in the stump.</p> <p><i>Disarticulation at the Elbow</i></p> <p>Disarticulation at the elbow consists of removal of the forearm, resulting in a slightly bulbous stump (<b>Fig. 16</b>), but usually one with good end-weight-bearing characteristics. The long bulbous end, while presenting some fitting problems, permits good stability between socket and stump and thus allows use of nearly all the rotation normally present in the upper arm-a function much appreciated by the amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Amputation through the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Above-Elbow Amputation</i></p> <p>Any amputation through the upper arm is generally referred to as an above-elbow amputation (<b>Fig. 9</b>). In practice, stumps in which less that 30 per cent of the humerus remains are treated as shoulder-disarticu-lation cases; those with more than 90 per cent of the humerus remaining are fitted as elbow-disarticulation cases.</p> <p><i>Shoulder Disarticulation and Forequarter Amputation</i></p> <p>Removal of the entire arm is known as shoulder disarticulation, but, whenever feasible, the surgeon will leave intact as much of the humerus as possible, to provide stability between the stump and the socket (<b>Fig. 17</b>). When it becomes necessary to remove the clavicle and scapula, the operation is known as a forequarter, or interscapulothoracic, amputation. The very short above-elbow, the shoulder-disarticulation, and the forequarter cases are all provided with essentially the same type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. A true shoulder disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Postsurgical Period</h3> <p>The period between the time of surgery and time of fitting the prosthesis is an important one if a good functional stump, and thus the most efficient use of a prosthesis, is to be obtained. The surgeon and others on his hospital staff will do everything possible to ensure the best results, but ideal results require the wholehearted cooperation of the patient.</p> <p>It is not unnatural for the patient to feel extremely depressed during the first few days after surgery, but after he becomes aware of the possibilities of recovery, the outlook becomes brighter, and he generally enters cooperatively into the rehabilitation phase.</p> <p>It has been generally agreed through the years that the earlier a patient could be fitted, the easier would be the rehabilitation process. However, until a few years ago, virtually no patients were provided with a prosthesis before six weeks after amputation, and such cases were rare - the average time probably being closer to four months.</p> <p>With the advent of improved cast-taking methods, and temporary legs in which alignment can be easily adjusted, Duke University, about 1960, began an experiment to determine the earliest practical time after surgery for providing amputees with limbs. By 1963, it had been shown clearly that it was not only practical but desirable to fit a temporary, but well-fitted limb as soon as the sutures were removed, some two to three weeks after surgery. In 1963, Dr. Marian Weiss of Poland, in an address in Copenhagen, reported success with fitting amputees immediately after surgery while the patient was still anesthetized, and beginning ambulation training the day afterward.<a></a> Dr. Weiss's work stimulated similar work in this country, notably at the University of California, San Francisco; the Oakland Naval Hospital; the Prosthetics Research Study, Seattle, Washington; Duke University; the University of Miami; Marquette University; and New York University. Records on several thousand patients of all types have shown immediate postsurgical fitting of prostheses to be the method of choice when possible. Healing seems to be accelerated; postsurgical pain is greatly alleviated; contractures are prevented from developing; phantom pain seems to be virtually nonexistent; fewer psychological problems seem to ensue; and patients are returned to work or home at a much earlier date than seemed possible only a few years ago.</p> <p>The procedure consists essentially of providing a rigid plaster dressing over the stump which serves as a socket, and the use of an adjustable leg which can be removed and reinstalled easily (<b>Fig. 18</b>).<a></a> The cast-socket is left in place for 10 to 12 days, during which ambulation is encouraged. At the end of this time, the cast-socket is removed, the stitches are usually taken out, and a new cast-socket is provided immediately. The original prosthetic unit is replaced and realigned. The second cast-socket is left in place for eight to ten days, at which time a new cast can be taken for the permanent, or definitive, prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. 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." <i>Inset: </i>A below-knee amputee fitted with the immediate postsurgical prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Special courses in immediate postsurgical fitting and early fitting are being offered to qualified prosthetics clinic teams by Northwestern University, the University of California at Los Angeles, and New York University.</p> <h4>CONTRACTURES</h4> <p>When immediate postsurgical fitting is employed, there is little opportunity for contractures to develop. When these procedures are not used, it is most important to avoid the development of muscle contractures. They can be prevented easily, but it is most difficult, and sometimes impossible, to correct them. At first, exercises are administered by a therapist or nurse; later, the patient is instructed concerning the type and amount of exercise that should be undertaken. The patient is also instructed in the methods and amount of massage that should be given the stump to aid in the reduction of the stump size. Further, to aid shrinkage, cotton-elastic bandages are wrapped around the stump (<b>Fig. 19</b>) and worn continuously until a prosthesis is fitted. The bandage is removed and reapplied at regular intervals-four times during the day and at bedtime. It is most important that a clean bandage is available for use each day.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Compression wrap for above-knee amputation. The wrap of elastic bandage aids in shrinking the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee is taught to apply the bandage unless it is physically impossible for him to do so, in which case some member of his family must be taught the proper method for use at home.</p> <p>To reduce the possibility of contractures, the lower-extremity stump must not be propped upon pillows. Wheelchairs should be used as little as possible; crutch walking is preferred, but the above-knee stump must not be allowed to rest on the crutch handle (<b>Fig. 20</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Actions to be avoided by lower-extremity amputees during the immediate postoperative period. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>THE PHANTOM SENSATION</h4> <p>After amputation, the patient almost always has the sensation that the missing part is still present. The exact cause of this is as yet unknown. The phantom sensation usually recedes to the point where it occurs only infrequently or disappears entirely, especially if a prosthesis is used. In a large percentage of cases, moderate pain may accompany the phantom sensation, but in general this too eventually disappears entirely or occurs only infrequently. In a small percentage of cases, severe phantom pain persists to the point where medical treatment is necessary.<a></a></p> <h4>DEFINITIONS</h4> <p><i>Preparatory Prosthesis</i></p> <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> <p><i>Pylon</i></p> <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> <p><i>Rigid Dressing</i></p> <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> <p><i>Immediate Postsurgical Prosthetic Fitting</i></p> <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> <p><i>Early Prosthetic Fitting</i></p> <p>A procedure wherein a preparatory prosthesis, as defined above, is provided for the amputee immediately following removal of sutures.</p> <p><i>Permanent Prosthesis</i></p> <p>A replacement for a missing limb, which meets accepted checkout standards for comfort, fit, alignment, function, appearance, and durability.</p> <h3>Prostheses for Various Types of Amputation</h3> <p>Much time and attention have been devoted to the development of mechanical component, such as knee and ankle units, for artificial limbs, yet by far the most important factors affecting the successful use of a prosthesis are the fit of the socket ot the stump and the alignment of the vairous parts of the limb in relation to the stump and other parts of the body.</p> <p>Thus, though many parts of a prosthesis may be mass-produced, it is necessary for each limb to be assembled in correct alignment and fitted to the stump to meet the individual requirements of the intended user. To make and fit artificial limbs properly requires a complete understanding of anatomical and physiological principles and of mechanics; craftsmanship and artistic ability are also required.</p> <p>In general, an artificial limb should be as light as possible and still withstand the loads imposed upon it. In the United States, willow and woods of similar characteristics have formed the basis of construction for more limbs than any other material, although aluminum, leather-and-steel combinations, and fiber have been used widely. Today, plastic laminates so popular in small-boat construction form the basis for construction of most artificial limbs. Some artificial legs are made of wood, and occasionally leather is used for sockets, but the trend is toward the plastic laminates. They are light in weight, easy to keep clean, and do not absorb perspiration. They may be molded easily and rapidly over contours such as those found on a plaster model of a stump. Plastic laminates can be made extremely rigid or with any degree of flexibility required in artificial-limb construction.</p> <p>A procedure for making a porous plastic laminate has been developed for use when perspiration presents a difficult problem. A new material, synthetic balata, which can be molded directly over the stump, is now being used in some clinics, primarily to form temporary prostheses.</p> <p>As in the case of the tailor making a suit, the first step in fabrication of a prosthesis is to take the necessary measurements for a good fit. If the socket is to be fabricated of a plastic laminate, an impression of the stump is made. Most often this is accomplished by wrapping the stump with a wet plaster-of-paris bandage and allowing it to dry, as a physician does in applying a cast when a bone is broken (<b>Fig. 21</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Steps in the fabrication of a plastic prosthesis for a below-knee amputation: <i>A, </i>taking the plaster cast of the stump; <i>B, </i>pouring plaster in the cast to obtain model of the stump; C, introducing plastic resin into fabric pulled over the model to form the plastic-laminate socket; <i>D, </i>the plastic-laminate socket mounted on an adjustable shank for walking trials; <i>E, </i>a wooden shank block inserted in place of the adjustable shank after proper alignment has been obtained; <i>F</i>, the prosthesis after the shank has been shaped. To reduce weight to a minimum, the shank is hollowed out and the exterior covered with a plastic laminate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of devices have been introduced in recent years to aid the prosthe-tist in obtaining accurate casts rapidly.<a></a> Most use an apparatus that permits the patient to absorb some of the weight-bearing load through the affected side while the cast is being formed (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Special jig developed by the Veterans Administration Prosthetics Center to facilitate casting above-knee stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast, or wrap, is removed from the stump and filled with a plaster-of-paris solution to form an exact model of the stump which-after being modified to provide relief for any tender spots, to ensure that weight will be taken in the proper places, and to take full advantage of the remaining musculature-can be used for molding a plastic-laminate socket. Often a "check" socket of cloth impregnated with beeswax is made over the model and tried on the stump to determine the correctness of the modifications.</p> <p>For upper-extremity cases, the socket is attached to the rest of the prosthesis, and a harness is fabricated and installed for operation of the various parts of the artificial arm. For the lower-extremity case, the socket is fastened temporarily to an adjustable, or temporary, leg for walking trials (<b>Fig. 23</b>). With this device, the prosthetist can easily adjust the alignment until both he and the amputee are satisfied that the optimum arrangement has been reached. A prosthesis can now be made, incorporating the same alignment achieved with the adjustable leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Using the above-knee adjustable leg and alignment duplication jig. <i>Top, </i>adjusting the adjustable leg during walking trials; <i>center, </i>the socket and adjustable leg in the alignment duplication jig; <i>bottom, </i>replacement of the adjustable leg with a permanent knee and shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A more refined procedure uses the "Staros-Gardner" coupling (<b>Fig. 24</b>) <a></a>. Not only is the need for the alignment jig eliminated, but in the case of above-knee fittings the alignment adjustments can be made with the knee unit that is to be used permanently, an important factor when sophisticated knee units are used because the present adjustable leg is available with only a single-axis, constant-friction joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Adjustable coupling used for alignment of artificial legs. This unit was designed by the Veterans Administration Prosthetics Center and is suitable for below-knee as well as above-knee legs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An even more refined procedure consists of using one of the adjustable pylon types of prostheses that were originally designed for use in immediate postsurgical fitting. These units are strong enough and sufficiently inexpensive so they can form part of the permanent, or definitive, prosthesis (<b>Fig. 25</b> and <b>Fig. 26</b>). A light, removable, cosmetic cover is used over the pylon. This arrangement permits the prosthetist to change alignment easily at any time. An added feature of the VAPC above-knee "standard" pylon is provision for inter-changeability of a number of knee units, ranging from the simple constant-friction unit to complex hydraulic units. Thus, the patient may try a number of different methods of knee control, at little expense, in order to determine which meets his needs the best.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. An adjustable below-knee pylon with cosmetic cover. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. An adjustable above-knee prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>There are many kinds of artificial limbs available for each type of amputation, and much has been written concerning the necessity for prescribing limbs to meet the needs of each individual. This of course is particularly true in the case of persons in special or arduous occupations, or with certain medical problems, but limbs for a given type of amputation actually vary to only a small degree. Following are descriptions of the artificial limbs most commonly used in the United States today.</p> <h4>LOWER-EXTREMITY PROSTHESES</h4> <p><i>Prostheses for Syme's Amputation</i></p> <p>Perhaps the major reason Syme's amputation was held in such disfavor in some quarters was the difficulty in providing a comfortable, sufficiently strong prosthesis with a neat appearance. The short distance between the end of the stump and the floor made it extremely difficult to provide for ankle motion needed. Most Syme prostheses were made of leather reinforced with steel side bars, resulting in an ungainly appearance. Research workers at the Prosthetic Services Centre at the Department of Veterans Affairs of Canada were quick to realize that the use of the proper plastic laminate might solve many of the problems long associated with the Syme prosthesis. After a good deal of experimentation, the Canadians developed a model in 1955 which, with a few variations, is used almost universally in both Canada and the United States today (<b>Fig. 27</b>)<a></a>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. The Syme prosthesis adopted by the Canadian Department of Veterans Affairs. The posterior opening extends the length of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Necessary ankle action is provided by making the heel of the foot of sponge rubber. The socket is made entirely of a plastic laminate. A full-length cutout in the rear permits entry of the bulbous stump. When the cutout is replaced and held in place by straps, the bulbous stump holds the prosthesis in place. In the American version (<b>Fig. 28</b>), a window-type cutout is used on the side because calculations show that smaller stress concentrations are present with such an arrangement. An increasing number of prosthetists have been using a double-wall socket with an expandable inner wall in order to eliminate the need for the window.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Two views of the Canadian-type Syme prosthesis as modified by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In those cases where, for poor surgery or other reasons, full body weight cannot be tolerated on the end of the stump, provisions can be made to transfer all or part of the load to the area just below the kneecap.<a></a> </p> <p><i>Prostheses for Below-Knee Amputations</i></p> <p>Until recently, most below-knee amputees were fitted with wooden prostheses carved out by hand (<b>Fig. 29</b>). A good portion of the body weight was carried on a leather thigh corset, or lacer, attached to the shank and socket by means of steel hinges. The shape of the corset and upper hinges also held the prosthesis to the stump. The distal, or lower, end of the socket was invariably left open. Other versions of this prosthesis used aluminum, fiber, or molded leather as the materials for construction of the shank and socket, but the basic principle was the same. Many thousands of below-knee amputees have gotten along well with this type of prosthesis, but there are many disadvantages. Because the human knee joint is not a simple, single-axis hinge joint (<b>Fig. 30</b>), relative motion is bound to occur between the prosthesis and the stump and thigh during knee motion when single-jointed side hinges are used, resulting in some chafing and irritation. To date it has not been possible to devise a hinge to overcome this difficulty. Edema, or accumulation of fluid, was often present at the lower end of the stump. Most of these prostheses were exceedingly heavy, especially those made of wood.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Below-knee prosthesis with wood socket-shank, thigh corset, and steel side bars. <i>Courtesy Veterans Administration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Section through the medial condyles of the femur and tibia. The center of curvature is shown for three parts of the articular surface. As gliding occurs in the joint, the instant center moves along the curve connecting these three centers. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In an attempt to overcome these difficulties, the Biomechanics Laboratory of the University of California, in 1958, designed what is known as the patellar-tendon-bear-ing (PTB) below-knee prosthesis (<b>Fig. 31</b>). In the PTB prosthesis no lacer and side hinges are used, all of the weight being taken through the stump by making the socket high enough to cover all the tendon below the patella, or kneecap.<a></a> The patellar tendon is an unusually inelastic tissue which is not unduly affected by pressure. The sides of the socket are also made much higher than has usually been the practice in the past, in order to give stability against side loads. The socket is made of molded plastic laminate that provides an intimate fit over the entire area of the socket, and is lined with a thin layer of sponge rubber and leather. Because it is rare for a below-knee stump to bear much pressure on its lower end, care is taken to see that only a very slight amount is present in that area. This feature has been a big factor in eliminating the edema problem in many instances. The PTB prosthesis is generally suspended by means of a simple cuff, or strap, around the thigh just above the kneecap, but sometimes a strap from the prosthesis to a belt around the waist is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Cutaway view of the patellar-tendon-bearing leg for below-knee amputees. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of variations have been introduced during the past few years which make the PTB even more versatile. Many prosthetists feel that not only can many of the problems associated with perspiration be ameliorated by elimination of the soft inner liner, but that a better physiological fit can be obtained with the "hard socket" PTB. Two methods of eliminating the suspension have been introduced from Europe. From France, there is the "pro-these tibiale a emboitage supracondylien," popularly known as the PTS, in which the proximal border extends above the patella anteriorally and the femoral condyles medially and laterally (<b>Fig. 32</b>). Not only does this arrangement eliminate the need for other means of suspension, but it also provides a certain amount of mediolateral stability when required. Another means for eliminating the need for suspension straps was introduced from Germany, known as the wedge-suspension system. In this variation, a molded removable plastisol wedge is inserted between the wall of the proximal area of the socket and the area of the stump along the medial condyles of the femur (<b>Fig. 33</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. A below-knee amputee wearing a PTS-socket prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. The supracondylar-wedge suspension method. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <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, the University of California designed the air-cushion socket, consisting of a rigid outer socket and an elastic inner sleeve (<b>Fig. 34</b>). Stump support is provided by the tension of the sleeve and by compression of the air between the sleeve and socket. Nearly all of these innovations are compatible with each other, and the Committee on Prosthetics Research and Development has prepared a chart for use by clinical teams in prescribing for the below-knee amputee (<b>Fig. 35</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Cutaway view of the air-cushion socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the PTB socket has been made, it is installed on a special adjustable leg (<b>Fig. 36</b>) or one of the newer pylons (<b>Fig. 37</b>) so that the prosthetist can try various alignment combinations with ease. When both prosthetist and patient are satisfied, the leg is completed, utilizing the alignment determined with the adjustable unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Trial below-knee adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Below-knee pylon-type prostheses that can be used for fitting immediately after surgery. <i>A, </i>Hosmer Postoperative Pylon; <i>B, </i>Northwestern Pylon (Hosmer); C, Veterans Administration Prosthetics Center (VAPC) "Standard" Pylon; <i>D, </i>Canadian "Instant" Prosthesis (Hosmer); <i>E, </i>U.S. Manufacturing Co. Pylon; <i>F, </i>Finnie-Jig (Arthur Finnieston Co.), <i>Courtesy of Veterans Administration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The shank for the definitive prosthesis is usually made of wood reinforced with plastic laminate. When the new light pylons are used, a cosmetic cover is often provided. The foot prescribed in most instances is the SACH (solid-ankle, cushion-heel) design, but any other type may be used.</p> <p>It is now general practice in many areas to prescribe the PTB prosthesis in most new cases and in many old ones, and if side hinges and a corset are indicated later, these can be added.</p> <p>Stumps as short as two and one-half inches have been fitted successfully with the PTB prosthesis.</p> <p>In special cases such as extreme flexion contracture, the so-called kneeling-knee, or bent-knee, prosthesis may be indicated. The prosthesis used is similar to that used for the knee-disarticulation case.</p> <p><i>Prostheses for the Knee-Disarticulation and Other Knee-Bearing Cases</i></p> <p>Because of the bulbous shape of the true knee-disarticulation stump, it is not possible to use a wooden socket of the type used on the tapered above-knee stump. To allow entry of the bulbous end, a socket is molded of leather to conform to the stump, and is provided with a lengthwise anterior cutout that can be laced to hold the socket in position (<b>Fig. 38</b>). The length of the knee-disarticulation and supracondylar stump makes it difficult to install any of the present knee units designed for above-knee prostheses; therefore, heavy-duty below-knee joints are generally used. Most prosthetists try to provide some control of the shank during the swing phase of walking by inserting nylon washers between the mating surfaces of the joint to provide friction and by using checkstraps. Some prosthetists in the past have installed commercially available piston-type hydraulic swing-phase control units (<b>Fig. 39</b>), a procedure that requires extreme care to achieve the proper result. To make this task easier, the Hosmer Corporation has recently made available a special boring fixture for use in installing the Hosmer-DuPaCo hydraulic knee unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Typical knee-disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. DuPaCo swing-phase control unit installed in a knee-bearing prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Above-Knee Cases</i></p> <p>The articulated above-knee leg is in effect a compound pendulum actuated by the thigh stump. If the knee joint is perfectly free to rotate when force is applied, the effects of inertia and gravity tend to make the shank rotate too far backward and slam into extension as it rotates forward, except at a very slow rate of walking. The method most used today to permit an increase in walking speed is the introduction of some restraint in the form of mechanical friction about the knee joint. The limitation imposed by constant mechanical friction is that for each setting there is only one speed that produces a natural-appearing gait. When restraint is provided in the form of hydraulic resistance, a much wider range of cadence can be obtained, without introducing into the gait pattern awkward and unnatural motions.</p> <p>In recent years, a number of hydraulic units have been made available for control of the shank during the swing phase. Among them are the DuPaCo, the Henschke-Mauch Type S<a style="text-decoration:none;">*</a> (<b>Fig. 40</b>), and the Hydra-Knee. These units are all of the piston-cylinder type, provide for swing-phase control only, and are designed so that they can be incorporated into the more conventional leg structures. The Hydra-Cadence leg (<b>Fig. 41</b>), a complete knee-shin-foot unit, in addition to providing swing-phase control hydraulically, uses the hydraulic system to control ankle action in concert with knee motion. After the knee is flexed 20 degrees, the toe of the foot is lifted as the knee is flexed further, thereby giving more clearance between the foot and the floor as the leg swings through.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. The Henschke-Mauch Type S hydraulic unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. The Hydra-Cadence leg without cosmetic cover. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Throughout the past century, much time and effort have been spent in providing an automatic brake or lock at the knee in order to provide stability during the stance phase and to reduce the possibility of stumbling. Stability during the stance phase can be obtained by aligning the leg so that the axis of the knee is behind the hip and ankle axes. For most above-knee amputees in good health, such an arrangement has been quite satisfactory, but an automatic knee brake is indicated for the weaker or infirm patients.</p> <p>When an automatic brake is indicated, the Bock, the "Vari-Gait" 100, and the Mortensen knee units (<b>Fig. 42</b>) are the ones most generally used. All are actuated upon contact of the heel with the ground. The Bock and Vari-Gait units can be used with almost any type of foot, while a foot of special design is necessary when the Mortensen mechanism is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42/ Some examples of weight-actuated knee units. <i>A, </i>Bock "Safety-knee"; <i>B, </i>Vari-Gait knee; C, Mortensen leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The most sophisticated stance-phase control unit is the Henschke-Mauch Type S-N-S hydraulic unit. It has been thoroughly evaluated by the Veterans Administration and is now available commercially. The Type S-N-S unit contains the same swing-phase control device as the Type S and in addition provides a braking action about the knee when there is a tendency to buckle. The braking action is brought about by the attitude of a pendulum which in turn is controlled by the inertia forces in the shank. The "S" and "S-N-S" units are interchangeable.</p> <p>A number of methods for suspending the above-knee leg are available. For younger, healthy patients, the suction socket (<b>Fig. 43</b>A) has generally been the method of choice. In this design, the socket is simply fitted tightly enough to retain sufficient negative pressure, or suction, between the stump and the bottom of the socket when the leg is off the ground. Special air valves are used to control the amount of negative pressure created so as not to cause discomfort. No stump sock is worn with the suction socket. A major advantage of this type of suspension is the freedom of motion permitted the wearer, thus allowing the use of all the remaining musculature of the stump. Another important advantage is the decreased amount of piston action between stump and socket. Additional comfort is also obtained by elimination of all straps and belts.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Above-knee sockets and methods of suspension: <i>A, </i>total-contact suction socket; <i>B, </i>above-knee leg with Silesian bandage for suspension; C, above-knee leg with pelvic belt for suspension. Most above-knee sockets have a quadrilateral-shaped upper portion as shown. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In some cases, additional suspension is provided by adding a Silesian bandage (<b>Fig. 43</b>B), a light belt attached to the socket in such a way that there is very little restriction of motion of the various parts of the body.</p> <p>Patients with weak stumps and most of those with very short stumps often will require a pelvic belt connected to the socket by means of a "hip" joint (<b>Fig. 43</b>C). Because the connecting joint cannot be placed to coincide with the normal joint, certain motions are restricted. Pelvic-belt suspension is generally indicated for the older patient because of the problems encountered in donning the suction socket, especially that of bending over to remove the donning sock.</p> <p>Shoulder straps, at one time the standard method of suspending above-knee prostheses are still sometimes indicated for the elderly patient.</p> <p>Prior to the introduction of the suction socket into the United States soon after the close of World War II, virtually all above-knee sockets had a conical-shaped interior and were known as plug fits, most of the weight being borne along the sides of the stump. Such a design does not permit the remaining musculature to perform to its full capabilities. In the development of the suction socket, a design known as the quadrilateral socket (see <b>Fig. 43</b>) evolved, and it now is virtually the standard for above-knee sockets, regardless of the type of suspension used. When the pelvic belt or suspender straps are used, the socket is fitted somewhat looser than in the case of the suction socket, and the stump sock is generally worn to reduce skin irritation from the pumping action of the loose socket. A good part of the body weight is taken on the ischium, that part which assumes the load when an individual is sitting.</p> <p>The quadrilateral socket, because of the method employed to permit full use of the remaining muscles, does not resemble the shape of the stump, but, as the name implies, is more rectangular in shape. Until recently, the standard method of fitting a quadrilateral socket called for no contact over the lower end of the stump, a hollow space being left in this area. Although this method was quite successful, there remained a number of cases that persistently developed ulcers or edema over the end of the stump. Experiments involving the use of slight pressure over the stump end led to the development of what is known as the plastic total-contact socket<a></a> (<b>Fig. 43</b>A). As the name implies, the socket is in contact with the entire surface of the stump. In taking some pressure over the end of the stump, the pressure on the ischial area is reduced, thereby providing more comfort to the patient. It also appears that the pressure over the end of the stump helps circulation and improves proprioception. Today the total-contact socket is the method of choice for use by above-knee amputees.</p> <p>In fitting the wooden above-knee prosthesis, the prosthetist carves the interior of the socket, using measurements of the stump as a guide. When a satisfactory fit has been achieved the socket is usually mounted on an adjustable leg for alignment trial, after which the wooden shank and the knee are substituted for the adjustable unit, and the leg is finished by applying a thin layer of plastic laminate over the shank and the thigh piece.</p> <p>In the case of the total-contact socket, the prosthetist obtains a plaster cast of the stump, usually with the aid of a special casting jig (see <b>Fig. 22</b>), and thus obtains a model of the stump over which the plastic socket can be formed.</p> <p>Special adjustable pylon-type legs are available for fitting immediately after surgery, or use as a temporary leg. Provisions are made for all necessary adjustments, and a manually operated knee lock is provided for use by infirm patients.</p> <p><i>Prostheses for Hip-Disarticulation and Hemipeluectomy Cases</i></p> <p>A prosthesis (<b>Fig. 44</b>) developed by the Canadian Department of Veterans Affairs in 1954, and modified slightly through the years, is used almost universally. In the Canadian design, a plastic-laminate socket is used, and the "hip" joint is placed on the front surface in such a position that, when used with an elastic strap connecting the rear end of the socket to a point on the shank ahead of the femur, stability during standing and walking can be achieved without the use of a lock at the hip joint. The location of the hip joint in the Canadian design also facilitates sitting, a real problem in earlier designs.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Hip-disarticulation prosthesis, known as the Canadian type because its principle was originally conceived by workers at the Department of Veterans Affairs of Canada. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A constant-friction knee unit is most often used with the hip-disarticulation prosthesis, but some prosthetists have reported successful use of hydraulic knee units.</p> <p>The hemipelvectomy patient is provided with the same type of prosthesis, but the socket design is altered to allow for the loss of part of the pelvis.</p> <h4>Upper-Extremity Prostheses <a></a></h4> <p>The major role of the human arm is to place the hand where it can function and to transport objects held in the hand. The energy for operation of the hand-substitute in upper-extremity prostheses is generally derived from relative motion between two parts of the body. Energy for operation of the elbow joint, when necessary, can be obtained in the same way. The stump, of course, is also a source of energy for control of the prosthesis in all except the shoulder-disarticulation and forequarter cases. Force and motion can be obtained through a cable connected between the device to be operated and a harness across the chest or shoulders.</p> <p>In recent years artificial arms powered by electricity and by compressed gas have received considerable publicity. An artificial hand powered by electricity and controlled by electrical signals from muscles was developed first in Russia for below-elbow amputees. Versions of the Russian design are manufactured in England, Canada, Germany, and elsewhere. However, the below-elbow patient, of all the types of upper-extremity amputees, is the least handicapped and therefore is less in need of sophisticated devices. The devices are expensive, and in their present state of development seem to offer no real advantage over the simpler conventional devices. The real need is for powered devices for patients with amputations above the elbow and higher.</p> <p>A number of electrically powered elbow units are now being tested, including the so-called Boston Arm, but none are available for general clinical use. To date, no truly satisfactory method of controlling externally powered prostheses has been developed. A good deal of effort is being made both in the United States and abroad to overcome the control problem <a></a>.</p> <p>Sockets for artificial arms are usually made of plastic laminate formed over a modified plaster model of the stump. Synthetic balata, which is molded directly over the stump, is now being used in a few centers.</p> <p><i>Hand Substitutes</i>-<i>Terminal Devices</i></p> <p>All upper-extremity prostheses for amputation at the wrist level and above have in common the problem of selection of the terminal device, a term applied to artificial hands and substitute devices such as hooks. In some areas of the world, there is a tendency to supply the arm amputee with a number of devices, each designed for a specific task such as eating, shaving, hair grooming, etc. In the United States, such an approach has been considered too clumsy, and opinion has been that the terminal device should be designed so that most upper-extremity amputees can perform the activities of daily living with a single device, or at most with two devices.</p> <p>The so-called split hooks are much more functional than any artificial hand devised to date. The arm amputee must rely heavily upon visual cues in handling objects, and the hook offers more visibility. The hook also offers more prehension facility and can be more easily introduced into and withdrawn from pockets than a device in the form of a hand. Therefore, the hook is used in manual occupations and those avocations requiring manual dexterity. When extensive contact with the public is necessary and for social occasions, the hand is of course generally preferred. Many amputees have both types of devices, using each as the occasion warrants.</p> <p>Two basic types of mechanisms have been developed for terminal-device operation—voluntary-opening and voluntary-closing. In the former, tension on the control cable opens the fingers against an elastic force; in the latter, tension in the control cable closes the fingers against an elastic force. Each type of mechanism has its advantages and disadvantages, neither being superior to the other when used in a wide range of activities. Both hands and hooks are available with either type of mechanism.</p> <p>The major types of terminal devices are shown in <b>Fig. 45</b> and <b>Fig. 46</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Voluntary-closing terminal devices. <i>A, </i>APRL-Sierra Hand; <i>left, </i>cutaway view showing mechanism; <i>right, </i>assembled hand without cosmetic glove; <i>B, </i>APRL-Sierra Hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Voluntary-opening terminal devices. The wide range of models offered by the D. W. Dorrance Company includes sizes and designs for all ages. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Wrist-Disarticulation Case</i></p> <p>One of the problems in fitting the wrist disarticulation in the past has been to keep the overall length of the prosthesis commensurate with the normal arm. The development of very short wrist units, especially for wrist-disarticulation cases, has materially reduced this problem. However, these units are available in only the screw, or thread, type and cannot be obtained in the bayonet type which lesds itself to quick interchange of terminal devices.</p> <p>The socket for the wrist-disarticulation case need not extend the full length of the forearm, and is fitted somewhat loosely at the upper, or proximal, end to permit the wrist to rotate. A simple figure-eight harness and Bowden cable are used to operate the terminal device (<b>Fig. 47</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Typical methods of fitting below-elbow amputees with medium to long stumps. <i>Top, </i>the figure-eight, ring-type harness is most generally used. Where possible, flexible leather hinges and open biceps cuff or pad are used. When more stability between socket and stump is required, rigid (metal) hinges and closed cuffs can be used <i>(A </i>and <i>B). C </i>shows fabric straps that are used for suspension in lieu of a leather billet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Long Below-Elbow Case</i></p> <p>The prosthesis for the long below-elbow case is essentially the same as that for the wrist-disarticulation patient except that the quick-disconnect wrist unit can be used when desired.</p> <p><i>Prostheses for the Short Below-Elbow Case</i></p> <p>The socket for the short below-elbow stump, where there is no residual rotation of the forearm, is usually fitted snugly to the entire stump, and rigid hinges connecting the socket to a cuff about the upper arm are often used to provide additional stability. Either the figure-eight harness or the chest-strap harness may be used, the latter being preferred when heavy-duty work is required, since it tends to spread the loads involved in lifting over a broader area than is the case with the figure-eight design.</p> <p>A wrist-flexion unit, which permits the terminal device to be tilted in toward the body for more effective use, can be provided in the short below-elbow prosthesis, but it is seldom prescribed for unilateral cases.</p> <p><i>Prostheses for the Very Short Below-Elbow Case</i></p> <p>Often the very short below-elbow amputee cannot control the prosthesis of the short below-elbow type through the full range of motion, either because of a muscle contracture or because the stump is too short to provide the necessary leverage.</p> <p>When a contracture is present that limits the range of motion of the stump, a "split-socket" and "step-up" hinge may be used. With this arrangement of levers and gears, movement of the stump through one degree causes the prosthetic forearm to move through two degrees; thus, a stump that has only about half the normal range of motion can drive the forearm through the desired 135 degrees. However, when the step-up hinge is used, twice the normal force is required. When the stump is incapable of supplying the force required, it can be assisted by employing the "dual-control" harness, wherein force in the terminal-device control cable is diverted to help lift the forearm. When the elbow stump is very short or has a very limited range of motion, an elbow lock operated by stump motion is employed to obtain elbow function.</p> <p>Recently, a number of prosthetists have reported success in fitting very short be-low-elbow cases with an arm which is bent to give a certain amount of preflex-ion. This type of fitting, which was developed in Münster, West Germany, eliminates the necessity for using the rather clumsy step-up hinges and split socket, thus providing improved prosthetic control without a disadvantageous force feedback. Furthermore, the harness is not necessary for suspension of the prosthesis. The maximum forearm flexion may be limited to about 100 degrees, but this does not appear to be a significant disadvantage to unilateral amputees (<b>Fig. 48</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Comparison of split socket and Miinster-type fitting of short below-elbow case. <i>A, </i>split socket and step-up hinge provides 140 deg of forearm flexion; <i>B, </i>Münster-type fitting permits less forearm flexion but enables the amputee to carry considerably greater weight with flexed prosthesis unsupported by harness. <i>Courtesy New York University College of Engineering Prosthetic and Orthotic Research.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Elbow-Disarticulation Case</i></p> <p>Because of the length of the elbow-disarticulation stump, the elbow-locking mechanism is installed on the outside of the socket. Otherwise the prosthesis and harnessing methods (<b>Fig. 49</b>) are identical to those applied to the above-elbow case.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Typical prosthesis for the elbow-disarticulation case. The chest-strap harness with shoulder saddle is shown here, but the above-elbow figure-eight is also used. See Figure 50. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Above-Elbow Case</i></p> <p>For the above-elbow prosthesis to operate efficiently, it is necessary that a lock be provided in the elbow joint, and it is, of course, preferable that the lock is engaged and disengaged without resorting to the use of the other hand or pressing the locking actuator against an external object such as a table or chair.</p> <p>Several elbow units that can be locked and unlocked alternately by the same motion are available. This action is usually accomplished by the relative motion between the prosthesis and the body when the shoulder is depressed slightly and the arm is extended somewhat. The motion required is so slight that with practice the amputee can accomplish the action without being noticed. These elbow units contain a turntable above the elbow axis that permits the forearm to be positioned with respect to the humerus, supplementing the normal rotation remaining in the upper arm and thus allowing the prosthesis to be used more easily close to the midline of the body.</p> <p>The elbow units described above are available with an adjustable coil spring to assist in flexing the elbow when this is desired. The flexion-assist device may be added or removed without affecting the other operating characteristics.</p> <p>The socket of the above-elbow prosthesis covers the entire surface of the stump. The most popular harness used is the figure-eight dual-control design, wherein the terminal-device control cable is also attached to a lever on the forearm so that when the elbow is unlocked, tension in the control cable produces elbow flexion, and when the elbow is locked, the control force is diverted to the terminal device (<b>Fig. 50</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Typical prosthesis for the above-elbow case. The figure-eight harness is shown here but the chest-strap harness with shoulder saddle may also be used. See Figure 49. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The chest-strap harness may also be used in the dual-control configuration.</p> <p><i>Prostheses for the Shoulder-Disarticulation and Forequarter Cases</i></p> <p>Because of the loss of the upper-arm motion as a source of energy for control and operation of the prosthesis, restoration of the most vital functions in the shoul-der-disarticulation case presents a formidable problem; for many years, a prosthesis was provided for this type of amputation only for the sake of appearance. In recent years, however, it has been possible to make available prostheses which provide a limited amount of function (<b>Fig. 51</b>). To date it has not been possible to devise a shoulder joint that can be activated from a harness, but a number of manually operated joints are available. Various harness designs have been employed, but because of the wide variation in the individual cases and the marginal amount of energy available, no standard pattern has developed, each design being made to take full advantage of the remaining potential of the particular patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Typical prosthesis for the shoulder-dis-articulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Bilateral Upper-Extremity Amputees</i></p> <p>Except for the bilateral, shoulder-dis-articulation case, fitting the bilateral case offers few problems not encountered with the unilateral case. The prostheses provided are generally the same as those prescribed for corresponding levels in unilateral cases. Artificial hands are rarely used by bilateral amputees, because hooks afford so much more function. Many bilateral cases find that the wrist-flexion unit, at least on one side, is of value. The harness for each prosthesis may be separated, but it is the general practice to combine the two (<b>Fig. 52</b>). In addition to being neater, this arrangement makes the harness easier for the patient to don unassisted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. Harness for the bilateral below-elbow/ above-elbow case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some prosthetists have claimed success in fitting bilateral shoulder-disarticulation cases with two prostheses. Because of the lack of sufficient sources of energy for control, most cases of this type are provided with a single, functional prosthesis and with a plastic cap over the opposite shoulder, which provides an anchor for the harness and also fills this area to present a better appearance (<b>Fig. 53</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 53. Special harness arrangement for the bilateral shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Learning to Use the Prosthesis</h3> <p>To derive maximum benefit from his prosthesis, the amputee must understand how it functions and learn the best means of controlling it. A patient may be of the opinion that he is getting along very well when, in reality, he could do much better.</p> <p>Use of the prosthesis can best be learned under the supervision of an instructor who has had special training.</p> <p>All amputees using an artificial limb for the first time will need some instruction. In some instances, when a prosthesis is replaced with one of a different design, special instruction will be required. The time required for training depends upon the complexity of the device and the physical condition and degree of coordination of the patient. The time required will vary from a few hours to several weeks. In many instances, amputees themselves have become excellent trainers, but more often such training is given by physical or occupational therapists. Usually, physical therapists instruct lower-extremity patients, and occupational therapists teach upper-extremity cases.</p> <p>During the period of instruction, the trainer is careful to observe any effects the use of the prosthesis has on the patient, especially at points where the prosthesis is in contact with the body. Any changes are reported immediately to the physician in charge.</p> <h4>Lower-Extremity Cases</h4> <p>One of the major goals in training the leg amputee<a></a> is to enable him to walk as gracefully as possible. Training is begun as soon as the amputee is provided with a comfortable prosthesis. In the case of immediate postsurgical fitting,<a></a> training is often begun on the day following surgery and an adjustable leg is used. There is a growing tendency to train lower-extremity amputees on legs with adjustable features, even though they have not been fitted immediately after surgery. Some other goals of training are to teach the patient proper methods of donning the prosthesis, caring for the stump, arising after a fall, and using canes and crutches when necessary. The type of training will, of course, depend upon the level of amputation.</p> <p>A patient with a Syme amputation needs a minimum of training. The average below-knee case will require somewhat more, though usually not a great deal unless other medical problems are present. The training required is usually considerable for patients who have lost the knee joint.</p> <p>The ability to balance oneself is the first prerequisite in learning to walk, and so it is balance that is taught first to the above-knee amputee. Two parallel railings are used to give the patient confidence and to reduce the possibility of falling (<b>Fig. 54</b>). Balancing on both legs is practiced first, then on each leg. Walking in a straight line between the parallel bars is repeated until the patient no longer requires use of the hands for support. Walking in a straight line is practiced until the gait is even and smooth.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 54. Above-knee patient being trained to walk by a physical therapist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a rhythmic gait has been accomplished, more difficult tasks are learned, such as pivoting, turning, negotiating stairs and ramps, and sitting on and arising from the floor.</p> <p>Most unilateral above-knee patients can use their prostheses quite well without the necessity for a cane. However, in the case of short, weak stumps, it may be advisable to employ a cane for additional support and stability. If a cane is necessary, it should be selected to meet the needs of the patient, and it must be used properly if ungainly walking patterns are to be avoided. Canes with curved handles and made from a single piece of wood should be used. The shaft should not show any signs of buckling under the full load of the body weight, and should be just long enough so that the elbow is bent slightly when the bottom of the cane rests near the foot. The cane is used on the side opposite the amputation to help maintain balance, but it is not used to the extent that body weight is centered between the good leg and the cane (<b>Fig. 55</b>). Continued use of the cane in this manner usually results in a limp that is difficult to overcome. It has been found that, for biomechanical reasons, it is helpful for the amputee to carry a briefcase or purse on the side of the amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 55. Above-knee patient being taught correct use of cane. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Training The Hip-Disarticulation Cases</i></p> <p>The training of hip-disarticulation cases follows much the same pattern as that of above-knee cases. With the advent of the Canadian-type prosthesis, the training procedure has been considerably simplified. Some special precautions must be taken to avoid stumbling while ascending stairs.</p> <p><i>Special Considerations for Bilateral-Leg Cases</i></p> <p>As would be expected, bilateral-leg cases pose special problems in addition to those of the unilateral cases, and therefore a good deal of time will usually be required in training. Patients with two good below-knee stumps will seldom require canes. Some bilateral above-knee amputees can get along without canes, but as a general rule, at least one cane is required.</p> <h4>Upper-Extremity Cases</h4> <p>The first objective in the training program for upper-extremity amputees is to ensure that the patient can perform the activities encountered in daily living, such as eating, grooming, and toilet care. When this goal has been attained, attention is devoted to any special training that might be required in vocational pursuits (<b>Fig. 56</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 56. Upper-extremity amputees performing vocational tasks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before the prosthesis is put to useful purposes, the patient is shown how the various mechanisms are controlled, and is made to practice these motions until they can be performed in a graceful manner and without undue exertion. In general, the arm amputee soon becomes so adept in these procedures that they are carried out without conscious thought. During this period, the functioning of the prosthesis, especially of the harness and control cables, is watched carefully by the instructor and constantly rechecked to ensure maximum performance.</p> <p>Only when the patient has mastered use of the various controls is practice in handling objects and performing activities of daily living undertaken.</p> <h3>Care of the Stump</h3> <p>Even under the most ideal circumstances, the amputation stump, when called upon to operate a prosthesis, is subjected to certain abnormal conditions which, if not compensated for, may lead to physical disorders which make the use of a prosthesis impossible.</p> <p>Lack of ventilation as a result of encasing the stump in a socket with impervious walls causes an accumulation of perspiration and other secretions of glands found in the skin. In addition to the solid matter in the secretions, bacteria will accumulate in the course of a day. Both the solid matter and bacteria can lead to infection, and the solid matter, though it may appear to be insignificant, may result in abrasions and the formation of cysts. For these reasons, cleanliness of the stump and anything that comes in contact with it for any length of time is of the utmost importance, even when sockets of the newer porous plastic laminate are used.</p> <p>Therefore, the stump should be washed thoroughly each day, preferably just before retiring. A soap or detergent containing hexachlorophene, a bacteriostatic agent, is recommended, but strong disinfectants are to be avoided. To be fully effective, the bacteriostatic agent must be used daily. Some six or seven daily applications are necessary before full effectiveness is obtained, and any cessation of this routine lowers the agent's ability to combat the bacteria. A physician who is himself an amputee has suggested that, after an amputee takes a bath, the stump should be dried first, in order to minimize the risk of introducing infection to it by the towel.</p> <p>When the prosthesis is used without a stump sock, the stump should be thoroughly dry, as moisture may cause swelling that will result in rubbing and irritation. For such cases, it is especially desirable for the stump to be cleansed in the evening.</p> <p>The stump sock should receive the same meticulous care as the stump. The socks should be changed daily and washed as soon as they are taken off. In this way, the perspiration salts and other residue are easier to remove. A mild soap and warm water are used to keep shrinkage to a minimum. Woolite (a cold-water soap) and cold water in recent trials have given excellent results. A rubber ball inserted in the "toe" during the drying process ensures retention of shape.</p> <p>Elastic bandages should be washed daily in the same manner as stump socks, but should not be hung up to dry; rather, they should be laid out on a flat surface away from excessive heat and out of the direct rays of the sun. Hanging places unnecessary stresses on the elastic threads, and heat and sunlight accelerate deterioration.</p> <p>It is of the utmost importance that any skin disorder of the stump—no matter how slight—receive prompt attention, because such disorders can rapidly worsen and become disabling. The amputee should see a physician for treatment. He should also see his prosthetist; it may be that adjustment of the prosthesis will eliminate the cause of the disorder. In no case should iodine or any other strong disinfectant be used on the skin of the stump.</p> <p>Sometimes the skin of the stump is rubbed raw by socket friction. When this happens, the skin should be gently washed with a mild toilet soap. After the stump has been rinsed and dried, bacitracin ointment or some other antibacterial agent should be applied, and the area covered with sterile gauze. The prosthesis should be completely dry before it is put on. If such abrasions occur frequently, the prosthetist should be informed. If there is the slightest sign of infection, the amputee should see a physician.</p> <p>Small painless blisters should not be opened; they should be washed gently with a mild soap and left alone. Large, painful blisters should be treated by a physician.</p> <h4>Bandaging the Stump</h4> <p>The stump is usually kept wrapped in an elastic bandage from the time healing permits until the time the prosthesis is delivered. Also, bandaging is recommended when for some reason it is impracticable or impossible for the patient to wear his limb routinely. It is therefore highly desirable for the amputee, or at least one member of his family, to be able to apply the bandages. Many amputees can wrap their stumps unaided and, indeed, prefer to do so. Others prefer, and in some instances require, the help of another person.</p> <p>Recommended methods for applying elastic bandages for below-knee, above-knee, below-elbow, and above-elbow patients are shown in <b>Fig. 57</b>, <b>Fig. 58</b>, and <b>Fig. 59</b>. These illustrations first appeared in a booklet entitled <i>Industrial Amputee Rehabilitation, </i>prepared by Dr. C. O. Bechtol under the sponsorship of Liberty Mutual Insurance Company of Boston.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 57. Recommended method of applying elastic bandage to the below-knee stump. The bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 58. Recommended method of applying elastic bandage to the above-knee stump. The stump is kept in a relaxed position, and the bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 59. Elastic bandages applied properly to upper-extremity stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Care of the Prosthesis</h3> <p>In addition to the care required in keeping the inside of the socket clean, which has been stressed, best results can be obtained only if the prosthesis is maintained in the best operating condition. Like all mechanical devices, artificial limbs can be expected to receive wear and be discarded for a new device, but the length of useful life can be extended materially if reasonable care is taken in its use. An example often quoted is that of two identical automobiles. The car given the maintenance recommended by the manufacturer and operated with care will outlast many times the vehicle given spotty maintenance and operated with disregard for the heavy stresses imposed. So it is with artificial limbs. Some amputees require a new prosthesis every few years or even more often, while others who follow the manufacturer's instructions, apply preventive maintenance practices, and have minor problems corrected without delay have received satisfactory service from their limbs for periods as long as twenty years.</p> <p>Manufacturers' instructions vary with the design of the device. They consist mainly of lubrication practices, and should be followed closely. Too much lubricant can sometimes produce conditions as troublesome as excessive wear. Looseness of joints and fastenings should be corrected as soon as it is detected, for the wear rate increases rapidly under such a condition. Any cracks that appear in supporting structures should be reinforced immediately, in order to avoid complete failure and the necessity for replacement. The foot should be examined weekly for signs of excessive wear.</p> <p>A point often overlooked by leg amputees, but nevertheless one of the factors affecting optimum use of the artificial limb, is the condition of the shoe. Badly worn or improper shoes can alter alignment and therefore have adverse effects on the stability and gait of the wearer. This is a matter that requires especially close attention in the case of child amputees.</p> <p>Hooks and artificial hands should be treated with the same care that the normal hand is given. Because the sensation of feeling is absent in the terminal device, the upper-extremity amputee is all too prone to use hooks to pry and hammer and to handle hot objects that are deleterious to the hook materials. Hands with cosmetic gloves should be washed daily, and of course hot objects and staining materials should be avoided.</p> <h3>Special Considerations in Treatment of Child Amputees<a></a></h3> <p>Only a few years ago, it was seldom that a child amputee was fitted with a prosthesis before school age, and often not until much later. In recent years, experience has shown that fitting at a much earlier age produces more effective results.</p> <p>If there are no complicating factors, children with arm amputations usually should be provided with a passive type of prosthesis soon after they are able to sit alone, which is generally at about six months of age. Certain gross two-handed activities are thus made possible, crawling is facilitated, and the child becomes accustomed to using and wearing the prosthesis and moves easily into using a body-operated prosthesis as his coordination develops soon after his second birthday.</p> <p>Lower-extremity child amputees should be fitted with prostheses as soon as they show signs of wanting to stand. The development of muscular coordination of child amputees is the same as for non-handicapped children, and therefore this phase may take place as early as eight months or as late as twenty or more months.</p> <p>Children, especially when fitted at an early age, almost always adapt readily to prostheses. As the child grows, the artificial limb seems to become a part of him in a manner seldom seen in adults (<b>Fig. 60</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 60. Children with upper-extremity amputations performing two-handed activities. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Except for the very young, children's prostheses follow much the same design as those for the adult group. Special devices and techniques have been developed for initial fitting of infants and problem cases.</p> <p>Regardless of where the child amputee resides, or the extent of his parents' financial resources, he need not go without the treatment and prostheses required to make full use of his potentials. To ensure that such services are available, the Children's Bureau of the Department of Health, Education, and Welfare has assisted a number of states in establishing well-organized child-amputee clinics, and the facilities of those states are available to residents of states where such specialized services are not to be had. There is an agency in each state that can advise the parents of the proper course of action.</p> <p>Most children can be treated on an out-patient basis, but for the more severely handicapped, many of the clinics have facilities for in-patient treatment. The clinic team for children is often augmented by a pediatrician and a social worker, and sometimes by a psychologist.</p> <p>Training very young children is one of the most difficult problems of the clinic team. Although the learning ability of young children may be rapid, their attention span is of such short duration that extreme patience is required. Regardless of the ability of the therapist, successful results cannot be achieved without complete cooperation of the parents. The mental attitude of the parents is reflected in the child, and all too often children have rejected prostheses because the parents, consciously or subconsciously, could not accept the fact that a prosthesis was needed. Parents of children born with a missing or deformed limb often experience a sense of guilt, a feeling that only adds to an already difficult problem. The guilt feeling is unwarranted, inasmuch as the knowledge of the causes of congenital defects—and appropriate preventive measures—is very limited. The recent discovery of the effects of thalidomide suggests that other causes may be found.</p> <p>As a rule, lower-extremity amputees present fewer problems than the upper-extremity cases. It is natural for the child to walk, and almost invariably the lower-extremity patient adapts rather quickly. However, parents should keep close observation of the walking habits of the child, the condition of his stump, and the state of repair of his prosthesis, and above all they should present the child at the clinic at the recommended times. A gradual change in walking habit may indicate that the child has outgrown the prosthesis or that excessive wear of the prosthesis has taken place. Any unusual appearance of the stump should be reported to the physician immediately so that remedial steps may be taken, thereby avoiding more complicated medical problems at a later date. Children give a prosthesis more wear and tear than do adults, and it is important that the prosthesis be examined carefully at regular intervals and needed repairs made as soon as possible—not only to ensure the safety of the child but to avoid the necessity for major repairs at a later date.</p> <p>Many upper-extremity child amputees adapt readily to artificial arms (some even want to sleep with the arm in place), but in many cases the child will need a great deal of encouragement before he will accept the device and make use of it. At first, the unilateral amputee may feel that the prosthesis is a deterrent rather than an aid, but with the proper encouragement, this feeling is reversed.</p> <p>Parents can help by continuing the training given in the clinics. From the beginning, the artificial arm should be worn as much as possible. Young children should be given toys that require two hands for use, and older children should be given household chores that require two-handed activities. In the latter case, not only does the child learn to appreciate the usefulness of the prosthesis, but he also gains a feeling of being a useful member of the family and thus a better mental attitude is created.</p> <p>The child amputee should not be sheltered from the outside world, but should be encouraged to associate with other children and, to the extent that he can, to take part in their activities. Of course there are certain limitations, but the number of activities that can be performed with presently available prostheses is amazing. It goes almost without saying that the child should receive no more special attention than is necessary and should be made to perform the activities of daily living of which he is capable.</p> <p>It has been shown that it is preferable for the child amputee to attend a regular school, rather than one for the handicapped. Most child amputees can and do take their place in society, and the transition from school to work is much easier if they are not shown unnecessary special consideration. Nonhandicapped children soon accept the amputee and make little comment after the initial reaction.</p> <p>Here again, the arm amputee is apt to be faced with the most problems. Some public school officials have hesitated to admit arm amputees wearing hooks, for fear the child may use them as weapons. This attitude is unrealistic. If such incidents have occurred, they are rare indeed. However, arm prostheses should be removed when the child is engaged in body-contact sports such as football.</p> <p>Cleanliness of the stump, prosthesis, and stump sock is just as important for children as for adults. The same procedures as those outlined on pages 43-46 are recommended.</p> <h3>Special Considerations in the Treatment of Elderly Patients</h3> <p>Persons who have had amputations during youth or middle age seldom encounter additional problems in wearing their prostheses as they become older. However, for those patients who have an amputation in later life, many unusual problems are apt to be present. Most amputations in elderly patients are necessary because of circulatory problems, almost always affecting the lower extremity. For many years, the wisdom of fitting such patients with prostheses was debatable, the thought being that the remaining leg, which in most cases was subject to the same circulatory problems as the one removed, would be overtaxed and thus the need for its removal would be hastened. Energy studies in recent years have shown that crutch-walking is more taxing than use of an artificial limb. Experience with rather large numbers of elderly leg amputees has shown that failure of the remaining leg has not been accelerated by use of a prosthesis, and stumps that have been fitted properly have not been troublesome. As a result, more and more elderly patients are benefiting by the use of artificial limbs. A rule of thumb that is used in some clinics to decide whether or not to fit the elderly patient is that, if he can master crutch-walking, he should be fitted. This measure should be used with discretion because, in some instances, patients who could not meet the crutch-walking requirement have become successful wearers of prostheses.</p> <p>The patient should be fitted as soon as possible, to avoid such complications as the development of contractures. The availability of adjustable pylon-type legs and the use of plaster or plastic sockets now makes early fitting practical, and this approach is being adopted by more and more centers. Many geriatric patients have benefited from the immediate postsurgical fitting procedures.</p> <p>Most clinic teams feel that, if the patient can use the prosthesis to make him somewhat independent around the house, the effort is fully warranted.</p> <p>Artificial legs for the older patients, as a rule, should be as light as possible. Except for the most active patients, only a small amount of friction is needed at the knee for control of the shank during the swing phase of walking because the gait is apt to be slow. Suction sockets have rarely been used, because of the effort required in donning them. A quadrilateral-shaped socket is often used with one stump sock and a pelvic belt. Silesian bandages have been used successfully, allowing more freedom of motion and increased comfort.</p> <p>A new approach introduced recently by the University of Miami offers the geriatric amputee the possibility of using a suction socket by reducing the effort required in donning.<a></a> The flexible plastic inner liner, which contains a suction valve, is put on over the stump first, and then the stump and inner liner are inserted into the outer socket of rigid plastic and latched in place.</p> <p>For the elderly below-knee cases, the patellar-tendon-bearing prosthesis is being used quite successfully.</p> <h3>Cineplasty<a></a></h3> <p>In 1896, the Italian surgeon Vanghetti conceived the idea of connecting the control mechanism of a prosthesis directly to a muscle. Several ideas involving the formation of a club-like end or a loop of tendon in the end of a stump muscle were tried out in Italy. Just prior to World War I, the German surgeon Sauerbruch devised a method of producing a skin-lined tunnel through the belly of the muscle. A pin through the tunnel was attached to a control cable, and thus energy for operation of the prosthesis was transferred directly from a muscle group to the control mechanism. With refinements, the Sauerbruch method is available for use today, but it must be used cautiously.</p> <p>Although tunnels have been tried in many muscle groups, the below-elbow amputee is the only type who can be said to benefit truly from the cineplasty procedure. A tunnel properly constructed through the biceps can supply power for operation of a hand or hook, and there need be no harnessing above the level of the tunnel. Thus, the patient is not restricted by a harness, and the terminal device can be operated with the stump in any position. Training the tunneled muscle and care of the tunnel require a great deal of work by the patient; therefore if the cineplasty procedure is to be successful, the patient must be highly motivated.</p> <p>Some female below-elbow amputees have been highly pleased with results from a biceps tunnel, but as a rule, cineplasty does not appeal to women.</p> <p>Cineplasty is not indicated for children. Sufficient energy is not available for proper operation of the prosthesis, and the effects of growth on the tunnel are not known.</p> <p>Tunnels have been tried in the forearm muscles, but the size of these muscles is such that the energy requirements for prosthesis operation are rarely met. While tunnels in the pectoral muscle are capable of developing great power, in the light of present knowledge the disadvantages tend to outweigh the advantages. It is extremely difficult to harness effectively the energy generated, and very little, if any, of the harness can be eliminated. It is true that an additional source of control can be created, but with the devices presently available, little use can be made of this feature.</p> <p>No application for cineplasty has been found in lower-extremity amputation cases.</p> <p>Still another type of cineplasty procedure is the Krukenberg operation, whereby the two bones in the forearm stump are separated and lined with skin to produce a lobster-like claw. The result, though unattractive in appearance, permits the patient to grasp and handle objects without the necessity of a prosthesis. Because sensation is present, the Krukenberg procedure has been found to be most useful for blind bilateral amputees. Although prostheses can be used with Krukenberg stumps when appearance is a factor, the operation has found little favor in the United States.</p> <h3>U.S. Agencies That Assist Amputees</h3> <p>For several centuries at least, governments have traditionally cared for military personnel who received amputations in the course of their duties. But only in recent years, except in isolated cases, has the amputee in civilian life had much assistance in making a comeback. Today, there are available services to meet the needs of every category of amputee. Aside from the humanitarian aspects of such programs, it has been found to be good business to return the amputee to productive employment and, in the case of some of the more debilitated, to provide them with devices and training to take care of themselves.</p> <p>The armed services provide limbs for military personnel who receive amputations while on active duty, and many of these cases are returned to active duty. After the patient has been discharged from military service, the Veterans Administration assumes responsibility for his medical care and prosthesis replacement for the remainder of his life. The U.S. Public Health Service, through its marine hospitals, cares for the prosthetics needs of members of the U.S. Maritime Service.</p> <p>Each state provides some sort of service for child amputees. If sufficient facilities are not available within a state, provisions can be made for treatment in one of the regional centers set up in a number of states with the help and encouragement of the Children's Bureau of the Department of Health, Education, and Welfare. With assistance from the Social and Rehabilitation Service of the Department of Health, Education, and Welfare, every state operates a vocational rehabilitation program designed to help the amputee return to gainful employment. Some of these programs render assistance to housewives as well.</p> <p>The Medicaid and Medicare programs sponsored by the federal government make it possible for the elderly and indigent to be supplied with artificial limbs.</p> <p>Private rehabilitation centers, almost universally nonprofit and sponsored largely by voluntary organizations, greatly augment the state and federal programs.</p> <p>Information concerning rehabilitation centers serving a particular area may be obtained from the International Association of Rehabilitation Facilities, 7979 Old Georgetown Rd., Bethesda, Md., 20014.</p> <!--References Removed--> <p><b>References:</b></p> <ol> <li>Artif. Limbs, 4:2, Autumn 1957.</li> <li>Artif. Limbs, 6:1, April 1961.</li> <li>Artif. Limbs, 6:2, June 1962.</li> <li>Bechtol, Charles 0., and George T. Aitken, <i>Cineplasty, </i>in <i>Orthopaedic appliances atlas, </i>Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>5. Blakeslee, Berton, Ed., <i>The limb-deficient child,</i> University of California Press, Berkeley and Los Angeles, 1963.</li> <li>6. 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>Committee on Artificial Limbs, National Research Council, Washington, D.C., <i>Terminal research reports on artificial limbs, </i>covering the period from 1 April 1945 through 30 June 1947.</li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs, </i>in Klopsteg, Wilson, <i>et al., Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Foort, J., <i>Adjustable-brim fitting of the total contact above-knee socket, </i>No. 50, Biomechanics Laboratory, University of California, San Francisco and Berkeley, March 1963,</li> <li>Foort, James, <i>The patellar-tendon-bearing prosthesis for below-knee amputees, a review of technique and criteria, </i>Artif. Limbs, 9:1:4-13, Spring 1965.</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>Klopsteg, P. E., <i>The functions and activities of the Committee on Artificial Limbs of the National Research Council, </i>J. Bone Joint Surg., 29:538-540, 1947.</li> <li>National Academy of Sciences-National Research Council, <i>The control of external power in upper-extremity rehabilitation, </i>Publication 1352, 1966.</li> <li>Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, <i>A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, </i>Artif. Limbs, 10:1:52 55, Spring 1966.</li> <li>Sinclair, William F., <i>A suction socket for the geriatric above-knee amputee, </i>Artif. Limbs, 13:1:69-71, Spring 1969.</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>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasty, </i>in Klopsteg, Wilson, <i>et al., Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Thomas, Atha, and Chester C. Haddan, <i>Amputation prosthesis, </i>Lippincott, Philadelphia, 1945.</li> <li>Vultee, Frederick E., <i>Physical treatment and training of amputees, </i>in <i>Orthopaedic appliances atlas, </i>Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Weiss, Marian, <i>Neurological implications of fitting artificial limbs immediately after amputation surgery, </i>in Report of Fifth Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences- National Research Council, February 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bechtol, Charles 0., and George T. Aitken, Cineplasty, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Sinclair, William F., A suction socket for the geriatric above-knee amputee, Artif. Limbs, 13:1:69-71, Spring 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">5. Blakeslee, Berton, Ed., The limb-deficient child, University of California Press, Berkeley and Los Angeles, 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">6. 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></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Vultee, Frederick E., Physical treatment and training of amputees, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">National Academy of Sciences-National Research Council, The control of external power in upper-extremity rehabilitation, Publication 1352, 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>17.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, in Klopsteg, Wilson, et al., Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total contact above-knee socket, No. 50, Biomechanics Laboratory, University of California, San Francisco and Berkeley, March 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>Footnote</b></td></tr><tr><td class="clsTextSmall">The Type S replaces Model B. It provides the same function but is shorter and lighter.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Artif. Limbs, 6:2, June 1962.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Foort, James, The patellar-tendon-bearing prosthesis for below-knee amputees, a review of technique and criteria, Artif. Limbs, 9:1:4-13, 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>14.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52 55, 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>2.</b> </td><td class="clsTextSmall">Artif. Limbs, 6:1, April 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">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>11.</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>8.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, in Klopsteg, Wilson, et al., Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">6. 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></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Weiss, Marian, Neurological implications of fitting artificial limbs immediately after amputation surgery, in Report of Fifth Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences- National Research Council, February 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>1.</b> </td><td class="clsTextSmall">Artif. Limbs, 4:2, Autumn 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>2.</b> </td><td class="clsTextSmall">Artif. Limbs, 6:1, April 1961.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52 55, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">1440 N St., N.W., Washington. D.C. 20005.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">1440 N St., N.W., Washington. D.C. 20005.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Klopsteg, P. E., The functions and activities of the Committee on Artificial Limbs of the National Research Council, J. Bone Joint Surg., 29:538-540, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Washington, D.C., Terminal research reports on artificial limbs, covering the period from 1 April 1945 through 30 June 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Thomas, Atha, and Chester C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennet Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-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/1970_01_001/1970_01_001-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1970_01_001/1970_01_001-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource 1970 Limb Prosthetics Creator An entity primarily responsible for making the resource A. Bennet Wilson, Jr. * https://staging.drfop.org/files/original/e52cf9eac794bb9024231c39d7c2f051.pdf 413a609559c66e9af1293680829afbfb https://staging.drfop.org/files/original/166a665a9fc23bfb942fb45a0d328add.jpg c4cee2dc30891c4dbd453a9ff9e9011d https://staging.drfop.org/files/original/dbcd7e754b0a7ca302d6404ea3eb5802.jpg bdcfd7fbb9809d59b822c0d8ec33038f https://staging.drfop.org/files/original/f9037b7cea4f85149601c702a1aa5701.jpg d55cef0a8d268de336576c39f462689a https://staging.drfop.org/files/original/de19e93c24849987f2b78a59293b0356.jpg 1f2ce2deb67ef8d12a9c28e3c40958b6 https://staging.drfop.org/files/original/3f2cc93e4e236d72d78c81efe84fc44a.jpg d7b29c791929c0956a546a4a68f9d629 https://staging.drfop.org/files/original/af1b7b176b3438b5f1ae452d9e41bdf6.jpg dd70ef09a9e9d539df70116c0d4bd9ea DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_031.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 31 - 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/1969_02_031.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_02_031.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Method for Location of Prosthetic and Orthotic Knee Joints</h2> <h5>Henry F. Gardner <a style="text-decoration:none;">*</a><br />Frank W. Clippinger, JR, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>When it is necessary to use a mechanical knee joint, whether it be in a below-knee prosthesis or a long-leg brace, ideally there should be no relative motion between the patient's limb and the appliance during its use. Because the human knee is not a single-axis joint, analogues of the human knee employing more than one axis of rotation have been developed but none have proven practical, owing largely to bulki-ness, but to some degree to cost. At this time, therefore, we are faced with the problem of determining a method of placing the center of rotation of a single-axis mechanical knee joint with respect to the knee so that the least amount of relative motion will occur between the patient and the appliance.</p> <p>This article describes a method of determining the optimum location of single-axis knee joints, based on data accumulated recently from X-rays and from cadaver dissection.</p> <h3>Functional Characteristics of the Knee</h3> <p>Both the medial and lateral condyles of the femur appear as helical curves, the radii of which become progressively smaller from anterior to posterior. Only a small portion of the surface of the femur is in contact with the tibia at any given moment. Weight, however, is distributed over a larger area by the menisci, which provide smooth contact at any position.</p> <p>The knee structure is stabilized by cruciate and collateral ligaments, which control the range of motion of the joint and the relative positions of the articulating condylar surfaces. Because the medial and lateral condyles of the femur are not the same size, a transverse rotation of the femur takes place as the knee approaches full extension, causing the collateral and cruciate ligaments to tighten, and binding the femur and tibia tightly together in the weight-bearing position. Thus, as the knee begins to flex from the extended position and the femur rolls on the head of the tibia, the medial condyle rotates approximately 15 deg while the lateral condyle rotates approximately 20 deg. Then a slipping or gliding motion begins. Although the total flexion-extension range of the knee is approximately 160 deg, the first 110 deg is the most useful segment for prosthetic application, since this arc includes the full range required for walking (70 deg) and for sitting (100 deg).</p> <p>The numbered references if <b>Fig. 1</b> show the areas and the femoral condyle and the tibial plateau where contact is made successively as the knee is flexed or extended. Points "0" on the femur and tibia indicate the contact relationship between the bones when the knee is in 5 deg hyper-extension. During the first 20 deg of knee flexion, the condylar surfaces of the femur roll posteriorly on the tibia from point "0" to point "1." The greatest migration of the instantaneous center of rotation takes place during the first 15-20 deg of flexion. During the latter portion of the first 20 deg of knee flexion, a progressive sliding begins (between points "1" and "2"). Once the center of rotation reaches point "2," it remains relatively fixed during the remainder of the flexion range. This point is considered to be the optimum location for single-axis mechanical joints, especially if the knee is not permitted to extend fully. However, the usefulness of this point depends on one's ability to locate it by reference to external bony landmarks.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Points of contact between the femoral condyle and the tibial plateau during knee flexion and extension. The majority of translation occurs in the first 15 deg of knee flexion from a position of hyper-extension (point "0"). Successive flexion beyond this point concentrates the point of articulation between points 1 and 6. In prosthetics application, restriction of the knee to 10 deg before full extension confines the instantaneous center of femoral rotation between points 1 and 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>X-ray Studies of the Knee</h3> <p>X-ray studies of knee motion were undertaken in an attempt to find landmarks that had a constant relationship to the optimum center of rotation. Analysis of over 500 X-rays of the knee, such as those shown in <b>Fig. 2</b>, taken in various phases of extension and flexion revealed that the posterior femoral condyles, the posterior tibial condyles, and the posterior border of the head of the fibula are in approximately vertical alignment throughout the useful range of flexion-extension (lines 1, 2, and 3). Although the patella and the anterior fleshy-knee outline appear to recede posteriorly under the tensions exerted by the quadriceps, the posterior aspects of the femoral and tibial condyles and the posterior border of the fibula remain in the same relative posterior vertical alignment.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Typical transverse soft-tissue X-ray views of a normal knee showing the vertical relationship of the posterior borders of the major bony knee segments with the knee in the extended position and in 90 deg of flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because there is only very thin tissue covering the anterior border of the tibia and the tibial tubercle, they are easily palpable, and therefore should make better reference points than the poples.</p> <h3>Analysis Of The Knee Joint By Diissection</h3> <p>The knee-joint measurements obtained from 21 adult cadavers are given in <b>Table 1</b> and <b>Fig. 3</b>. An analysis of these measurements indicates that the difference between the anterior-posterior measurements of the stump and the actual bone dimensions is approximately 3/4 in. The medio-lateral dimensions vary approximately 3/4 in. between the external measurement and the actual epicondylar width.</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. Dimensional proportionality of widths at the femoral epicondyles related to the measurements between the tibial tubercle and the posterior border of the fibular head. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Location of Knee Center</h3> <p>Based upon the dimensional relationships shown in <b>Table 1</b> and <b>Fig. 3</b>, a method (<b>Fig. 4</b>) is advanced for locating the approximate functional knee center, using the figures in <b>Table 2</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Steps in locating functional knee 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 /> <p>A. With the patient standing and leg extended, measure the knee width at the condyles.</p> <p>B. With the patient standing, knee flexed and relaxed, locate the posterior border of the fibular head.</p> <p>C. With the patient standing and the knee vertically extended, mark a reference line up the knee and lower thigh.</p> <p>D. With the patient standing, leg unweighted and knee slightly flexed, locate the lateral tibial plateau by pressing into the knee with the thumb.</p> <p>E. Keeping the thumb in position to maintain the exact location as the patient extends the knee, mark the tibial plateau level horizontally.</p> <p>F. Using the applicable figure from <b>Table 2</b>, mark the measurement at the plateau level and extend a line vertically from that point toward the thigh.</p> <p>G. Using the same measurement as in step F, mark the axis reference on the anterior vertical line horizontally.</p> <p>H. To mark the knee center references on the medial side, have the patient sit with the medial aspects of the knees 1/2 in. apart, flexed at 90 deg. Place a straight edge across the patellas. Measure the distance from the straight edge to the lateral reference (step G) and mark the measurement on the medial side (I). Measure the distance of the lateral reference from the floor and mark the measurement on the medial side.</p> <h3>Acknowledgments</h3> <p>Edward Peizer, Ph.D., Chief, Bioengineering Research Service, Veterans Administration Prosthetics Center, assisted the authors in the design and analysis of the knee data. Gabriel Rosenkranz, M.D., Medical Consultant, gave guidance and encouragement.</p> <p><b>References:</b></p> <ol> <li>Berndt, Albert L., and Michael Harty, <i>Trans-chondral fractures (osteochondritis dissecans) of the talus</i>, J. Bone Joint Surg. (Amer.), 41A:5:988-1020, September 1959.</li> <li>Fleer, Bryson, and A. Bennett Wilson, Jr., <i>Construction of the patellar-tendon-bearing below-knee prosthesis</i>, Artif. Limbs. 6:2:25-73, June 1962.</li> <li>Klopsteg, Paul E., Philip D. Wilson, et al., <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Slocum, Donald B., <i>An atlas of amputations</i>, C. V. Mosby Company, St. Louis, 1949.</li> <li>Steindler, Arthur, <i>Kinesiology of the human body under normal and pathological conditions</i>, Charles C Thomas, Springfield, Ill., 1955.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Frank W. Clippinger, JR, M.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Orthopedic Surgery, Duke University Medical Center, Durham, N. C; Chief, Orthopedic and Prosthetic Appliance Clinic Team, Veterans Administration Hospital, Durham, N. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Henry F. Gardner </b></td></tr><tr><td class="clsTextSmall">Technical Assistant to the Director, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York, N. Y. 10001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_02_031/69autumn-06.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Method for Location of Prosthetic and Orthotic Knee Joints Creator An entity primarily responsible for making the resource Henry F. Gardner * Frank W. Clippinger, JR, M.D. * https://staging.drfop.org/files/original/e38c9d5be738df236a12e73aa11a7478.pdf 63744e2c2435c2b8aa6be87baa775d5b https://staging.drfop.org/files/original/56b68415d28babc42822184b94ea133f.jpg c1d1ab1268f7d844c5e4adb9f18570b1 https://staging.drfop.org/files/original/468c9f40dadb34370263e2258781e772.jpg 066f09438b83937ce9374ec73d152011 https://staging.drfop.org/files/original/f6b7d160b8278d855a477b3e2ea5c2cb.jpg f93f5d0c017f506a7192b341323b7b69 https://staging.drfop.org/files/original/bf1c26f96bb42345b531ec1166264189.jpg 9fd52199760b1396b088edc497712c32 https://staging.drfop.org/files/original/96c04506d1db97cbfd92fea9a88f48b2.jpg cd55c79d19ab9841de50523ab1e0419a https://staging.drfop.org/files/original/01a220eb783cc84d9ce7dad16b20bdf9.jpg bd31c2caa285cf8fd77da049a48cf137 https://staging.drfop.org/files/original/49d84cfc8f81b98ee25f6ed516a68603.jpg 348aae2a8ee726a6780827ea3caa5d52 https://staging.drfop.org/files/original/f04bf788ae7667d4ba0783d1f063dbeb.jpg fddd1ca9fcc7c38b79f776f973540e84 https://staging.drfop.org/files/original/d15fb9bfe71401e0c9e78eee923227ae.jpg de5d7ef764071728608ace84183afd4a https://staging.drfop.org/files/original/73879f8eef1bcebd75a39d4efb07bbe5.jpg 0c17a23c627102a5b74bfa203bc0affd https://staging.drfop.org/files/original/faf957c4e45f636ead6709d159155cbb.jpg 6a41e41b6042f89654f9aa13b55cff12 https://staging.drfop.org/files/original/e7adf4c708c388d05f78818bc47b73bc.jpg 0224ffefe34ab3baefa64141bd79eaef DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_037.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 37 - 48 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_01_037.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_037.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Mechanical Properties of Bone</h2> <h5>F. Gaynor Evans. Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Bone is the material with which the orthopaedic surgeon deals. Consequently, some knowledge of its mechanical properties is of importance for an understanding of the mechanism and management of fractures, as well as the design of prosthetic or orthotic appliances and protective gear, <i>e.g., </i>crash helmets. The behavior of a body under a load or force is a function not only of the form and structure of the body, but also of the mechanical properties of the material composing the body. For example, a steel beam will support a higher load before breaking and will behave differently under loading than will an oak beam of exactly the same shape and dimensions because of differences in the mechanical properties and structure of steel and of wood.</p> <p>The mechanical properties of bone are determined by the same methods used in studying similar properties of metals, woods, and other structural materials. These methods are based on certain fundamental principles of mechanics, a knowledge of which is essential for understanding the terminology employed.</p> <p><i>Mechanics, </i>the science dealing with the effect of forces upon the form or the motion of bodies, has two subdivisions- statics and dynamics. <i>Statics </i>is the study of bodies at rest or in equilibrium as a result of the forces acting upon them. <i>Dynamics </i>is the study of moving bodies. The mechanical properties of materials are usually studied under static conditions, <i>i.e., </i>under a slowly applied force or load, because the behavior of the test specimen can be more easily analyzed when the load is slowly applied.</p> <p>A <i>force </i>is anything which tends to change the state of a body with respect to its motion or the relative position of the molecules composing the body. More simply stated, a force is a push or a pull. There are three primary kinds of forces: (1) <i>compressive </i>or pushing together forces, (2) <i>tensile </i>or pulling apart forces, and (3) <i>shearing, </i>or forces which make one part of the body slide with respect to an adjacent part (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Types of pure force-stress and strain. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a force is applied to a body, it produces stress and strain within the body. <i>Stress </i>(<b>Fig. 1</b>) is the ratio between the force and the area upon which it acts, <i>i.e., </i>force per unit area. Stress is generally computed in terms of pounds per square inch (psi) or kilograms per square millimeter (ksm). Recently, some investigators of the strength characteristics of bone and other biological materials have been recording stress values in terms of kiloponds, dynes, or newtons per unit area, instead of pounds or kilograms because pounds and kilograms are units of mass as well as units of force. There will be no misunderstanding, however, if one specifies that stress values are in terms of <i>pounds force or kilograms force per unit area. </i>Stress is often used synono-mously with strength, but the term has little value unless the kind of strength, <i>i.e., </i>tensile, compressive, etc., is indicated. All strength values in the following discussion are in terms of <i>pounds force per square inch.</i></p> <p><i>Strain </i>is a change in the linear dimensions of a body as the result of the application of a force (<b>Fig. 1</b>). Since there are no standard units of measurement for strain, it can be recorded as percentage, inches/inch, centimeters/centimeter, etc. Strain can be seen if it is sufficiently large, <i>e.g., </i>as in stretching of a rubber band, but stress, which is only the ratio between force and area, is always invisible. The kind of stress and strain in a body is the same as the kind of force producing it.</p> <p>When stress is plotted against strain, a <i>stress-strain curve </i>is obtained (<b>Fig. 2</b>). From a tangent drawn to the straightest part of the stress-strain curve the <i>modulus of elasticity </i>of the material, or the ratio between unit stress and unit strain, can be computed. The modulus of elasticity is a measure of the <i>stiffness </i>of a material, not its elasticity as one might assume from the name. <i>Elasticity </i>is the property of a material that allows it to return to its original dimensions after the removal of a force or load. The <i>energy </i>the specimen absorbs to failure can be determined by measuring the area below the stress-strain curve.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Stress-strain curves for a dry- and a wet-tested specimen of compact bone from the posterior quadrant of the proximal third of the femoral shaft of a 70-year-old white man who died from pulmonary tuberculosis. The stress values are in pounds force per square inch <a></a>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The method of choice in determining the tensile or compressive strength of a material is to make a test specimen of a standardized size and shape and test it under a pure tensile or a pure compressive force. Under these conditions the cross-sectional area of the specimen is known, or can be easily computed, and only one force—tension or compression—is involved. Furthermore, the force is uniformly distributed over the cross-sectional area of the specimen. Consequently, the ultimate tensile or compressive strength of the material can be easily calculated from the formula <i>S </i>= <i>P/A, </i>in which S is stress, P is force or load, and A is the cross-sectional area of the specimen (<b>Fig. 1</b>).</p> <p>If the specimen is tested like a simple beam (i.e., supported at the ends and loaded midway between the supports) and bending occurs, tensile, compressive, and shearing forces are all involved. Tensile forces develop on the convex side of the bent specimen while compressive forces occur on the opposite (concave) side (<b>Fig. 3</b>). Both types of forces are maximum at the surface and decrease inwardly to zero at the neutral plane or axis. There are also shearing forces which, like the tensile and compressive forces, are not uniformly distributed over the cross section of the specimen. Under bending conditions, the force responsible for failure as well as its magnitude is more difficult to determine. The bending forces in the neck of the femur, as a result of the load applied to the head of the bone (<b>Fig. 4</b>), have been determined by Zarek <a></a> , an engineer who is currently working in biomechanics. For further discussion of forces in bending, see Harris' <i>Strength of Materials</i>. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Distribution of tensile and compressive forces in a body tested like a simple beam <a></a>. L = length or span between supports; N. A. = neutral axis or plane; P = force or load. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Stress distribution in the neck of the femur.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The speed at which a force is applied to a specimen influences the values obtained for some of its mechanical properties. Mc-Elhaney and Byars <a></a> found that the ultimate compressive strength and the modulus of elasticity of fresh and embalmed femoral cortical bone from cattle and man increased with higher strain rates of loading while the energy-absorbing capacity and the strain at failure decreased. The effect of high strain rates of loading on specimens of beef bone, cut and tested in different directions, has recently been investigated by Bird et al. <a></a></p> <p>Embalming also affects the mechanical properties of bone, at least those of compact bone. Thus, the mean ultimate tensile strength (in the long axis of the specimen and of the intact bone) is greater at the 0.01 significance level in embalmed wet- and dry-tested tibial specimens than in similarly tested unembalmed specimens <a></a>. Furthermore, embalmed, wet-tested tibial specimens have a higher mean tensile strain, a greater mean single shearing strength (perpendicular to the long axis of the specimen) and are harder (Rockwell No.) than similarly tested embalmed specimens <a></a>. However, the latter type of specimens has a higher mean modulus of elasticity. An analysis of variance showed that the increase in the hardness of the embalmed specimens was significant at the 0.01 level. As far as I am aware, there are no similar studies concerning the effect of embalming on the mechanical properties of spongy bone.</p> <p>Two types or forms of bones are found in the foot-irregularly shaped bones (the tarsals) and miniature long bones (the metatarsals and the phalanges). The tarsal bones are essentially shells of compact bones filled with spongy bone, fat, marrow substance, blood, etc. The actual amount of osseous material in bones, such as the tarsals and the bodies of vertebrae, is not very great. According to Policard and Roche <a></a> the talus and the calcaneus are about 80 per cent nonosseous tissue. The percentage of bone in the bodies of 92 human lumbar vertebrae studied by Bromley <i>et al. </i><a></a> varied from a maximum of approximately 24 per cent to a minimum of 15.5 per cent in males and from 21 per cent to 12 per cent in females at 5 and 70 years of age, respectively. As far as I am aware, there are no studies on the mechanical properties of spongy bone from the foot. Therefore, examination of such properties will be based on data obtained from the human femur.</p> <p>Two types of specimens were used-a rectangular bar (the standard specimen) 0.79 cm. x 0.79 cm. x 2.5 cm. and a cube 0.79 cm. on a side. The specimens were obtained from the head, neck, greater trochanter, and condyles of the femur with the long axis of the standard specimens oriented in different directions.</p> <p>The specimens were tested under direct compression in a Riehle 5000-lb. capacity testing machine, equipped with an automatic stress-strain recorder and calibrated to an accuracy of ±0.5 per cent. The low range scale of the machine (0-200 lbs.) was used with the load registered on the dial of the machine in units of 0.5 lbs. The specimens were loaded at a speed of 0.45 in. per min.</p> <p>All specimens were tested wet to more nearly approximate the condition in the living foot. Drying of compact bone increases its ultimate tensile strength (in the long axis of the specimen), its modulus of elasticity, and its hardness (Rockwell No.) but decreases its single shearing strength (perpendicular to the long axis of the specimen) and its tensile strain.<a></a> Similar studies have not, to my knowledge, been made on spongy bone.</p> <p>The ultimate compressive stress (strength) and strain, the modulus of elasticity, and the energy absorbed to failure were computed from stress-strain curves for wet-tested specimens. The density of air-dried specimens was determined with a strontium 90 densitometer developed by Evans, Coolbaugh, and Lebow <i><a></a>. </i>Dry specimens were used to avoid the effects of moisture that might be trapped within the interstices of the specimens. A total of 69 rectangular (standard) specimens and of 15 cubic specimens from 1 adult, white female, 3 adult, Negro males, and 6 adult, white males were tested. All specimens were kept in saline solution until tested. A minimum of 20 load-deformation readings were taken for each specimen during the test period.</p> <p>The results of the study showed that the mean compressive stress (strength) of the cubic specimens was greater than that of the rectangular (standard) specimens from the same region (<b>Fig. 5</b>). This phenomenon is characteristic of practically all materials. In cubic specimens high frictional forces developed between the ends of the specimen and the testing machine to resist the tendency of the specimen to be squeezed out of the machine. Furthermore, the upper part of the cube tends to be impacted into the lower part. Both of these factors contribute to higher values for compressive stress and modulus of elasticity in cubic than in specimens which are longer than wide. Because of these factors, it is felt that the values obtained from the rectangular (standard) specimens more accurately represent the true mechanical properties of spongy bone.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Mean and range of variation in some mechanical properties of spongy bone from different regions of the femur. Compressive stress values in pounds force per square inch. Gt. troch. = greater trochanter; Lat. = lateral; Med. = medial; Cond. = condyle. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the living body, most of the bones are subjected to bending action as a result of gravity, muscular activity during movement, and blows. Consequently, the bones are subjected to a combination of tension, compression, and shearing rather than to a single pure force. The question then arises as to why the strength of bone is usually determined by testing the specimens under a pure force. The answer to this question, on mechanical grounds, has already been given. There are, however, other valid reasons for testing the strength of bone under pure tension or compression.</p> <p>Experimental studies with strain sensitive lacquers on bones within the living body as well as outside of it demonstrate that certain types of linear fractures of the skull, the pelvis, and the long bones all arise from failure of the bone from tensile stresses and strains produced in it by bending <a></a>. The determination of the tensile strength of bone under pure tension thus has direct application to the mechanics of fractures of those types. Clinical experience also indicates that tensile forces are important in the production of many types of fractures.</p> <p>Compression fractures are quite common in the bodies of the vertebrae, especially those in the lumbar region, and in the calcaneus, the most frequently fractured of the tarsal bones <i><a></a> . </i>Compression fractures of the talus also occur. There is, consequently, a sound practical reason for investigating the compressive strength of the tarsal bones, especially the calcaneus and the talus although, to my knowledge, it has not been done. The rationale for determining the strength of spongy bone from the femoral head and condyles under direct compression is that these regions of the bone are normally subjected to compression forces in the erect posture <i><a></a> . </i>Specimens from other regions were similarly tested for comparative purposes.</p> <p>When the results of the tests were compared according to the region of the bone from which the specimens were obtained, without regard to the direction of loading, several differences were found. The rectangular (standard) specimens from the neck had the highest and those from the greater trochanter the lowest mean compressive stress. Among the cubic specimens the highest and the lowest mean compressive stresses were found in specimens from the head and the medial condyle, respectively.</p> <p>Regional variation was also found in the modulus of elasticity (stiffness) of the specimens (<b>Fig. 5</b>). The mean stiffness of the rectangular specimens exceeded that of the cubic specimens from the same region except for the specimens from the head. The rectangular specimens from the neck and the medial condyle, respectively, had the highest and the lowest mean modulus. The maximum and the minimum stiffness means of the cubic specimens were found in those from the head and the medial condyle, respectively.</p> <p>Comparison of the mean compressive strain, mean energy absorbed to failure, and mean density of the rectangular and cubic specimens from different parts of the femur also reveals interesting differences (<b>Fig. 6</b>). The cubic specimens showed somewhat more variation in the mean compressive strain than did the rectangular ones, the strain being greatest in the specimens from the head and least in those from the medial condyle. Little difference was found in the mean compressive strain of the rectangular specimens, those from the head having a slightly greater strain than those from the condyles. The cubic and the rectangular specimens from the head had the highest while those from the medial condyle had the lowest mean energy absorbed to failure. However, the former specimens showed more regional difference than did the latter. The mean density for both types of specimens was greatest in those from the head and least in the ones from the lateral condyle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Mean and range of variation of some mechanical properties of spongy bone from various regions of the femur. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A statistical analysis of the above data from the rectangular (standard) specimens revealed the following significant differences between the means. The mean compressive stress of the strongest specimens (from the neck) was greater, at the 0.02 significance level, than that of the weakest specimens (from the greater trochanter). The difference between the mean compressive strain of the specimens from the head, which had the highest, and that of specimens from the medial condyle, which had the lowest, was significant at the 0.01 level.</p> <p>The mean energy absorbed by the specimens from the head was significantly greater, at the 0.02 level, than that absorbed by specimens from the medial condyle. The differences between the means for the other mechanical properties of the rectangular specimens were not statistically significant. The number of cubic specimens tested was not sufficiently large for statistical analysis.</p> <p>Comparison of the maximum compressive stress and modulus of elasticity (<b>Fig. 7</b>) of the rectangular and cubic specimens according to the direction of loading showed that spongy bone is an anisotropic material, i.e., a material that is not equally strong in all directions. The rectangular specimens loaded in the direction of the long axis of the neck of the femur showed the highest, while those loaded in the anterior-posterior direction showed the lowest mean compressive stress. Among the cubic specimens, the highest mean compressive stress was found in specimens loaded in a lateral-medial direction and the lowest in specimens loaded in a superior-inferior direction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Mean and range of variation in some mechanical properties of femoral spongy bone according to the direction of loading. Stress values in pounds force per square inch. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rectangular specimens loaded in a lateral-medial direction had the highest mean modulus of elasticity and those loaded in the anterior-posterior direction the lowest. The cubic specimens loaded in a lateral-medial direction had the highest mean modulus of elasticity while the lowest was found in the specimens loaded in a superior-inferior direction.</p> <p>Considerable variation was also found in the energy absorbed to failure, the compressive strain at failure, and the density of the specimens when evaluated with respect to different directions of loading (<b>Fig. 8</b>). The rectangular specimens loaded in a lateral-medial direction had the highest mean energy-absorbing capacity whereas those located in an anterior-posterior direction had the lowest. The highest mean energy-absorbing capacity among the cubic specimens was found in those loaded in a lateral-medial direction and the lowest in the specimens loaded in a superior-inferior direction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Mean and range of variation in some mechanical properties of femoral spongy bone according to the direction of loading. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rectangular specimens loaded in a lateral-medial direction had the highest average compressive strain and those loaded in the direction of the long axis of the neck had the least. The compressive strain of the cubic specimens loaded in a lateral-medial direction far exceeded that of all other specimens. The lowest compressive strain among cubic specimens was found in those loaded in the superior-inferior direction.</p> <p>Surprising differences were found in the density of specimens cut in different directions. The density of rectangular and cubic specimens cut in the lateral-medial direction was the same but greater than that of any other specimens. The rectangular specimens cut in the superior-inferior and in the anterior-posterior direction were the least dense. Cubic specimens were the least dense when cut in the superior-inferior direction. These differences in density of the specimens suggest directional variation in the orientation and abundance of trabeculae in various parts of the femur.</p> <p>A statistical analysis of the means for the various mechanical properties with respect to the direction of loading revealed the following significant differences. The variation between the energy absorbed by rectangular specimens, loaded in the lateral-medial direction, was significantly greater at the 0.01 level than that of the specimens subjected to anterior-posterior and to superior-inferior loading. The difference between the maximum compressive strain (found in lateral-medial loading) and the minimum strain (found in specimens loaded in the direction of the long axis of the neck) was significant at approximately the 0.04 level. No other significant differences were found between the means for the other mechanical properties when analyzed with respect to the direction in which the specimens were cut and loaded.</p> <p>Although spongy bone is much weaker than compact bone (<b>Fig. 9</b>), its foam-like structure makes it a good energy-absorbing material, as demonstrated experimentally more than a century ago by Dr. Physick <a></a> and more recently suggested by Evans, Pedersen, and Lissner <i><a></a> . </i>The presence of fat, marrow substance, and blood in the interstices of spongy bone in the living condition enhances its energy-absorbing capacity by making it act like a quasi-hydrostatic system. The capacity of bone to absorb energy is one of its important mechanical properties as far as fracture mechanics is concerned because, as pointed out by Lissner and Evans, <a></a> all physical injuries arise from the absorption of energy. Most fractures are produced by impacts or blows and thus involve energy absorption.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Mean and range of variation in strength of various bones according to type (compact or spongy) and. direction of loading <a></a>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another mechanical property of bone to be considered is its fatigue life. This is especially important in relation to march, stress, or fatigue fractures which are most common in the metatarsal bones although they have also been reported in other bones. These fractures are thought to be the result of repetitive loading such as occurs during marching, hence the name "march" fracture.</p> <p>The only investigation known to me on the fatigue life of intact bones is one we made several years ago <i><a></a> . </i>In this study the strength of intact human metatarsal bones was determined by loading them to failure in a Sonntag Flexure Fatigue machine equipped with an automatic counter (which recorded the number of cycles to failure) and shutoff. The chief advantage in using this type of fatigue machine is that it has an inertia force-compensator spring which absorbs or eliminates all unknown inertia forces. Consequently, the force in the specimen being tested, regardless of its rigidity, is equal to the known force produced by the oscillator assembly.</p> <p>Forty-one bones were tested with a force of 15 lbs. (the maximum that could be applied with our machine), 3 bones with 12 lbs., and 8 bones with 10 lbs. Only the second through fifth metatarsals were tested because the first one was too large for the fatigue machine. The influence of moisture upon the fatigue life of the specimens was investigated in 10 bones by allowing water to drip on them during a test. The bones were not degreased and all were tested at room temperature. None of the bones exhibited any known pathologic condition. In order to hold the bone in the fatigue machine during a test, the ends were embedded in Selectron 5026 plastic. The number of repetitions to failure was automatically recorded and the machine shut off as soon as the specimen broke. A cycle means the bone is bent once up and once down.</p> <p>Comparison of the results obtained for the wet- and the dry-tested specimens showed that drying tended to decrease the fatigue life of the bones (<b>Table 1</b>). The probable explanation is that drying increased the modulus of elasticity of the bone and hence the specimens were stiffer. The number of repetitions to failure, with a 15-lb. force, varied from 1,000 to 10,297,000 for the dry specimens and from 150,000 to 13,908,000 for the wet specimens. Metatarsals 2 and 3 showed the greatest fatigue life when tested wet. No consistent relations were found between the fatigue life of the bones and their size or age of the individuals from whom they were obtained. The type of fracture produced experimentally (<b>Fig. 10</b>) was similar to some reported <a></a> in the clinic literature (<b>Fig. 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Experimentally produced fatigue fracture of an intact human metatarsal bone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. A clinical fatigue fracture of a metatarsal bone.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is interesting to speculate how long an individual must walk before the metatarsals would be subjected to the same number of repetitions at which failure occurred in our experiments. If it were assumed that an individual walked at the army pace of 120 steps per min., walking 50 min., resting 10 min., one would have to walk continuously for almost a month before the second metatarsal would be subjected to the number of repetitions at which the failure occurred in the present study. During each cycle of loading, the bone was bent up and down in a vertical plane. The fracture was probably a tensile failure initiated on the side which, at the instance of failure, was the convex or tensile side.</p> <p><b>References:</b></p> <ol> <li>Bird, F., H. Becker, J. Healer, and M. Messer, <i>Experimental determination of the mechanical properties of bone</i>, Aerospace Med., 39:1:44-48, 1968.</li> <li>Bromley, R. G., N. L. Docku, J. S. Arnold, and W. S. S. Jee, <i>Quantitative histological study of human lumbar vertebrae</i>, J. Geront., 21: 537-543, October 1966.</li> <li>Evans, F. G., <i>Stress and strain in bones, their relation to fractures and osteogenesis</i>, Charles C Thomas, Springfield, Ill., 1957.</li> <li>Evans, F. G., <i>Significant differences in the tensile strength of adult human compact bone</i>, in H. J. J. Blackwood, Proceedings of the first European bone and tooth symposium, pp. 319-331, Pergamon Press, Oxford, 1964.</li> <li>Evans, F. G., <i>Relazioni tra alcune proprieta meccaniche e struttura istologica dell'osso compatto umano</i>, Arch. Putti, in press.</li> <li>Evans, F. G., <i>Relation of the physical properties of bone to fractures</i>, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 18:110-121, 1961.</li> <li>Evans, F. G., and M. Lebow, <i>Regional differences in some of the physical properties of the human femur</i>, J. Appl. Physiol., 3:9:563-572, March 1951.</li> <li>Evans, F. G., and M. Lebow, <i>The strength of human compact bone as revealed by engineering technics</i>, Amer. J. Surg., 83:3:326-331, 1952.</li> <li>Evans, F. G., C. C. Coolbaugh, and M. Lebow, <i>An apparatus for determining bone density by means of radioactive strontium (Sr90)</i>, Science, 114:2955:182-185, 1951.</li> <li>Evans, F. G., H. E. Pedersen, and H. R. Lissner, <i>The role of tensile stress in the mechanism of femoral fractures</i>, J. Bone Joint Surg., 33A: 485-501, 1951.</li> <li>Harris, C. O., <i>Strength of materials</i>, American Technical Society, Chicago, 1963.</li> <li>Key, J. A., and H. E. Conwell, <i>The management of fractures, dislocations, and sprains</i>, C. V. Mosby, St. Louis. 1951.</li> <li>Koch, J. C, <i>The laws of bone architecture</i>, Amer. J. Anat., 21:177-298, March 1917.</li> <li>Kraus, G. R., and J. R. Thompson, <i>March fracture: An analysis of 200 cases</i>, J. Roent. Radium Therapy, 52:281-290, 1944.</li> <li>Lease, G. O'D., and F. G. Evans, <i>Strength of human metatarsal bones under repetitive loading</i>, J. Appl. Physiol., 14:1:49-51, 1959.</li> <li>Lissner, H. R., and F. G. Evans, <i>Engineering aspects of fractures</i>, Clin. Orthop., 8:310-322, 1956.</li> <li>McElhaney, J. H., and E. F. Byars, <i>Dynamic response of biological materials</i>, Amer. Soc. Mech. Eng., 65-WA/HUF-9, December 1965.</li> <li>Policard, A., and J. Roche, <i>La formation de la substance osseuse</i>. Essai de coordination des donnees histologiques et biochimiques. Ann. Physiol. Physicochim. Biol., 13:645-703, 1937.</li> <li>Wistar, C, <i>A system of anatomy</i>, Ed. 4, Carey, Lea and Carey, Philadelphia, 1827.</li> <li>Zarek, J. M., <i>Biomechanics: Its application to surgery</i>, Chap. 6 in L. Gillis, Modem trends in surgical materials, Butterworth and Co. Ltd., London, 1958, pp. 106-123.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Kraus, G. R., and J. R. Thompson, March fracture: An analysis of 200 cases, J. Roent. Radium Therapy, 52:281-290, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Kraus, G. R., and J. R. Thompson, March fracture: An analysis of 200 cases, J. Roent. Radium Therapy, 52:281-290, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Lease, G. O'D., and F. G. Evans, Strength of human metatarsal bones under repetitive loading, J. Appl. Physiol., 14:1:49-51, 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Evans, F. G., Relation of the physical properties of bone to fractures, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 18:110-121, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Lissner, H. R., and F. G. Evans, Engineering aspects of fractures, Clin. Orthop., 8:310-322, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Evans, F. G., H. E. Pedersen, and H. R. Lissner, The role of tensile stress in the mechanism of femoral fractures, J. Bone Joint Surg., 33A: 485-501, 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Wistar, C, A system of anatomy, Ed. 4, Carey, Lea and Carey, Philadelphia, 1827.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Koch, J. C, The laws of bone architecture, Amer. J. Anat., 21:177-298, March 1917.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Key, J. A., and H. E. Conwell, The management of fractures, dislocations, and sprains, C. V. Mosby, St. Louis. 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Evans, F. G., Stress and strain in bones, their relation to fractures and osteogenesis, Charles C Thomas, Springfield, Ill., 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Evans, F. G., C. C. Coolbaugh, and M. Lebow, An apparatus for determining bone density by means of radioactive strontium (Sr90), Science, 114:2955:182-185, 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Evans, F. G., and M. Lebow, Regional differences in some of the physical properties of the human femur, J. Appl. Physiol., 3:9:563-572, March 1951.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Evans, F. G., and M. Lebow, The strength of human compact bone as revealed by engineering technics, Amer. J. Surg., 83:3:326-331, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bromley, R. G., N. L. Docku, J. S. Arnold, and W. S. S. Jee, Quantitative histological study of human lumbar vertebrae, J. Geront., 21: 537-543, October 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Policard, A., and J. Roche, La formation de la substance osseuse. Essai de coordination des donnees histologiques et biochimiques. Ann. Physiol. Physicochim. Biol., 13:645-703, 1937.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Evans, F. G., Relazioni tra alcune proprieta meccaniche e struttura istologica dell'osso compatto umano, Arch. Putti, in press.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Evans, F. G., Significant differences in the tensile strength of adult human compact bone, in H. J. J. Blackwood, Proceedings of the first European bone and tooth symposium, pp. 319-331, Pergamon Press, Oxford, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bird, F., H. Becker, J. Healer, and M. Messer, Experimental determination of the mechanical properties of bone, Aerospace Med., 39:1:44-48, 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">McElhaney, J. H., and E. F. Byars, Dynamic response of biological materials, Amer. Soc. Mech. Eng., 65-WA/HUF-9, December 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Zarek, J. M., Biomechanics: Its application to surgery, Chap. 6 in L. Gillis, Modem trends in surgical materials, Butterworth and Co. Ltd., London, 1958, pp. 106-123.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Evans, F. G., Relation of the physical properties of bone to fractures, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 18:110-121, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Harris, C. O., Strength of materials, American Technical Society, Chicago, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Zarek, J. M., Biomechanics: Its application to surgery, Chap. 6 in L. Gillis, Modem trends in surgical materials, Butterworth and Co. Ltd., London, 1958, pp. 106-123.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Evans, F. G., and M. Lebow, Regional differences in some of the physical properties of the human femur, J. Appl. Physiol., 3:9:563-572, March 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>F. Gaynor Evans. Ph.D. </b></td></tr><tr><td class="clsTextSmall">Department of Anatomy and Highway Safety Research Institute, The University of Michigan, Ann Arbor, Mich. 48104.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_037/spring69-33.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_037/spring69-34.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_037/spring69-35.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_037/spring69-36.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_037/spring69-37.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_037/spring69-38.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_037/spring69-39.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_037/spring69-40.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_01_037/spring69-41.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_01_037/spring69-42.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_01_037/spring69-43.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_01_037/spring69-44.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Mechanical Properties of Bone Creator An entity primarily responsible for making the resource F. Gaynor Evans. Ph.D. * https://staging.drfop.org/files/original/4ebe6c9358e369d2dfcc780525f71744.pdf 01ca7a3bb92c5f91b306060769848ed9 https://staging.drfop.org/files/original/fd2a976afd43f432a91856fbb3542adb.jpg 4cd388f1bb2e5bb5c7d6e8658721feb3 https://staging.drfop.org/files/original/5ea20b480864b5662268ba574fb4df90.jpg 404b82d99bc176c0c3b47905d236e7ef https://staging.drfop.org/files/original/2c56957b9735b01a9f5c9fe75689c927.jpg 57e264451217b8c83f7667a500f4caca https://staging.drfop.org/files/original/0939c6a9623e986d55b567dbe6f9704f.jpg 3da4ca037b4b925d204360e54d41830b https://staging.drfop.org/files/original/83f69a234f7756caf1d51f0b94e4ce93.jpg efc5c9cd7ee1708de022357d15829c4a https://staging.drfop.org/files/original/7b3ddab93a637e18d8e2ceb0c867ea1a.jpg d263fb414ce5d3e085085e28830834eb https://staging.drfop.org/files/original/135a37db3f3673e23afdb5ba5411f6b0.jpg 34b6fbf004c0a0ea762ecccc0a6e38fb https://staging.drfop.org/files/original/38ea4d432e4466c58292d70162ecd0a2.jpg 8150ce6a83ac114ca162be9ae6615263 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_049.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 49 - 58 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_049.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_049.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>Dynamic Structure of the Human Foot</h2> <h5>Herbert Elftman <a style="text-decoration:none;">*</a><br /></h5> <p>The foot is one of the most dynamic structures in the human body. The lively interplay of forces which makes its function possible is easily forgotten and it is too often treated like the graven image of a static structure. The success of modern therapeutic measures in solving other problems has owed much to close cooperation between Nature working from within and assistive devices from without. The forces within the foot can be powerful allies in such a partnership.</p> <p>The human foot acts in concert with the rest of the body during standing and movement. It provides man with his most effective physical contact with the environment and is especially responsible for successful regulation of initial and final contact of the body with the ground. The foot must also provide adjustable support during the characteristic human occupations of manipulating the environment or of simply standing in line.</p> <p>Human bipedality was made possible by the redesign of an ancestral foot with five long toes used for the grasping of the limbs of trees. We still testify to our heritage by having a big toe larger than the rest but no longer opposable. The heel bone was brought down into contact with the ground to provide additional area of support. Each of these changes traded an old advantage for a new one and the barter is still going on.</p> <h3>The Foot in Motion</h3> <p>Walking is more characteristic of human movement than running, since man has substituted cunning in the management of external devices for fast movement of body parts when speed is desired. The foot must constantly adjust to the varying loads imposed upon it. Particularly important are the stresses it must withstand at the initiation of contact with the ground and again at its termination.</p> <h4>Initiation Of Contact</h4> <p>The heel is the first part of the foot to touch the ground in walking. It is consequently entrusted with the delicate mission of gradually bringing the foot to rest on the ground. In running this can be done without the help of the heel since the limb is already in the midst of its backward swing with respect to the body and the ball of the foot can touch the ground at zero velocity.</p> <p>In walking, the advanced leg has barely started its backward swing with respect to the body when the heel touches the ground. The initial velocity of the ankle after contact is only slightly less than that of the hip joint, making heel-roll imperative. As the ankle approaches zero velocity at ball contact, the forward velocity of the hip joint is preserved by ankle and knee flexion (<b>Fig. 1</b>). Failure to do this properly is one of the most common deficiencies of assistive devices.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Forces acting on the foot during two important phases of its activity: (1) completion of heel roll; (2) initiation of rolling off on the hall. From Elftman, 1967. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The normal human heel is specialized for the part it plays in walking. Resilience is supplied by the construction of the connective tissue under the heel. The collagenous fibers are arranged so as to produce cylindrical compartments filled by more fluid tissues. Since the fluid changes volume only slightly in compression, pressure is accommodated by elastic deformation of the surrounding connective tissue. While this elastic deformation is taking place the foot rolls forward on the heel. The character of this movement is determined by the contour of the calcaneous combined with the shape which the heel-pad assumes under pressure. Artificial heels can be of assistance if properly shaped, usually achieved when wear erases original design.</p> <h4>Termination Of Contact</h4> <p>Although the foot moves only slightly in the interval between ball contact and heel rise, it is subjected to constantly changing stresses. As the body moves forward over the ankle until the knee becomes almost straight, tension is built up in the calf muscles in preparation for the critical events which terminate ball and toe contact. In this phase of walking the transformation of the ape foot into a human foot shows its functional worth. With grasping no longer the chief function of the toes, they have been shortened and the connective tissue pad beneath the ball has become stronger. The great toe has lost its opposability and is permanently aligned parallel to the others. This relieves the peroneus longus muscle of its ancestral responsibility of adducting the hallux and enhances the aid which it gives to the tibialis posterior in resisting splaying of the foot. The first metatarsal and its attendant phalanges retain the size which they had attained in the ape. This led to the accentuated use of this toe during push-off and the important role which the flexor hallucis longus plays in terminal contact with the ground.</p> <p>Rolling over the ball of the foot has a function similar to that of the heel but acting in reverse. It must control the gradual acceleration of the ankle so that the lower limb as a whole is moving forward with body speed close to the time at which the advanced heel makes contact and double support begins. Here again knee flexion adjusts the relative velocities of the limb segments and allows the calf muscles to push off the limb as it begins its forward swing.</p> <h4>Control Of Foot Position By Hip And Knee</h4> <p>Primary control of foot position is exercised at the hip joint with assistance from the knee when it is flexed. After the primary position of the foot is determined by these distant factors, fine control is added by joints of ankle and foot. The forces and moments which act on the foot are largely determined by the disposition and accelerations of other parts of the body. The importance of knee and hip joints in controlling the spatial relationships of the foot is emphasized frequently by unwelcome responses in these joints to abnormal stresses in the foot.</p> <h3>Fundamental Architecture of the Foot</h3> <p>The foot consists of 26 bones controlled by 42 muscles and is held together by an almost unbelievable number of ligaments. Fortunately, in the normal performance of its major functions, many of these parts co-operate so closely that an initial workable concept of the foot can be based on very few units. The talus is the uppermost of these. When it is removed, the subtalar part of the foot reveals two major divisions: the calcaneus and, articulating with it by the calcaneocuboid joint, a semirigid constellation of bones terminating in the ball of the foot. This leaves the toes jutting out, to become of importance in activities which require forward extension of the base of support beyond the ball.</p> <h4>The Ankle-Joint Complex</h4> <p>The talus is a bony meniscus which allows the movements of the foot with respect to the shank to be divided between a pair of articulations: the subtalar below and the ankle joint above. Since the same external forces act on both joints, the normal body is interested in their combined movement but the clinician is frequently faced with the results of differential insult.</p> <p>In the ankle joint, normal pressure is transmitted from the tibia to the trochlear surface of the talus and lateral bending moments are resisted, within limits, by the malleoli and ligaments. When the joint is compressed, as in weight bearing, the instant axis is determined by the curvatures of the surfaces in contact at the moment. The classical concept of an invariant axis passing horizontally through the lateral malleolus to emerge just below the medial malleolus has been revised in recent years. Barnett and Napier (1952) have described the difference in curvature between the parts of the talus used as movement progresses. Close and Inman (1952) have emphasized a component of vertical rotation conforming to the curved lateral surface of the talus. Both of these factors are sufficiently variable to require assessment in each individual.</p> <p>Even more variable is the orientation of the axis of the ankle joint with respect to the foot and to the transverse axis of the knee. The situation in any individual can be estimated by observing the position of the malleoli; the results of such measurements recorded by Elftman (1945) are shown in <b>Fig. 2</b>. It is obvious that the orientation of the ankle joint determines the plane in which dorsi- and plantar flexion occur and this influences the amount of movement required in the subtalar joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Range of variation in the orientation of the axis of the ankle joint. Two-thirds of the individuals measured were within the limits shown here. From Elftman, 1945. ties. Indispensable for our ancestors in tree climbing, it is still our chief accommodation to rough terrain. Its large component of vertical rotation gives us the possibility of transverse rotation at the ankle under gravitational control. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The subtalar joint is guided in its movement, when it is under compression, by the areas of contact between the calcaneus and the lower surface of the talus. These surfaces are beautifully sculptured to form parts of a helical or screw-shaped surface. The helix is right-handed in the right foot; the resulting advance of the talus during eversion is important for the control of the transverse tarsal joint, but may be neglected during consideration of the ankle. For this purpose the major axis of the helix, also called the compromise axis, suffices. Its position in one foot is shown in <b>Fig. 3</b>. This axis emerges from the talus so as to pierce the tendon of the tibialis anterior; its other end is variably located on the lateral surface of the calcaneus. The movements about this axis are called inversion and eversion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The instant axis for the combined movement in the upper ankle joint and the subtalar joint lies in the thin disc represented by the dashed circle. Attention is also called to another variable functional feature, the arc of the ball of the foot. From Elftman, 1954. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The obliquity of this axis confers on the subtalar joint its most significant properties. Indispensable for our ancestors in tree climbing, it is still our chief accommodation to rough terrain. Its large component of vertical rotation gives us the possibility of transverse rotation at the ankle under gravitational control.</p> <p>Since the ankle joint and the subtalar joint are not subject to independent regulation, the resultant movement when the two are combined is of greater practical value than the separate components. The location of this resultant axis is indicated in <b>Fig. 3</b>. If the two joint axes actually intersected, the resultant would lie in the plane determined by the two axes. Since they almost intersect, but not quite, the resultant is confined within a thin disc which may be treated as a plane for practical purposes. Once this plane is determined, the problem of substituting new artificial axes for the old ones is simplified.</p> <p>Movement in the ankle-joint complex is controlled by: (1) moments due to the ground reaction; (2) constraints due to joint surfaces and ligaments; and (3) moments produced by the leg muscles which pass over the ankle. The part played by the ankle muscles can be studied quantitatively from the data shown in <b>Fig. 4</b>. This is essentially an oblique section through the ankle oriented so as to include the axes of the ankle joint and the subtalar joint. The lever arms of the muscles with respect to these axes can be read from the diagram; the relative maximum strengths of the muscles are proportional to the areas of the circles which represent them. The resultant moment of various muscle combinations can then be found. Important points to note are: (1) the tibialis anterior is a dorsiflexor and not an in-vertor in this position; (2) the gastrocnemius and soleus are strong invertors as well as plantar flexors; (3) the peroneal muscles are stronger for eversion than for plantar flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Muscular control of the ankle. The figure is essentially a section through the right ankle in the plane of the disc shown in Figure 3 and includes the ankle-joint axis (TC) and subtalar axis (ST). The circles representing the muscles are proportional in area to the physiologic cross sections. The muscles may be identified by their initials, e.g., triceps surae (TS). From Elftman, 1960. The calcaneocuboid joint was described as a saddle-shaped joint by Adolf Fick in 1854; only one other joint of this type is present in man, at the base of the first metacarpal. More than a century elapsed before an adequate description of this joint was provided by Elftman in 1960. For practical purposes a simplified description will suffice. The principal axis (labeled CC in Fig. 5) passes obliquely through the calcaneus in such a fashion that an extension of it would almost intersect the subtalar axis in the neck of the talus. Associated with the major movement of rotation about this axis is a slight translation parallel to the axis. The total movement is known as supination and pronation. The man in the street calls these raising and lowering of the arch. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Transverse Tarsal Joint</h4> <p>The part of the foot which lies immediately in front of the talus and calcaneus forms a semirigid unit articulating with the rear part of the foot by means of two joints, the calcaneocuboid and the talonavicular. Since they act together much of the time, it is convenient to call the combination the transverse tarsal joint.</p> <p>The calcaneocuboid joint was described as a saddle-shaped joint by Adolf Fick in 1854; only one other joint of this type is present in man, at the base of the first metacarpal. More than a century elapsed before an adequate description of this joint was provided by Elftman in 1960. For practical purposes a simplified description will suffice. The principal axis (labeled CC in <b>Fig. 5</b>) passes obliquely through the calcaneus in such a fashion that an extension of it would almost intersect the subtalar axis in the neck of the talus. Associated with the major movement of rotation about this axis is a slight translation parallel to the axis. The total movement is known as supination and pronation. The man in the street calls these raising and lowering of the arch.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Transverse tarsal joint, pronated at left, supinated at right. The joint axes are labeled as follows: AJ, ankle joint; ST, subtalar; CC, calcaneocuboid; TN, talonavicular. When the heel is placed on the ground in the supinated position, inversion in the subtalar joint restores the vertical orientation of the shank and rotates the head of the talus so as to lock the transverse tarsal joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The talonavicular joint is the controlling element in the transverse tarsal joint complex. The head of the talus is a cam of ellipsoidal shape which is not concentric about the subtalar axis but makes a considerable angle with respect to it. As a consequence of this, rotation of the head of the talus during rotation about the subtalar axis changes its orientation, and movement in the transverse tarsal joint ensues to bring the navicular concavity to a conformable position. The important thing to remember is that inversion produces supination and eversion causes pronation. At the extremes of this range of association, the transverse tarsal joint becomes independent of the subtalar in extremely pronated (flat) feet and the subtalar motion can occur alone at extreme supination.</p> <h4>Ball Of The Foot</h4> <p>The structures which allow the heads of the metatarsals to transmit pressure to the ground consist of connective tissue and skin which have been modified in the human foot to spread the pressure in the hope of preventing painful concentrations. When weight is not borne by this region, a transverse metatarsal arch is visible. Even slight pressure is sufficient to bring the heads of the metatarsals in alignment with the ground and the arch disappears. The extreme variability in the lengths of the metatarsals has important consequences for foot action. The distribution of pressure as the heel is raised is very closely dependent on the contour of a line connecting the metatarsal heads, as shown in <b>Fig. 3</b>. Morton (1935) has stressed the difficulties resulting from first metatarsals which are short or have posteriorly located sesamoids. Equally disastrous effects can come from contours which are sharply curved or hairpin in shape.</p> <p>Among a number of variable features in this part of the foot is the extent to which the base of the fifth metatarsal transmits weight to the ground. Another condition, splaying of the foot, can result when the cooperative efforts of the tibialis posterior and the peroneus longus are insufficient to give transverse stability.</p> <h4>Toes</h4> <p>Although human toes can be used for grasping when occasion demands, their customary use is accessory to the ball of the foot which lies behind them. The toes are the anchors for the long flexors which play an important part in managing the ankle-joint complex. By differential contraction of the flexors of the toes it is possible to adjust the distribution of pressure between parts of the ball of the foot. Because of the strength of the big toe and the long flexor attached to it, this part of the foot is usually the last to leave the ground and contributes the final touch to the control of movement.</p> <h3>Control of the Foot by the Heel</h3> <p>When the body rolls forward on the heel until the foot rests on the ground, the position which the foot assumes is determined by the manner in which the calcaneous rolls forward. Proper contouring of the sole of the shoe where the heel nests in it will not only provide assistive forces but will also originate sensory feedback to stimulate better foot alignment.</p> <p>If the heel cup is so constructed that its anteromedial quadrant is elevated, the calcaneus will come to rest with a predetermined amount of inversion about the subtalar axis. This places the contact area of the calcaneus more nearly under the vertical thrust of the body, decreasing its rotational moment. Since the ankle-joint axis strives for a horizontal position, the talus is forced into inversion and this drives the transverse tarsal joint into supination. Sensory feedback, in the course of a few steps, will encourage the hip joint to bring the foot down in a slightly toed-in position, thus restoring the knee joint to its usual orientation.</p> <p>The details of the sculpturing of the heel cup need not be left to chance since the desired conformation of the internal architecture of the foot is almost identical with that which it assumes when the subject stands on an inclined plane. Instant orthotics can be achieved by placing the proper compound in the shoes and having the subject stand in them, with heels supported at a proper elevation, to impress the functional shape.</p> <h3>Measurement of Foot Function</h3> <p>The foot is sandwiched between the pressure of the ground below and the weight and inertia forces of the body above. Since these are the forces to which the foot must accommodate, their measurement assumes primary importance.</p> <p>The total pressure of the ground on the foot and the point at which its resultant is applied can be measured easily when the individual is standing. The only equipment needed consists of three reasonably accurate scales and a ruler. The usefulness of the information which can be obtained should not be underestimated; it is sufficient to tell whether many therapeutic devices achieve their objectives.</p> <p>When the body is in motion, measurement of the ground reaction is more important and becomes more difficult. This can be accomplished by means of force plates, the earliest results of which are shown in <b>Fig. 6</b> from Elftman (1939). From data such as this and photographic determination of the location of joint axes, muscle moments and joint forces can be obtained.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Force plate record of the ground reaction acting on the foot of J. T. Manter during a step described by Elftman, 1939. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In foot problems the distribution of the ground reaction over the foot is frequently of greater interest than its total value. Many interesting methods of making such measurements have been recorded and some are still useful; they have been reviewed by Elftman (1934). Since the distribution of pressure changes in the course of movement, instantaneous recording is of value. This can be accomplished by means of the barograph, introduced by Elftman in 1934. The changes in area of a pressure transducer placed under the foot are recorded photographically. <b>Fig. 7</b> shows two phases of a step; when the pressure is on the ball of the foot the structural characteristics of this region reveal themselves. Calibration of the pressure transducer allows the derivation of quantitative data from the photographic record. In <b>Fig. 8</b> it is even possible to recognize the concentration of pressure under the sesamoid bones beneath the head of the first metatarsal.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Barograph record of the distribution of pressure at two phases of the step. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Load distribution on the human foot during one step of J. T. Manter. (Isobars at 4 lb. per sq. in.) 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L., Jr., <i>The growth of the human foot and its evolutionary significance</i>, Contrib. Embryol. Camegie Inst., 19:93-134, 1927.</li> <li>Straus, W. L., Jr., <i>The foot musculature of the highland gorilla</i>, (Gorilla beringei), Quart. Rev. Biol., 5:261-317, 1930.</li> <li>Thomas, D. P., and R. J. Whitney, <i>Postural movements during normal standing in man</i>, J. Anat., 93:524-539, 1959.</li> <li>Thoren, O., <i>Os calcis fractures</i>, Acta Orthop. Scand., Suppl. 70, 1964.</li> <li>Volkov, T., <i>Les variations squeletique du pied chez les primates et dans les races humaines</i>, Bull. Mem. Soc Anthrop. Sci., 5T4-632, 1903; 5:1:201-331, 1904.</li> <li>Weidenreich, F., <i>Der Menschenfuss</i>, Z. Morph. Anthrop., 22:51-282, 1921.</li> <li>Weidenreich, F., <i>Evolution of the human foot</i>, Amer. J. Phys. Anthrop., 6:1-10, 1923.</li> <li>Wetzenstein, H. A., <i>A new method for assessment of the status and dynamic weight bearing of the foot</i>, Acta Orthop. Scand., 30:2:91-100, 1960.</li> <li>Wetzenstein, H., <i>A new method for assessment of the status and dynamic weight bearing of the foot</i>, 75, 1964.</li> <li>Whitney, R. J., <i>The stability provided by the feet during manoeuvers whilst standing</i>, J. Anat., 96:103, 1962.</li> <li>Wright, D. G., S. M. Desai, and W. H. Henderson, <i>Action of the subtalar and ankle-joint complex during the stance phase of walking</i>, J. Bone Joint Surg., 46A:361-382, March 1964.</li> <li>Wright, D. G., and D. C. Rennels, <i>A study of the elastic properties of plantar fascia</i>, J. Bone Joint Surg., 46A:482-492, April 1964.</li> <li>Wyller, T., <i>The axis of the ankle joint and its importance in subtalar arthrodesis</i>, Acta Orthop. Scand., 32:4:320-328, 1963 </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>Herbert Elftman </b></td></tr><tr><td class="clsTextSmall">Department of Anatomy, Columbia University, New York, N.Y. 10016 The foot is one of the most dynamic structures in the human body. The lively interplay of forces which makes its function possible is easily forgotten and it is too often treated like the graven image of a static structure. The success of modern therapeutic measures in solving other problems has owed much to close cooperation between Nature working from within and assistive devices from without. The forces within the foot can be powerful allies in such a partnership.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_049/spring69-45.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_049/spring69-46.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_049/spring69-47.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_049/spring69-48.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_049/spring69-49.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_049/spring69-50.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_049/spring69-51.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_049/spring69-52.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 Dynamic Structure of the Human Foot Creator An entity primarily responsible for making the resource Herbert Elftman * https://staging.drfop.org/files/original/02af16250516ded97985a715859e1d48.pdf 65d14eece6f79ba597a6dae38a00de2a https://staging.drfop.org/files/original/e39a0401f8bbfac0d7ecc2b81b69051f.jpg 8d0aee0aac22824b626b3f8d2b09410b https://staging.drfop.org/files/original/ec0662366f6e7d988cba99c4979f2001.jpg 107421598388ffad0c304b8ffb5f9550 https://staging.drfop.org/files/original/1270e5e0a05e215c9e3ce92571815ce9.jpg 1c1fe45517ca27d04646ba18f75d20c9 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_053.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 53 - 64 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_01_053.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_053.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Material for Direct Forming of Prosthetic Sockets</h2> <h5>A. Bennett Wilson, Jr. <br /></h5> <p>For a number of years, prosthetics research groups have been attempting to develop a method of forming sockets directly on amputation stumps, in order to reduce the time required to produce a satisfactory socket and to eliminate the messy working conditions inherent in the use of plaster of paris.<a></a></p> <p>Direct forming requires a material that: (<i>a</i>) is plastic at temperatures moderately above ambient, but which requires reasonably high temperatures for subsequent softening; <i>(b) </i>is easily handled under conditions found in most limb shops; (<i>c</i>) exhibits minimum creep or deformation under normal loads, even at temperatures slightly above body temperature; (<i>d</i>) is nontoxic; and (<i>e</i>) has a reasonable strength-to-weight ratio.</p> <p>Recently, research and development groups in Canada and the United States have developed successful techniques for direct forming of some types of sockets by using a synthetic balata, Polysar<a style="text-decoration:none;">*</a> X-414.</p> <p>Polysar X-414 has been found to possess the properties most essential for direct forming: (a) it becomes plastic at temperatures between 160 and 180 deg F; <i>(b) </i>it can be applied to the amputation stump within a minute or two after heating; (c) it remains reasonably plastic after its surface temperature drops 20 to 30 deg; <i>(d) </i>after it cools and becomes nonplastic, it maintains its shape, even under stress and subsequent heating to temperatures of 120 deg F; and (e) it can be reheated and reformed to permit socket modification after fabrication. In the plastic state, it exhibits cohesive properties which facilitate fabrication. It yields a slightly flexible socket which is considered desirable by most patients, and it is practical to use all conventional components and accessories with Polysar X-414.</p> <p>Clinical findings indicate that the sockets remain durable, provided they are not exposed to excessive heat <i>(e.g., </i>leaving the prosthesis in the sun, in the trunk of a car on a hot day, or leaning against a house radiator). Also, excessive contact with perspiration may cause erosion of the material in a year's time; however, stump socks normally provide an adequate barrier.</p> <p>The socket-forming procedure is relatively simple. The need for making a plaster-of-paris wrap cast, pouring a positive cast, and modifying the positive cast is eliminated. Thus, not only is fabrication time reduced, but the chance of the errors that are likely to occur when fabricating a socket with conventional materials also is lessened.</p> <h4>Lower-Extremity Sockets</h4> <p>A practical method for direct forming of sockets over the below-knee stump has been developed recently at the Veterans Administration Prosthetics Center. Early attempts included the use of a pneumatic bag over a tube of synthetic rubber to provide the pressure necessary for forming the socket over the stump (<b>Fig. 1</b>) <a></a>, a procedure which worked satisfactorily for bony, mature stumps but which often produced sockets that were too loose when molded over flabby stumps. Further experimentation resulted in a technique in which pressure is provided by wrapping pressure-sensitive tape spirally around the tube of Polysar X-414 and molding it with the hands as the tube cools (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Pneumatic pressure was applied to the softened synthetic rubber to form the socket on the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Direct forming of a below-knee socket with a pressure-sensitive tape wrap and hand molding of the softened synthetic rubber tube. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This method, described in the article beginning on page 57, has proved to be successful in a number of clinics, especially for use in temporary, or preparatory, prostheses. If a pylon is used, the patient can be provided with a well-fitted prosthesis in a very few hours. If subsequent socket modifications are required, they can usually be carried out readily, and if one of the adjustable pylons is used, alignment can be changed easily when required. A satisfactory cosmetic effect (<b>Fig. 3</b>) can be achieved relatively easily, to provide a "permanent" prosthesis. Such a prosthesis has proved to be quite successful as a "permanent" prosthesis for many patients in the old-age group.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. A "permanent" below-knee prosthesis, consisting of a synthetic rubber socket, adjustable pylon, foam-block covering (note cutout for access to the adjustment mechanism), and stocking. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because of the size of the above-knee socket and the usual need for rather drastic modification of the socket with respect to the shape of the stump, a successful method of molding sockets directly over the above-knee stump has not yet been developed. However, work is continuing at VAPC.</p> <h4>Upper-Extremity Sockets</h4> <p>A technique for satisfactorily forming sockets for permanent prostheses directly over below-elbow stumps has been developed, also at VAPC. Again, extruded tubing of Polysar X-414 is used. All pressure necessary for forming is provided by the prosthetist's hands. Several types of cosmetic coverings are available when further cosmetic treatment is desired. The time required for fabrication of a typical below-elbow prosthesis can be reduced by half. The VAPC technique is described fully in the article beginning on page 65.</p> <p>The Ontario Crippled Children's Centre, Toronto, Canada, has been routinely using Polysar X-414 in fabrication of the open-shoulder, above-elbow socket, described in <i>Artificial Limbs </i>for Autumn 1969. Sockets preformed roughly to the shape required are heated and applied over the stump.</p> <p>The Prosthetics Research Center, Northwestern University, has developed a successful method for forming more conventional above-elbow sockets directly over the stump. An article describing this technique is scheduled for publication in the next issue of <i>Artificial Limbs.</i></p> <h4>Implications</h4> <p>Forming sockets with synthetic balata offers the prosthetist and orthotist the opportunity to provide quicker service to the patient, and also opens up many possibilities for improving the designs of sockets and orthotic components. The use of temporary prostheses can now be made routine, giving the clinic team ample time to determine the optimum prescription for the patient. Errors can be rectified easily, and new ideas can be tried with a minimum expenditure of time. Orthotists are already using synthetic balata for cuffs and molded supports. It is expected that many more uses for this remarkable material will be developed in the future.</p> <p><b>References:</b></p> <ol> <li>Committee on Prosthetics Research and Development, <i>Fracture bracing, </i>A report of a workshop, National Academy of Sciences, Washington, D.C., February 1969. </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> </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">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 the 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>1.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Fracture bracing, A report of a workshop, National Academy of Sciences, Washington, D.C., February 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_01_053/tmp399-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_01_053/tmp399-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_01_053/tmp399-3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Material for Direct Forming of Prosthetic Sockets Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr.  https://staging.drfop.org/files/original/5724c58acfdabe747b7c60927a4a24b5.pdf 4a65f44f3c20bce5b481525068819737 https://staging.drfop.org/files/original/8d0af8c9cdc4c818379f8f4094eeec16.jpg 52aaa3f3899a02ce896dc9f5fd82ba1c https://staging.drfop.org/files/original/ace50222cdc84974cc159ef1646c56ad.jpg 784acabf15b2c43c1dadb7ce14e7d49e https://staging.drfop.org/files/original/f101d6c6bc81000f4f4882cccedb60ba.jpg e449ffc3b155c41c90a50c19331e96b7 https://staging.drfop.org/files/original/5c4e1ab1e0cd9ee721de1e4279d2d9e0.jpg db093c4fcf07979d3cd3a7508481c2de DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_036.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 36 - 40 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_036.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_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>Radiographic Evaluation of Stump-Socket Fit</h2> <h5>C. B. Taft <a style="text-decoration:none;">*</a><br /></h5> <p>The critical relationship between accurate fit of a prosthesis and amputee comfort and function constitutes the foundation of all prosthetic fitting. Consequently, one of the most important features of a lower-extremity prosthesis is the distribution of the pressures applied to the stump by the socket. Since World War II, considerable progress has been made in the design of sockets, leading to the widespread use of "total-contact" sockets for amputations at all levels. However, reliable objective information regarding the relationship of the stump to the socket below its proximal brim is masked by the opaqueness of the socket material. The use of conventional materials <i>(e.g., </i>chalk, talcum, clay, and lipstick) to determine the adequacy of fit and the achievement of total contact has proved of limited value in the accurate diagnosis of fitting problems.</p> <p>The use of X-rays as a means of checking stump-socket fit has been discussed by several investigators. <a></a> Conventional X-ray films of the stump in the socket from the front and side under weight-bearing conditions have been of considerable value in determining total contact, fit, and alignment, but the films obtained by conventional techniques do not always reveal a clear demarcation between the soft tissues of the stump and the inner surface of the socket. <a></a> A radiographic method or procedure that would consistently give an adequate visualization of the stump-socket interface would provide valuable information for the physician and for the prosthetist in fitting patients. Such a procedure would also contribute to overall knowledge in this area of prosthetics, and this knowledge would aid in teaching the proper fabrication of sockets.</p> <p>Some preliminary experimental work relevant to the above-stated deficiency, reported by Dr. N. C. McCollough, involved the topical application of an X-ray contrast material to the skin of the stump. <a></a> Two or three coats of a saturated solution of sodium iodide in absolute alcohol were applied to the stump with a sponge and allowed to dry. The usual number of stump socks were then applied, the stump was inserted into the prosthesis, and films were made under weight-bearing conditions in the anteroposterior and lateral projections. The films obtained by this method provided a clear outline of the periphery of the stump, and any lack of total contact was easily recognized.</p> <p>The purposes of the present study were to assess the value of radiopaque materials in the evaluation of stump-socket fit on a broader basis, and to develop a satisfactory procedure for routine clinical use in determining achievement of total contact and in diagnosing pressure problems more accurately.</p> <h3>Sample</h3> <p>The sample for this study consisted of 16 adults (15 males and 1 female), of whom 8 were below-knee and 8 were above-knee amputees. The below-knee prostheses were the patellar-tendon-bearing type, with and without Kemblo inserts. The above-knee prostheses had quadrilateral sockets of various types: wood open end, wood distal air chamber, and plastic total-contact suction socket.</p> <p>Prior to participation in the study, each prospective subject was questioned concerning previous X-ray exposure and allergy to iodine solutions, in order to exclude patients with a history of extensive X-ray exposure or iodine sensitivity. A statement of informed consent was executed by each subject.</p> <h3>Methodology</h3> <p>The study encompassed investigation of the following radiopaque materials and X-ray techniques.</p> <h4>Materials</h4> <ol> <li>Hypaque-M, 90% (Winthrop): An aqueous solution of sodium and meglumine (methylglucamine) diatrizoates, water-soluble organic compounds, used primarily as a contrast medium in studies of the cardiovascular system. Each milliliter supplies 462 mg of iodine.</li><li>Sodium iodide: A saturated solution in absolute alcohol.</li><li>Sodium iodide: A saturated solution (44%) in isopropyl alcohol (70%). Each milliliter supplies 374 mg of iodine.</li></ol> <h4>Procedures</h4> <p>Two or three coats of the contrast medium were applied with a sponge to the entire surface of the stump; the skin was allowed to dry between coats. The procedure was varied by also applying the contrast medium to the inner surface of the socket insert, and by applying lead foil on pressure-sensitive tape to the inner surface of the socket (or socket insert) as a radiopaque marker. The patient then donned his prosthesis, and weight-bearing films were made in the anteroposterior and lateral projections, using either highspeed screens or Kodak Royal Blue Ready-Pack Medical X-ray Film.</p> <p>The X-ray unit used was a Westing-house with an 85-kv peak capacity, and the settings were varied from 100 ma, 1/2sec, 70 kv, 36-in. tube distance, to 100 ma, 1-1/4 sec, 85 kv, 36-in. tube distance, depending on the type of film.</p> <p>Additional films were taken <i>without </i>application of a contrast medium to the stump for half of the subjects. Also, in several instances films were taken while the artificial leg was bearing no weight, <i>i.e., </i>in the mid-swing position.</p> <h3>Results</h3> <p>The techniques used in this study were very satisfactory in providing a definite outline of the periphery of the stump. The films demonstrated a sharp demarcation between the soft tissues of the stump and the inner surface of the insert or socket, thereby clearly indicating the presence or absence of total contact and identifying pressure areas more accurately.</p> <p>With the X-ray equipment used for this study, the optimum settings were determined to be:</p> <p>High-Speed Screens: 100 ma, 75 kv, 1/2sec, 36-in. distance</p> <p>Ready-Pack Film: 100 ma, 85 kv, 1 sec, 36-in. distance</p> <p>Excellent results were obtained with all three of the contrast media, and no significant differences were noted in the films obtained with the three solutions. The saturated solution of sodium iodide in absolute alcohol dries on the skin a little more rapidly than a saturated solution in isopropyl alcohol 70%, but because of Federal regulations, detailed record-keeping is required when absolute alcohol (ethanol) is used. Hypaque-M, 90%, while more expensive than a sodium iodide solution, has the advantage of being commercially available and therefore not requiring the services of a pharmacist for its preparation. Because the iodine compounds are highly water-soluble, they are readily washed off the skin with water after completion of the X-ray exposures. No adverse effects <i>(e.g., </i>skin eruptions) were manifested by any of the patients as a result of these preparations.</p> <p>Application of a contrast medium to the inside of the Kemblo insert (leather backed by rubber) or the inside of the socket (plastic or wood) was not found to be necessary in order to secure satisfactory results. The rubber backing of the Kembio insert and the plastic or wood of the socket are adequately radiopaque for clear demarcation of the inner surface of the prosthesis. The films obtained with the additional step were only marginally superior to those obtained without it, and furthermore, the contrast media tend to stain socket materials, particularly leather.</p> <p>In several instances, lead foil was used successfully as a radiopaque marker of the interface between stump and insert, particularly in cases involving a removable distal-end pad which was not satisfactorily delineated otherwise. This material is available from the Minnesota Mining and Manufacturing Company as Pressure-Sensitive Tape #420-Lead Foil.</p> <p>Examples of films obtained after application of a contrast medium to the stump are shown in <b>Fig. 1</b>, <b>Fig. 2</b>, and <b>Fig. 3</b>. The periphery of the stump is clearly outlined in the films, so that the accuracy of socket fit may be readily determined: whether there is total contact; whether the suitable weight-bearing areas of the stump, such as the patellar tendon, the popliteal space, and the medial and lateral condyles, are being utilized to the best advantage; and whether adequate reliefs have been provided for the head of the fibula and the tibial tubercle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Left, anteroposterior and right, lateral weight-bearing views of a below-knee stump, coated with contrast material, in a well-fitting PTB socket. Note excellent contact between stump and insert except for small air space posteriorly at distal end. Note also the undesirable space between insert and socket at distal end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Left, anteroposterior and right, lateral weight-bearing views of a below-knee stump, coated with contrast material, in a poorly fitting PTB socket. Note lack of distal contact and inadequate bearing on the patellar tendon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Left, anteroposterior and right, lateral weight-bearing views of a below-knee stump, coated with contrast material, in a hard-socket PTS prosthesis with medial condylar wedge. Note that total contact is satisfactory, except for small air spaces at distal end, but the patellar-tendon bar is too high and the posterior brim is insufficiently flared to provide an adequate shelf in the popliteal area. Note also (right) the apparent increased radiodensity in the patellar-tendon weight-bearing area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Inspection of the contrast-medium films for objective indications of stump-socket pressure gradients tentatively suggests, as also remarked upon by McCollough, that areas of compression <i>(e.g., </i>over the patellar tendon) show increased density of the contrast material. An example of this phenomenon is shown in the lateral view of <b>Fig. 3</b>, where increased radiodensity is apparent in the patellar-tendon weight-bearing area.</p> <p>Although X-ray films obtained by routine methods, without the use of a contrast medium, provide considerable useful information about stump-socket fit, they do not always reveal a clear demarcation between the soft tissues and the socket. This observation was confirmed in the present study on comparing films made with and without a contrast medium taken on the same patient, using the same X-ray settings for both series. With few exceptions, the contrast-medium films were superior to the routine films in outlining the periphery of the stump more sharply. An example of this superiority may be seen in comparing the two views in <b>Fig. 4</b>. This improvement in the delineation of the stump-socket interface makes it easier to read the films and eliminates any doubts that may arise concerning the exact relationship between the stump and the socket at various stump levels.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Left, anteroposterior weight-bearing view of an above-knee stump, coated with contrast material, in a plastic hard-end total-contact suction socket. Note clear delineation of the stump-socket interface, showing excellent total contact. Right, conventional anteroposterior weight-bearing view of same stump and socket, using same X-ray settings. Note blurring of stump-socket interface. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>References:</b></p> <ol> <li>Clippinger, Frank W., <i>The temporary patellar tendon bearing limb</i>, Inter-Clinic Inform. Bull., 3:8:5-7, June 1964.</li> <li>Clippinger, Frank W., and Bert R. Titus, <i>A "hard socket" patellar tendon bearing below-knee prosthesis</i>, Inter-Clinic Inform. Bull., 4:10:16-18, August 1965.</li> <li>King, Richard E., <i>X-rays as an adjunct to patellar-tendon-bearing fitting</i>, Inter-Clinic Inform. Bull., 2:6:1-8, April 1963.</li> <li>Lambert, Claude N., <i>Applicability of the patellar tendon bearing prosthesis to skeletally immature amputees</i>, Inter-Clinic Inform. Bull., 3:7:7, May 1964.</li> <li>McCollough, Newton C, and Raymond E. Gilmer, Jr., <i>A method of determining total contact in prostheses</i>, Inter-Clinic Inform. Bull., 6:5:9-13, February 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>5.</b> </td><td class="clsTextSmall">McCollough, Newton C, and Raymond E. Gilmer, Jr., A method of determining total contact in prostheses, Inter-Clinic Inform. Bull., 6:5:9-13, February 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">McCollough, Newton C, and Raymond E. Gilmer, Jr., A method of determining total contact in prostheses, Inter-Clinic Inform. Bull., 6:5:9-13, February 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>1.</b> </td><td class="clsTextSmall">Clippinger, Frank W., The temporary patellar tendon bearing limb, Inter-Clinic Inform. Bull., 3:8:5-7, June 1964.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Clippinger, Frank W., and Bert R. Titus, A 'hard socket' patellar tendon bearing below-knee prosthesis, Inter-Clinic Inform. Bull., 4:10:16-18, August 1965.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">King, Richard E., X-rays as an adjunct to patellar-tendon-bearing fitting, Inter-Clinic Inform. Bull., 2:6:1-8, April 1963.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Lambert, Claude N., Applicability of the patellar tendon bearing prosthesis to skeletally immature amputees, Inter-Clinic Inform. Bull., 3:7:7, May 1964.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">McCollough, Newton C, and Raymond E. Gilmer, Jr., A method of determining total contact in prostheses, Inter-Clinic Inform. Bull., 6:5:9-13, February 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>C. B. Taft </b></td></tr><tr><td class="clsTextSmall">Present address: Columbia Medical Center, 630 W. 168th St., New York, N. Y. 10032.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_02_036/69autumn-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_02_036/69autumn-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_02_036/69autumn-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_02_036/69autumn-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 Radiographic Evaluation of Stump-Socket Fit Creator An entity primarily responsible for making the resource C. B. Taft * https://staging.drfop.org/files/original/b5321419e7289e34cedd7b3e0cbe4493.pdf 1cb64ea6151a427da372f111e67022a4 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_041.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 41 - 42 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_041.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_02_041.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Clinical Study of the Application of the PTB Air-Cushion Socket</h2> <h5>Eric Lyquist <a style="text-decoration:none;">*</a><br /></h5> <p>From January 1966 to September 1968, the Orthopaedic Hospital in Copenhagen conducted a clinical evaluation study of the patellar-tendon-bearing (PTB) air-cushion socket (see p. 1).</p> <p>The Prosthetic/Orthotic Research Department at the hospital fabricated the sockets, using the casting procedure described by Wilson and Lyquist <a></a> and the fabrication procedures described by Lyquist and his associates<a></a>. These procedures and the results of fitting 45 amputees were published in September 1968.<a style="text-decoration:none;">*</a></p> <p>Forty-five amputees were selected for the test series and fitted with air-cushion sockets. Four patients were eventually dropped from the study, three because of their inability to return for re-examination, and one because of her confinement to a wheelchair as a result of progressive vascular disease.</p> <p>The group of 41 amputees consisted of 30 males and 11 females, with ages ranging from 7 to 74 years (average age: 44).</p> <h3>Clinical Evaluation</h3> <p>Seventeen of the amputees had been satisfied wearers of a PTB prosthesis for at least 12 months. After being fitted with air-cushion sockets, 13 noted improved comfort and function, 3 found no change in comfort and function, and 1 was dissatisfied because of nocturnal stump pain.</p> <p>Seven patients had previously been fitted with the standard type of PTB prosthesis, but satisfactory fittings had never been achieved. With fitting of the air-cushion socket, 4 amputees obtained satisfactory comfort and function. One patient was able to wear a modified air-cushion socket with a soft insert. The remaining 2 had to abandon the socket; both had short stumps (2-1/2 in.) with distal hypersensitivity.</p> <p>Seven amputees had previously worn prostheses, but with complications such as ulcerations and secondary distal edema. Six obtained satisfactory comfort and function with the air-cushion socket, but one who had a short stump (2 in.) and extensive skin transplants was fitted after four weeks with a standard PTB prosthesis.</p> <p>Four amputees had successfully worn conventional BK prostheses for periods of 40, 30, 13, and 6 years. Nonetheless, when fitted with an air-cushion socket, each preferred it to the conventional prosthesis.</p> <p>Of the remaining 6 amputees, 5 had never worn a prosthesis. Two of those had distal edema and ulceration, which healed when an air-cushion socket was applied. Another had stump problems not attributable to the prosthesis, but he managed well with the air-cushion socket. A fourth patient had no stump problems, and successfully wore the socket. One amputee had to be fitted with a different type of prosthesis because his stump was hypersensitive distally and the volume was constantly changing.</p> <h3>Summary</h3> <p>Of the 41 amputees fitted with the air-cushion socket, 36 had previously worn prostheses. In that group, 27 noted increased comfort and function, 4 were considered unchanged, 3 returned to wearing a standard PTB prosthesis, and 1 required fitting with a conventional prosthesis. One amputee had previously been fitted with an air-cushion socket by a private pros-thetist, and got along very well. Of the 5 amputees who had not previously worn a prosthesis, 1 was not successfully fitted, but 4 were able to manage well with the air-cushion socket.</p> <p>At the time of this report, 36 of the 41 amputees evaluated in this study were wearing the air-cushion socket. Although extensive final medical examinations of the entire group have not been completed, it is unlikely that the information resulting from those examinations will differ greatly from the results presented in this report.</p> <p><b>References:</b></p> <ol> <li>Lyquist, E., L. A. Wilson, and C. W. Radcliffe, <i>Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, principles and fabrication procedures</i>, Technical Memorandum, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 1965.</li> <li>Wilson, L. A., and E. Lyquist, <i>Plaster bandage wrap cast</i>, Pros. Int., 3:4-5:3-7, 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">Prosthetic/Orthotic Research Department technical report (Danish).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Lyquist, E., L. A. Wilson, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, principles and fabrication procedures, Technical Memorandum, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 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">Wilson, L. A., and E. Lyquist, Plaster bandage wrap cast, Pros. Int., 3:4-5:3-7, 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>Eric Lyquist </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetic/Orthotic Research Department, Orthopaedic Hospital, Copenhagen, Denmark.</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 Clinical Study of the Application of the PTB Air-Cushion Socket Creator An entity primarily responsible for making the resource Eric Lyquist * https://staging.drfop.org/files/original/785f66484a457dd5ea36486281669c63.pdf 2a13be21d16b3cba581d0f5c39829307 https://staging.drfop.org/files/original/de0295080d2342091ee8d35f8b9eb492.jpg 67f6018770a74ed03cb90a1fdcf80b22 https://staging.drfop.org/files/original/a2e780143e6e8508bc090f38eec6847b.jpg ce791d7bd02f539672bfd6aafc1c7955 https://staging.drfop.org/files/original/01140c6f2bcd0a25691175b8982667e4.jpg e646a27436a751e896353b213a2dacc9 https://staging.drfop.org/files/original/039eec2639e19736a06618dc61593eb5.jpg 8c7aaa7044354c386391909637bb056e https://staging.drfop.org/files/original/2acaa9f6178a16d99894a0ec19c23ef7.jpg 4a7f9f5704a2518e642edd71b92c8c87 https://staging.drfop.org/files/original/fb289d965166e603e52ef903cea429f0.jpg 5c402e4e8983f7fc34a947dfa7335046 https://staging.drfop.org/files/original/d63440c21a0f69b8b5fb63b022e61190.jpg 66831f497f8cdab5da95d86117ef5763 https://staging.drfop.org/files/original/85b340c5dff8d0a0258af2bdad391640.jpg e637b228d06590314f7d668b4f83decf https://staging.drfop.org/files/original/3db34f12dfb1ec30ad911b4f9f24f9b3.jpg 47a226f4750a71f160e119ae48cff694 https://staging.drfop.org/files/original/20eafe5419c83630cf610007cac7a089.jpg 1863122494926efc5d49d2ad8f203365 https://staging.drfop.org/files/original/874cfc1d92441810888b9aa4c0d9f3ae.jpg da650953df53e1189a6777e2c01b1726 https://staging.drfop.org/files/original/7dc88dda4cf9dc97e0c41a5b9d4df0d9.jpg cad29965382e0be70dcc5c64fea49d17 https://staging.drfop.org/files/original/4ad6c948c583a6f956dd404eb175790b.jpg 78415e090cb4b1a74fd776db498158fb https://staging.drfop.org/files/original/41b685212583f4394899d15ff59a4ff5.jpg a6bbba17a745d1a8aed594e0f6dd0292 https://staging.drfop.org/files/original/65118f6ccc79f81819690361de395d17.jpg 9e265f25fc1297f5a01dd3614e1cd25e https://staging.drfop.org/files/original/194efbb8bfd7cd41bd9e251cf5345c21.jpg cf723eb59e370d89b74acefbeb52cb82 https://staging.drfop.org/files/original/df9ae6774a07620814409dcd6667d120.jpg 47ea548a6ed55d80d656723d22946d5f https://staging.drfop.org/files/original/0ca4197cba7b3be9c1adb317f610eeb7.jpg f97971b37ea237eb8c1ce8cbaef544a9 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_057.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 57 - 64 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_01_057.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_057.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Direct Forming of Below-Knee PTB Sockets with a Thermoplastic Material</h2> <h5>Anthony Staros <br />Henry F. Gardner <br /></h5> <p> Prior to forming the socket, a careful evaluation of the stump must be made. The usual prosthetics data must be noted, especially any stump characteristics which would require special considerations for socket comfort. </p> <p> With the patient seated, a lightweight cast sock is applied snugly <b>Fig. 1</b> to maintain tension. The top of the sock is clamped to a strap encircling the patient's hips. The strap is made of two halves of mating Velcro for easy adjustment behind the patient's back, and the two free ends are equipped with Yates clamps, which are placed medially and laterally at the top of the sock. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Application of a lightweight cast sock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A strip of 1/4-in. felt, cut to form a tib-ial-crest relief, is positioned from the superior border of the tibial tubercle to <i>and over the end of the stump </i><b>Fig. 2</b>. The portion of the pad over the tubercle is made approximately 1 1/4<i> </i>in. wide, tapering to a 5/8-in. width for the entire length of the tibial crest relief. All edges are carefully skived. If adhesive-backed felt is not available, medical adhesive may be used to attach the pad. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Placement of the relief for the tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A second lightweight cast sock is pulled snugly over the tibial relief and fastened in the same manner as the first sock <b>Fig. 3</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Stump with second cast sock applied. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Using the VAPC knee caliper, the anterior-to-posterior knee measurement at the level of the patellar tendon is taken <b>Fig. 4</b>. The medial-to-lateral dimensions of the epicondyles of the femur are measured in the same manner. These dimensions are useful in determining the accuracy of the socket. The maximum depth of the patellar ledge is determined by the A-P measurement. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Measuring stump dimensions with the VAPC caliper. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Socket Forming </h4> <p> A section of Polysar<a style="text-decoration:none;">*</a> X-414 synthetic rubber tubing with a 1/4-in. wall is selected. The diameter of the tubing should be one-third of the mid-stump circumference. The tube length should be approximately one and one-half times the distance measured <i>from the top of the knee to the end of the stump </i><b>Fig. 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Determining the proper length of tubing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A section of Helenca stockinet 36 in. long is used to pull the heated tube over the stump. One end of the stockinet is pulled up on the stump as shown in <b>Fig. 6</b>. The other end is passed through the heated tube. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The stockinet in position over the stump for pulling on heated plastic tubing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The inside surface of the tube is thoroughly cleaned to remove all plastic dust. (When heated, the dust would cohere to the inner walls, causing undesirable irregularities.) </p> <p> The dust-free tube is softened by immersing it in water heated to 180 deg F, or just under the boiling point, for four to six minutes. Because the inner walls of the tube would cohere instantly if permitted to touch when heated, <i>the tube is placed on its end in the water container.</i> </p> <p> To facilitate slipping the tube over the knee, the upper half is enlarged by spreading (hands together, palms out). The end of the stockinet hanging from the stump is pulled through the heated tube. The tube is pushed on the end of the stump and carried up over the stump by a continuous pull on the stockinet <b>Fig. 7</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Pulling the heated tube over the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Twists or folds in the stockinet should be avoided while drawing the stockinet and plastic tube over the stump. </i>The forming pressures which compress the soft thermoplastic produce a slight imprint of the stockinet material on the inner surface of the socket, and any folds or twists in the stockinet will cause undesirable irregularities in the inner socket wall. The top of the stockinet is then clamped in the same manner as the cast socks. </p> <p> The upper socket borders are trimmed with bandage scissors, leaving the posterior borders approximately 1/2<i> </i>in. higher than the required measurement, for later rolling out of the material to form a relief for the hamstrings <b>Fig. 8</b>. The remainder of the socket border is cut transversely above the superior edge of the patella. The lower tube end and the stockinet are trimmed to provide an extension of 3 in. beyond the stump. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Trimming the upper socket borders before molding. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The stump is held relaxed in 5 to 10 degrees of flexion. Starting approximately 1/2<i> </i>in. above the stump end, a snug wrap of 1-in. elastic pressure-sensitive tape is applied over the tube in a continuous anterior-to-medial spiral, with increasing </p> <p> tension approaching the level of the medial tibial flare and continuing over the knee <b>Fig. 9</b>). The tension is controlled best if one steadies the socket while the other wraps half of the circumference. The hands then change functions to wrap the other half of the circumference. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Application of pressure using an elastic pressure-sensitive-tape wrap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The section of soft tubing extending below the stump will tend to sag. This must be prevented by supporting this section until it cools while molding the material. Approximately 10 minutes are required for the material to harden. During this time, the socket is molded to provide freedom over the anterior end of the tibia by massaging the taped surface of the socket to define the tibial crest and medial flares of the tibia <b>Fig. 10</b>. During the molding process, all surface irregularities may be pressed out of the socket. The socket should not be removed from the stump until the thermoplastic is no longer deformable by hand. The tape is removed, and with the knee flexed to at least 90 degrees, the socket is forced from the stump. Later, pressure-sensitive fiberglass or nylon tape may be put on the socket as a circumferential (barrel hoop) reinforcement, usually required only around the proximal brim. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Hand molding to define the medial tibial flare and tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The resulting open-end socket will permit easy attachment of the shank. Once the socket extension has been secured to the shank, the end of the socket chamber is filled with foam, or another type of resilient end pad is provided. </p> <h4> Socket Modifications </h4> <p> To modify the socket, heat is focused with a heat gun fitted with a cone <b>Fig. 11</b>. With one hand placed inside the socket against the surface to be modified, heat is directed to the <i>immediate area from close range </i>until the heat is sensed by the fingers through the socket wall. <i>Large areas should not be heated, nor should heat be directed against the socket for a prolonged period of time, because excessive temperature will cause the plastic to boil and discolor. </i>When molding for a pressure point, one finger should press from inside the socket, and the surrounding areas should be supported on the outside of the socket with the fingers of the other hand. After the molded area has cooled sufficiently to retain its shape, the socket should be chilled with cold water or refrigerated for a short interval to reset the plastic. <i>Caution must be exercised to avoid heating the entire socket. The heat should be concentrated on the one spot until the pressure applied with the fingers inside the socket causes the material to yield.</i> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Heat gun with modified cone for control of heated area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A similar procedure is followed to shape the patellar-tendon ledge. For patients who have previously worn prostheses, the A-P measurements obtained by caliper are used to determine the depth of the ledge. For recent amputees, the patellar-tendon ledge is not molded to the maximum depth in one adjustment. Instead, three or more adjustments should be made at intervals of one month until the required A-P dimension is reached. </p> <p> The proximal posterior socket border is heated and rolled out to form a smooth radius for comfortable knee flexion <b>Fig. 12</b>, the border being maintained at approximately the patellar-ledge level. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Rolling out the softened posterior socket wall. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> An adjustable pylon is prepared with a wood socket-attachment block 1 V'2 in. thick and 3 in. in diameter, with a Vi-in. deep circumferential groove at the midpoint of the block. The block is tapered to a slightly smaller diameter around the bottom, then fastened permanently to the pylon with bolts and cement <b>Fig. 13</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. The pylon and socket ready for assembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The tube end extending distally from the socket is heated, then fitted over the wood pylon-attachment block, with the groove helping to make a good bond. <i>A 1-in. space between the stump end and the attachment block must be maintained. </i>The tube is taped tightly to the wood block and permitted to cool <b>Fig. 14</b>. Any excess tubing extending below the wood can be trimmed while the plastic is still soft. When hardened, the tube is fastened permanently to the wood block with four screws set at 90-degree angles to one another. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. The heated socket bottom is joined to the pylon with elastic-tape wrap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Suspension </h4> <p> To provide for suspension, the socket can be trimmed at the regular PTB level and a separate cuff used above the knee. Of the several kinds of PTB suspension that can be provided with this socket, suprapatellar-supracondylar suspension is described. </p> <p> The patient is seated in a chair with his knee flexed at approximately 45 degrees, and the stump is covered with two cast socks. The upper socket walls above the level of the upper border of the patella are softened by holding the socket (bottom up) in hot water. When the socket top is heated, the stump is pushed into the socket. The plastic is molded against the thigh over the condyles by wrapping tightly with pressure-sensitive tape and hand molding. </p> <p> After the patient has been fitted and the prosthesis aligned, the bottom of the socket chamber should be foamed to obtain a total-contact fitting. To avoid difficulty in quickly inserting the stump into the socket, the stump is covered with a lightweight sock and a powdered PVA bag. Three 1/8-in. holes are drilled through the lower socket wall at the level at which the stump begins to taper inwardly, away from the socket wall. A foam mixture is prepared and poured into the socket <b>Fig. 15</b>. The patient's stump is inserted into the socket and the patient stands still until the foam has set. The. foam mixture may vary, depending upon the type of stump and condition of the distal tissues. Usually a combination of foam and RTV rubber is used. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Pouring the foam mixture to form the total-contact socket bottom. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Shaping and Finishing</h4> <p> A leg shape can be made from prefabricated sections of semirigid foam, Koroseal Spongex.<a style="text-decoration:none;">*</a> Beginning at the level of the patella, a paper pattern is cut to fit around the socket at this level. The pattern is traced upon one foam section <b>Fig. 16</b>. The foam is carefully sanded to form a hollow for the socket. It is necessary to obtain a tight, gap-free fitting of the foam to the socket; best results are obtained from a slight stretch fit. For this, the foam is heated in an oven at 180 deg F before placement over the socket. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Foam blocks prepared for fitting over the pylon and socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> To cover the remaining part of the pylon, a foam block is cut to correspond to the measurement between the bottom of the foam surrounding the socket and the top of the foot plus 1/4 in. A hole is made through the length of the block large enough to receive the pylon tube. Since the foam is semirigid, the areas for the alignment coupling and ankle plug of the pylon are cut slightly undersize to permit a snug fit about the pylon <b>Fig. 17</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Foam blocks fitted over the socket and pylon and rough-shaped. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A 1/2-in. hole is bored transversely through the foam block to permit entry of a screwdriver to fasten the tube clamp. The two foam sections are <i>not </i>glued together, in order to facilitate removal for alignment adjustments. Compression of the foam block between the socket base and the foot will prevent any movement of the block. </p> <p> The blocks are shaped with a band saw or knife and sanded with a drum or cone sander. For cosmesis, either a flexible poly-urethane coating over the foam or a stocking cover is recommended <b>Fig. 18</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. The prosthesis with a flexible plastic coating over stocking-covered foam. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <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">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>Footnote</b></td></tr><tr><td class="clsTextSmall">Registered trademark of the Polymer Corporation Limited</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1970_01_057/tmp39A-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 Direct Forming of Below-Knee PTB Sockets with a Thermoplastic Material Creator An entity primarily responsible for making the resource Anthony Staros  Henry F. Gardner  https://staging.drfop.org/files/original/f705a88b62579919ebd280734cc87c01.pdf b9eacb74fddcfd81decdd065a6705fdd https://staging.drfop.org/files/original/e05b257845dff7213c7f075b57cf5fcc.jpg bd523911342105f9a2128e78a1aeb6cb https://staging.drfop.org/files/original/11cd3f8a84385221430f3e8c6b68d7a8.jpg b96e00d451e355e664197cf1f6c096b8 https://staging.drfop.org/files/original/81be0b0e594f36536b95cc888ea0798a.jpg 23da1b6dc1872b1b5797b235a956b7c7 https://staging.drfop.org/files/original/3791a0eb792a4d25c7f40b60c75e5b2d.jpg bad29a39e144a9990815beb05f7bbdc6 https://staging.drfop.org/files/original/a2c4d5480f72caa73d1807874cb70fce.jpg 8a15ca8c6b8342bd3cf706868a599486 https://staging.drfop.org/files/original/6f0562d37d37b957ceba489c2e2ca39b.jpg 96e365de47b09be1e0e2dd80223633ac https://staging.drfop.org/files/original/b01cfe724a87500df31cadb5038854e7.jpg bddf845abdebf1a394bf9fd15257f9db https://staging.drfop.org/files/original/3de6676506062bef75f71a38287a7578.jpg 2445d12e95b2289f26c3cbd6f2a18c05 https://staging.drfop.org/files/original/74f77a4af134297887250161d208c62c.jpg 8c549b1b71dbc8c982018a1cee1545fb https://staging.drfop.org/files/original/070812cad4152c89454a35f884e2e3e9.jpg 2a7a6bb1dd1ed4f8098878287bc3d4e8 https://staging.drfop.org/files/original/a2fe1d3281087c6ce407dd3a40dd4c21.jpg f1f8ea956fc5d035040e0eefd468e990 https://staging.drfop.org/files/original/5cab3bf9dca0d59b832e1adb6cb078dd.jpg b7419f891e57061df0c34997b04d0bd5 https://staging.drfop.org/files/original/70128bff2c284b7089ab9d7941dd8170.jpg 3cf6e7ffb74689f5ef7610709e4932dd https://staging.drfop.org/files/original/35d21b8cabb98a340036e5d94c747608.jpg 4372e34ed61e9169c31341fc400b42d2 https://staging.drfop.org/files/original/8e48f7a2f951dd4704f7f69bc1d7c09c.jpg e1364dfabd6d579d4acd84dc43569812 https://staging.drfop.org/files/original/53aa38977adfa885dd4446a080079bea.jpg 047c02beb59db92227b8a507b687614f https://staging.drfop.org/files/original/680e550c3416ad1257bf7172cd07a96b.jpg 0dbe82e84dd46cc9172de94cf4cb754c https://staging.drfop.org/files/original/0018b73701a2a03adb1202951eb9890e.jpg 2bd534a213d889b949b9f5e556cdf482 https://staging.drfop.org/files/original/341143f786b503326091116f2cafa449.jpg af22ca80378e8cdccdf571b5f1d5e0ad DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_065.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 65 - 72 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_01_065.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_065.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>Direct Forming of Below-Elbow Sockets</h2> <h5>Gennaro Labate <a style="text-decoration:none;">*</a><br />Thomas Pirrello <br /></h5> <p>The following equipment and materials are required for this direct-forming procedure:</p> <ul> <li> Polysar<a style="text-decoration:none;">*</a> X-414 tubing</li> <li> Hot plate (thermostatic control optional)</li> <li> Tote pail and cover (height 22 in.; diameter 10 in.)</li> <li> Rubber casting sleeves</li> <li> Silicone spray</li> <li> Manila folders</li> <li> Pressure-sensitive tape</li> <li> Trichloroethylene</li> <li> Heat gun and adapter</li> <li> Cosmetic covers</li> </ul> <p>All the prosthetics information required to fabricate a conventional socket is necessary for forming a socket with Polysar synthetic rubber.</p> <p> 1. A rubber sleeve that will best conform to the stump is selected. (The three sizes which will accommodate most below-el-bow stumps are 3 in. x 6 in. x 14 in., 3 1/2 in. x 6 in. x 14 in., and 4 in. x 6 in. x 14 in.) The rubber sleeve is pulled snugly over the stump, and the proximal end is fastened with Yates clamps to a figure-eight harness. The sleeve is lubricated generously with silicone spray. <b>Fig. 1</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 2. Tubing whose circumference 2 in. from the distal end is closest to <i>but less than</i> the circumference of the stump is selected. (The three tube sizes which accommodate most below-elbow stumps are 4 3/4 in., 5 1/2 <i></i> in. and 6 1/4 in.) The tubing is cut 3 in. longer than the measurement from the lateral epicondyle to the stump end. The inner surface of the tube is cleaned to remove loose particles. <b>Fig. 2</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 3. The tube is immersed in water heated to approximately 180 deg F. (The tube may float when it is completely soft and ductile.) <b>Fig. 3</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 4. The softened tube is removed from the water and the entire inner surface is lubricated with silicone spray. <b>Fig. 4</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 5. After the tube has cooled to skin tolerance, it is drawn up on the stump to a point where the proximal brim is about 1 in. above the olecranon. <b>Fig. 5</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 6. The tube is encircled at the distal end of the stump with nylon cord, and the cord is gently pulled until the tubing conforms to the end of the stump and is completely sealed. <b>Fig. 6</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 7. The excess tubing is cut off close to the cord. <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 /> <p> 8. The tube is molded on the stump to produce the desired contours. The working time is approximately 5 minutes. <b>Fig. 8</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 9. While the tubing is still soft, a trim line is marked according to the socket plan and the tube is trimmed. The socket is cooled before removing it from the stump: the covered stump is immersed in cold water, and hand and finger pressure are used to maintain the socket contours while it is immersed. <b>Fig. 9</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>10. The socket is removed from the stump and trimmed to its final shape. Large areas requiring reshaping may be resoftened by immersion in hot water. Smaller areas may be softened by use of a heat gun and reshaped on the stump. (When using a heat gun on Polysar X-414, it is advisable to use a conical adapter.)</p> <p> 11. The forearm extension is made over a manila folder formed into a conical tube, incorporating the desired wrist fitting. The length of the tube is equal to the epicon-dyle-to-ulnar-styloid measurement. The tube is adjusted so that the proximal end flares into the socket approximately 3 in. over the distal end. <b>Fig. 10</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 12. A length of Polysar tubing is cut approximately 2 in. longer than the manila tube and immersed in hot water until soft. <b>Fig. 11</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 13. A section of 2-in. stockinet which is twice the length of the Polysar tube is pulled through the softened tube. <b>Fig. 12</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 14. With the stockinet used as a "pull sleeve," the softened tube is pulled down until the proximal edge overlaps the proximal end of the manila tube by 1 in. The tube extension is cooled by immersion of the entire assembly in cold water. <b>Fig. 13</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>15. Realignment reference lines are marked on both the socket and the extension, and the extension, manila tube, and wrist fitting are removed.</p> <p>16. The socket surface covered by the extension is sanded lightly, and the socket and the extension are wiped with trichlo-roethylene.</p> <p> 17. The extension tube is replaced on the socket and realigned according to the reference lines. The proximal 3 in. of the extension are heated until soft. <i>(The socket is not allowed to become soft.)</i> The softened end of the extension is compressed until it adheres evenly to the socket, then the socket and extension are immersed in cold water. <b>Fig. 14</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 18. The epicondyle-to-ulnar-styloid measurement is checked, and the extension is trimmed if necessary. <b>Fig. 15</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 15.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 19. One inch of the distal end of the extension is immersed in hot water until soft. The wrist fitting is inserted into the softened extension and the tube compressed around the wrist fitting with pressure-sensitive tape. The alignment is again checked and adjusted if necessary, and the tube is cooled in cold water. <b>Fig. 16</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 16.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 20. The extension and socket are flared by sanding. The wrist fitting is secured with four 3/8-in. #6 self-tapping pan-head sheet-metal screws. <b>Fig. 17</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 17.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>21. The proximal socket brim is buffed with a felt wheel and wiped with trichlo-roethylene to produce a smooth surface.</p> <h4> <i>Finishing</i> </h4> <p> Below-elbow prostheses fabricated with synthetic-rubber sockets are best finished with prefabricated flexible cosmetic covers. Although the sockets may also be finished by conventional laminating procedures, laminates tend to reduce the yielding property of Polysar X-414, and therefore are not recommended. Three cosmetic coverings are illustrated: contoured vinyl sleeve, armlet stockinet, and tubular rubber sleeve. <b>Fig. 18</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 18.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The contoured vinyl sleeve (A) is pulled over the arm after softening in hot water. The cover is trimmed approximately 1/4 in. above the proximal socket brim. </p> <p> The armlet stockinet <i>(B)</i> is sewn closed at the unfinished end. A small opening in the sewn end is made to accommodate the threaded stud of the terminal device. The armlet is pulled over the prosthesis. (The proximal end is not cut.) </p> <p>The tubular rubber sleeve (C) must be bonded to the prosthesis, as follows.</p> <p> 1. A length of 3-in. stockinet is used as a "pull sleeve." The stockinet is inserted into a rubber sleeve cut one and one-half times the length of the prosthesis. <b>Fig. 19</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 19.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 2. The stockinet is pulled over the prosthesis until the rubber sleeve extends 1 in. past the proximal socket edge. <b>Fig. 20</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 20.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 3. Approximately half of the rubber sleeve is rolled back, and the stockinet is trimmed. <b>Fig. 21</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 21.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 4. The exposed portion of the socket is coated with rubber cement, and the rubber sleeve is unrolled while the cement is still wet. <b>Fig. 22</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 22.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 5. The cementing procedure is repeated at the proximal end after removal of the remaining stockinet. When the cement is completely dry, the excess rubber sleeve is trimmed. <b>Fig. 23</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 23.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> <i>Hinges and Transmission System</i> </h4> <p>Metal or leather joints are aligned and fastened with Speed rivets. All other components are installed in the conventional manner.</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">Registered trademark of th ePolymer 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>Gennaro Labate </b></td></tr><tr><td class="clsTextSmall">Veterans Administration Prosthetics Center, New York, N.Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-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 Direct Forming of Below-Elbow Sockets Creator An entity primarily responsible for making the resource Gennaro Labate * Thomas Pirrello  https://staging.drfop.org/files/original/80bd7e168ac76f3973055be7e00862b9.pdf e97318035d3d30c66366bd3b043f7eed DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_073.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 73 - 74 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_01_073.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_073.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Evaluation of Polysar Below-Elbow Fitting </h2> <h5>Clyde M. E. Dolan <br /></h5> <p>The technique of forming sockets directly on below-elbow stumps using Polysar<a style="text-decoration:none;">*</a>, presented in a January 1968 manual by Gennaro Labate and Thomas Pirrello of the Veterans Administration Prosthetics Center, was used to prepare complete prostheses for three amputees, following a demonstration of the technique by VA personnel. The subjects were male, unilateral below-elbow amputees, with stump lengths in the range of 40-60% of the sound-side measurement. Each amputee had previously worn a conventional prosthesis; one had been using a Munster-type fitting immediately prior to wearing the experimental prosthesis.</p> <p>The instructions in the manual were considered by our staff prosthetists to be clear and comprehensive; however, the demonstration of the procedure was particularly helpful. No difficulties were encountered in interpretation or application of the fabrication technique. Each prosthesis was fabricated, from measurement to delivery, in approximately one-half day.</p> <p>At the time of delivery, each synthetic-rubber prosthesis was weighed for comparison with the previously worn conventional product. A staff therapist checked out each prosthesis, and the subject was instructed to wear the arm exclusively during the evaluation period. No special precautionary measures were advised. Initial reactions of the subjects were recorded, with specific reference to weight, cosmesis, the soft foam covering, and comfort.</p> <p>The experimental arms were considerably heavier than the respective conventional arms worn by the subjects. The weights of the complete prostheses (including harness, cable, and APRL hand and glove) were:</p> <table> <tbody> <tr> <td> <p><strong>Subject    </strong></p> </td> <td> <p><strong>Conventional    </strong></p> </td> <td> <p><strong>Experimental    </strong></p> </td> <td> <p><strong>Difference    </strong></p> </td> <td> <p><strong>% Increase    </strong></p> </td></tr> <tr> <td> <p>A</p> </td> <td> <p>788.5 g</p> </td> <td> <p>967.5 g</p> </td> <td> <p>179.0 g</p> </td> <td> <p>22.7</p> </td></tr> <tr> <td> <p>B</p> </td> <td> <p>842.0 g</p> </td> <td> <p>1133.5 g</p> </td> <td> <p>291.5 g</p> </td> <td> <p>34.5</p> </td></tr> <tr> <td> <p>C</p> </td> <td> <p>777.0 g</p> </td> <td> <p>921.5g</p> </td> <td> <p>144.5 g</p> </td> <td> <p>18.7</p> </td></tr></tbody></table> <p>Despite these substantial differences, none of the subjects commented adversely about the weight of the synthetic-rubber prosthesis.</p> <p>Two of the subjects experienced problems related to cosmesis during the initial fitting. The cosmetic cover of Subject B's prosthesis was not sufficiently opaque, and irregularities in the foam underlayer presented an unsatisfactory appearance. This defect was remedied by covering the foam with a layer of Helenca stockinet to improve the color uniformity. Subsequent shifting of this layer caused a wrinkle to develop in the vinyl cover, but this did not disturb the patient.</p> <p>On initial fitting of Subject C's prosthesis, it was apparent that the foam (a 50-50 combination of Silastic 385 and 386) had collapsed in the area proximal to the wrist unit, producing an unsightly configuration. This difficulty was remedied by the use of a somewhat denser foam mixture, one which retained sufficient flexibility to simulate normal flesh turgor but which was nonetheless strong enough to maintain cosmetic shape when the cover was applied.</p> <p>Once those initial problems were solved, all reactions to the soft foam, with a vinyl cover, were highly positive. Initial reactions to the comfort of the experimental sockets were also positive.</p> <p>The three subjects wore the experimental prostheses for periods ranging from two to four months. Only one (Subject A) subsequently experienced problems, and these required that the prosthesis be replaced. It is worth noting that this patient was the one who had previously worn a Miinster-type prosthesis. After wearing the experimental socket for five weeks, he expressed a preference for his previously worn prosthesis in terms of comfort. His socket produced from Polysar had developed embossed ridges caused by the stockinet, which resulted in considerable discomfort and skin irritation. In addition, the socket had deformed, becoming elliptical in the direction of cable pull, which may have contributed to a dermatitis which occurred after that fitting.</p> <p>The other two subjects reported at the close of the period of wear that they preferred the synthetic-rubber fitting to their conventional prosthesis. Subject B reported increased comfort and cosmesis, and also reported greater range of motion, which may be due to slightly lower proximal trim lines and some socket flexibility. Subject C felt that he could wear the prosthesis continuously without discomfort; he found no problem with the weight of the prosthesis and felt "more secure" with the experimental prosthesis than with the previously worn arm.</p> <p>To summarize, the fabrication procedure using Polysar, as demonstrated and as presented in the draft manual, seems to offer advantages in terms of: <i>(a)</i> saving of shop time (the technique requires approximately one-half day, while standard techniques require nearly a full day, not considering curing time), <i>(b)</i>elimination of some opportunities for error through the reduction of the number of steps in the fabrication process, and <i>(c)</i> fabrication of a prosthesis with a soft external surface which simulates normal flesh turgor. Difficulties encountered were: (<i>a</i>) collapse of the foam cover (tending to dent when the sleeve was applied), which may be ameliorated by the use of a denser foam; <i>(b)</i>low opacity of the sleeves, which may be improved by using a dilaminar or a thicker material; (<i>c</i>) weight, which seemed excessive although not noted by the subjects; and (<i>d</i>) possible deformation or embossing of the socket, as noted in the case of Subject A.</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">Registered trademark of the Polymer Corporation Limited.</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 Evaluation of Polysar Below-Elbow Fitting Creator An entity primarily responsible for making the resource Clyde M. E. Dolan  https://staging.drfop.org/files/original/99ea32a0e2c94d4c7589431c1ce25157.pdf 2e7fbc0fa2eb0306b0ca796e5ddda33f https://staging.drfop.org/files/original/db98a4319f901a5df31650f9d7aaafee.jpg 0fa803d29cb641dc7320e3d9a863936f https://staging.drfop.org/files/original/64d9411b67eb520fc954e715926b9298.jpg 726bcec99286d9cecafabb7eb8dc978d https://staging.drfop.org/files/original/16c6695c898c94d3672358c548efdb97.jpg 79d67a4e4d9d172c26b6a84ae56bf6d9 https://staging.drfop.org/files/original/52576dcdb3ac9adc947bf94d02d02a39.jpg ea6217584377d64348133ea09815076b https://staging.drfop.org/files/original/58f2050e89cae296d63c129ffca2499c.jpg e164595194dd9613126ebed26bc18d6f https://staging.drfop.org/files/original/e2bcd7e4954572b656575f76c6af042f.jpg a1cd131317ea4a80a7ff5fa68bb4b971 https://staging.drfop.org/files/original/ab3796e5b9f95a10bab6a6a4709fa759.jpg 929d3223aba1e1b2a7483eeebec5b0cd https://staging.drfop.org/files/original/c6047dac85ad7f0f42b9c09184f5c29b.jpg 65c71a86ab2789401328078e47ef9466 https://staging.drfop.org/files/original/ecf16ce9b6a02f16a28b7068eae7fa6a.jpg bfd62cca40c1d6ea9aa12468949eb70a https://staging.drfop.org/files/original/f517f80846ccc5574405da3e9e1627c2.jpg fde37795ae610a1848e2baff68929c95 https://staging.drfop.org/files/original/f762ec99d412e60f2d8d35ce9d55db87.jpg e26a637f131da62ed04ac2a515036959 https://staging.drfop.org/files/original/b166d882aab8ca9bff2a7ca99b8d8045.jpg 5dfee50cca7846001283b3b9c216796f https://staging.drfop.org/files/original/d6e1c536ddb7878b64b3bb95f1c31c0f.jpg c09e884e976731eb2d27af842c9614ad https://staging.drfop.org/files/original/c751d02f21559b315e9457299166cfeb.jpg 8d9e303bb98ad2f59b8056e9ffca5dca DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_001.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 1 - 18 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Prosthetics and Orthotics Program</h2> <h5>A. Bennett Wilson. Jr. <a style="text-decoration:none;">*</a><br /></h5> <p> Early in 1945, at the request of the Surgeon General of the Army, the National Research Council sponsored a conference of surgeons, engineers, physicists, and prosthetists to consider the feasibility of effecting improvements in artificial limbs<a></a>. Conclusions that emerged from the conference were that virtually no organized research of significance had been conducted in the field of limb prosthetics, and that application of technology already in existence should produce improved devices. </p> <p> Organization of Research Program</p> <p>Subsequently, at the request of the surgeon general, the NRC established the Committee on Prosthetic Devices (later the Committee on Artificial Limbs) to organize a research program<a></a>. (The members of the Committee on Prosthetic Devices were: Paul E. Klopsteg, Ph.D., Chairman; Harold R. Conn, M.D.; Roy D. McClure, M.D.; Robert R. McMath, D.Sc; Mieth Maeser; Paul B. Magnuson, M.D.; Edmond M. Wagner; and Philip D. Wilson, M.D. Consultants: Robert S. Allen and Charles F. Kettering.) Subcontracts were entered into with sixteen universities, industrial laboratories, and foundations: </p> <ul> <li>Adel Precision Products Corp., Burbank, Calif. </li><li>Armour Research Foundation, Chicago, Ill. </li><li>C. C. Bradley and Sons, Inc., Syracuse, N.Y. (Catranis, Inc.) </li><li> Goodyear Tire and Rubber Co., Akron, Ohio </li><li>A. J. Hosmer Corp., Los Angeles, Calif. </li><li>International Business Machines Corp., Endicott, N.Y. </li><li> Mellon Institute of Industrial Research, Pittsburgh, Pa. </li> <li> National Research and Manufacturing Co., San Diego, Calif. </li> <li> Northrop Aircraft, Inc., Hawthorne, Calif. </li> <li> Northwestern University, Evanston, Ill. </li> <li> Research Institute Foundation, Detroit, Mich. </li> <li> Sierra Engineering Co., Sierra Madre, Calif. </li> <li> United States Plywood Corp., New Rochelle, N.Y. </li> <li> University of California, Berkeley and San Francisco, and Los Angeles </li> <li> Vard, Inc., Pasadena, Calif. </li> </ul> <p> Funds were initially supplied by the Office of Scientific Research and Development. With the impending disestablishment of OSRD shortly after World War II, the Office of the Surgeon General of the Army for a short time assumed fiscal responsibility for the program. Then, for fiscal year 1947, the Army and the Veterans Administration shared the support. The Army, the Navy, and the Veterans Administration cooperated by establishing laboratories within their own organizations. </p> <p> In some laboratories, development of components and application of new materials was begun, but it soon became clear to the committee that more knowledge of the patients' requirements was needed if significant progress was to be made. This in turn required a more detailed knowledge of the biomechanics of human extremities, and thus projects in this area were started. Also, anthropometric data were obtained with the idea of selecting rationally a series of standard sizes of components. </p> <p> The activities of the various groups were initially coordinated by the Committee on Artificial Limbs, and considerable progress was made during the first two years. By the spring of 1947, the committee felt that it had completed its task of establishing an organized program and suggested that contracts between the government and the research laboratories be made directly, and that the committee be reconstituted as an advisory group to the sponsoring agency. At that time, the majority of service-connected amputees had been discharged from the armed forces, and their medical care had become the responsibility of the Veterans Administration. Therefore, new contracts were effected between the VA and those laboratories in which promising developments were identifiable (1947: Catranis, Inc.; Northrop Aircraft, Inc.; University of California, Berkeley and San Francisco, and Los Angeles; 1948: New York University.) At the request of the VA, the NRC established the Advisory Committee on Artificial Limbs to continue the coordination and the correlation of the program. The Army, the Navy, and the VA continued to operate their own laboratories. </p> <p> The general feeling at the beginning of the program was that the solution to the problem of providing better prostheses lay in developing new devices, and rapid advances were made by applying new materials and fabrication methods. It was apparent, however, that fit, suspension, and control were at least as important as components were in the successful use of an artificial limb, and perhaps even more so. Letters of inquiry were sent by the committee early in its history to all known limb manufacturers, and one of the first subcontracts was made with the Research Institute Foundation, a laboratory operated by the Orthopedic Appliance and Limb Manufacturers Association. </p> <p> In the spring of 1946, arrangements were made with certain prosthetists to fit experimental suction-socket above-knee limbs, with cooperation from local surgeons and assistance from the committee staff. Studies to establish the principles of socket configuration, fitting, and alignment were initiated as supplements to the existing projects. Both fitting and harnessing of artificial arms were studied at other projects. </p> <h4> Public Law 729 </h4> <p> In 1948, the Eightieth Congress, recognizing the need for continuity in a program of this kind, passed Public Law 729, which authorized the expenditure of $1,000,000 annually for research in limb prosthetics and sensory aids (amended by P.L. 85-56, Eighty-fifth Congress, to remove the $1,000,000 limitation). The Veterans Administration was designated as the appropriate agency for the administration of the funds, and the Administrator of Veterans Affairs was authorized and encouraged to make the results of the proposed program widely available, so that all disabled persons might benefit. </p> <h4> Suction-Socket "Schools" </h4> <p> By October 1948, experience in a number of experimental settings indicated that the suction socket provided significant advantages over other methods of fitting and suspension for above-knee amputations, and that the technique should be released for general use. Because of the many factors which enter into the successful application of the suction socket, however, the publication of a teaching manual was not considered sufficient to ensure success. Therefore, with the assistance of the Orthopedic Appliance and Limb Manufacturers Association (now the American Orthotic and Prosthetic Association) and a distinguished group of surgeons, the NRC organized a series of regional workshops to teach surgeons and prosthetists the proper application of the suction socket. The University of California at Berkeley was assigned the initial responsibility for this program. The regional workshops were continued under VA auspices with cooperation of OALMA through 1952, by which time it was felt that the suction-socket technique had become established. During the entire program, approximately forty workshops were held. </p> <h4> Prosthetics Education Program </h4> <p> Through the findings of the UCLA case study and other endeavors, a considerable body of knowledge in upper-extremity prosthetics had been accumulated by 1952. Hence, the development was undertaken of a medium through which knowledge about the greatly improved devices and techniques that were available could be disseminated throughout the nation. Since the new developments involved the use of plastic laminates for all upper-extremity amputation levels, the time required for thorough instruction in fabrication of prostheses ruled out the use of regional teaching sessions. The Veterans Administration therefore financed the organization and operation of the Prosthetics Education Program at the University of California at Los Angeles. Following a pilot school in 1952 for teams from the Chicago area, participation in the UCLA cources was ultimately extended to surgeons, physicians, occupational and physical therapists, and prosthetists from all over the United States. Prosthetists attended for six weeks; they were joined by the therapists for the last two weeks, and by the physicians and surgeons for the final week, during which these disciplines worked together as a clinic team. </p> <p> The upper-extremity courses proved to be extremely popular and very successful. During the initial, intensive phase of the program (1953-55), 12 courses were conducted. As a result of these efforts, personnel constituting 75 specialized amputee clinics, and representing 30 states and the District of Columbia, were trained. Twenty-eight of these clinics were held at Veterans Administration installations, while 47 were at other public and private institutions. Concomitant with the upper-extremity education program, the VA funded a nationwide field study, conducted by New York University, to assess the value not only of specific devices but also of the treatment program taught at the schools. This study gathered much useful information and also served to reinforce the instructional material. </p> <p> This combined education-research program not only served to introduce new improved concepts in the management of upper-extremity amputees, but also was a tremendous stimulus to the formation of amputee clinics and clinic teams throughout the nation. Today, more than 400 amputee clinics staffed with trained personnel are in operation in the United States. This treatment concept has also spread to other countries throughout the world. </p> <p> The education program at UCLA proved to be so successful that the VA sponsored the establishment of a similar education program at New York University in 1956 to meet the needs of clinic personnel. Subsequently, the Vocational Rehabilitation Administration funded an additional prosthetics school at Northwestern University in 1959. As new devices and techniques emerged from the research program, additional courses were developed at all three schools, so that today every aspect of amputee management is covered. </p> <h4> Present Program Organization</h4> <p> By 1953, the Advisory Committee on Artificial Limbs recognized that child amputees had special problems, and began to work with the Michigan Crippled Children Commission to determine what might be done to solve some of these problems. The Children's Bureau supported the establishment of several research centers, and in 1955 the committee created the Subcommittee on Child Prosthetics Problems. </p> <p> From the beginning, the committee had felt that much of the experience gained in research in limb prosthetics was applicable to the field of orthopedic bracing, but it recognized that problems in orthotics were even more complex. Therefore, work was initially concentrated on prosthetics. About 1960, the Committee on Prosthetics Research and Development took steps to assist in the development of improved orthotic devices and techniques. At the present time, an active program in orthotics, supplementary and complementary to the prosthetics program, is under way. </p> <p> In 1966, at the request of the Veterans Administration, CPRD formed the Subcommittee on Sensory Aids to advise the VA concerning its research program in that area. The subcommittee also serves the Social and Rehabilitation Service in the same capacity. </p> <p> Prior to 1954, most of the research, development, and education activities in prosthetics and orthotics in the United States were supported by the Veterans Administration. In 1954, Congress enacted the Vocational Rehabilitation Act, which for the first time authorized the Office of Vocational Rehabilitation (later the Vocational Rehabilitation Administration and now the Social and Rehabilitation Service of the Department of Health, Education, and Welfare) to support research and education in rehabilitation. The prosthetics and orthotics research and education programs of the VRA were initiated gradually, beginning in 1955-a significant milestone being the assumption of the fiscal responsibility for the three prosthetics schools. </p> <p> Today the Veterans Administration, the Social and Rehabilitation Service, the Maternal and Child Health Service, and, to a limited extent, the National Institutes of Health, all support extramural research in these fields. The VA, the Army, and the Navy also operate research and development laboratories as part of their respective organizational endeavors. </p> <p> The VA, SRS, and MCHS support the Committee on Prosthetics Research and Development, which is responsible for correlating the various research projects and for advising the interested governmental agencies on matters related to prosthetics and orthotics. The VA and SRS also support the Committee on Prosthetic-Orthotic Education of the Division of Medical Sciences, National Academy of Sciences—National Research Council. CPOE's activities are directed toward the stimulation of educational programs for medical and paramedical personnel. </p> <p> Laboratories supported by the VA, SRS, MCHS, the Army, and the Navy, and their areas of interest, are listed at the end of this article. </p> <h4> Accomplishments </h4> <p> As a result of the research program, virtually every aspect of the management of amputees has been changed and improved. A similar program has now been initiated in orthotics, with the findings of the prosthetics program already strongly influencing research and clinical practice in orthotics. </p> <h4> Fundamental Studies </h4> <p> The fundamental studies supported originally by the VA, supplemented later by support from SRS and NIH mainly at the University of California at Berkeley and at Los Angeles<a></a>, have widely increased our knowledge about human locomotion, phantom pain, the functions of the upper extremities, the properties of voluntary muscle, and energy consumption. These studies not only have provided the basis for most of the new designs that have emerged from the research program but also have proven to be a stimulus to others to investigate the basic principles underlying the neuromuscular system. It is anticipated that fundamental studies will continue to contribute to the total research effort. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical force-plate results for a normal subject during level walking, illustrative of the information obtained in fundamental studies. (From Klopsteg, Wilson, et at., "Human Limbs and Their Substitutes,'' p. 453.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Fitting, Alignment, and Harnessing Techniques </h4> <p> Prior to the research program, it was the general surgical practice to amputate at certain specified levels, referred to as "sites of election." Most lower-extremity amputations resulted either in below-knee stumps that were six inches or shorter, or, in the case of above-knee amputations, in stumps no longer than two-thirds the length of the original thigh. Similar circumstances prevailed for upper-extremity amputations. The primary reason for these surgical practices was the lack of satisfactory techniques for fitting the longer stumps, especially those involving disarticulation, despite the fact that, in most cases, the longer the stump, the more functional it is. Improved techniques have now been developed for fitting stumps at all levels, and surgeons have been encouraged to save all length medically feasible. <b>Fig. 2</b>,<b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Force-length measurement of a biceps tunnel. (From "Human Limbs and Their Substitutes," p. 328.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Total-tension I, passive P, and developed-tension ? curves for flexor muscles of the human forearm. (From "Human Limbs and Their Substitutes," p. 328.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> New approaches to alignment based on biomechanics have been established for most amputation levels. New devices to aid in achieving optimum alignment have been devised and made available commercially. Descriptions of the new alignment principles, techniques, and instruments have been widely published, and their application is stressed in the Prosthetics Education Program. <b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. A quadrilateral, total-contact socket developed for above-knee amputees under the program at University of California, Los Angeles. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> As an outcome of biomechanical analyses, new lower-extremity socket designs have been developed for all levels of amputation. The new socket designs have revolutionized fitting practices not only in the United States but also throughout the world. <b>Fig. 5</b>,<b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. The figure-eight, ring-type harness for below-elbow amputees developed at Northwestern University. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The prosthesis for a Syme's amputation developed by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> New harnessing techniques for upper-extremity prostheses, also based on biomechanical analyses, have been developed and made available for general use. </p> <p> Not only have the new fitting, alignment, and harnessing techniques provided the patient with increased function and comfort, but they also are easier for the prosthetist to apply than the older methods. <b>Fig. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The casting jig for above-knee stumps developed by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Among the more significant techniques developed under the program are: the plastic Syme prosthesis, the patellar-tendon-bearing below-knee prosthesis and its variations, the quadrilateral total-contact above-knee socket (with or without suction suspension), the Canadian-type hip-disarticulation and hemipelvectomy prostheses, and various plastic-socket designs for upper-extremity amputations. </p> <h4> Devices </h4> <p> A large number of mechanical components have been developed to provide additional or improved functions. While most of the designs have involved individual components, each was planned in relation to the total prosthesis. Hence, these new items can be used in various combinations to meet the needs of each individual patient. Noteworthy examples among the components developed through the research program are: the harness-operated elbow lock, the APRL voluntary-closing hand and hook, the Northrop 2-load hook, voluntary-opening hand sizes 1-5, the SACH foot, the Henschke-Mauch "Hydraulik" knee units, the Hosmer-DuPaCo "Hermes" unit, and the UCB pneumatic knee unit. <b>Fig. 8</b>,<b>Fig. 9</b>,<b>Fig. 10</b>,<b>Fig. 11</b><b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The Henschke-Mauch "Hydraulik" knee unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The APRL-Sierra Model 44C artificial hand (without glove). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. The Northrop Model C elbow unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The Multiplex above-knee pylon-type prosthesis. Various knee-control devices are interchangeable when this unit is used. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. A below-knee prosthesis fabricated of synthetic balata, with a cosmetic cover, developed by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Clinic-Team Concept </h4> <p> As a planned objective of the VA research program, the clinic-team concept was introduced and encouraged as the preferred method of amputee management. The results achieved have fully established the validity of this concept in providing superior service to the amputee and in promoting more successful use of prostheses. Today, utilization of the amputee clinic team is standard practice in the VA, and many state agencies have followed the lead of the VA by insisting that their patients be treated by a clinic team. Moreover, as a result of the VA experience, the Children's Bureau has encouraged the establishment of more than twenty specialized clinics throughout the United States to serve child amputees. <b>Fig. 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Steps in the clinic-team procedure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Specifications and Checkout Procedures</h4> <p> In the course of the research program, specifications for manufactured components have been developed. The Veterans Administration Prosthetics Center in New York City regularly checks components against the specifications in order to insure that quality is being maintained. This procedure not only insures the provision of safe, durable devices to veterans, but also helps to keep the quality of the devices used by others at a high level. </p> <p> Procedures designed to assure that the total prosthesis is adequately constructed, fitted, and aligned have been developed for the use of clinic teams. These "checkout" procedures are modified as new devices and techniques become available, and have been of great assistance in raising the quality of amputee management. </p> <h4> Reduction in Rehabilitation Time </h4> <p> As a result of the introduction of immediate postoperative fitting procedures<a></a>and early fitting procedures, a substantial reduction in the time between amputation and return to home and job has been effected. The use of a rigid dressing immediately after amputation also helps to reduce edema and pain. </p> <p> At one time it was the rule in many hospitals, once the decision was made to remove part of a limb because of peripheral vascular disease, to amputate through the thigh because of the better blood supply in that region. Various studies have shown, however, that the knee joints in peripheral vascular cases can, with judicious care, be saved. As a result of these studies, rehabilitation time for many geriatric cases has been reduced even further. Indeed, the probability of rehabilitation itself can be markedly increased. </p> <h4> Reduction in Costs </h4> <p> The Veterans Administration has shown that, because of improved devices and procedures for fitting and aligning prostheses, artificial limbs were lasting twice as long in 1968 as they were in 1948. Although the average cost of artificial limbs increased 116.5% during that period, the increased "life" reduced the cost per year per eligible amputee veteran to about the same as it was in 1948.<a></a> </p> <p> In addition to an effective reduction in the cost of the devices, repair, maintenance, and clinic visits were also reduced substantially. There has been no discernible increase in the number of prosthetists in the United States over the past 20 years, yet the number of patients being served has increased considerably during that period, owing to the increase in the general population and to an increase in the number of amputations because of peripheral vascular disease in a population surviving to greater ages. </p> <h4> Dissemination of Information </h4> <p> <i>Prosthetics Education Program</i> </p> <p> The Prosthetics Education Programs originally established by the VA for training its clinic teams have proven to be extremely successful. The short-term courses have made possible the rapid and effective introduction to clinic teams of the new devices and techniques developed by the research program. </p> <p> Since the Prosthetics Education Program was organized in 1953, over 15,000 students have attended the courses offered by the three participating schools-New York University, Northwestern University, and the University of California at Los Angeles. </p> <p> <i>Degree and Associate in Arts Programs</i> </p> <p> Historically, the provision of educational opportunities in a given discipline has tended to create a demand for further education. This phenomenon has also been true of prosthetists and ortho-tists, and has led to the establishment of longer-term courses at several institutions. <b>Fig. 14</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. A typical laboratory scene in prosthetics-orthotics education. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> New York University undertook the most ambitious venture by establishing, in 1964, a four-year curriculum in prosthetics and orthotics leading to the Bachelor of Science degree. Two-year courses leading to the degree of Associate in Arts in prosthetics were begun at Chicago City Junior College (1965) and Cerritos College (1964). </p> <p> These expanding educational endeavors, plus numerous additional offerings such as the certificate course at UCLA and the technicians course at Delgado College, have raised the standard of prosthetics- orthotics practice at all levels, and have exerted a steady upward pressure on the requirements for certification. </p> <p> <i>Publications</i> </p> <p> From the beginning of the research program, it has been the policy of the sponsoring agencies to make new information available as it is developed to those concerned with the welfare of the amputee. This program, which has involved both periodic and special reports,<a></a> was financed initially by the Veterans Administration. SRS and the MCHS have since added their support. </p> <p> <i>Artificial Limbs, </i>a semiannual journal, was created in 1953 to provide a vehicle for dissemination of timely information, primarily to clinic-team personnel. Publication and distribution of the journal is the responsibility of the Committee on Prosthetics Research and Development, and it is mailed gratis to more than 4300 physicians, surgeons, therapists, pros-thetists, and research personnel. </p> <p> In 1961, the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development inaugurated the publication of the <i>Inter-Clinic Information Bulletin, </i>a monthly bulletin which serves as a vehicle for the exchange of information between child amputee clinics. The material for each issue is provided on a regularly scheduled basis by the 29 clinics affiliated with the SCPP's cooperative research program. More than 2500 copies of the ICIB are distributed gratis each month to interested individuals and institutions in the United States and abroad. </p> <p> In 1964, the Prosthetic and Sensory Aids Service of the VA began publication of its own semiannual journal, the <i>Bulletin of Prosthetics Research, </i>which is designed primarily to meet the needs of PSAS and covers a wide range of topics. It is available from the Superintendent of Documents of the U.S. Government Printing Office. Typically, some 2300 copies of each issue are sold, in addition to an official distribution of 3500 copies. </p> <p> In 1954, <i>Human Limbs and Their Substitutes<a></a>, </i>published by McGraw-Hill Book Company, was prepared principally from manuscripts developed by research personnel supported by the VA, and with the collaboration of the Office of the Surgeon General of the Army. This book was essentially a report on the results of the research program up to that time, and contains much basic information. Four thousand copies were printed, and the book had been out of print after 1960 until it was reprinted by the Hafner Publishing Company in 1968. </p> <p> Reports of special conferences organized by the Committee on Prosthetics Research and Development have been prepared in order to provide information useful to others as well as to those attending the meeting.<a></a> </p> <p><b>References:</b></p> <ol> <li>Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, <i>The management of lower-extremity amputations, </i>TR 10-6, Prosthetic and Sensory Aids Service, Veterans Administration, August 1969. </li> <li>Committee on Artificial Limbs, National Research Council, <i>Terminal research reports on artificial limbs covering the period from 1 April 1945 through 30 June 1947 </i>(to the Office of the Surgeon General of the Army and the U.S. Veterans Administration).</li> <li>Committee on Prosthetics Research and Development, Selected bibliography on limb prosthetics, <i>Artif. Limbs, </i>12:2:42-48, Autumn 1968. </li> <li>Klopsteg, Paul E., Philip D. Wilson, et al., <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954. (Reprint edition, Hafner, 1968) </li> <li>Talley, William H., Prosthetics research-a cost reduction program, an editorial, <i>Bull. Pros. Res. </i>10-10, Fall 1968. </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>Report to the Committee on Artificial Limbs, National Research Council, 1947, two volumes. </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Selected bibliography on limb prosthetics, Artif. Limbs, 12:2:42-48, Autumn 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Klopsteg, Paul E., Philip D. Wilson, et al., Human limbs and their substitutes, McGraw-Hill, New York, 1954. (Reprint edition, Hafner, 1968) </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Committee on Prosthetics Research and Development, Selected bibliography on limb prosthetics, Artif. Limbs, 12:2:42-48, Autumn 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Talley, William H., Prosthetics research-a cost reduction program, an editorial, Bull. Pros. Res. 10-10, Fall 1968. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, The management of lower-extremity amputations, TR 10-6, Prosthetic and Sensory Aids Service, Veterans Administration, August 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Fundamental studies of human locomotion and other information relating to design of artificial limbs, Report to the Committee on Artificial Limbs, National Research Council, 1947, two volumes. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Terminal research reports on artificial limbs covering the period from 1 April 1945 through 30 June 1947 (to the Office of the Surgeon General of the Army and the U.S. Veterans Administration).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Terminal research reports on artificial limbs covering the period from 1 April 1945 through 30 June 1947 (to the Office of the Surgeon General of the Army and the U.S. Veterans Administration).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson. Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_02_001/tmp627-14.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Prosthetics and Orthotics Program Creator An entity primarily responsible for making the resource A. Bennett Wilson. Jr. * https://staging.drfop.org/files/original/2fc85c60c7226a13a0b36a4c3f55b706.pdf 1015ca384fb4c55450ab7336157f0e12 https://staging.drfop.org/files/original/9870ea49ca3b524810cc617ce5a3d94f.jpg ab9b271621f72f599c670d82a60509c4 https://staging.drfop.org/files/original/14cc0167c932bde5447863a5f7b623a2.jpg 1cea191f2b4b6608ae4da1574d8fe317 https://staging.drfop.org/files/original/05e104352fa9f9e876932479241f9950.jpg 2f2d99f4d352e789d25910f31122d770 https://staging.drfop.org/files/original/6616944a8dfe6b9525902b40b9dd8b3f.jpg 0ae46995ab7fc9d9679598930bc78367 https://staging.drfop.org/files/original/4d92d55e81af301ff9120f73e722a5ea.jpg d6be1661567bf95eecc853d4a701e159 https://staging.drfop.org/files/original/7f6815a20e1116d8b330d4ffeedec915.jpg 70b9dc35d1c49d7b2367f5786110d7f4 https://staging.drfop.org/files/original/1a03792b27840a1c78fa47f1533aadcc.jpg a1f0ebfdcb8835c34368e4e18a0aa96f https://staging.drfop.org/files/original/d2e5e817ec855cf8a5090203ea04252a.jpg c2e18000a9d63f607414445538a5127a https://staging.drfop.org/files/original/99b1110729d5be53d5372632b1f99f5e.jpg e60ffa11bf1e0160104c6961469365f5 https://staging.drfop.org/files/original/179a4cb425c7c1c3e2b4e69d0deb4b0d.jpg 6936f368155280a6ee861a8d47eae6f4 https://staging.drfop.org/files/original/e257a61c4b3d755547715e26cd4cc4c8.jpg 7c20544d9553748d7ed0bdd741f458a3 https://staging.drfop.org/files/original/aeff19372033051006f60acf23519201.jpg 82814034b6a4eee6b8cea4b79c240fee https://staging.drfop.org/files/original/4c5243190441aaf3d7b39ae66ba22b05.jpg 55814a198f6be93b1165b6dc5f3131a1 https://staging.drfop.org/files/original/7de2b8f37e5098a8bc01f68f89dde50c.jpg 799a900e53acffb7eca6cc27c90c190d https://staging.drfop.org/files/original/ffe762e095ce674cba543f8c6b6af54c.jpg 3cc825142523b27489f284b2df669e90 https://staging.drfop.org/files/original/59e80fe2ca0645265ca467285ab4d708.jpg aaee867706a31c5316cec9088da436e1 https://staging.drfop.org/files/original/db34b03f5f13f15d12b39da96302664b.jpg d5f6e5526a745813d293d449c0128cc6 https://staging.drfop.org/files/original/b1801ada4ed2cd7b7840441a0fe940ba.jpg 187b96b2ae0c03c64bc3bb5daa73d350 https://staging.drfop.org/files/original/505d245ee4399ae61784d79459bbb730.jpg d9906c28819fc1c7f9a42256a7dd469f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_019.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 19 - 48 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_02_019.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_02_019.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>Amputees and Their Prostheses</h2> <h5>Elizabeth J Davies. M.A. <a style="text-decoration:none;">*</a><br />Barbara R. Friz, M.S. <a style="text-decoration:none;">*</a><br />Frank W. Clippinger, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p> Information on 8,698 amputations was collected during a period of approximately two years, ending June 30, 1967. This information was extracted from case-record forms provided by 44 prosthetics facilities in 30 states. The case-record form used was initially developed and standardized by the Conference of Prosthetists of the American Orthotic and Prosthetic Association. Its purpose was to encourage prosthetists in the accurate recording of pertinent information relating to the amputee and his prosthesis. Duplicate copies of the case-record forms were submitted to the Committee on Prosthetic-Orthotic Education (CPOE)<a></a>, National Research Council, in order that significant data could be identified and reported. </p> <p> "The Facility Case Record Study: A Preliminary Report"<a></a> and "Children with Amputations"<a></a>, both reporting findings emerging from this study, have been published previously. </p> <p> Data analyzed in the study included those related to age, sex, level and cause of amputations, reamputations, stump length and contractures, work status of amputees, referrals, months to delivery of prosthesis, age of replaced prosthesis and reason for replacement, components most frequently prescribed for upper- and lower-extremity prostheses, and source of payment for prostheses. </p> <h4> Methods</h4> <p> Each of the 44 facilities submitted case record forms on amputees as they were seen. Three forms were utilized, one for the amputee's medical history, one for the lower-extremity prosthesis, and one for the upper-extremity prosthesis. In cases where the meaning of the data was uncertain, follow-up forms were sent to the prosthetics facilities to clarify or add to the information provided. </p> <p> A coding system was devised, and information was transferred from the case-record forms to coding sheets and then to IBM cards and magnetic tape. Selection of pertinent data for retrieval was determined by an ad hoc group and the staff of CPOE. </p> <p> In order to make comparisons between different areas of the country, the states represented in the study were arbitrarily grouped into five geographical regions <b>Fig. 1</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Subjects</h4> <p> The study included 8,323 amputees with a total of 8,698 amputations. Statistics in this study refer only to patients fitted with a prosthesis; amputees not fitted are not included. <b>Table 1</b> indicates the types of cases included in the study. </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> Amputees or amputations being fitted for the first time were considered "new" cases. Amputees or amputations being fitted with replacement prostheses were considered to be "old" cases. There was a total of 4,034 "new" amputations and 4,664 "old" amputations <b>Table 2</b>. Amputations in males accounted for 6,848 amputations, and amputations in females, 1,850-a ratio of 3.7:1. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Findings </h4> <p><i> Aage of Amputees</i></p> <p> <b>Table 3</b> shows the age of amputees fitted in prosthetics facilities during the two years covered by this study. The incidence of amputations for males peaked in the fifth decade; for females, the peak was reached in the seventh decade. Forty-eight per cent of the amputees were 51 years of age or older, 30 per cent were over 61 years, and 12 per cent were over 71 years. The fact that 23 per cent of the amputees were fitted with either a new or a replacement prosthesis after 65 years of age has Medicare implications. (It should be noted that Medicare was in effect during only the second year of data collection.) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i> Level of Amputations </i></p> <p> Amputations of the lower extremity accounted for 86 per cent of the total number of amputations <b>Table 4</b>. Of these, 53 per cent were at the below-knee level. In the upper extremity, 57 per cent of the amputations were at the below-elbow level. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> There was no significant difference in the incidence of left- and right- side amputation in either the upper or lower extremities. A total of 4,386 left-limb and 4,312 right-limb amputations was reported. The right upper extremity was involved slightly more than the left, 605 to 573, and the left lower extremity fractionally more than the right, 3,813 to 3,707. </p> <p><i> Cause of Amputation</i> </p> <p> Causes of amputation were considered in four categories: congenital, tumor, trauma, and disease. Cases of infection, gangrene, or osteomyelitis resulting from trauma were classified under "trauma." Cases of trauma associated with vascular disease were classified under "disease." </p> <p> Causes of amputation were analyzed by age group and level. Of the 8,698 amputations reported in this study, the cause was known for 8,487 cases; both cause and age were known for 8,394 cases. Fifty per cent of all amputations were caused by trauma, 37.3 per cent by disease, 8.4 per cent were of congenital origin, and 4.3 per cent were due to tumor. <b>Table 5</b> shows the relative incidence of amputation by cause and level. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In <b>Fig. 2</b> the total number of amputations by cause of amputation and age is indicated. Amputees most frequently fitted or returning for replacement in the first ten years of life were those with congenital limb deficiencies. Amputations for trauma led all other categories fitted or returning for replacement between the ages of 11 through 50. In the third, fourth, and fifth decades, this group accounted for 76 per cent, 82 per cent, and 72 per cent, respectively, of all cases fitted or returning. Of those fitted in the sixth decade of life, the incidence was almost equally distributed between traumatic amputations and amputations due to disease. After age 60, the latter group led all other categories by a ratio of more than 2:1. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>"New" Cases by Cause</i> </p> <p> Analysis of all amputations entered in the study gives an overview of the type of amputee being seen and fitted in prosthetics facilities, as reported above. Analysis of those being fitted for the first time, however, provides a picture of persons amputated during the two-year period of data collection and gives a better current indication of cause related to age, sex, and level of amputation. </p> <p> It is probable that the statistics on age are slightly distorted, since age was reported as of the time of fitting. Age at the time of amputation, therefore, would be less, and to a variable degree. </p> <p> In the group of "new" amputees, cause was reported for 3,963 cases, and both cause and age for 3,920. <b>Fig. 3</b> indicates the incidence of amputation by age. Of the "new" cases, 60.2 per cent of amputations were caused by disease, 29.1 per cent by trauma, 5.9 per cent by tumor, and 4.8 per cent were of congenital origin. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The predominance of trauma as the cause of amputation in the overall amputee population of the study <b>Fig. 2</b> is in striking contrast to the predominance of disease as a cause of amputation when only new patients are considered <b>Fig. 3</b>. In the overall picture, the ratio of trauma to disease is 1.3:1, whereas in new patients the ratio is reversed, and disease as a cause of amputation outnumbers trauma 2:1. </p> <p> Thus, the total sample data obviously includes a considerable number of traumatic amputees who lost their limbs at an earlier age and survived to require replacement prostheses. However, the noteworthy finding is that, in the period surveyed, disease-caused amputations were occurring at double the rate of those attributable to trauma. </p> <p> <i>Congenital. </i>In the 191 reported n males, 86 in females <b>Table 6</b>. Of this number, 137 did not require amputation surgery, while 54 did. This surgery presumably involved the conversion of anomalous limbs to stumps that were more suitable for the fitting of a prosthesis. Eighty-three amputations occurred in the lower extremity, of which 44 were at the below-knee level. Of 108 upper-extremity amputations, 78 were at the below-elbow level. Thirty-two per cent of congenital amputations were not fitted until after 11 years of age. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Tumor. </i>Of 235 "new" amputations caused by tumor, 206 (88 per cent) were of the lower extremity <b>Table 7</b>. There were 120 amputations at the above-knee level, accounting for 58 per cent of the lower-extremity amputations. An additional 27 per cent were at a level higher than above-knee, i.e., hip-disarticulation or hemipelvectomy. Males outnumbered females 130 to 105. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The highest incidence of tumor (66 cases or 29 per cent) occurred in the second decade of life. Within this decade, no particular pattern of incidence is discernible <b>Table 8</b>. These data are somewhat at variance with those reported by Taft and Fishman<a></a> from a study conducted by the staff of New York University Child Prosthetic Studies. This study, which involved a larger sampling (278 children whose amputations were caused by tumor), showed a gradual increase in incidence beginning about the 6-8 year period and peaking in the 14-16 year group. Unfortunately, the age groupings are slightly different from those of our study, so an exact comparison cannot be made. However, both studies agree that tumor occurs most frequently in the second decade by a wide margin. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Trauma. </i>Of the 1,156 new cases of amputations resulting from trauma, amputations in males accounted for a total of 1,050, and those in females for 106, a ratio of approximately 10:1 <b>Table 9</b>. The highest incidence of trauma-related amputations occurred in the third decade (250 cases), followed closely by that in the fourth decade (216 cases). The number of amputees in these two decades accounted for 41 per cent of all new cases where age was known. The incidence of amputations in females varied only slightly in each decade between the ages of 11 and 60. The incidence of amputations in males exhibited a sharp rise through the second and third decades, and then receded gradually. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In every decade the involvement of the lower extremity exceeded that of the upper. Actually, the lower extremity was involved 1.9 times as often as the upper, 753 times as opposed to 403. </p> <p> <i>Disease. </i>Sixty per cent (2,381 cases) of all new amputations were caused by disease <b>Fig. 13</b>. Although males outnumbered females by more than 2:1 in this category, the relative percentages of males and females in each age group were closely parallel, e.g., 980 or 61 per cent of males were over the age of 61 years, while 464 or 62 per cent of females were also over the age of 61. After 40 years of age, a sharp rise in the incidence of amputations caused by disease was noticeable. Approximately one-third of the amputations occurred in the seventh decade. Eighty-five per cent of all new amputees in the disease category were over the age of 51 years, and 49 per cent were in the Medicare age group. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In disease-caused "new" amputations, involvement of the lower extremity greatly exceeded that of the upper, the ratio being 73:1. </p> <p> <i>Comparison with Amputee Census</i> </p> <p> The Glattly study<a></a>, reported in 1964 and commonly referred to as the "Amputee Census," included only "new" amputees. It is of interest to compare the findings of that study with the present one. Findings of our study relating to the sex and age of new amputees and the cause, side, and level of amputations closely parallel the findings of the Glattly study. Comparative data of the two studies are depicted in <b>Fig. 4</b>, <b>Fig. 5</b>, <b>Fig. 6</b>, and <b>Fig. 7</b>, and <b>Table 11</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In our study, newly fitted amputees 51 years of age and older accounted for 60.2 per cent of the total, as compared with 58.8 per cent in the Amputee Census <b>Fig. 4</b>. In both studies, the highest incidence of amputation was in the seventh decade. Because many geriatric amputees are not fitted with prostheses, the incidence of amputation in the older age groups would presumably be even higher if statistics on nonfitted amputees were included. </p> <p> In both studies, male amputees exceeded female amputees by approximately three to one <b>Fig. 5</b>. </p> <p> The distribution of right- and left-side amputations was almost equal in both studies, and lower-extremity amputations still accounted for about 85 per cent of all new fittings <b>Table 11</b>. In <b>Fig. 6</b> a higher incidence of below-knee amputations and a lower incidence of above-knee amputations were evident in the more recent study. Among new patients in this study, there was a total of 3,254 above-and below-knee amputations. Of these, 50.9 per cent were above-knee. </p> <p> The relative incidence of trauma as a cause of amputation decreased by four per cent from the Glattly to the present study, and the incidence by cause in other categories increased, but by relatively small amounts <b>Fig. 7</b>. </p> <p> <i>Original Level of Amputation for Disease Correlated with Geographical Area and Age</i> </p> <p> The original level of amputation for disease was examined for 2,242 new cases whose amputations were at either the above- or below-knee level. Comparisons were made between below- and above-knee as the choice of amputation level in each of the five geographical areas <b>Table 12</b>. Below-knee appeared to be the site of choice in less than half the total number of cases. The South led the other geographical areas in percentage of amputations at the below-knee level (54 per cent), followed in order by the Midwest (51 per cent), New England (48 per cent), East Central (46 per cent), and the West (45 per cent). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 12. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A look at the site of the original disease-related amputation for new patients 41 years of age and above revealed some interesting statistics <b>Table 13</b>. In the fifth decade, below-knee was selected in preference to above-knee in 58 per cent of the cases. This percentage gradually decreased over the next two decades to a low of 43 per cent in the seventh decade. After the seventh decade, there was an increase to 47 per cent in the eighth decade and to 50 per cent after the eighth decade. For all new amputations for disease in patients 41 years of age and above, above-knee was selected in 52 per cent of the cases, below-knee in 48 per cent. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 13. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The lack of a consistent pattern in these data is intriguing. A progressive decrease in the proportion of below-knee amputations with increase in age might logically be anticipated. Surgeons, for example, might wish to be more sure of obtaining healing in older patients and elect to amputate at the above-knee level. However, other factors than age of patient obviously enter into the selection of amputation level. </p> <p><i> Specific Causes of Traumatic Amputations</i></p> <p> Trauma was listed as the primary or precipitating cause of 4,306 amputations ("old" and "new" cases). As noted earlier, some of this number were classified in categories other than trauma, since trauma was not considered the primary cause of amputation; hence, the number 4,306 exceeds the number of cases actually coded in the trauma category. Of these 4,306 instances where trauma was mentioned, there were 392 cases where the type of trauma was unknown, so, for purposes of this analysis, reference will be to the 3,914 cases where type was known. </p> <p> <b>Fig. 8</b> summarizes the causes of traumatic amputations. In this category, men were affected ten times as frequently as women: 3,561 to 353. In males, cars, industrial accidents, and war each accounted for approximately 20 per cent of the cases. On the other hand, automobiles were by far the outstanding cause of traumatic amputations in women (49 per cent), with no other cause approaching this in frequency. It is noteworthy that the ratio of male to female automobile-caused amputations was in the order of 4:1, in contrast to the 10:1 overall ratio. Since it is not known whether these female victims were predominantly drivers or riders, the full significance of these data is not clear. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <b>Table 14</b> relates cause of trauma to sex, side, and level of amputation. Involvement of the right upper extremity in males was greater than the left. This preponderance was especially evident in farm and industrial accidents and is doubtless related to handedness. In car accidents, the left upper extremity was involved significantly more than the right for both males and females, 62 per cent as compared with 38 per cent. One can speculate that this incidence might be attributable to the fact that many motorists ride with the left elbow extending beyond an open window. In the small sample of train accidents, the involvement of the left upper extremity in males was also considerably greater than the right but, because of the small number, this probably was without significance. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 14. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The left lower limb was involved slightly more than the right in males, and the right and left limbs almost equally in females. </p> <p> <b>Table 15</b> compares causes cited for "new" traumatic amputations in males with those given for "old" traumatic amputations. Twenty-six per cent of the amputations of "old" cases were due to war injuries, whereas only 2 per cent of the new cases were due to this cause. At the time of this study, the Vietnam War had not yet exerted its full impact. The greatest increase in trauma-caused amputations was seen in the industrial-accident category. Industrial accidents caused 29 per cent of the "new" traumatic amputations, but only 15 per cent of the "old" amputations. Elimination of war cases from the total number avoids distortion of the data due to the preponderance of old war injuries, and thus presents a somewhat truer comparative picture of other traumatic causes. With war injuries eliminated, industrial accidents accounted for 29 per cent of the "new" amputations and 20 per cent of the "old" amputations, which still reflects an increased incidence of amputations caused by industrial accidents. Industrial accidents exceeded all other categories as the cause of amputation in new patients. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 15. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i> Reamputations of the Lower Extremity</i></p> <p> Reamputations were studied in relation to cause, original level of amputation, and present level. Level was reported for 396 reamputations of the lower extremity. Some members of this group had second reamputations, but for the purposes of this study, only the original and present level of amputation were considered. An attempt was made to exclude simple revisions that involved no shortening of bone. </p> <p> In reviewing the figures presented here, it should be remembered, again, that only those patients fitted with prostheses at the time of the study are considered. Despite this limitation, analysis of the available data is thought-provoking. Of 396 reamputations reported, 189 were in the disease-related category involving a total of 3,122 cases <b>Table 16</b>, and 182 were in the trauma-caused group with 3,387 total cases <b>Table 17</b>. Thus, reamputations in the first group ran a shade over 6 per cent, those in the second group a shade under 6 per cent. Stated in reverse, approximately 94 per cent of the cases in both groups did not require re-amputation. The statistics for specific levels are also quite fascinating. In disease-related below-knee amputations, approximately 6 per cent required reampu-tation versus approximately 5 per cent in the like trauma group. In the above-knee group, the comparative proportions are 1 per cent versus 0.6 per cent. At the Syme's level, comparative figures are 25 per cent versus 28 per cent, and for partial feet 96 per cent versus 25 per cent. The reasons for the sharp increase in reampu-tations at the last two levels are worthy of further study. It would also be of interest to know whether partial foot amputations, for example, were or were not successfully performed on many patients who were never fitted with prostheses. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 16. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 17. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> For the 189 (48 per cent) reamputations due to disease, <b>Table 16</b> gives the final as compared to the original level. Of 93 below-knee amputations requiring ream-putation, 22 (24 per cent) remained in the same segment, 67 (72 per cent) were converted to an above-knee level, 3 to a knee-disarticulation, and 1 to a hip-disarticula-tion level. Of the 15 original above-knee amputations, 9 were reamputated in the same segment and 6 became hip disarticulations. </p> <p> Of the 11 Syme's reamputations reported, 2 were reamputated to an above-knee level and 9 to a below-knee level. Of the 67 reamputations at the partial foot level, 22 were converted to an above-knee, 41 to below-knee, and 4 to a Syme's level. </p> <p> Causes of reamputation for patients in the disease category were indicated for 181 of the 189 reamputations. In some instances, two causes of reamputation were cited. In each instance where a cause was mentioned, it was counted as contributing to the reamputation. The total number of contributing causes to reamputation in the disease category therefore was 192 <b>Table 18</b>. "Recurrence of the original cause of amputation" accounted for almost half (48 per cent) of the reasons cited for reamputations. This generalized response is interpreted as meaning a continuance of the original vascular problem responsible for the initial amputation. Specific causes cited were a nonhealing wound (18 per cent), gangrene (12 per cent), infection (5 per cent) stump breakdown (3 per cent), and "other" (14 per cent). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 18. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Most reamputations in the disease category occurred very shortly after the original surgery, 49 per cent occurring in less than 1 1/2 months, and 60 per cent occurring in less than 2 1/2 months. Eighty-two per cent occurred in the first year following the amputation. </p> <p> In the category of traumatic amputations, levels for 182 reamputations of the lower extremity were reported. Of the 114 amputations at the below-knee level requiring reamputation, 57 per cent (65 amputations) remained at the below-knee level, a percentage considerably higher than was the case for reamputations due to disease. Forty-five amputations were converted to above-knee levels and 4 were converted to knee disarticulations. There were 29 Syme's reamputations, of which 23 were converted to below-knee, 3 to above-knee, and 3 remained at the Syme's level. Of the 22 partial foot reamputations, 14 were converted to below-knee levels, 7 to Syme's and 1 to above-knee. </p> <p> Causes of reamputation were known for 157 of the trauma cases. As with reamputations in the disease category, every instance where a cause was mentioned was counted. There were 165 contributing causes to reamputations <b>Table 19</b>. In 71 instances (43 per cent), "other" was coded as the cause of reamputation. Included in the "other" category were causes that could not be readily classified, such as "stump not satisfactory for prosthesis," "shorten bone and remove neuroma," "painful stump." The median number of months between amputation and reamputation was six. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 19. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> There were 16 reamputations for congenital amputees and 6 for patients whose amputations were caused by tumor. Three of the latter were reamputated because of recurrence of the tumor. Reported reasons for reamputations in congenital amputees were too diverse for classification, except that 4 reamputations were because of bony overgrowth. </p> <p> <b>Table 20</b> summarizes the total number of reamputations for each level and includes the percentage of reamputations converted to a higher segment or remaining in the same segment. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 20. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Bony overgrowth was cited eight times as a reason for reamputation: four tibial overgrowths, two fibular overgrowths, and two not specified. All of these reamputa-tions were performed on children, with the exception of one on a 27-year-old amputee. While not implicit in the data, it is conceivable that this 27-year-old had had bony overgrowth for a long time prior to reamputation (his first amputation occurred at age 10). </p> <p><i> Stump Length and Contractures</i></p> <p> There were 2,602 above-knee amputations for which the presence or absence of contractures of the hip was reported. Of this group, 1,345 had either no flexion contracture or a contracture of less than 5 deg, and are not included in this analysis, other than the notation that they comprised over half of the group reported. Stumps with 5+ deg of contracture ranged in length from 2 - 2 1/2<i> </i>inches to 14 - 15 1/2 inches. Three stumps had flexion contractures of more than 60 deg. Hip-flexion contractures were greatest in the very short stump. The average contracture at the above-knee level fell in the 5-9 deg range. </p> <p> There were 3,781 below-knee amputations for which the presence or absence of knee contractures was reported. Of this number, only 12 per cent were reported as having contractures of 5 deg or more. In general, the shorter the stump, the more severe the contracture. Considering only those cases reporting contractures of 5 deg or more, stumps averaging more than 7 1/2<i> </i>in. in length had average contractures of between 5 and 9 deg; for stumps between 4 and 7 1/2<i> </i>in. long, contractures averaged between 10 and 14 deg; and for stumps 3 1/2 in. and less in length, contractures averaged 15 to 19 deg. The average contracture, excluding those of less than 5 deg, was 10-14 deg. Three stumps had contractures of 60 deg or more. </p> <p><i> Work Status</i></p> <p> The work status of "old" male amputees between the ages of 21 and 64, with 2,694 amputations, was reported. "New" amputees were not studied, since the majority of the group had not yet had time to return to employment. Eighty-four per cent of the "old" amputees in the cited age group were employed, the highest employment rate (89 per cent) occurring in the 41- to 50-year-old age group <b>Fig. 9</b>. In each of the age groups studied, a higher rate of employment was reported for upper-extremity than for lower-extremity amputees. It should be noted here that only 6.4 per cent of amputees between the ages of 21 and 64 were reported as not being gainfully employed. The remainder of the group (9.3 per cent) were students, retired, or fell into some other category. This percentage of unemployment is a little higher than that reported for the national average for the years 1965, 1966, and 1967 (4.5, 3.8, and 3.8 per cent respectively). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The rate of employment in relation to each upper- and lower-extremity amputation level appears in <b>Fig. 10</b> and <b>Fig. 11</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Work status was reported for 383 female amputees between the ages of 21 and 64. Of this number, 200 were housewives, 148 were gainfully employed, and only 18 were not gainfully employed. Seventeen had either retired or reported their work status in some other category. </p> <p><i>Referrals</i></p> <p> The majority (58 per cent) of cases fitted at prosthetics facilities were referred by amputee clinics; 26 per cent were referred by physicians; 16 per cent were not referred. Of the "new" cases, 5 per cent were not referred to prosthetics facilities by either a clinic or physician, as contrasted to the 26 per cent of the "old" cases not so referred. </p> <p><i> Months to Delivery of Prostheses</i></p> <p> For "new" amputations, the time from amputation (or from birth for congenital amputees not requiring surgery) to date of delivery of the prosthesis was analyzed by level and cause for the five geographical regions <b>Table 21</b>. The median period to delivery for all prostheses was 6 months. Comparing geographical areas, the median was 5 months for New England, the Midwest and West, 6 months for the South, and 7 months for the East Central region. Of the 3,588 prostheses with times to delivery reported, 71 were delivered in 1 month or less, 67 were not delivered for 99 months or longer. Thirty-seven of the latter were for congenital amputations not requiring surgery, i.e., 37 children were not fitted with their first </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 21. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> prosthesis until after the age of eight years, three months. A comparison of time to delivery by levels indicated that the median time lapse was 5 months for the below-knee prosthesis and 6 months for all other levels. Time to delivery of prostheses ranged from a median of 4 months for below-knee prostheses in the New England area and the West to a median of 10 months for below-elbow prostheses in the East Central region. These data will provide a basis for later comparisons in areas where programs of immediate and early prosthetic fitting have been instituted. </p> <p> Data on months to delivery were analyzed by cause of amputation and related to geographical regions <b>Table 22</b>. The shortest median length of time for delivery was 3 months for congenital amputees who had had surgery. The longest time was for congenital amputations without surgery, where the median was 31 to 36 months; however, it should be recognized here that this median also represents the median age of congenital amputees not requiring surgery who were being fitted for the first time. Median time to delivery for amputations caused by tumor was 4 months; by trauma, 5 months; and by disease, 6 months. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 22. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i> Age of Replaced Prostheses and Reasons for Replacement</i></p> <p> The average age of replaced prostheses for all patients was 6.1 years. For children up to 21 years of age, it was 2.5 years, and for adults, 6.7 years. </p> <p> Comparisons of the ages of replaced prostheses for above- and below-elbow and above- and below-knee amputees in relation to the age of the patient (by decade) are shown in <b>Table 23</b>. In almost every instance, the "life" of the prosthesis increased with the age of the patient. The average life of above-elbow prostheses for 124 amputations was 9.2 years. The range was from 2.5 years for the child through the age of 10 years to 16.7 years for amputees over the age of 61. The average age of below-elbow prostheses for 349 amputations was 6.5 years, ranging from 2.5 years for the child through age 10, to 10.3 years for amputees over age 51. The average age of above-knee prostheses for 1,269 amputations was 6.2 years, with a range from 2.2 years for the child in the first decade, to 8.1 years for amputees over age 71. The below-knee prosthesis had the shortest life, averaging 5.8 years for 2,201 amputations, and ranging from an average of 1.7 years for the child through age 10, to 8.6 years for amputees over 71 years of age. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 23. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In comparing ages of replaced prostheses by cause of amputation and the sex of the amputee, it is found that prostheses for congenital amputees had the shortest life, averaging 3.5 years, and prostheses for traumatic amputees had the longest life, averaging 6.8 years <b>Table 24</b>. The growth rate of children in the congenital group undoubtedly accounts for the more frequent replacements of prostheses evident here. Replacement of prostheses for patients in the disease category occurred, on average, every 5 years, and there was very little difference between replacements for males and females. The life of prostheses for tumor patients also averaged 5 years; however, prostheses for males in this category needed more frequent replacement, lasting 4.5 years as compared with an average 5.6 years for females. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 24. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> It is interesting to note that the age of replaced prostheses for males averaged 6.2 years, and that of females 5.4 years. The large number of males in the trauma category may account for this difference, inasmuch as the average life of prostheses in this category is longer than in others. </p> <p> <b>Table 25</b> indicates the reason for replacement of prostheses. The majority of prostheses were replaced because they were worn out. "Worn out" was listed as the sole or contributing cause of replacing a prosthesis in 58 per cent of the cases. It was the leading reason for replacing prostheses of persons whose amputations were caused by tumor (50 per cent), trauma (67 per cent), and disease (44 per cent). As would be expected, the primary reason for replacing prostheses of congenital amputees was that the prosthesis was "outgrown." In 52 per cent of replacements for congenital amputees, the prosthesis was outgrown; in 33 per cent of the cases it was worn out. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> "Unsatisfactory" was cited as the reason for replacement in four per cent of the cases. However, it should be noted that although the "unsatisfactory" category was meant to include only those cases in which problems arose relating to fabrication or patient tolerance, it was often cited for other reasons which rendered the prosthesis unsatisfactory. Had this item been interpreted correctly, the percentage undoubtedly would have been lower. </p> <p> The average age of all "worn out" prostheses that were replaced was 7.6 years <b>Table 26</b>. This exceeds the average age of prostheses replaced for any reason (6.1 years) by a year and a half. This higher age undoubtedly reflects the longer life of the prostheses of traumatic amputees reported above, since "worn out" was the sole or contributing factor for 67 per cent of the replacements in the trauma category. Additionally, the lower average age of all the replaced prostheses was affected by the inclusion of children's prostheses, which had shorter lives. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 26. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ccomponents for Upper-Extremity Prostheses</i></p> <p> The components most frequently used for upper-extremity prostheses at the above- and below-elbow levels are depicted in <b>Fig. 12a</b>,<b>Fig. 12b</b>. The voluntary-opening hook was used with 87 per cent (201 instances) of the above-elbow prostheses and 90 per cent (517 instances) of below-elbow prostheses. The preference for this type of hook was reflected in all areas except the West, which showed a preference for the voluntary-closing hook with below-elbow prostheses. New England was the only area that did not prescribe the voluntary-closing hook at all. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12a. Most frequently used components for above-elbow prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12b. Most frequently used components for below-elbow prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The hand-type terminal device was utilized to a limited extent, being prescribed 309 times as opposed to the hook-type device which was prescribed 806 times. Many amputees for whom hooks were prescribed were also equipped with hands. Where hand-type devices were reported, the voluntary opening hand was prescribed for above-elbow prostheses 40 per cent of the time (36 cases) and for below-elbow prostheses 36 per cent of the time (79 cases). Both the East Central and Midwest areas preferred voluntary-closing hands for use with above-elbow prostheses. The East Central and Western areas preferred voluntary-closing hands for below-elbow prostheses. New England showed a preference for the passive hand with the below-elbow prosthesis. </p> <p> The simple friction wrist unit was overwhelmingly preferred to quick-change types in all geographical areas, being used with 83 per cent of above-elbow and 85 per cent of below-elbow prostheses. </p> <p> Although the triceps pad was used with 56 per cent of the below-elbow prostheses, its use ranged from 35 per cent in the South to 94 per cent in the New England area. The South preferred the half cuff. Plastic laminate was the cuff material of choice in 61 per cent of the total cases, although the East Central and Western areas preferred leather to the extent of 54 per cent and 55 per cent respectively. </p> <p> The double-wall socket was used in 89 per cent of the above-elbow and 77 per cent of the below-elbow prostheses. Pre-flexed sockets, some of which also had double walls, were used in 11 per cent of the below-elbow prostheses. Sixty-one per cent of the preflexed sockets were utilized by children. </p> <p> In 98 per cent of the upper-extremity prostheses, the sockets were made of plastic. </p> <p> The elbow unit with internal lock was the item of choice for above-elbow prostheses in all geographical areas, being used in 78 per cent of all fittings. Seventeen per cent of all elbow units had spring-flexion assists. Sixty-four per cent of the elbow hinges used in below-elbow prostheses were flexible, the range being from 44 per cent in the West to 92 per cent in New England. The Midwest showed almost equal preference for the single-pivot (47 per cent) and the flexible hinge (50 per cent). </p> <p> Dual-control systems were used in 80 per cent of above-elbow and single control in 96 per cent of the below-elbow prostheses. </p> <p> Eighty-three per cent of the harnesses for above-elbow prostheses were of the figure-eight type, the majority of this group (55 per cent) being equipped with the Northwestern University harness ring. The East Central area and the West showed a preference for the figure-eight harness without the ring. Of the 14 cases with reported type of harness in the West, none used the ring with the figure-eight. The South used the ring to the greatest extent for above-elbow prostheses. </p> <p> Ninety-two per cent of the below-elbow harness were of the figure-eight type, 59 per cent of these being equipped with rings. The East Central, South, and Midwest areas showed greatest preference for the ring figure-eight harness; the New England and Western areas used the figure-eight harness without the ring almost as often as with it. </p> <p> <i>Components for Lower-Extremity Prostheses</i> </p> <p> Components most frequently used for above- and below-knee prostheses appear in <b>Fig. 13a</b>,<b>Fig. 13b</b>. The various geographical areas showed more consistency in prescription of lower-extremity than upper-extremity components. In most instances, only the percentage varied, not the type of component. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13a. Most frequently used components for above-knee prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13b. Most frequently used components for below-knee prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The SACH foot was prescribed for 55 per cent of the above-knee and 73 per cent of the below-knee prostheses. In area comparisons, the South showed the greatest usage of the SACH foot, and the Midwest the lowest. For the above-knee prosthesis, prescription of the SACH foot rose from 76 per cent in the first to 83 per cent in the second decade, and then gradually declined with advancing amputee age. In the below-knee group, the SACH foot was prescribed 96 per cent of the time for children under 10 years of age; the percentage declined steadily to a low of 56 per cent in the eighth decade, then rose to 63 per cent for the group of amputees 81 years of age and over. </p> <p> Wood was used as the shank material in 95 per cent of the above-knee and in 90 per cent of the below-knee prostheses. </p> <p> The most frequently used knee component for above-knee prostheses was the single axis, with friction being used in 74 per cent of the fittings. Twelve per cent of the knees were single axis with manual locks. Eight per cent of the knees were hydraulic, with the West showing the greatest preference (17 per cent) and the Midwest the least (4 per cent). In instances where metal joints were reported for below-knee prostheses, the lap joint was specified in 48 per cent of the cases and the clevis joint in 22 per cent. The type of joint was not specified in 30 per cent of the cases. </p> <p> For above-knee amputees, the quadrilateral socket was used in 85 per cent of the prostheses. It was the overwhelming choice in each of the geographical areas. The socket of choice for below-knee amputations was the patellar-tendon-bearing. Preference for this socket averaged 58 per cent, the South and West showing greatest utilization, 79 per cent and 82 per cent respectively, and the New England and Midwest areas the least utilization, 44 per cent and 47 per cent respectively. </p> <p> Wood was used most often for above-knee sockets, averaging 57 per cent, although the South showed a preference for plastic, using it for 55 per cent of all sockets. Below-knee sockets were most often (55 per cent) fabricated in plastic. New England showed a preference for leather sockets, and the Midwest preferred wood (41 per cent) to either plastic or leather. </p> <p> The pelvic belt was the preferred method of suspension (56 per cent) for above-knee prostheses. Only in the West did the use of suction, either alone or in combination with other suspension, exceed the use of the pelvic belt. In correlating methods of suspension with age, it was noteworthy that during the second, third, and fourth decades, suction alone was preferred to all other types of suspension. In all other decades, the pelvic belt was preferred. </p> <p> In considering types of suspension reported for all below-knee prostheses, the knee cuff alone was the choice of suspension in 36 per cent of the cases. It was least used in the Midwest (22 per cent). The South and West utilized the knee cuff alone most frequently (55 per cent). When type of suspension for the patellar-tendon-bearing prosthesis is analyzed by age group, it is found that, while the knee cuff alone was used for 62 per cent of all </p> <p> the prostheses, greatest usage occurred in the second decade (73 per cent) and next greatest in the third decade (71 per cent). Least use of the knee cuff alone occurred in the very young child (48 per cent), but the inclusion of cases where a waist belt was used in conjunction with the knee cuff raised this percentage to 68. </p> <p><i> Sources of Payment </i></p> <p> <b>Table 27</b>, <b>Table 28</b>, and <b>Table 29</b> indicate the sources of payment for prostheses. More than one source was sometimes listed, in which case they are reported under "combinations of the above "or" "other". Medicare had been in operation only one year prior to the conclusion of this study and presumably would rank considerably higher as a source of payment at the present time. As mentioned earlier, over 23 per cent of the amputees in this study were in the Medicare age bracket. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 27. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 28. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 29. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Source of payment was given for 8,631 prostheses <b>Table 27</b>. The greatest contributors to defraying the costs of prostheses were State Bureaus of Vocational Rehabilitation (22.5 per cent) and the patient himself (22.8 per cent). Next in order were the Veterans Administration (14.3 per cent), welfare (10.8 per cent) and insurance (9.9 per cent). </p> <p> The Children's Bureau paid for 46.5 per cent of the prostheses for children up to the age of 21. Through the wage-earning years, 21 to 64, State Bureaus of Vocational Rehabilitation paid for 31.9 per cent of the prostheses, the amputee for 24.3 per cent, and the Veterans Administration for 19.3 per cent. During the retirement years, 65 and over, the amputee alone paid for 29.9 per cent of the prostheses, Social Security and Medicare for 19.5 per cent, and welfare for 15.3 per cent. </p> <p> A further analysis of sources of payment relating to the wage-earning years yields some interesting facts <b>Table 28</b>. The Veterans Administration paid for 30 per cent of replacement prostheses, but only 10 per cent of new prostheses. This statistic doubtless reflects the continuing supply of prostheses to veterans of World War II and the Korean War and a decreased number of fresh cases. More "new" male amputees were supported by insurance or compensation than "old" male amputees, 24 per cent as opposed to 8 per cent. This may reflect the policy of some insurance companies to pay for the first prosthesis only. On the other hand, it may indicate an increase in opportunity for insuring oneself against disability and a greater awareness of the values of health insurance. In comparing source of payment for males and females in this age group, one notices the higher level of support by the amputees themselves and the Bureaus of Vocational Rehabilitation for the female group, and also the very low percentage of females supported by insurance or compensation. </p> <p> In correlating source of support with occupation, only "old" amputees were considered, since in most instances "new" amputees had not yet returned to work at the time the data forms were submitted. Amputees were studied in three categories: those gainfully employed, those not gainfully employed, and those who were students, housewives, or retired <b>Table 29</b>. </p> <p> Of the 3,055 "old" cases included above, only 187, or 6 per cent, were reported as not being gainfully employed. The Bureaus of Vocational Rehabilitation paid for 35 per cent of the prostheses for the gainfully employed group, the Veterans Administration for 28 per cent, and the amputee for 25 per cent. For the group of amputees not gainfully employed, the Bureaus of Vocational Rehabilitation were the source of payment for 28 per cent of the prostheses, the Veterans Administration for 27 per cent, and welfare for 24 per cent. In the 468 amputations of students, housewives, or retired amputees, 31 per cent of the prostheses were paid for by the amputee, 28 per cent by the Bureaus of Vocational Rehabilitation, and 17 per cent by the Veterans Administration. </p> <h4> Discussion </h4> <p> In recent years, there has been increasing interest in defining the characteristics of the amputee population, and also in providing amputees with functional stumps and prostheses. Much progress has been made in understanding the amputee and his problems, and in the fabrication of improved prosthetic components. This study has sought to document some of the characteristics of the amputee and his prosthesis during a particular period in time-the approximately two years ending June 30, 1967. </p> <p> Certain characteristics of amputees, namely sex and age, and the cause, side, and site of amputation, were well established in Glattly's study of 12,000 new amputees for whom data were collected over a two-year period, ending in 1963. In the present study of over 8,000 amputees, 4,034 of whom were new, data were likewise collected over a two-year period which ended in 1967, four years later. Unless some catastrophic event had occurred immediately before or during either of the two periods, it would be expected that in large samples such as these, the sex and age of the amputee and side and cause of the amputation would be relatively constant. Such was indeed the case, indicating that the sample in the latest study was a valid cross-section of the amputee population. As noted before, neither the Medicare Act nor the conflict in Vietnam had exerted a significant impact on this study. Although medical advances over a number of years have been largely responsible for the increasing age of the amputee, with a resulting shift from trauma to disease as a predominant cause of amputation, such changes would not be expected to exert a significant difference in as short a period as four years. </p> <p> In amputations caused by disease, the site of amputation can be influenced by medical judgment at a particular time. In the vast majority of cases where amputation is categorized as disease, the amputees had vascular insufficiency. For this condition, amputation at a level above the knee had been widely advocated for many years because it was felt that this procedure facilitated healing. It has been found, however, that amputation may be performed at a below-knee level, with primary healing occurring in the majority of cases.<a></a> By preserving the knee joint, amputation at this level greatly enhances the rehabilitation potential of the patient. </p> <p> Burgess has reported that most below-knee amputations for ischemia heal primarily, and with proper prosthetic care do not break down.<a></a> Lim reports that 92 per cent of below-knee amputations were successful when a popliteal pulse was present, and 75 per cent were successful when pulse was absent.<a></a> He also reports a lower mortality rate for below-knee amputees, 16 per cent as opposed to 35 per cent for above-knee amputations. Tracy cites a 90 per cent successful healing rate for below-knee amputations for ischemic gangrene.<a></a></p> <p> Although the increase in the percentage of below-knee amputations in our study, as compared with the Glattly study, is relatively small in view of the <i>potential </i>increase, it is nevertheless an encouraging trend, and it is to be hoped that a dramatic increase will be reflected in future surveys as the results of ongoing educational programs take effect. </p> <p> Although the incidence of amputations due to trauma appears to have declined, as far as percentage of the total amputee population is concerned, this does not necessarily imply a decrease in the overall incidence of traumatic amputations. Actually, the increasing age of amputees, with its corollary of increasing incidence of amputations due to disease, is certainly partly responsible for the decline in percentage of trauma cases. In the younger age groups, trauma continues as the major cause of amputations. The Public Health Service report<a></a> published in 1964 shows that "absence of major extremity," classified as an accident "while at work," occurred almost three times as often as amputation caused by "moving motor vehicles." In the present study, the ratio was closer to 1:1 than 3:1, i.e., moving vehicles as a cause of traumatic amputations was almost equal to that of industrial accident. A higher percentage of auto accidents than industrial accidents occurred in the female group, a pattern which is typical of other reported findings. These results may indicate improved safety controls in industry, or may underscore the soaring rate of automobile accidents, or both. The large number of amputations resulting from trauma continues to have strong implication for improved accident-prevention programs and more effective human-factors engineering. The need for greater safety of design, particularly in cars and industry, continues to be great. </p> <p> It is of interest to note that prosthetic prescription varied among the geographical areas, some areas having a greater tendency than others to incorporate newer prosthetic techniques. It might be expected that the latest prosthetic developments would be incorporated into prosthetic practice in those areas which were near the prosthetic-orthotic educational centers (New York, Chicago, and Los Angeles) or in areas of greatest concentration of prosthetic facilities (California, Pennsylvania, New York, and Illinois), or amputee clinics (New York, Pennsylvania, California, and Texas). With the exception of the West, where newer developments were used in a high percentage of cases, there appeared to be no relationship between the nature of prosthetic services provided and the factors cited above. Both the South and the West showed a more consistent use of newer techniques than did the other areas. </p> <p> The provision of prosthetic services reported in the study indicates that much improvement is to be desired as far as length of time for delivery of the prosthesis is concerned. The time between the date of amputation (or reamputation) and delivery of the prosthesis was inordinately long, ranging from a median of four months for patients whose amputations were caused by tumor to six months for patients with vascular disease. The provision of temporary prostheses and immediate postsurgical fitting of prostheses would help shorten this time lag. </p> <p> The finding that a relatively high percentage of congenital amputees (32 per cent) were not fitted until after their eleventh birthday is distressing. Since current philosophy is to fit congenital amputees at a very early age, it would be interesting to know the reason for this reported delay. Whether the fault lies with amputee clinics, or with parents who are either reluctant to take their children to clinics or are ignorant of the prosthetic opportunities available to them, is not evident from the present analysis. The implication is that more needs to be done at the educational level. The growth and implementation of dynamic treatment programs would surely result in a much more optimistic picture. </p> <p> A composite picture of amputees reported in this study would present the following profile: </p> <ol> <li>The congenital amputee seen in prosthetic facilities was a male under 10 years of age with involvement at the below-knee level. </li><li>The amputee whose amputation was caused by tumor was a male between 11 and 20 years of age whose amputation was at the above-knee level. </li><li>The traumatic amputee was a male now between the ages of 41 and 50 years who had received his amputation between the ages of 21 and 30 years. His amputation was at the below-knee level and was most likely received as a result of a car accident, industrial accident, or war injury. </li><li>The amputee whose amputation was caused by disease was also a male, between the ages of 61 and 70 years, who was amputated during these same years. His amputation was as likely to be at the above-knee level as at the below-knee level. </li></ol> <h4> Summary </h4> <ol> <li>This study, which extended over a two-year period ending in June 1967, presents data on 8,323 amputees with 8,698 amputations, all of whom were fitted with prostheses. </li><li>Of the "new" amputations seen in prosthetic facilities, 60 per cent were caused by disease, 29 per cent by trauma, 6 per cent by tumor, and 5 per cent were of congenital origin. </li><li>Of all amputations, "new" and "old," being fitted in prosthetic facilities, 50 per cent were caused by trauma, 37.3 per cent were caused by disease, 8.4 per cent were of congenital origin, and 4.3 per cent were caused by tumor. </li><li> The greatest incidence of disease-caused amputations occurred in the seventh decade, those of trauma in the third decade, and those of tumor in the second decade. </li><li>Males outnumbered females in every category, the ratio for "new" amputations of males to females being approximately 2:1 for disease, 10:1 for trauma, and 1.2:1 for both congenital causes and tumor. </li><li>Eighty-six per cent of the total number of amputations were of the lower extremity, with 53 per cent of this group being at the below-knee level. </li><li>Although automobile accidents were cited as the single greatest cause of all traumatic amputations, war injuries, industrial accidents, and automobile accidents were cited almost equally for male amputees. </li><li>Forty-eight per cent of all reampu-tations were in the disease category, 60 per cent of these occurring within two and one-half months of the original amputation. The reamputation rate for below-knee amputations caused by disease was not significantly higher than that for trauma-caused amputations-approximately 6 per cent in both instances. </li><li>Degree of contracture reported at both hip and knee varied inversely with the length of the stump. Excluding contractures of less than 5 deg, the average hip flexion contracture for above-knee amputations was in the 5-9 deg range; the average knee flexion contracture for be-low-knee amputations fell in the 10-14 deg range. Fifty-two per cent of those cases reporting presence or absence of contractures had either no contracture or one of less than 5 deg. </li><li> Unemployment rate for "old" male amputees between the ages of 21 and 64 was 6.4 per cent, slightly higher than the national average for the years covered by the report. </li><li>Fifty-eight per cent of patients were referred to prosthetic facilities by amputee clinics, 26 per cent by physicians, and 16 per cent were not referred. </li><li>The median time from amputation to delivery of a prosthesis was six months, the below-knee prosthesis being delivered in the shortest length of time. Congenital amputees who required surgery received prostheses in a median time of three months postsurgery. Patients in the disease category waited the longest time- six months. </li><li> Prostheses had an average life of 6.1 years, with the life of the prosthesis increasing with the age of the patient. Below-knee prostheses generally and prostheses for congenital amputees had the shortest life. Prostheses for males lasted longer than those for females. "Worn out" was the primary reason given for replacing a prosthesis. </li><li>Prosthetic prescription varied in the geographical areas, some regions demonstrating a greater tendency than others to incorporate newer prosthetic techniques. Generally, as the age of the amputee advanced, there was a tendency to use the older types of components, e.g., pelvic hands, articulated ankles. </li><li>The Children's Bureau was the largest single source of financial support for the purchase of prostheses for children, and the State Bureaus of Vocational Rehabilitation provided the greatest financial support for amputees during the wage-earning years. The Veterans Administration paid for a high percentage of prostheses for males who were in the "old" category. In all, the federal government paid entirely for 48 per cent of all prostheses and provided partial support for another 3 per cent. </li></ol> <h4> Acknowledgments </h4> <p> Grateful appreciation is extended to the 44 facility owners and their staffs who provided the data on which this study is based. </p> <p><b>References:</b></p> <ol> <li>Burgess, Ernest M., The below-knee amputation, <i>Bull. Pros. Res., </i>10-9:19-25, Spring 1968. </li> <li>Davies, E. J., B. R. Friz, and F. W. Clippinger, Jr., Children with amputations, <i>Inter-Clinic Inform. Bull., </i>9:3:6-19, December 1969. </li> <li>Friz, Barbara R., and Frank W. Clippinger, Jr., The facility case record study: a preliminary report, <i>Orth. and Pros., </i>23:1:8-17, March 1969. </li> <li>Glattly, H. W., A statistical study of 12,000 new amputees, <i>Southern Med. J., </i>57:1373-1378, November 1964, </li> <li>Lim, R. C, Jr., et al.. Below-knee amputation for ischemic gangrene, <i>Surg. Gynec. Obstet., </i><b>125: </b>493-501, September 1967. </li> <li>Sarmiento, A., and W. D. Warren, A re-evaluation of lower extremity amputations, <i>Surg. Gynec. Obstet., </i>129:799-802, October 1969. </li> <li>Taft, C. B., and S. Fishman, Survival and prosthetic fitting of children amputated for malignancy, <i>Inter-Clinic Inform. Bull., </i>5:5:9-28, February 1966. </li> <li>Tracy, G. D., Below-knee amputation for ischemic gangrene, <i>Pacif. Med. Surg., </i>74:251-253, September-October 1966. </li> <li>U. S. Department of Health, Education, and Welfare, Public Health Service, <i>Impairments due to injury by class and type of accident, United States, July 1959-June 1961, </i>Washington, D.C., 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>9.</b> </td><td class="clsTextSmall">U. S. Department of Health, Education, and Welfare, Public Health Service, Impairments due to injury by class and type of accident, United States, July 1959-June 1961, Washington, D.C., 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>8.</b> </td><td class="clsTextSmall">Tracy, G. D., Below-knee amputation for ischemic gangrene, Pacif. Med. Surg., 74:251-253, 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>5.</b> </td><td class="clsTextSmall">Lim, R. C, Jr., et al.. Below-knee amputation for ischemic gangrene, Surg. Gynec. Obstet., 125: 493-501, September 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">Taft, C. B., and S. Fishman, Survival and prosthetic fitting of children amputated for malignancy, Inter-Clinic Inform. Bull., 5:5:9-28, February 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>6.</b> </td><td class="clsTextSmall">Sarmiento, A., and W. D. Warren, A re-evaluation of lower extremity amputations, Surg. Gynec. Obstet., 129:799-802, October 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Glattly, H. W., A statistical study of 12,000 new amputees, Southern Med. J., 57:1373-1378, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Taft, C. B., and S. Fishman, Survival and prosthetic fitting of children amputated for malignancy, Inter-Clinic Inform. Bull., 5:5:9-28, February 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>2.</b> </td><td class="clsTextSmall">Davies, E. J., B. R. Friz, and F. W. Clippinger, Jr., Children with amputations, Inter-Clinic Inform. Bull., 9:3:6-19, December 1969. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Friz, Barbara R., and Frank W. Clippinger, Jr., The facility case record study: a preliminary report, Orth. and Pros., 23:1:8-17, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Lim, R. C, Jr., et al.. Below-knee amputation for ischemic gangrene, Surg. Gynec. Obstet., 125: 493-501, September 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>Frank W. Clippinger, M.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Orthopaedic Surgery, Duke University; Chairman, Subcommittee on Prosthetics Clinical Studies, CPOE.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Barbara R. Friz, M.S. </b></td></tr><tr><td class="clsTextSmall">Executive Secretary, Committee on Prosthetic-Orthotic Education, Division of Medical Sciences, National Academy of Sciences-National Research Council, Washington, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Elizabeth J Davies. M.A. </b></td></tr><tr><td class="clsTextSmall">Formerly Professional Assistant, Committee on Prosthetic-Orthotic Education.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-19.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 Amputees and Their Prostheses Creator An entity primarily responsible for making the resource Elizabeth J Davies. M.A. * Barbara R. Friz, M.S. * Frank W. Clippinger, M.D. * https://staging.drfop.org/files/original/0fa05d6068c4d9c2c30ab2adf76bb0aa.pdf deefaab5793bb40f246278d00e8ccc28 https://staging.drfop.org/files/original/156df68bab8e0e67d6486f1c12d72e33.jpg 6afb18c555faff017f2713757a472544 https://staging.drfop.org/files/original/ab11f9a0172e3e77c4a779876507f1ec.jpg 953c6d12e2f388522a9851ae0b7342c1 https://staging.drfop.org/files/original/39765be2abc491c73fbb77f348b80811.jpg 75738c583a9d5fa06b2b9cc98ec8bc8a https://staging.drfop.org/files/original/8b190de4debac89f24143367201adc54.jpg afed0ba76e9ca50e2977297894f48191 https://staging.drfop.org/files/original/af863b7df0cad2ab58bb6e8daddd1fae.jpg 90d61436ff957d9a832970284d907b05 https://staging.drfop.org/files/original/f35503438fe05e1cdbc250b4e82f94d5.jpg 99c5889626100eef344a612d0ef0144b https://staging.drfop.org/files/original/b6385b9e916c2dc4ec8d882d296ffbec.jpg 903e5a50735dddcf70b53d421d8535f1 https://staging.drfop.org/files/original/cc1bcdcf0aa82448482125d7233c2050.jpg 54761632a865da1bb94d6a98a6490944 https://staging.drfop.org/files/original/d947b49fd92dd2f0d72c609efb65047e.jpg fbbe8888586ee697db72bd6897bfedbf https://staging.drfop.org/files/original/989181df6cb3cb6b55290a5bec7bf202.jpg a10287ef2e996756c2aa320a34f8dcd2 https://staging.drfop.org/files/original/b766abead8153e3f82f59b077962e0d6.jpg d553d8b4fe2b3d70ec894cad702d03f9 https://staging.drfop.org/files/original/2e918fb95e99cacf4c82973b0212bccc.jpg 005e417a4aafce0105f700f8a6515eef https://staging.drfop.org/files/original/613b9a4452de0437198cd813baaa61e1.jpg acd412db35de4685ce2b71355c40d708 https://staging.drfop.org/files/original/0e7cc252f4b3a1626acbb5dc867a5025.jpg 32c10baf22ef8472383f3c2360990a4a https://staging.drfop.org/files/original/30c3612232851dc3f8d5431dbfe34810.jpg 0a6ff1698181ad1d40fdafef9b9b5b68 https://staging.drfop.org/files/original/087223721d10e6073542b807509106fd.jpg aa7e8d1c20b1c29b8149b00326d1aa1d https://staging.drfop.org/files/original/a4305ebe705f8f02e0602b51a3c82b45.jpg c7376f54499e82996efdbdf24e3aa938 https://staging.drfop.org/files/original/8b3557f24cd0dcb0ef944b5f9d6bbdbe.jpg ad65f6bd2df274a4e558eaadbf017a68 https://staging.drfop.org/files/original/565202e80a39f6169372423c5e5c3957.jpg 31958624e459cec8528a2897b3ecdb11 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_01_001.pdf Year 1971 Volume 15 Issue 1 Page Number(s) 1 - 14 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_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>Premodified Casting for the Patellar-Tendon-Bearing Prosthesis</h2> <h5>Joseph H. Zettl. C.P <a style="text-decoration:none;">*</a><br />Joseph E. Traub. C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>Methods for producing a functional, comfortable, and well-fitting patellar-tendon-bearing prosthesis have been the subject of considerable discussion, and in fact some controversy, since the prosthesis was first introduced several years ago. Prosthetists use a variety of techniques to cast below-knee stumps, and there is an extensive literature on the subject, not excluding the technicians' differing viewpoints. There is agreement, however, that the effectiveness of the prosthesis depends to a great extent upon how well the wrap-cast (negative) was taken and, subsequently, how precisely the male plaster mold (positive) was modified.</p> <p>The positive mold is modified in order to relieve pressure-sensitive areas by the addition of build-ups, and to increase the pressure to the pressure-tolerant (or natural weight-bearing) areas of the stump by the judicious removal of small amounts of plaster. These alterations prevent vertical displacement during stance and provide for comfortable accommodation of the stump during full weight-bearing. The precise amount of plaster removed varies with the individual patient, depending upon the muscle tone and the amount and resilience of the subcutaneous tissue. The procedure is by no means a difficult one, but timing is a complicating factor.</p> <p>Authorities on the subject encourage immediate rather than later modification of the positive cast in order to prevent improper interpretation of the individual stump characteristics. Consequently, the well-qualified prosthetist who finds himself with a large number of plaster positives to be modified, or the less experienced prosthetist who is just developing a keen sense of technical judgment, is at a disadvantage because, even with the best memory and with detailed prosthetic information, he is limited by techniques which involve nothing more than intelligent guesswork and which are conducive to at least an occasional error, regardless of the individual's experience and skill.</p> <p>This difficulty can be overcome by modifying the cast on the patient's stump when the negative-cast impression for the permanent prosthesis is taken. This paper describes such a procedure, essentially initial socket fitting during casting, which provides a plaster negative-positive that requires only a final smoothing to be ready for socket lamination. The method includes the application of felt pads to strategic areas of the stump. Elastic plaster bandage is used for the negative plaster wrap because it effectively conforms to the irregular stump surfaces, controls tissue compression and displacement, and yields a precise stump impression. The resulting positive plaster mold resembles the stump contours accurately, thus providing the basis for a comfortable, well-fitting, and functionally acceptable PTB prothesis.</p> <p>Provision of a total-contact, hard PTB socket, without a soft end or the customary insert, is the standard procedure at the Prosthetics Research Study, and the pre-modified-casting procedure results in a precise reproduction of the stump socket, so essential in hard-socket prostheses. This method has been used routinely at this facility since 1964, during which time several hundred PTB prostheses have been effectively fitted.</p> <p>The premodified-casting procedure can be used, with but relatively minor modifications, for the patellar-tendon supracondylar or the patellar-tendon supracondylar-suprapatellar (PTS) prosthesis, with wedge suspension. We have also used this technique, with promising results, for the production of interim prosthetic sockets using both synthetic rubber, Polysar X-414 (TM), and Lightcast (TM). Both these materials will produce an effective interim prosthetic socket for immediate and early fitting.</p> <h3>Procedure</h3> <h4>Negative Plaster Wrap</h4> <p><i>Prosthetic Information</i></p> <p>Examine the stump to obtain all pertinent prosthetic information. Measurements of the normal leg can also be recorded at this time on page B of the prosthetic information form, but measurement of the stump is postponed until all felt relief pads have been applied to the stump.</p> <p><i>Materials and Equipment</i></p> <p>Materials required for the premodified plaster cast for a PTB prosthesis are:</p> <ul> <li>One lightweight cast sock</li> <li>One heavyweight cast sock</li> <li>Dow Corning Medical Adhesive Spray Type B</li> <li>Two rolls of 4- or 5-in. elastic plaster bandage</li> <li>One roll of 4-in. conventional plaster bandage</li> <li>Four plaster splints, 4 in. x 15 in., extra-fast-setting</li> <li>Soft felt, approximately 5 in. x 10 in. x 1/8 in. thick</li> <li>Medium felt, approximately 5 in. x 10 in. x 3/8 in. thick (or a right or left set of prefabricated felt relief pads, as used in immediate postsurgical prosthetic fitting)</li> </ul> <p>Equipment required for this procedure is:</p> <ul> <li>Two 48-in. lengths of 1-in. elastic webbing</li> <li>Four Yates clamps</li> <li>One pair medium-size scissors</li> <li>Skiving knife</li> <li>Inside calipers</li> <li>Measuring tape</li> <li>Combination square</li> <li>VAPC knee-measuring caliper</li> <li>Preshaped piano-felt, hamstring-tendon relief pads</li> <li>Below-knee casting fixture</li> <li>Bucket or basin of clear water, approximately 70 degrees F</li> </ul> <p><i>Preparation of Patient</i></p> <p>Have the amputee sit on a table approximately 30 inches high, with the knee of the amputated leg extending six to eight inches beyond the table edge (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Roll the heavy cast sock onto the stump and attach the proximal portion of the cast sock with two Yates clamps to the 1-in. elastic-webbing strap which encircles the amputee's hips and crosses the amputated leg approximately four inches proximal to the patella (<b>Fig. 2</b>). The strap should exert considerable tension on the cast sock in order to support all soft tissues of the stump, particularly those located distally. <i>This is most important </i>because improper tissue support would result in too large a cast, necessitating modifications of the positive model or prosthetic socket to achieve proper fit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Direct the amputee to flex his knee approximately 35 degrees and to maintain this flexion in a relaxed attitude throughout the entire casting procedure.</p> <p><i>Preparation of Pressure-Relief Pads</i></p> <p>By palpation, locate the surface areas of the stump which require pressure relief.</p> <p>For the <i>tibial crest:</i></p> <ol> <li>Measure the entire length of the crest of the tibia from the proximal border of the anterior tibial tubercle to 1/2<i> </i>in. beyond the posterior edge of the transected tibia.</li><li>Measure the width of the anterior tibial tubercle and the cut end of the tibia.</li><li>Cut a piece of <i>soft </i>felt, 1/8-in. thick, to the length dimension taken in step 1 and width dimension taken in step 2. This results in a felt relief pad (<b>Fig. 3</b>) which has a long rectangular form and widens in its distal aspect into a well-rounded teardrop shape, approximating the contours of the cut end of the tibia.</li><li>Neatly skive the periphery of the tibial relief pad to assure a smooth transition between the stump sock and pad.</li><li>Usually, additional relief of the distal anterior tibial area is indicated. The additional relief pad should represent the contours of the cut end of the tibia, resulting in the general shape of a large metatarsal pad. The periphery of the pad is smoothly skived to blend in with the tibial relief pad (<b>Fig. 4</b>).</li></ol> <p>For the <i>head of the fibula:</i></p> <ol> <li>Measure the proximal-distal and anterior-posterior dimensions of the head of the fibula.</li><li>Fashion a piece of <i>soft </i>felt, 1/8-in. thick, to those dimensions, rounding off all corners and neatly skiving the periphery. The fibular relief pad should have a shape similar to a large metatarsal pad.</li></ol> <p>VARIATION: If the cut end of the fibula is prominent, sensitive, or close to the surface, provide another felt relief pad according to its dimensions and skive all edges.</p> <p>For the <i>anterolateral condylar ridge of the tibial plateau:</i></p> <ol> <li>Measure the length and width of this area.</li><li>Fashion a piece of <i>soft </i>felt, 1/8-in. thick, to the dimensions obtained in step 1 (<b>Fig. 5</b>).</li><li>Round off all corners and neatly skive the entire periphery. This results in an oval-shaped condylar-ridge relief pad.</li></ol> <p><i>Application of Pressure-Relief Pads</i></p> <ol> <li>Spray all felt relief pads with Dow Corning Medical Adhesive Type B on the reverse, or unskived, side and allow the adhesive to dry for five seconds.</li><li>Spray the appropriate areas on the cast sock where the relief pads will be located and allow the adhesive to dry for five seconds.</li><li>Apply the felt relief pads in their pre-established locations and recheck to be sure they adequately cover the bony prominences on the stump (<b>Fig. 6</b> and <b>Fig. 7</b>).</li></ol> <p><i>Stump Measurements</i></p> <ol> <li>Remind the patient to maintain his stump in an attitude of 35 degrees of flexion, with the stump musculature relaxed.</li><li>Place the appropriate portion of the VAPC knee-measuring caliper on the femoral condyles. Measure the mediolateral stump diameter and record on the prosthetic-information form (<b>Fig. 8</b>).</li><li>Place the appropriate portion of the VAPC knee-measuring caliper on the patellar tendon and the popliteal tissues. With the stump relaxed, measure the anteroposterior diameter and record on the prosthetic-information form (<b>Fig. 9</b>).</li><li>Mark the apex of the patellar tendon with an indelible pencil (<b>Fig. 10</b>). Place one end of the combination square rule on the patellar tendon and rest the blade of the rule against the long axis of the tibial-crest felt relief pad. Square the distal stump end and record the resulting stump-length measurement in the appropriate box on the prosthetic-information form.</li></ol> <p><i>Second Cast Sock and Hamstring-Tendon Relief</i></p> <ol> <li>The second cast sock, lightweight, is applied very wet. Carefully roll the sock onto the stump without displacing the previously applied felt relief pads.</li><li>The posterior socket brim line should have a well-rounded flare for comfort during prolonged sitting. Appropriate relief for the hamstring tendons provides additional comfort when the knee is maintained in an attitude of 90 degrees of flexion. For this purpose, two standard sets of relief pads in sizes large and average are fashioned from one-inch-thick piano felt. Each set consists of a right and left relief pad. They must resemble the finished rounded contours of the posterior socket brim and include skived distal projections for medial and lateral hamstring-tendon relief. Pad selection is based on matching the distal projections against the hamstring tendons.<br />Select a right or left piano-felt hamstring-tendon relief pad of the proper size (<b>Fig. 11</b>) and place it at the approximate level of the posterior socket brim behind the knee, between the first and second cast socks (<b>Fig. 12</b>). The projections on either side of the relief pad should be located directly over the hamstring tendons behind the knee. Maintain the knee in 35 degrees of flexion.</li><li>With the hamstrings relief pad in place, the second, or lightweight, cast sock is pulled up tight and attached with Yates clamps to a second 1-in. elastic-webbing strap which encircles the amputee's hips and crosses the amputated leg approximately 4 in. above the patella (<b>Fig. 13</b>). This elastic-webbing strap must also exert considerable tension on the second cast sock, without creating wrinkles.</li><li>Recheck all felt relief pads for retention of their proper locations and adjust if indicated.</li></ol> <p><i>Preparation of Compression Pads</i></p> <p>By palpation, locate the surfaces of the stump which are pressure tolerant.</p> <p>For the <i>pretibial area lateral to the tibial crest:</i></p> <ol> <li> Measure the length of the crest of the tibia from the inferior border of the anterior tibial tubercle to within 1/2<i> </i>in. of the anterior cut end of the tibia.</li><li> Measure the distance between the lateral edge of the previously applied tib-ial-relief pad to the anterior border of the fibular head.</li><li> Cut a piece of 3/8-in. <i>medium </i>felt to the dimensions recorded in steps 1 and 2.</li><li> Round off all corners of the pad. The entire periphery is now provided with a 1/2-in. skived border, with a uniform gradual taper, finishing in a feathered edge (<b>Fig. 14</b>).</li></ol> <p>For the <i>pretibial area medial to the tibial crest, </i>including the medial tibial condylar flare:</p> <ol> <li>Measure the length of the crest of the tibia from the inferior border of the tibial tubercle to within 1/2<i> </i>in. of the anterior cut end of the tibia.</li><li>Measure the distance between the medial border of the previously applied tibial relief pad at the level of the tibial tubercle and the medial head of the gastrocnemius muscle.</li><li>Cut a piece of <i>medium </i>felt, 3/8-in. thick, to the dimensions recorded in steps 1 and 2.</li><li>Measure down from one end of the felt compression pad 2 in. and mark that point with chalk.</li><li>Palpate the width of the tibia medial to the crest and measure this distance.</li><li>Mark the felt compression pad at the same distance from the long edge one inch below the mark made in step 4 (<b>Fig. 15</b>). Mark on the felt compression pad a smooth S curve from the posterior edge of the felt to the marks in steps 4 and 5.</li><li>Continue the mark made in step 5 with a straight line to the distal end of the felt compression pad (<b>Fig. 16</b>).</li><li>Cut the felt along the marked lines made in steps 4, 6, and 7 (<b>Fig. 17</b>).</li><li>Round off all corners. The entire periphery of the felt compression pad is now provided with a 1/2-in. skived border, with a uniform, gradual taper, finishing in a feathered edge.</li></ol> <p>For the <i>long shaft of the fibula:</i></p> <ol> <li>Measure the length of the fibula from the inferior border of the head to within 1/2 in. of the distal cut end of the bone.</li><li>Measure the anteroposterior dimension of the head of the fibula.</li><li>Cut a piece of <i>medium </i>felt, 3/8-in. thick, to the dimensions recorded in steps 1 and 2 (<b>Fig. 18</b>).</li><li>Round off all corners. The entire periphery of the fibular compression pad is now provided with a 1/4-in. skived border with a uniform, gradual taper, and finished in a feathered edge.</li></ol> <p><i>Application of Compression Pads</i></p> <p>Apply the felt compression pads to the second (lightweight) sock.</p> <ol> <li> Spray all felt relief pads with Dow Corning Medical Adhesive Type B on the reverse, or unskived, side and allow the adhesive to dry for five seconds.</li><li> Spray the corresponding areas of the cast sock where the felt compression pads will be located and allow the adhesive to dry for five seconds.</li><li>Carefully locate the felt compression pads in their pre-established positions on the thin cast sock (<b>Fig. 19</b>, <b>Fig. 20</b>, and <b>Fig. 21</b>). These pads <i>must not overlap </i>the areas of the previously applied pressure-relief pads. The felt compression pads should be in firm smooth contact with the thin cast sock to avoid reproduction of wrinkles, rough edges, or other irregularities in the plaster wrap.</li></ol> <p><i>Application of Elastic Plaster Bandage</i></p> <p><i>Wraps One and Two. </i>The wrap is always started on the distal lateral aspect of the stump, approximately 1 in. from the distal stump end, to avoid medial displacement of the gastrocnemius muscle (<b>Fig. 22</b>). Minimal tension is applied to the bandage with this circumferential wrap, which is applied clockwise for a right stump and counterclockwise for a left stump (viewed anteriorly). One and three-quarter circumferential wraps will secure the felt compression pads and anchor the elastic plaster bandage to itself (<b>Fig. 23</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Wrap Three. </i>The wrap is now at a posterior-lateral point on the stump. Bring it anteriorly in a diagonal direction over the distal <i>lateral </i>portion of the stump, pulling the plaster bandage almost to its limit of elasticity. At the anterior stump margin, release the tension slightly and carry the wrap medially and then posteriorly, with only a slight pull to the plaster bandage (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Wrap Four. </i>This wrap is almost identical to wrap three, except that now the bandage covers the distal <i>center </i>of the stump, bandaging in an anteroposterior plane. The direction of the wrap is altered anteriorly and carried toward the lateral side of the stump, as if to resume circumferential wrapping.</p> <p><i>Wrap Five. </i>The wrap is brought anteriorly up over the distal <i>medial </i>stump aspect with the same controlled tension to the plaster bandage (<b>Fig. 25</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Wrap Six. </i>To achieve sufficient cast strength, a second layer of elastic plaster bandage is applied by repeating wrap five.</p> <p><i>Wrap Seven. </i>Repeat wrap four, again altering the direction of the wrap to the medial side, which will cover the distal <i>center </i>of the stump with a second layer of plaster bandage.</p> <p><i>Wrap Eight. </i>Repeating wrap three will now cover the distal <i>lateral </i>stump aspect with a second layer of plaster bandage. The remainder of the elastic bandage is wrapped in a circular manner to a level 1/2 in. superior to the adductor tubercle of the femur.</p> <p>A second roll of elastic plaster bandage is applied when indicated. Pull the plaster bandage firmly so that it conforms smoothly to the stump without leaving wrinkles or ridges. Maximum tension should be applied to the bandage distally, with gradually decreasing tension as the wrap is extended proximal to the knee joint. Smooth the plaster gently to assure complete adherence of all layers, but avoid molding of the plaster as it hardens (<b>Fig. 26</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Application of Below-Knee PRS-Model Casting Fixture</i></p> <p>With the plaster still wet, apply the BK casting fixture (<b>Fig. 27</b> and <b>Fig. 28</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>Open the casting fixture and place the patellar bar on the patellar tendon.</li><li>Push the patellar bar into the joint space until firm resistance is felt, then release slightly. Push in a direct line with the femur (<b>Fig. 29</b>).</li><li>Attach the posterior popliteal section to the anterior portion of the casting fixture. Contouring of the plaster cast in the area of the popliteal space is achieved by joining the two sections of the casting fixture in proper relationship to the casted stump (<b>Fig. 30</b>).</li><li>Be sure that the patient is completely relaxing his stump musculature and that the knee-flexion angle is maintained at 35 degrees.</li><li>Adjust the casting fixture to the patellar size by rotating both halves of the patellar inverted-horseshoe section.</li><li>Recheck and maintain the outline of the patella. Makes necessary adjustments by means of the thumbscrews as indicated.</li><li>Hold the casting fixture in place until the plaster has hardened completely. Check the distal end of the cast to determine final firmness of the plaster wrap.</li><li>Open the casting fixture and remove carefully (<b>Fig. 31</b>).</li></ol> <p><i>Reinforcement of Negative Plaster Wrap</i></p> <p>Apply conventional plaster bandage to reinforce the cast.</p> <ol> <li>Two double layers of 4 in. x 15 in. plaster splints are applied over the distal portion of the cast, one anteroposteriorly and one mediolaterally (<b>Fig. 32</b>).</li><li>Reinforcement of the plaster wrap is completed with a roll of 4-in. conventional plaster bandage, starting at the distal stump aspect (<b>Fig. 33</b>) and wrapping prox-imally with even, overlapping, circular wraps.</li></ol> <p><i>Removal of Negative Plaster Wrap</i></p> <p>Remove the cast negative only after the plaster wrap has completely hardened.</p> <ol> <li>Release both elastic-webbing straps which hold the cast socks suspended.</li><li>Roll the proximal portion of the second (or thin) cast sock down over the brim of the cast negative.</li><li>Remove the posterior piano-felt hamstring-relief pad from between cast socks 1 and 2. If necessary, use a pair of long-nose pliers or the equivalent (<b>Fig. 34</b>).</li><li>Roll the top of the first (or heavy) cast sock down over the brim of the plaster wrap.</li><li>Place your fingers in the popliteal space and your thumbs in the patellar-tendon depressions. Direct the amputee to completely relax his stump.</li><li>With the amputee's knee flexed and relaxed, pull the proximal portion of the plaster wrap towards you to release the area of the patellar tendon by compression of the posterior soft tissue (<b>Fig. 35</b>).</li><li>Carefully remove the first (or heavy) inner cast sock from the negative (<b>Fig. 36</b>). Be extremely careful not to disturb the thin cast sock that adheres to the inside of the plaster-cast negative.</li><li>Inspect the cast critically to be sure that it is smooth and well contoured throughout (<b>Fig. 37</b>).</li></ol> <p><i>Negative Plaster-Cast Measurements</i></p> <p>To check the inside dimensions of the cast negative:</p> <ol> <li>Place the inside calipers in the cast to measure the anterior-posterior dimensions between the patellar-tendon shelf and the posterior popliteal bulge. Record this measurement on the prosthetic information form, side B. The measurement should be the same as the AP dimension plus 1/8<i> </i>inch.</li><li>Place the inside calipers in the cast at the level of the medial and lateral condyles of the femur. Record this measurement on the prosthetic information form, side B. The dimension should not be more than 3/8 inch larger than the ML stump dimension.</li></ol> <p>To check the length of the cast:</p> <ol> <li>Place a ruler in the socket and measure the dimension from the deepest point of the cast to the center of the patellar-tendon bar. Keep the edge of the ruler parallel to the line of the crest of the tibia.</li><li>Compare this measurement to the length of the stump dimension on the prosthetic information form. It must be within ! <i>s </i>inch of the recorded length.</li></ol> <p>NOTE: If any of the measurements recorded in steps 1 and 2 are not within the tolerances stated and cannot be reconciled by remeasurement of the stump, it will be necessary to make a new negative plaster wrap. Also, a new plaster negative must be taken if the plaster wrap has collapsed or if the wrap shows deep ridges or other severe irregularities.</p> <p>The Negative-Positive Plaster Mold</p> <p><i>The Positive Cast Model</i></p> <ol> <li>Fill the negative wrap cast with liquid plaster of paris in the usual manner.</li><li>As the plaster begins to harden, insert a length of vacuum pipe to a sufficient depth, but avoid contacting the negative plaster wrap.</li><li>After the plaster has set for 20 to 30 minutes, cut and strip off all wraps, exposing the positive model. Be careful not to disturb the contours of the model (<b>Fig. 38</b>).</li><li>If necessary, fill all holes in the model left by air bubbles in the plaster. Usually, this will not be necessary if proper care has been taken when filling the negative-cast wrap.</li><li>With a Surform (TM) rasp, smooth off all minor bumps and the irregularities on the model caused by the seam in the cast sock.</li><li>Provide a final smooth finish over the entire model with screen wire and finish with wet-or-dry Fabricut (TM) silicon carbide, 180 grit (<b>Fig. 39</b>). (Screen-baked Durite [TM] would be equally satisfactory.)</li><li>Seal the completed plaster model positive with Hosmer-Lac or the equivalent to prevent the dampness in the plaster from affecting the inner PVA bag during lamination.</li></ol> <h4>Socket Fabrication</h4> <p>Proceed with the standard PTB lay-up used for fabricating a polyester hard-socket laminate. The resulting prosthetic socket accommodates the stump very snugly, in most instances with a three-ply wool stump sock. If preferred, the conventional Kemblo (TM) insert can be prepared in the usual manner prior to the polyester lamination procedure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Fajal, Guy, Stump casting for the PTS below-knee prosthesis: prothese tibiale supra condylienne, <i>Prosthetics International</i>, 3:4-5:22-24, 1968.</li> <li>Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, <i>Artif. Limbs</i>, 6:2:25-73, June 1962.</li> <li>Gardner, Henry, A pneumatic system for below-knee stump casting, <i>Prosthetics International</i>, 3:4-5:12-14, 1968.</li> <li>Hampton, Frederick L., The suspension method for casting of below-knee stumps,<i> Prosthetics International</i>, 3:4-5:9-11, 1968.</li> <li>Murdoch, George, The "Dundee" socket for the below-knee amuptation, <i>Prosthetics International</i>, 3:4-5:15-21, 1968.</li> <li>Radcliffe, C. W , and J. Foort, <i>The Patellar-Tendon-Bearing Below-Knee Prosthesis</i>, Biomechanics Laboratory, University of California, Berkeley andSan Francisco, 1961 (rev. ed.).</li> <li>Wilson, Leigh A , and Erik Lyquist, Plaster bandage wrap cast: procedure for the below-knee stump, <i>Prosthetics International</i>, 3:4-5:3-7, 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>Joseph E. Traub. C.P. </b></td></tr><tr><td class="clsTextSmall">Consultant, Rehabilitation Engineering, Social and Rehabilitation Service, Department of Health, Education, and Welfare, Washington, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>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> Figure 1 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-22.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-23.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-24.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-25.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-26.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-27.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-28.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-03.jpg Figure 11 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-04.jpg Figure 12 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-05.jpg Figure 13 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-06.jpg Figure 14 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-07.jpg Figure 15 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-08.jpg Figure 16 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-09.jpg Figure 17 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-10.jpg Figure 18 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-11.jpg Figure 19 http://www.oandplibrary.org/al/images/1971_01_001/1971_01_001-12.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 Premodified Casting for the Patellar-Tendon-Bearing Prosthesis Creator An entity primarily responsible for making the resource Joseph H. Zettl. C.P * Joseph E. Traub. C.P. * https://staging.drfop.org/files/original/7a75c3d9c233cf93787c08c21ed693e3.pdf e5110d02dd384bb6a5f6f5a10d2586ba https://staging.drfop.org/files/original/dd9cefbe75906e9bba04a5826a47ec5f.jpg 7703fefe919d06bde880ad14c32d7f75 https://staging.drfop.org/files/original/1ec821d58a0459aef4c5528b6090c4c4.jpg bcb495632b7e2d3954e57ff157efed5e https://staging.drfop.org/files/original/1379cb8157b2580aa03fb6a64d890b95.jpg a581fb1c72db3af322da27e57eaa0f6e https://staging.drfop.org/files/original/5bdb4472cef92dc9646b1510876e7782.jpg 1591cb62ca55a5fe3e1780a2e5b6a80d https://staging.drfop.org/files/original/4fce8019d5930c0d95a39cb58a87c9c3.jpg 528c9b83635d9135a577534f3859d802 https://staging.drfop.org/files/original/657b4b73124d4aa6f38ae9451948f8ba.jpg 8b789aec8e717b99d01ede87115e9e6d https://staging.drfop.org/files/original/736753da520fdd6d08411546b891cd1a.jpg 69932579ec5c82657a8978acf7988bf4 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_049.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 49 - 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/1970_02_049.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_02_049.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 Use of External Support in the Treatment of Low Back Pain</h2> <h5>Jacquelin Perry. M.D. <a style="text-decoration:none;">*</a><br /></h5> <p> The origin of therapeutic procedures can generally be traced to local efforts directed toward resolving continuing disability of the patient. In the treatment of low back pain, this approach often included designing special supports by individual physicians and orthotists. Such independent activity in numerous locales resulted in a long list of brace designs, many of which carry impressive eponyms that tend to stress differences rather than elements of commonality. </p> <p> To compile the available information concerning bracing, the American Academy of Orthopaedic Surgeons published the <i>Orthopaedic Appliances Atlas</i><a></a> in 1953. Of the 30 types of spinal support described in that volume, 17 were specifically designed for the sacroiliac or lumbosacral areas. Ten years later, in 1962, a survey of orthopedic services in the United States by Nattress and Litt<a></a> identified 30 braces, of which 22 corresponded to the design customarily considered effective at the lumbosacral region. These two reports, along with the present study, described a total of 40 different devices designed for low back problems. </p> <p> Details of designs are readily available, but objective criteria to weigh the relative merits of the different devices are almost nonexistent. As a consequence, physicians generally make their selection either by adopting the customs observed during their training, or by accepting the preference of the local orthotist. Undoubtedly, some braces have withstood the test of time, while others have become items only of historical interest. Superimposed on this background, the more recent introduction of prefabricated parts for brace construction has probably influenced the frequency with which certain types of braces are prescribed.</p> <p> The extent to which these influences have altered the availability and prescription of brace designs today has not been reported. Also unknown is the nature of the relationship between the etiology of the low back pain and the type of support that clinicians have found to be effective. Identification of this type of information is pertinent because the subject of orthotics is now being presented in formally organized courses on a nationwide basis. </p> <p> This paper records the results of a three-phase study conducted in 1968-69 by the Subcommittee on Orthotics, Committee on Prosthetic-Orthotic Education (CPOE) of the National Research Council. Approval of the Executive Committee of the American Academy of Orthopaedic Surgeons was obtained. The purpose of the survey was to identify the current practices of orthopedic surgeons with respect to external supports for the management of low back pain. </p> <h4> Method</h4> <p><i> Pilot Study </i></p> <p> An unstructured pilot questionnaire was sent to 150 orthopedic surgeons selected because of their considerable experience in the management of low back pain. They were asked to list the types of support they prescribed, and to indicate the clinical conditions for which each support was chosen. The results of this pilot study formed the basis for the next phase of the investigation. </p> <p> The 90 physicians (60%) who responded were explicit in their choice of a device and the clinical indication for its use. Eighty-three reported frequent prescription of external support as part of their therapeutic program. (Two said they never used external supports, and five indicated they rarely prescribed such aids.) </p> <p> Within each class of support (brace, corset, cast), a similar pattern of practice was evident. Numerous designs were listed, but most were mentioned only occasionally. The majority of the respondents preferred one or two types of support. Within a total of 12 different braces reported, three-fourths of the physicians listed the Chairback (Knight) and Williams braces (<b>Fig. 1</b>, <b>Fig. 2</b>, and <b>Fig. 3</b>). Six other designs were mentioned only once. Identification of corset preference was a bit clouded by the indiscriminate use of both generic and trade names. The generic term "lumbosacral" was specified by half of those responding. An additional one-fourth of the pilot-study participants used trade names such as Camp, Spencer, and Winchester. The next most frequently mentioned device was the sacroiliac belt (8%). Of the six casts identified, the flexion jacket was preferred by more than half of the pilot-study orthopedists; the second choice was the body jacket (19%). In designating the clinical conditions warranting external support, two response patterns developed in the pilot survey. Seven types of disability were mentioned frequently and in explicit terms, viz., postoperative fusion, spondylolisthesis, chronic backache, acute strain, disc syndrome, degenerative joint disease, and the postoperative disc. Several other conditions, identified by a wide variety of terminology, were mentioned with moderate to rare frequency. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The Knight dorsolumbar brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. A typical modification of the Knight brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The Williams lumbosacral brace. (Illustrations from Orthotics for Physicians and Therapists, Prosthetic-Orthotic Education, Northwestern University Medical School, Chicago, HI.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>National Survey of AAOS</i></p> <p> The findings of the pilot survey were used to construct a questionnaire applicable for a comprehensive national study. This questionnaire was sent to the membership of the American Academy of Orthopaedic Surgeons (AAOS). The form (presented at the end of this article) was a check sheet on which physicians were asked to match the types of support they prescribed with the clinical conditions they treated in this manner. </p> <p> The following supports, all of which were more than rarely mentioned in the pilot study, were included. (The restriction on corset choice was the result of a decision to use generic rather than trade names in order to avoid repeating the confusion produced in the pilot study.) </p> <p><b><i>Braces</i></b></p> <ol> <li> Chairback (Knight) </li><li>Williams </li><li>Norton-Brown </li><li>Goldthwaite </li><li>Bennett </li></ol> <p> <i>Corsets</i> </p> <ol> <li>Lumbosacral </li><li>Sacroiliac </li></ol> <p> <i>Casts</i> </p> <ol> <li>Flexion </li><li>Body jacket </li><li>Cast with one leg </li></ol> <p> Eleven clinical conditions were selected for the national inquiry, based upon the </p> <p> returns of the pilot study and upon the clinical experience of the NRC committee. Provision was made throughout for physicians to indicate devices or clinical problems other than those listed on the form. The questionnaire was also designed to indicate the relative frequency ("usually" or "rarely") of the prescriptions. </p> <p><i> Survey of the Functions of Support</i></p> <p> Late in 1968, a second national survey was conducted among the AAOS membership to determine prevailing opinions about the functions of the various types of support. The purpose of this phase of the study was to attempt to relate the anticipated function of the external support to the different preferences in prescription. </p> <p> Profiting from the findings of part one of the national survey, the list of supports was again shortened. This time, the orthopedists were queried about two braces (Williams and Chairback [Knight]); "corset" was listed as a single category, as were the flexion casts. A miscellaneous category was added for other comments. (The questionnaire appears on page 57.) </p> <p> Six probable functions were selected for study. These included: immobilization of the spine, restriction of lumbosacral motion, unloading of the intervertebral disc, support of the abdomen, correction of posture, and psychological effect. As always, there was a provision for other choices. </p> <h4> Results </h4> <p> On the first national survey, 5,215 questionnaires were mailed. With the aid of one follow-up, 3,140 (60%) were returned completed. An additional 1% of the returns were incomplete because the physicians had retired or their practices did not include patients with low-back problems. </p> <p> In the second phase of the study, the same number of forms were sent out, with 2,192 (42%) being filled in and returned. No follow-up mailing was conducted, </p> <p> Annotated responses or explanatory letters accompanied 1,034 (33%) of the questionnaires. These consisted of: (<i>a</i>) identification of the type of device they preferred if it was not specifically mentioned on the form; <i>(b) </i>comments regarding precise fitting or construction characteristics considered to be important; (<i>c</i>) reasons for not prescribing external support; and (<i>d</i>) other modes of treatment which should accompany use of a support. </p> <p><i> Use of Supports for Low-Back Problems</i></p> <p> Most of the orthopedic surgeons indicated use of a judicious selection of braces, casts, and corsets; the average physician reported that he used three different devices in his practice. A small group stated that they used only one type of device: a brace (4%), a corset (4%), or a cast (1%). Only 14 respondents stated that they "never used support" for the patient with a low-back problem. </p> <p> Among the clinical indications, the inclusion of the term "fracture" caused considerable confusion in the information collected. Either all types of braces are used for fractures in the "low back," or the orthopedist's attention was directed to fractures of the spine in general. The latter seemed highly probable, as most indicated that a brace other than those listed was used. Typically, these were the Jewett, Taylor, and Baker types, commonly used for lesions in the thoracic and thoracolumbar areas. As the extent of this confusion could not be identified, all data referring to "fracture" were omitted from the analysis. </p> <p> Certain characteristics in the prescription of external support became evident. A majority of the profession used the same groups of devices. The nature of the disability dictated the frequency of prescription as well as the type of support preferred. </p> <p><i> Support Preference </i></p> <p> The lumbosacral corset is the most popularly used low-back support, followed by the Chairback (Knight) spinal brace. Utilization of the other types of support fell far behind these two leaders <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> The degree of dominance by the lumbosacral corset varied with the method of comparison; 28.5% of the physicians indicated use of the lumbosacral corset for at least one condition. When all clinical indications were considered, preference for the lumbosacral corset was 44.2%. The Chairback brace was used by 21% of the physicians for 22% of the clinical conditions listed. All other types of support were used less than 9% of the time. The Williams brace was third in popularity. A variety of casts preceded any other choice of brace or corset <b>Table 1</b>. </p> <p> As "lumbosacral corset" is a generic term that overlooks design differences between the Camp, Winchester, Spencer, and other specific corset styles, a comparison was made with the designated preferences for the total group of "low-back braces." The relative preference between the corset and the low-back brace again depended on the method of comparison. The use of a brace at some time was indicated by 40.2% of the physicians, in comparison to 32.4% for corsets. However, when all the clinical indications were totaled, the preference reversed, with the corsets dominating (46.7% in contrast to 39.0% for braces). </p> <p> Some geographic patterns for brace preference were found, especially for those used less frequently <b>Table 2</b>. The middle and southeastern sections of the United States were the only areas where the Williams brace was used widely; it was fourth in preference on the West coast. With the exception of New York, no mention of it was made in the eastern or New England states. The Bennett brace was second in popularity in Maryland and third in Ohio. Predominance of the Norton-Brown<a></a> brace was restricted to Massachusetts and Maine, a note consistent with the fact that the originators are from Boston. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Clinical Indications</i> </p> <p> The survey form asked the physician to check whether he rarely or usually used some type of support for each of ten clinical conditions listed <b>Table 3</b>). Three patterns of use were apparent. The responding physicians seldom used external support in the treatment of an acute strain (17%), for an obese person with pain (19%), or during the postoperative period following disc surgery (28%). When support was used for these conditions, it was generally a corset. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> At the other extreme, most physicians used support following spine fusion (84%), for treatment of spondylolisthesis (70%), and for pseudoarthrosis (66%). In these instances, the most common type of support was a brace. </p> <p> The orthopedists were evenly divided as to the advisability of prescribing any type of support in treating the degenerative back, the disc syndrome of chronic backache, or as a preoperative trial. A similar lack of agreement was indicated concerning the type of support preferred. As a preoperative trial, there was equal preference for a brace or cast. For the other disabilities, the preferred support was the lumbosacral corset. </p> <p> Comparison between the specific brace design and the clinical condition <b>Table 4</b> showed that the Chairback was the most frequently used brace in each situation, and the Williams brace ranked second in preference. Spondylolisthesis and the disc syndrome were the most common indications for the Williams brace. Spondylolisthesis was also the primary reason for using the Bennett brace. Otherwise, preference for the Norton-Brown, Goldthwaite, and Bennett braces paralleled the use of back support in general. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Function of External Supports</i> </p> <p> Three approaches to the data collected on functions of supports seemed pertinent: the general expectation for external supports, the types of support chosen for each of these functions, and the functions expected of each of the support designs. </p> <p> The function most commonly ascribed for external support was restriction of lumbosacral motion (30%); abdominal support was second (19%), followed by postural correction (15%) and immobilization of the spine (12%). </p> <p> To restrict lumbosacral motion, the Chairback (Knight) brace or a corset were equally preferred. The Williams brace was the third specific device indicated for this purpose, although a larger number of physicians indicated that they used some type of cast to restrict motion. </p> <p> Abdominal support was most often assigned to the corset. This dominated its next competitor, the Chairback (Knight) brace, by a ratio of two to one. Again, the Williams brace ranked third for the function of supporting abdominal muscles. </p> <p> Postural correction was almost equally divided between the corset and a Williams brace, although the use of casts was not uncommon. </p> <p> An interesting situation developed in the category of spinal immobilization. It was the only function identified for the flexion cast, yet this device was fourth in preference. The support most often indicated for spinal immobilization was the Chairback (Knight) brace, a finding which probably reflects its national popularity. </p> <p> While external supports are seldom used for psychological reasons, when the practice is followed the corset is the most popular device, followed by the Chairback brace. </p> <p> The concept of unloading the disc has obviously not been accepted by the majority of orthopedic surgeons, since only 8% indicated this as a function of external support. However, those who did think in these terms showed a strong preference for the Williams brace, with a cast as an alternate. </p> <p> Focus on the individual types of support showed that the prime functions of the corset were considered to be abdominal support and restriction of lumbosacral motion. The Chairback (Knight) brace was assigned the same functions, but with greater emphasis on restriction of motion. This function was also considered the main purpose of the Williams brace, with correction of posture as its second indication. Casts were generally used to restrict lumbosacral motion, although a surprisingly larger number were also assigned the function of correcting posture. Consistent with the belief that immobilization, as opposed to restriction of lumbosacral motion, is seldom accomplished with external support, even casts were assigned this as a third function. </p> <p> In addition to completing the survey form, a third of the respondents (1,034) added notes to further explain their preferences. These varied from a single listing of a specific brace to lengthy letters explaining their philosophies of low-back management. A majority of these replies were focused on either the fitting or construction characteristics of their support preferences. </p> <p> Sixty respondents emphasized the advantages of using exercise early in the treatment of low back pain. Two purposes were expressed: to avoid external support and to overcome the muscle weakening and contracture development that accompanies prolonged immobilization. One respondent summarized this philosophy very succinctly by stating he "never prescribed support without a plan to eliminate it." A smaller group (30) felt that the disadvantages were sufficient to preclude any prescription of external support. All who said they "never" or "rarely" used support emphasized instead their reliance on an organized program of exercise. Specific application of this philosophy was frequently mentioned in relationship to postoperative management of spine fusions. Many respondents also brought out the fact that the treatment of low back pain must be individualized to fit the particular patient's need. This fact must never be forgotten, of course, and the purpose of the survey was not to contradict the concept of individualized patient care, but merely to identify the spectrum of external support which physicians have found adequate to meet their multiple goals. </p> <h4> Discussion </h4> <p> The potential list of 40 external-support designs for low back pain has been severely pruned by the influences of prolonged clinical experience, greater intermingling of orthopedists through professional meetings, and the use of prefabricated parts. Notes by some of the respondents indicated that cost, emphasis on exercise, and early surgery are other important influences. </p> <p> The clinical indications for use or non-use of external support were rather sharply defined, but there is no comparable distinction between the accepted styles of support. The latter was indicated by the overlap between clinical entity and support design, as well as by the identification of the functions of the different devices. The mechanical characteristics and the limitations of these various designs which lead to such ambiguity have yet to be objectively identified. </p> <p> Investigators<a></a> have found that, unless the support is carefully designed, motion at the lumbosacral joint could be increased with the support rather than </p> <p> restricted. Personal experience indicates that this might also lead to increasing the patient's pain. </p> <p> A problem still not studied is identification of the characteristics of the patients which govern the choice of support. </p> <h4> Summary </h4> <p> The lumbosacral corset is the most commonly prescribed external support for low back pain. The Chairback (Knight) and Williams braces are next in preference, with a cast being used least frequently. There is a definite relationship between the etiology of the low back pain and the type of support chosen. The major indication for support prescription is to restrict lumbosacral motion. </p> <p><b>References:</b></p> <ol> <li>American Academy of Orthopaedic Surgeons, <i>Orthopaedic appliances atlas, vol. 1, braces, splints, shoe alterations, </i>J. W. Edwards, Ann Arbor, Mich., 1952. </li> <li>Nattress, LeRoy Wm., Jr., and Bertram D. Litt, <i>Orthotic services USA 1962, report 2, survey to determine the state of services available to amputees and orthopedically disabled persons, </i>American Orthotic and Prosthetic Assoc, Washington, D.C., 1962. </li> <li>Norton, Paul L., and Thornton Brown, The immobilizing efficiency of back braces: their effect on the posture and motion of the lumbosacral spine, <i>J. Bone Joint Surg., </i>39A:111-139, January 1957. </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Norton, Paul L., and Thornton Brown, The immobilizing efficiency of back braces: their effect on the posture and motion of the lumbosacral spine, J. Bone Joint Surg., 39A:111-139, January 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>3.</b> </td><td class="clsTextSmall">Norton, Paul L., and Thornton Brown, The immobilizing efficiency of back braces: their effect on the posture and motion of the lumbosacral spine, J. Bone Joint Surg., 39A:111-139, January 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>2.</b> </td><td class="clsTextSmall">Nattress, LeRoy Wm., Jr., and Bertram D. Litt, Orthotic services USA 1962, report 2, survey to determine the state of services available to amputees and orthopedically disabled persons, American Orthotic and Prosthetic Assoc, Washington, D.C., 1962. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">American Academy of Orthopaedic Surgeons, Orthopaedic appliances atlas, vol. 1, braces, splints, shoe alterations, J. W. Edwards, Ann Arbor, Mich., 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>Jacquelin Perry. M.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Kinesiology Service, Rancho Los Amigos Hospital, Downey, Calif.; Associate Clinical Professor of Orthopaedic Surgery, University of Southern California School of Medicine, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_02_049/tmp649-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Use of External Support in the Treatment of Low Back Pain Creator An entity primarily responsible for making the resource Jacquelin Perry. M.D. * https://staging.drfop.org/files/original/1bda4488b7bcaad58f689c611e408747.pdf 3dbe8feffcd1fb52115ac4f72537fb35 https://staging.drfop.org/files/original/2b5c10bb36baba4b040aee904e471d71.jpg 58a95731305645b10b6f85d8f67c0245 https://staging.drfop.org/files/original/7eafccb497b126ccef5122f33650546e.jpg 95f4117b856b786b71073155002d428d https://staging.drfop.org/files/original/fb0a7e94a169ec63ff7cf95527d469db.jpg bfcf718cf5f1dbeb7d91194c1cd973f3 https://staging.drfop.org/files/original/2afccc1e2421258e552469eb88bf971e.jpg 9b7fc5a4e7b85110d68fd68f2807d779 https://staging.drfop.org/files/original/38d490d55a00c077b1478f5a0103487b.jpg 45ffc4432052bb51531a1472db207f25 https://staging.drfop.org/files/original/fbd0d897aea6ec8ffb409a610bdb0565.jpg 1391815c9cc113e718f2a49af9320dd0 https://staging.drfop.org/files/original/e74beaad9794f0c38e5b4a2167e3ad53.jpg 0b0a047d912ac402d46d3935c3b9c31e https://staging.drfop.org/files/original/300d567518504315a715a10eb776fea3.jpg 65e2651387f382c71b4515df75547aeb https://staging.drfop.org/files/original/bd66530125b2eec809b4a982578e7298.jpg a604f5d8d25c448cebce95a930d473b4 https://staging.drfop.org/files/original/8c57d9a3ad45c3dddd9363974ba16cbf.jpg c00ad4fa54bb32068faf2b1ce4351adf https://staging.drfop.org/files/original/5ef1b1af6313f0e9535a397f23f3dc8e.jpg 9f2caa21c1bd051f677d1a98f1525b34 https://staging.drfop.org/files/original/3b4dfae891f5fe8d20b4805a2c42caad.jpg f62e04fc490408ac07010086995967df https://staging.drfop.org/files/original/f101f2f8cfe7c638bd4fe254d6a41eeb.jpg ddecbf2853ea7cf90f4c5ea0d633cba4 https://staging.drfop.org/files/original/e2fd7092fcbfa3cff3fcdb2b8d67522f.jpg d7cdaf9276e991c1515ed26738370b8b https://staging.drfop.org/files/original/7c9b09638c60a8e08f198d66a29c3e89.jpg eeec08eb556f5a122fd20be791683be6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_01_015.pdf Year 1971 Volume 15 Issue 1 Page Number(s) 15 - 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/1971_01_015.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_01_015.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>Technique for Forming Sockets Directly on Above-Elbow Stumps</h2> <h5>F. L. Hampton, C.P. <a style="text-decoration:none;">*</a><br />J. N. Billock, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The ability to make a socket by applying a thermoplastic material such as Poly-sar X-414 (Polymer Corp. Ltd. TM) directly to an amputee's stump offers many advantages to the prosthetist, as pointed out by Wilson. <a></a> Direct forming obviously eliminates the casting procedures necessary to produce a good modified replica of the stump and eliminates the laminating procedures necessary to produce the socket. The thermoplastic properties of Polysar X-414 allows quick postforming of the socket in areas which may require relief, and the material lends itself well to the attachment of components during assembly. These time-saving advantages enable the prosthetist to fit amputees with a temporary prosthesis much earlier than the time normally required for a definitive fitting. This hastens the amputee's rehabilitation and helps to condition him <i>and </i>his stump for the definitive prosthesis. The prosthetist also has the advantage of noting any corrections which are applicable to the definitive prosthesis. These advantages are also helpful to the research prosthetist, for he can save valuable time in evaluating new control techniques and testing new components.</p> <p>A direct-forming technique related to those developed by Staros and Gardner <a></a> for below-knee PTB sockets and by Labate and Pirrello <a></a> for below-elbow sockets using Polysar X-414 has been developed for above-elbow sockets. If done properly, this technique will provide a well-fitting socket which has the above-mentioned advantages. A complete above-elbow prosthesis can be fabricated in approximately three hours.</p> <p>The technique was used at this center to construct Polysar sockets for four above-elbow amputees who participated in an evaluation study of externally powered upper-extremity prosthetic components. Each amputee (described briefly below) wore his prosthesis successfully for two hours a day, three days a week, during a two-month period without problems.</p> <p><i>D. H., </i>a 38-year-old male, with a right above-elbow amputation 11 in. distal to acromion, acquired in June 1964. He was fitted with a standard above-elbow prosthesis, which he has used actively as a laborer since.</p> <p><i>R. W., </i>a 35-year-old male congenital amputee, with a right 11-in. above-elbow stump from the acromion. He was fitted with his first standard above-elbow prosthesis in June 1954, and has been an active prosthesis wearer since that time. He is presently employed as a hotel clerk.</p> <p><i>J. H., </i>a 44-year-old male with a left above-elbow amputation 8% in. distal to the acromion, acquired in March 1964. He was fitted with a standard above-elbow prosthesis and has been an active prosthesis wearer since that time. He is presently employed as a quality-control inspector for a leather factory.</p> <p><i>R. R., </i>a 22-year-old male with a left above-elbow amputation 9 1/2 in. distal to the acromion, acquired in November 1968. He was fitted with a standard above-elbow prosthesis and has used it actively since. He is a student in college at the present time.</p> <h3>Materials and Equipment</h3> <p>A tube of the synthetic rubber 3 in. ID x 1/4 in. x 12 in. is adequate for the average above-elbow stump. The diameter can be reduced for smaller stumps by elongating the tube after it has been heated. Larger sizes of tubing should be used for larger stumps.</p> <p>The only special equipment needed is a deep, water-filled container, approximately 20 in. in height and 8 in. in diameter. The water should be preheated to a temperature of 160 degrees F to 180 degrees F.</p> <p>The following materials and equipment should be available within the prosthetic facility:</p> <ul> <li>Two 1 in. x 40 in. elastic webbings</li> <li>Four Yates clamps</li> <li>Tubegauz (TM), size #56 (tubular gauze)</li> <li>Heavy cast sock</li> <li>Braided Dacron (TM) line, approximately 130-lb-test</li> <li>Standard Hosmer elbow turntable</li> <li>Hose clamp, expandable to 11-in. circumference</li> <li>Hot plate</li> <li>Parallel bar</li> <li>Pressure-sensitive tape</li> </ul> <h3>Preparations for Casting</h3> <p>Cut a length of tubular gauze approximately 18 in. longer than the stump and slit it 6 in. from the proximal end. Apply the tubular gauze with the slit in the axilla, allowing the tubular gauze to encompass the shoulder proximal to the acromion process. Pass a piece of 1-in. elastic webbing under the axilla on the sound side and attach it to the anterior and posterior wings of the tubular gauze (<b>Fig. 1</b>). Cut the toe from a heavy cast sock and slit the proximal end in the same manner as the tubular gauze. Pull the cast sock on the distal third of the stump, with the slit under the axilla (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Tubular gauze suspended with elastic webbing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Heavy east sock applied to distal one-third of stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Mark the proximal section of the synthetic rubber tube to be cut out for the axilla. The width of the section will depend on the stump size, and the depth must be sufficient to allow the synthetic rubber to pass over the acromion. The synthetic rubber stretches well; therefore, caution should be taken not to cut out too large a section. For average stumps, a section 3 in. x 3 in. is adequate.</p> <p>Completely immerse the synthetic rubber tube in the preheated water. The tube will rise to the surface when it has reached the appropriate temperature. Remove it from the water and cut out the axilla section (<b>Fig. 3</b>). Allow the tube to cool until the hand may be placed inside the tube without discomfort.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Cutting out axilla section after tube is heated. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Application of Synthetic Rubber</h3> <p>Stretch the proximal end of the tube at the axilla level to aid in starting the tube on the stump (<b>Fig. 4</b>). Roll the axilla edge to provide a good flare for the axilla (<b>Fig. 5</b>). Insert the tubular gauze and cast sock through the tube and apply the tube to the distal third of the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Synthetic rubber tube stretched at axilla level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Medial edge rolled to provide a good flare for axilla. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The tubular gauze is anchored to a parallel bar so that the amputee can apply tension on the tubular gauze. The tension will compress the stump tissues and prevent tissue-bunching while the synthetic rubber tube is being applied. An adjustable webbing belt with an O ring is used as the anchoring point on the parallel bar (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Synthetic rubber tube applied to the distal end of the stump and tension applied to the tubular gauze. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Stand the amputee away from the parallel bar with the stump in abduction and the shoulder in depression. This will assist in placing the tube well into the axilla. Pull the synthetic rubber tube onto the stump, using the cast sock to work it up the stump (<b>Fig. 7</b>). Make sure it is well into the axilla and over the acromion. Support the tube with a piece of elastic webbing in the same manner as the tubular gauze (<b>Fig. 8</b>). This will also aid in forming the proximal end of the socket. Eliminate any wrinkles in the cast sock by pulling on it at the distal end of the tube.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Synthetic rubber tube is pulled up the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The tube suspended with elastic webbing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Contouring the Socket</h3> <p>When contouring the socket for a left amputee, place the left hand firmly into the axilla, keeping the hand parallel to the sagittal plane. Have the amputee move back to the parallel bar, adduct his stump, and elevate his shoulder to the neutral position (<b>Fig. 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Left hand in the axilla and right hand contouring distal end of socket to accept elbow turntable </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Firm tension should be maintained on the tubular gauze without causing the amputee to strain. Only the shoulder muscles should be used to maintain the tension. The finished socket will be loose if the stump muscles are contracted during contouring of the socket.</p> <p>Reduce the diameter of the synthetic rubber distally to conform to the stump and to approximate the circumference of the turntable if necessary (<b>Fig. 9</b>). Mold the proximal section by placing the right hand so that the thumb and forefinger outline the anterior and posterior borders of the deltoid muscle group. The thumb is used to mold the anterior wing, and the remaining fingers to mold the posterior wing (<b>Fig. 10</b>). Hold the socket in this manner until the synthetic rubber cools enought to retain the contours.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Right hand contouring the proximal socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Mark the proximal trim line before removing the socket. Either the conventional trim line can be used or the open-shoulder described by McLaurin et al. <a></a> After the trim line is cut out, the edges can be finished with a felt cone, fine-sand cone, or toluene.</p> <h3>Attachment and Alignment of Turntable</h3> <p>Determine the proper distance for the elbow center from the acromion process and mark where the turntable will be located on the tube. Reheat the distal end of the tube approximately one-half inch above the mark by immersing it in water. Insert the turntable into the tube and work the synthetic rubber into the knurling and tie-off groove. Secure the synthetic rubber by wrapping 130-lb-test, braided Dacron (TM) line around the tube and pulling it into the tie-off groove (<b>Fig. 11</b>). Two passes of line are sufficient. Cut away the excess tubing and apply pressure-sensitive tape around the tube, making sure the synthetic rubber conforms to the turntable (<b>Fig. 12</b>). A hose clamp can be used for more strength if necessary (<b>Fig. 13</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Turntable tied in place and excess synthetic rubber trimmed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Socket compressed against turntable with pressure-sensitive tape. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Turntable attached with hose clamp. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Attach the elbow unit and forearm section and check the alignment of the turntable. If it is not properly aligned, reheat the distal end in water and realign.</p> <p>The harness and cable system are attached in the conventional manner (<b>Fig. 14</b> and <b>Fig. 15</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. The completed prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. The completed prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Acknowledgments</h3> <p>The authors wish to thank Miss Carole Herhold and Dr. Dudley S. Childress for their help in the preparation of this report.</p> <p><b>References:</b></p> <ol> <li>Labate, Gennaro, and Thomas Pirrello, Direct forming of below-elbow sockets, Artif. Limbs, 14:1:65-72, Spring 1970.</li> <li>McLaurin, C. A., W. F. Sauter, C. M. E. Dolan, and G. R. Hartmann, Fabrication procedures for the open-shoulder above-elbow socket, Artif. Limbs, 13:2:46-54, Autumn 1969.</li> <li>Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, Artif. Limbs, 14:1:57-64, Spring 1970.</li> <li>Wilson, A. Bennett, Jr., A material for direct forming of prosthetic sockets, Artif. Limbs, 14:1:53-56, Spring 1970.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">McLaurin, C. A., W. F. Sauter, C. M. E. Dolan, and G. R. Hartmann, Fabrication procedures for the open-shoulder above-elbow socket, Artif. Limbs, 13:2:46-54, Autumn 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Labate, Gennaro, and Thomas Pirrello, Direct forming of below-elbow sockets, Artif. Limbs, 14:1:65-72, Spring 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, Artif. Limbs, 14:1:57-64, Spring 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., A material for direct forming of prosthetic sockets, Artif. Limbs, 14:1:53-56, Spring 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>J. N. Billock, C.P. </b></td></tr><tr><td class="clsTextSmall">Research Prosthetist, Northwestern University Prosthetic Research Center.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>F. L. Hampton, C.P. </b></td></tr><tr><td class="clsTextSmall">Coordinator, Prosthetic Research and Education, Northwestern University Prosthetic-Orthotic Center.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-15.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 Technique for Forming Sockets Directly on Above-Elbow Stumps Creator An entity primarily responsible for making the resource F. L. Hampton, C.P. * J. N. Billock, C.P. * https://staging.drfop.org/files/original/848c4d3ac131b5dd1f6aa772c7f8a431.pdf e817c23d305059d5eb0443856e4b4387 https://staging.drfop.org/files/original/36b983688348af4a118989fc5fb897c9.jpg 6cb2b221554b0b485d8fc79981ef09a6 https://staging.drfop.org/files/original/24dfe7339220fe553a1c64a284121f9f.jpg a77726724bb605b1b62088c61fa199fe https://staging.drfop.org/files/original/30555cd9d726c783eed81b24037c5cd4.jpg 9a82f709360468920d35880d9de0a173 https://staging.drfop.org/files/original/426fd84a7ec08befbdd52faee128f558.jpg f857fbf49e56777769bc3f0b1a131af4 https://staging.drfop.org/files/original/b4c608d131a05575666bb7d89f3e757a.jpg dc4cf48f9a16720c6e9c13db8d6428ab https://staging.drfop.org/files/original/ee370f1cc7c95a6fe60c95c4f0819351.jpg df2aa330418617744cac4fc848f4db40 https://staging.drfop.org/files/original/1ec16330c2317e239c81f3dca00e95eb.jpg 4cf2e1cb947b42839a66044354310fee https://staging.drfop.org/files/original/6b9d52df99dff7d840e2ec6557a4b1ac.jpg 348b4c2cc2203c0a6e6442d32a5dd6da https://staging.drfop.org/files/original/c847a8882afd28e78043d628ef01b4d1.jpg 1191ffe8bde507257ac7dcd9dd61efad DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_02_001.pdf Year 1971 Volume 1 Issue 2 Page Number(s) 1 - 5 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/1971_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_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>A Method of Early Prosthetics Training for Upper-Extremity Amputees</h2> <h5>Timothy V. Reyburn, MAJ., AMSC <a style="text-decoration:none;">*</a><br /></h5> <p>Over the past ten years, there have been gradual changes in the treatment and training of patients who have had upper-limb amputations.<a></a> This paper discusses early training techniques used over a two-year period at Valley Forge General Hospital on 67 (32 above-elbow and 35 below-elbow) amputees. Thirty-four of the amputees were treated from July 1968 to February 1969, and 33 from February 1969 to July 1970.</p> <p>Prior to February 1969, there was no separate ward for amputees, and each patient was placed on a ward appropriate to his overall disability, rather than according to his amputation. The upper-extremity amputees were pretrained in the leather-laced practice prosthesis with plaster-shell insert. However, this type of practice prosthesis was not fitted to the patient's stump until all wounds had healed and drainage had ceased. Consequently, preprosthetic training was delayed, and unilateral patterns could develop in the interim. When the patient did receive his practice prosthesis, training was initiated, with limited practice periods in occupational therapy for one hour a day. At first, the amputee wore the practice prosthesis only in the clinic. After he had mastered its operation and could tolerate the socket for longer periods, he was allowed to wear it the entire day. The patient was instructed to remove the prosthesis at night and to use the standard stump-wrapping procedure to control edema. A major problem during the training period was the constant separation of the plaster socket from the leather-laced cuff. Also, the functional alignment and the appearance were anything but desirable (<b>Fig. 1</b>). The therapist noted that the patients did not voluntarily wear their practice prostheses outside the supervised clinic environment. It was apparent that a more functional and streamlined type of practice prosthesis was urgently needed. In February 1969, the chief of orthopedics organized a separate amputee service, and a new training plan was initiated. The successful treatment of lower-extremity amputees by a technique in which a rigid dressing and plaster pylons were applied immediately after surgery lead to the hypothesis that a similar procedure might be beneficial for upper-extremity amputees. A practice prosthesis that consisted of a plaster socket with the terminal device and cable attachments embedded within the outer shell was fabricated (<b>Fig. 2</b>). From February 1969 to July 1970, 30 patients were fitted with the device (three amputees could not be fitted, because of transfer, infection, etc.). Their ages were between 19 and 39; the average age was 22 years.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. A leather-laced practice prosthesis with plaster-shell insert. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Adapted above- and below-elbow practice prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The key to a successful practice prosthesis is a firm, nonconstrictive, well-made socket. Both the above- and below-elbow sockets must be formed firmly and evenly to control swelling and to forestall blisters from developing by movement of the stump within a poorly fitting socket. Fabrication of the plaster-of-paris socket and prosthesis is relatively easy, and the procedure is basically the same for both above- and below-elbow prostheses.</p> <p>For the below-elbow socket, a layer of stockinet is pulled over the stump (<b>Fig. 3</b>) and extended two or three inches above the elbow, which allows for a fold and a trim on the proximal end. The distal end of the stockinet is cut and folded smoothly over the stump. Double thicknesses of three-inch plaster roll are thoroughly soaked and placed lengthwise on the stump. An area is left open ventrally to allow room for maximum flexion of the forearm. Circular, non-constricting, single-thickness wraps are then applied (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The first layer of stockinet applied to a below-elbow stump. </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 plaster to the below-elbow stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For an above-elbow socket, the stump is completely covered with stockinet. The distal end of the stockinet is cut and folded smoothly over the stump. Double thicknesses of three-inch plaster roll are thoroughly soaked and placed lengthwise on the stump (<b>Fig. 5</b>). Each strip is ended three or four inches distal to the axilla to facilitate removal of the piaster socket. Circular, nonconstricting, single-thickness wraps are then applied. The lateral proximal apex is reinforced in order to provide a firm base for attachment of the lateral harness buckle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Plaster being applied over the stockinet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Aluminum struts are attached to the prosthetic appliance and plastered into the socket (<b>Fig. 6</b>). When the socket is finished, a figure-eight harness with a Northwestern ring is fitted to the patient, and a terminal device is attached to the practice prosthesis. All of the cable, base-plate, and harness connections are adjusted for each patient. Once the connections are attached and in proper alignment, the patient is trained to operate the practice prosthesis (<b>Fig. 7</b>). Additional sockets are fabricated if stump shrinkage exceeds the thickness of two single-ply stump socks. This basic prosthesis is used by the patient until he receives his final prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Affixing aluminum struts and a terminal device to the plaster socket. </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 below-elbow amputee learns to operate the terminal device on a practice prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because these prostheses have proved so acceptable to the amputees, a plaster socket is fitted immediately upon the patient's admission. A below-elbow amputee can be fitted and can start to use his prosthesis all in the same day. An above-elbow amputee, if not ready for a practice prosthesis, is fitted with a plaster-shell socket and figure-eight harness (<b>Fig. 8</b>). Anterior and posterior elastic straps are attached to the plaster shell to provide an even upward pressure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. An above-elbow amputee fitted with a plaster shell with figure-eight harness and Northwestern ring. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The plaster shell replaces the standard elastic wrap and provides an exercise modality for the patient. The protection provided by the hard plaster shell and the non-constricting but firm pressure against the patient's stump are superior to that provided by an elastic-bandage wrap. An elastic bandage, when wrapped properly, is firm distally and becomes less and less firm proximally. The wrap is thus very unstable, and it readily falls off. The plaster shell provides a more constant pressure, and the elastic straps can be adjusted easily.</p> <p>Once the patient masters his practice prosthesis, he is assigned to a work-therapy job, which usually is related to his future vocational interest. The ability to use his prosthesis on the job convinces the patient that he can function normally, which is another step in preparing the man for his permanent prosthesis and eventual discharge. If the patient cannot perform a certain function with his prosthesis, a therapist shows him how to solve the problem. The ability to hold grain sacks, handle meat knives, and lift pails are just a few of the everyday tasks that can be taught in work-therapy assignments.</p> <p>At this point in his rehabilitation, the patient receives a thirty-day leave. It is during this period that the amputee can really give his prosthesis a workout, by wearing it around the house and using it while doing repair work or mechanical tasks. Completely relying on his prosthesis is the best way for him to work out any problems in its operation. He learns what works best for him, and this knowledge is of great value when he is sent to the prosthetist for the fitting of the permanent prosthesis. After the patient receives his permanent prosthesis, he needs no further training; he can operate it with maximum efficiency, and all that is needed is a final check-out. After minor pressure points and alignment problems are adjusted, the patient is ready for discharge.</p> <p>If necessary, amputees can be fitted while their stumps were still open and in traction. The importance of skin traction cannot be overemphasized; 75 percent of the amputees received for treatment needed some type of skin traction before being fitted.</p> <p>The skin-traction weight is removed, and the traction ties are folded back over the stump end. Another stockinet is then pulled over the skin traction, and a plaster socket is fabricated over both.</p> <p>Although at first only the less open stumps were fitted in this manner, the method was so successful that we used it on grossly open stumps, and the fittings were accomplished without difficulty (<b>Fig. 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Stump ready for fitting with practice prosthesis and traction still maintained. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Training sessions in occupational therapy with the practice prosthesis are a tremendous boost to the patient's well-being. After the training session, he removes the prosthesis, reties the traction, and attaches the traction weights. As skin coverage and healing improve, skin-traction time becomes less, and practice-prosthesis-wearing time increases.</p> <h3>Discussion</h3> <p>Acceptance of the permanent prosthesis by the 30 patients fitted after February 1969, and their functional use of it, was evaluated. The degree of acceptance and functional use decreased as the level of amputation increased, with positive acceptance of the long below-elbow prosthesis and a gradual rejection of the shoulder-dis-articulation prosthesis. Every patient was given and trained with an APRL (Army Prosthetic Research Laboratory) hand. Two of the 30 patients preferred the APRL hand to the hook; both of these had shoulder disarticulations.</p> <p>The post-February 1969 patients were fitted three to four weeks earlier than the pre-February 1969 patients. Duration of hospitalization remained about the same, but the post-February 1969 patients were on work therapy and were productive three to four weeks earlier.</p> <p>Ease of fabrication and patients' acceptance of the streamlined practice prosthesis were noted. The patients' stumps tolerated the hard-shell sockets without difficulty.</p> <p>Early fitting over open stumps and over skin traction is possible. Edema is reduced and the stump is desensitized while the patient uses his prosthesis.</p> <p>Rehabilitating the upper-extremity amputee to normal activities as soon as possible requires a total team approach. Close coordination among the physicians, nurses, physical therapists, occupational therapists, and prosthetists is necessary. If everyone on the team understands the problems of the upper-extremity amputee, then all can work together in directing and guiding his treatment.</p> <p><b>References:</b></p> <ol> <li>Bailey, Ronald B., <i>An upper extremity prosthetic training arm</i>, Amer. J. Occup. Ther. 24:5:357-359, July-August 1970.</li> <li>Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, <i>The Management of Lower-Extremity Amputations</i>, TR 10-6, Prosthetic and Sensory Aids Service, Veterans Administration, August 1969, p. 11.</li> <li>Sarmiento, Augusto, Newton C. McCollough III, Edward M. Williams, and William F. Sinclair, <i>Immediate postsurgical prosthetics fitting in the management of upper-extremity amputees</i>, Artif. Limbs 12:1:14-19, Spring 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>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bailey, Ronald B., An upper extremity prosthetic training arm, Amer. J. Occup. Ther. 24:5:357-359, July-August 1970.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, The Management of Lower-Extremity Amputations, TR 10-6, Prosthetic and Sensory Aids Service, Veterans Administration, August 1969, p. 11.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, Newton C. McCollough III, Edward M. Williams, and William F. Sinclair, Immediate postsurgical prosthetics fitting in the management of upper-extremity amputees, Artif. Limbs 12:1:14-19, 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>Timothy V. Reyburn, MAJ., AMSC </b></td></tr><tr><td class="clsTextSmall">Now Chief of Occupational Therapy, Fort Riley, Kans. 66442.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_02_001/ArtificialLimbs-Autumn1971-9.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Method of Early Prosthetics Training for Upper-Extremity Amputees Creator An entity primarily responsible for making the resource Timothy V. Reyburn, MAJ., AMSC * https://staging.drfop.org/files/original/dac6e2c4c77d922124f665142308ab03.pdf 07ba4022d5e4a00af7689393d53a592c https://staging.drfop.org/files/original/b6bc3b3683b2300e9b27ae2ed97f13dc.jpg ed1395ee4b4bcc598159c9a0fbf84376 https://staging.drfop.org/files/original/371604048f3ca3974f54163916203dbc.jpg 783624f0922a0b6f959baf9245307c2c https://staging.drfop.org/files/original/4ef0a8b46b25cfcaf6599240c376a532.jpg fcd99d6ba6cfc086b4508d4150bdf886 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_058.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 58 - 67 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_02_058.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_02_058.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>Evaluation of Synthetic Balata for Fabricating Sockets for Below-Knee Amputation Stumps</h2> <h5>A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>At the present time, most sockets for artificial limbs are made of a plastic laminate (usually polyester resin and Dacron) which has been molded over a modified replica of the stump. A replica of the stump is required because human tissues cannot withstand the temperatures generated by the exothermic reaction of the plastic as it cures. The replica is modified, using general rules established by research groups, in order to achieve a relationship between the stump and socket that is physiologically satisfactory, yet permits weight-bearing and provides stability. In addition, reliefs must be provided to accommodate bony prominences and any tender spots. A simple plaster-of-paris wrap will usually be too loose for normal use. Therefore, fabrication of plastic-laminate sockets with presently available materials involves at least the following steps <b>Fig. 1</b>: (a) development of a female mold of the stump by wrapping the stump with plaster-of-paris bandages, (b) casting a male model of the stump by filling the female mold with plaster of paris, (c) modification of the male model by trimming away plaster in selected areas and building it up in other areas when necessary, and (d) lay-up and cure of the plastic laminate. The average time required to make a hard socket below-knee plastic prosthesis is eight man-hours.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Steps in the fabrication of a plastic prosthesis for a below-knee amputation. <i>A, </i>taking the plaster cast of the stump; <i>B, </i>pouring plaster in the cast to obtain model of the stump; <i>C, </i>introducing plastic resin into fabric pulled over the model to form the plastic-laminate socket; <i>D, </i>the plastic-laminate socket mounted on an adjustable shank for walking trials; <i>E, </i>a wooden shank block inserted in place of the adjustable shank after proper alignment has been obtained; <i>F, </i>the prosthesis after the shank has been shaped. To reduce weight to a minimum, the shank is hollowed out and the exterior covered with a plastic laminate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It has been the goal of a number of research workers to find a simpler and less time-consuming method for fabricating satisfactory sockets for all levels of amputation. After many experiments involving a number of casting methods and a variety of materials, the Veterans Administration Prosthetics Center<a style="text-decoration:none;">*</a> by 1961 had developed a technique for molding a socket of synthetic balata directly over a below-knee stump. The first successful results were achieved by using an air-pressure sleeve over a tube of synthetic balata,<a style="text-decoration:none;">*</a> which had been softened by immersion in hot water (160 deg F) and then pulled over the stump<a></a> <b>Fig. 2</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The air-pressure method of forming synthetic balata sockets for PTB prostheses: application of the tube to the lubricated sleeve of the stump; application of pressure to the sock-covered pressure sleeve; and the socket and bonded tubing attached with screws to the pylon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Upon the recommendations of the CPRD Subcommittee on Design and Development, the Subcommittee on Evaluation undertook responsibility for the evaluation of the new technique.</p> <p>The claims of the development laboratory were: (a) a substantial decrease in elapsed time between measurement of the stump and production of a wearable limb, thereby speeding the rehabilitation process, (b) a substantial reduction in man-hours involved, (c) a capability for easy adjustment of the prosthesis at any time, and <i>(d) </i>a decrease in the amount of skill and training required to produce an adequate socket.</p> <h4>Procedure</h4> <p>A protocol (given at the end of this article) was developed and five clinics<a style="text-decoration:none;">*</a> were asked to participate in the evaluation. The prosthetists from the clinics were trained as a group at the Veterans Administration Prosthetics Center on November 6-8, 1968. Each clinic was requested to fit five new amputees and five amputees who had worn PTB prostheses before, and provided with sufficient material and equipment to carry out the fittings.</p> <h4>Results</h4> <p>Follow-up in the spring of 1969 revealed that all the prosthetists were encountering difficulty in obtaining adequate fits in nearly all cases except those with long tapered stumps, most of the sockets being too loose proximally. To overcome this problem, the VAPC devised a method whereby the air bag was eliminated, and molding pressure was brought about by wrapping the softened balata tube with one-inch-wide elastic webbing and controlling the shape of the socket with the hands and fingers as it cooled.</p> <p>All of the participating prosthetists were instructed in the revised method, and other prosthetists were instructed in the new procedure at the same time. Shortly afterwards, plastic pressure-sensitive tape was substituted for the elastic webbing <b>Fig. 3</b>.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The tape-wrap method of forming synthetic balata sockets: application of pressure with elastic, pressure-sensitive tape; molding by hand to define the medial tibial flare and tibial crest; and the heated socket bottom joined to the pylon by an elastic tape wrap. (Courtesy Veterans Administration Prosthetics Center. New York, NY) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The results with the revised procedure were considerably better. The average synthetic balata prosthesis, with pylon but without cosmetic treatment, weighed 3 1/2<i> </i>lb, and could be made in 2 1/2 hr. All of the claims of the developer were substantiated with the exception of the relative amount of skill required, a factor that would be very difficult to measure at this stage of development. At any rate, it is safe to say that no more skill is required for the new technique than for older methods.</p> <p>All prosthetists who used the technique, with one exception, felt that synthetic balata is quite useful for temporary prostheses. Some have adopted the method as standard procedures where procurement practices permit use of temporary prostheses of this type.</p> <h4>Conclusions</h4> <p>When this technique is used, a considerable saving in time can be effected, and the patient can be provided with a prosthesis within a few hours. Furthermore, the use of synthetic balata permits easier adjustment of the socket later, and the adjustable pylon permits adjustment in alignment at any time.</p> <p>It is therefore recommended that use by federal and state agencies of the VAPC technique for fabricating below-knee temporary prostheses be encouraged, and that the technique be included in the curricula of all below-knee prosthetics courses.</p> <p><b>References:</b></p> <ol> <li>Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, <i>Artif. Limbs, </i>6:2:25-73, June 1962.</li> <li>The Staff, Veterans Administration Prosthetics Center, Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material, <i>Orth. and Pros., </i>23:1:36-61, March 1969.</li> <li>Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, <i>Bull. Pros. Res., </i>10-12:34-47, Fall 1969.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, Bull. Pros. Res., 10-12:34-47, Fall 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">Rancho Los Amigos Hospital, Duke University, the University of Miami, the Veterans Administration Hospital/Los Angeles, and the Veterans Administration Hospital/Buffalo</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, Artif. Limbs, 6:2:25-73, June 1962.</td></tr><tr><td class="clsTextSmall"><b>2 .</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">From Polysar X-414 resin produced by thePolymer Corporation Limited, Sarnia, Ontario,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>Footnote</b></td></tr><tr><td class="clsTextSmall">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>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_058/tmp64A-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_058/tmp64A-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_058/tmp64A-3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evaluation of Synthetic Balata for Fabricating Sockets for Below-Knee Amputation Stumps Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/78226bca3eceb612d7d8db7908b1afea.pdf 17ea92cb6ada6610f2fbaf86eea54a0f https://staging.drfop.org/files/original/261df725d54dd7f063e4c1480fe2b3d3.jpg e794ee1f0b5fff92c69ded224bd3aa44 https://staging.drfop.org/files/original/5dfcfa64de6eb114dc3fd23266ad039f.jpg 154d7c1efbfef010c8ffd5299e701802 https://staging.drfop.org/files/original/26f6f61c5da43145a36acf58b1b84714.jpg 710d554f2eca75d9ec64650b02660da0 https://staging.drfop.org/files/original/11c9646efd2d9c0d69c2c465b47da84c.jpg d2191235871cd29462432969c2b36907 https://staging.drfop.org/files/original/db60e11c55d82008b2c099fe8ebda7ea.jpg 92cd2270b0e64d666d64407d4727ea18 https://staging.drfop.org/files/original/52834292f43677d81a9dc47f6f0f8db8.jpg da920604014ba63f1c778df76f95429d https://staging.drfop.org/files/original/f25fe005117d51ad9f0f54b235e228b3.jpg 2b8bb51f1b1e51f6d17abf901bde4539 https://staging.drfop.org/files/original/77e0f06a236e310a84838dc1ae8ea654.jpg b54a96a32abe60f41a30de18539467e7 https://staging.drfop.org/files/original/717dfa7fc8a884e6add25d763cbec268.jpg ac4508fff3afb9d1e91dc55704c0ecd5 https://staging.drfop.org/files/original/9833ca023913ff88aa0624da3d7d60eb.jpg ee895b1e9c8002f8f13bd6e78e37fcef https://staging.drfop.org/files/original/016bae82750ffc63db29627f435b81be.jpg 49366f88c3c52085520c43c8c7d454eb https://staging.drfop.org/files/original/7aec942c558625876ab59a8cbfa191da.jpg 2d09d1494909a8173317549ba8eaaff0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_068.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 68 - 80 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_02_068.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_02_068.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A New Approach to Patient Analysis for Orthotic Prescription- Part I: The Lower Extremity</h2> <h5>Newton C. Mccollough III. M.D. <a style="text-decoration:none;">*</a><br />Charles M. Fryer. MA. <a style="text-decoration:none;">*</a><br />John Glancy, CO. <a style="text-decoration:none;">*</a><br /></h5> <p>There is little question that the field of orthotics has taken a back seat to prosthetics in modern times, and perhaps for good reason. The needs of the amputee are more immediate and obvious, and the wars of the past thirty years have yielded untold numbers of young men in their prime whose productivity depended upon satisfactory functional restoration of their missing limbs. Medicine, engineering, and the prosthetic profession have responded to the needs of the amputee through extensive research and development, widespread educational programs, improved fabrication and fitting techniques, and better delivery of services. The field of orthotics remains in comparative disarray with more limited, though no less sophisticated, research activities, few educational endeavors, and little improvement upon local fabrication and delivery services over the past fifty years.</p> <p>Much of the blame for this rather distressing state of affairs must be laid to the physician, whose approach to orthotic prescription has been somewhat less than scientific. More often than not, little thought is given to analyzing specific biomechanical defects present in an extremity with the aim of translating them into an appropriate mechanical substitute. Even when this is done, all too often the device that is prescribed impairs to some degree the normal biomechanical functions which coexist in the same extremity. For example, a long leg brace prescribed for genu recurvatum may also limit normal functioning of the subtalar joint. Much of the physician's casual approach to orthotic prescription stems from a relatively sparse education in orthotic principles, but an even greater deficiency is the failure to relate well-known biomechanical principles to the mechanical substitute, or orthosis. Therein lies the trap, for without this awareness, prescriptions will continue to reach the orthotist calling for simply a "short leg brace" or a "long leg brace," and thus there is no stimulation for new or improved design criteria for orthotic components and systems.</p> <p>There is little doubt that the great advances which have been made in prosthetics in recent years have resulted primarily from a systematic appraisal of normal human posture and locomotion, with resultant attempts to duplicate not only the missing anatomy but also the biomechanical functions of the extremity. The problem in orthotics is somewhat different: specific functional losses must be substituted for in the presence of intact anatomy, and the variety of functional losses which may be present in a given extremity necessitates correspondingly varied design criteria. It is apparent, therefore, that an initial step in developing a rational approach to orthotic design and prescription would be some means of systematically analyzing the biomechani-cal losses in an impaired extremity. Once properly identified, these losses could then be matched against specific components or component systems to substitute for the functions lost. In addition, such an analysis might point up certain areas or functions for which truly satisfactory components are not available, and thus it might serve as a stimulus for future design and development.</p> <p>Recognizing the need for a more organized and systematic approach to orthotic prescription as a part of current efforts to revise volume 1 of the <i>Orthopaedic Appliances Atlas, </i>the Committee on Orthotics and Prosthetics of the American Academy of Orthopaedic Surgeons appointed an ad hoc committee for the development of a lower-extremity analysis form. In essence, this article represents a report of that committee, whose work commenced two years ago. During the development of the form, workshops were held periodically with the parent committee, together with representatives of the American Orthotic and Prosthetic Association, the Veterans Administration Prosthetics Center, and the Committee on Prosthetics Research and Development of the National Research Council. The form underwent periodic revision as it was applied to patients with a variety of disabilities, utilizing several clinics. The most recent and final application of the lower-extremity analysis form was in conjunction with the Workshop Panel on Lower-Extremity Orthotics held at Rancho Los Amigos Hospital in Downey, California, in March 1970. Its applicability to the evaluation of lower-extremity disability is now felt to be such as to warrant description for more widespread usage.</p> <h4>Lower-Extremity Analysis Form</h4> <p>The form consists of four pages of appropriate size for insertion into the patient's hospital chart. The first page <b>Fig. 1</b> contains spaces for patient data, including the diagnosis and a summary of major impairments existing in one or both extremities. At the bottom of the first page there is a legend for symbols to be used on the extremity diagrams. The second and third pages <b>Fig. 2</b>,<b>Fig. 3</b> contain skeletal outlines of the right and left lower extremities, respectively, in the sagittal, coronal, and transverse planes. Overlying the major joints are shaded areas, representing the normal ranges of joint motion within a circle divided into thirty-degree segments. Similar smaller circles overlie the mid-shafts of the long bones for diagraming angular, rotational, or translational deformities of the femur and tibia. The fourth page <b>Fig. 4</b> includes spaces for summarizing the functional disability, and for orthotic recommendations based upon this summary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Front sheet of patient analysis form, including summary of major impairments and legend. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Second page of patient analysis form, with diagram of right lower extremity. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Third page of patient analysis form, with diagram of left lower extremity. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Fourth page of patient analysis form provides space for summary of patient's functional disability and for the orthotic recommendation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Instructions for Use</i></p> <p>Most of the "Major Impairments" portion of the form is self-explanatory. "Abnormal bone and joint" conditions may include such entities as osteoporosis, Paget's disease, and coxa vara. "Muscle" may be normal, flaccid, or spastic, but a space is provided for description of rarer disorders such as muscular dystrophy and fibrosis of muscle. Under the heading of "ligament," check boxes are provided to indicate abnormal laxity of the major ligaments of the knee and ankle. The sections on "sensation," "skin," and "vascular" impairments cover considerations which may influence orthotic design, and are self-explanatory.</p> <p>"Balance" is either normal or impaired, and if impaired, the following definitions are applicable: "mild" impairment is compatible with independent ambulation; "moderate" impairment is compatible with ambulation utilizing external support; and "severe" impairment indicates the need for maximal support or personal assistance in ambulation.</p> <p>"Extremity shortening" is recorded as follows: ischial tuberosity to sole of heel, ischial tuberosity to medial tibial plateau, and medial tibial plateau to sole of heel.</p> <p>In leg-length discrepancies exceeding one-half inch, X-ray studies of leg length may be indicated, and an appropriate space is provided for this measurement.</p> <p><i>Legend and Extremity Diagrams</i></p> <p>Two terms must first be defined:</p> <ol> <li><i>"Translatory motion"</i> is motion in which all points of the distal segment move in the same direction, with the paths of all points being exactly alike in shape and distance traversed <b>Fig. 5</b>.</li><li><i>"Rotary motion"</i> is motion of a distal segment in which one point in the distal segment or in its (imaginary) extension always remains fixed <b>Fig. 6</b>.</li></ol> <p>The symbols described in the legend are used in conjunction with the right-and left-extremity diagrams according to the following rules:</p> <ol> <li><b>Recording motion:</b> The degrees of rotary motion or centimeters of translatory motion are to be obtained from passive manipulation, and are to reflect passive (not active) motion at the site being examined. In the lower extremity, joints are to be observed during weight-bearing, and if the degree of joint excursion is greater under conditions of loading than under passive manipulation, this figure is diagramed rather than the smaller figure (e.g., recurvatum of the knee). <ul><li><i>Translatory motion:</i> Linear arrows horizontally placed below the circle indicate the presence of (abnormal) translatory motion at one or more of the six designated levels of the lower extremity listed on the left side of the form. The head of the arrow always points in the direction of displacement of the distal segment relative to the proximal segment. Linear arrows vertically placed on the right side of the circle indicate(abnormal) translatory motion along the vertical axis at the site indicated.</li> <li><i>Rotary motion:</i> Normal ranges of rotary motion about joints are preshaded on the diagram. Abnormal rotary motion, either as limited or excess motion, is indicated by double-headed arrows placed outside and concentric to the circle, to indicate the extent of available motion present in the affected joint. In certain instances, it may be more meaningful to use two double-headed arrows in order to describe the range of motion to either side of the neutral joint axis, rather than a single arrow which describes the total range of motion present. If one head of an arrow fails to reach the preshaded margin, limitation of joint motion is denoted. Conversely, if one head of an arrow projects beyond the preshaded margin, excess motion is designated. Numbers in degrees are placed adjacent to the arrows to indicate the arc described. In addition, radial lines drawn from the center of the circle and passing through its perimeter at the tips of the double-headed arrow are to be used for more graphic representation of the arc of available motion. At sites where rotary motion does not occur (e.g., fracture site, or knee joint in the coronal plane), the presence of abnormal rotary motion is similarly designated by a double-headed arrow with adjacent numerical value in degrees.</li> <li><i>Fixed position:</i> Double radial arrows indicate a fixed joint position, and describe in degrees the deviation from the neutral joint position. Horizontal or vertical double arrows indicate a fixed joint position in a translatory sense, and the extent of abnormal translation is indicated in centimeters adjacent to the arrow (e.g.,subluxation of the tibia in a hemophiliac knee).<br /></li></ul></li><li><b>Muscle dysfunction: </b> <ul><li><i>Flaccid muscle:</i> Flaccid muscle is designated as such under the section on major impairments. Muscle-group strength, not individual muscle strength, is determined by conventional means on the examining table, and the letter grade corresponding to volitional force is recorded adjacent to the skeletal outline at the proper location for each muscle group. The letter grades correspond to the standard muscle-grading system used in poliomyelitis. No symbol is used if muscle strength is normal.</li> <li><i>Spastic muscle: </i>Spastic muscle is designated as such under the section on major impairments. It is further identified in the legend as "SP." The letter grade (e.g., SP_MO) for muscle-group tone, not individual muscles, is to be placed adjacent to the skeletal outline at the proper location for each muscle group. Spastic-muscle estimates are to be made with the patient in the functional position for the lower extremity, i.e., observation during standing and walking. The subletter grades for spastic muscle are as follows:<br /> "M" indicates a mild degree of spasticity;<br /> "MO" indicates a moderate degree of spasticity sufficient for useful holding quality;<br /> "S" indicates severe spasticity, obstructive in terms of function.<br /> In certain instances, muscle groups in a patient with spastic paralysis may be more appropriately graded according to volitional force, e.g., dorsiflexion of the foot in a hemiplegic.<br /></li></ul></li><li><b>Recording fracture or bone deformity: </b> All translatory or rotary motions at the fracture on the shaft of a long bone are diagramed on the circle located</li></ol> <p>The technique of completing the analysis forms for specific lower-extremity disabilities is shown in <b>Fig. 7</b>,<b>Fig. 8</b>,<b>Fig. 9</b>,<b>Fig. 10</b>,<b>Fig. 11</b>,<b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Record for patient with left hemiplegia. Information given on front sheet includes spastic muscle picture with inversion deformity of foot, mild loss of proprioception, venous stasis in left leg, and mild impairment of balance. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Diagram of patient E.L.'s left lower extremity. Muscles which are not normal are designated by letter grade. Muscles which are not spastic clinically and which possess volitional control are designated by conventional letter grading. The diagram illustrates presence of good hip flexors, extensors, and abductors, good knee extensors, fair knee flexors and foot invertors, poor foot dorsi flexors, zero foot evertors, and mild calf spasticity. There is 15° of hyperextension at the knee, and the heel cord is tight, limiting dorsiflexion of the foot to neutral. The presence of edema from the knee to the foot is also noted at the mid-shaft of each bone. The actual fracture site is indicated by the fracture symbol. All bony deformities such as valgus angulation of the shaft are likewise diagramed on the circle located at the center of the shaft, regardless of the position of the angular deformity. The location of the angular deformity is designated by circling the appropriate level on the left side of the chart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Summary of the patient's functional limb disability, and the orthotic recommendation based upon that summary. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Record for patient with residual poliomyelitis affecting his left lower extremity. Information given indicates flaccid paralysis with severe atrophy, laxity of the medial collateral ligament of the knee, and 1 3/4 in. shortening of the left lower extremity. In addition, the patient had an old supracondylar fracture of the femur and a previous triple arthrodesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Diagram of patient W.S.'s left lower extremity. In addition to showing the letter grades for muscle-group strength, the diagram also shows 20° of hyperextension at the knee, 15° of valgus instability of the knee, 15° of external tibial torsion, limitation of dorsiflexion at the ankle, abnormal inversion and eversion at the ankle, and a fixed position of the subtalar joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Summary of patient W.S.'s functional limb disability, and the orthotic recommendation based upon that summary. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Discussion</h4> <p>The stated purpose of developing a patient analysis form of this type is to organize a systematic approach to orthotic prescription. In addition, through stimulation of a careful appraisal of biomechani-ical faults in a given extremity, it may also serve as a basis for identifying certain areas in need of new or further design and development. It is also viewed as a valuable teaching tool for students of orthotics at both the technician and physician levels. Most importantly, it may serve as a common ground upon which both the orthotist and the physician can meet to work out satisfactory solutions to bracing problems. (Sample copies of the form are available from the CPRD office).</p> <p>As a further step in making such an analysis form more meaningful to orthotists and physicians, a list of available lower-extremity orthotic components is currently being compiled in such a way as to categorize these components by their biomechanical function. Ideally then, one might diagra-matically plot the biomechanical losses present in a limb and then select a mechanical device from the appropriate category to substitute for the lost function. In this way, the orthotic prescription can evolve as a carefully thought-out combination of specific components to create a suitable orthotic system for the deficient limb.</p> <p>A revitalized approach to orthotics is urgently needed. According to a recent estimate, there are 3,370,000 orthotic patients in the United States as opposed to 311,000 amputees, or ten times as many patients who need orthoses as need prostheses <i>(1). </i>Little that is new has been done for many of these patients until very recently. Several research centers in the United States and Canada are engaged in sophisticated and promising orthotic research. Unfortunately, by and large, the products of this research have not yet reached the masses of handicapped people. Stimulation of new approaches to mechanical design at the local level must be achieved through close and meaningful collaboration between physician and orthotist. It is hoped that the material presented in this article will be an initial step toward that goal.</p> <p>Work is currently being done on a similar approach to the upper extremity and the spine. These areas will be the subjects of future reports.</p> <h4>Acknowledgements</h4> <p>The authors wish to express special appreciation to Dr. George T. Aitken, former chairman of the American Academy of Orthopaedic Surgeons Committee on Prosthetics and Orthotics; Dr. Robert Keagy; Mr. A. Bennett Wilson, Jr.; Mr. Anthony Staros; and Dr. Edward Peizer for their specific contributions to this work.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> FIg. 5. "Translatory motion": motion in which all points of the distal segment move in the same direction, with the paths of all points being exactly alike in shape and in distance traversed. In all three examples, the pathways between original position "A" and final position "B" of four arbitrarily selected points in each figure are each exactly alike in direction, form, and distance traversed. Note that the long axes of the figures also remain parallel throughout the "translation" from A to B. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. "Rotary motion": motion of a distal segment in which one point in the segment, or in its (imaginary) extension, always remains fixed. The axis "O," in each of the three examples, represents a point in the figure (or as in "III" in its imaginary extension) that always remains fixed in position when the body "rotates" from position "A" to position "B." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Committee on Prosthetics Research and Development, <i>Report of the Seventh Workshop Panel on Lower-Extremity Orthotics of the </i><a><i>Subcom.it-</i></a><i>tee on. Design and Development, </i>National Research Council-National Academy of Sciences, March 1970.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>John Glancy, CO. </b></td></tr><tr><td class="clsTextSmall">Orthotic Division, Indiana University Medical Center, Indianapolis, Ind. 46207.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles M. Fryer. MA. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetic-Orthotic Center, Northwestern University Medical Center, Chicago, Ill. 60611.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Newton C. Mccollough III. M.D. </b></td></tr><tr><td class="clsTextSmall">Assistant Professor of Orthopaedics, Associate Director of Rehabilitation, University of Miami School of Medicine, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-07.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-08.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-09.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-10.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-11.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-12.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-05.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_02_068/tmp64B-06.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A New Approach to Patient Analysis for Orthotic Prescription- Part I: The Lower Extremity Creator An entity primarily responsible for making the resource Newton C. Mccollough III. M.D. * Charles M. Fryer. MA. * John Glancy, CO. * https://staging.drfop.org/files/original/4bc63286a052815b611c768021f481ba.pdf f1ec48cc2c9ab7ffffb5c555da764187 https://staging.drfop.org/files/original/f6478fbe791a100f3c1e5cc7f7ab632b.jpg de9916706b45884b00e9ba6dd49f8cac DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_02_006.pdf Year 1971 Volume 1 Issue 2 Page Number(s) 6 - 10 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/1971_02_006.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_02_006.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 Children's Prosthetics and Orthotics Program</h2> <h5>Hector W. Kay <a style="text-decoration:none;">*</a><br /></h5> <p>During the early 1950s, pioneering clinicians in the management of the child amputee repeatedly insisted that children were not miniature adults, to whom modes of fitting developed for adults could be applied indiscriminately. The physicians argued that these children had characteristics and problems that required special study and treatment. Primarily because of the missionary efforts of these men, the Committeee on Prosthetics Research and Development in February 1956 moved from an indirect role in the area of children's prosthetics to an active and dynamic one by the establishment of a standing Subcommittee on Child Prosthetics Problems (SCPP). The first chairman, Charles H. Frantz, M.D., guided the activities of the subcommittee until 1965, when he was succeeded by George T. Aitken, M.D. The current membership of the subcommittee appears at the end of this article.</p> <p>Concurrently with the establishment of the SCPP, the Child Prosthetics Studies program at New York University was created under the direction of Sidney Fish-man, Ph.D. From its inception, the New York University program has been closely related to the activities of the Subcommittee on Child Prosthetics Problems. In essence, New York University has acted as an executive arm of the subcommittee in implementing many of its recommendations. This relationship led to the initiation and completion of numerous significant studies, some of which were: (1) extensive laboratory and field evaluations of various models of the APRL-Sierra no. 1 hand; (2) tests of the Dorrance juvenile hand, size no. 2; (3) studies of the application of the quadrilateral suction socket to the juvenile above-knee amputee, and of the patellar-tendon-bearing prosthesis to the skeletally immature below-knee amputee; (4) a field evaluation, preceded by the development of a fabrication manual and an instructional course, on the Minister-type fitting for the below-elbow amputation stump; and (5) laboratory and field studies of the CAPP electric cart.</p> <p>Significant nonevaluation activities included studies of the prosthetic fitting of children amputated for malignancy, numerous surveys and census-type studies of children under treatment, and follow-up studies related to the early work of Frantz and O'Rahilly in the classification of congenital limb deficiencies, with efforts to achieve an internationally acceptable system.</p> <p>As a result of the activities of the subcommittee and of the studies conducted at its instigation by New York University, a number of important by-products have emerged:</p> <ol> <li>The treatment of the limb-deficient child has become a recognizable subspecialty in medicine that has attracted many competent physicians.</li><li>The principle of fitting the child with congenital limb deficits at a very early age has been well established.</li><li>The early fitting of the juvenile who loses a limb because of malignancy, other diseases, or trauma has also become generally accepted.</li><li>Developers and manufacturers have been encouraged to produce prosthetic components for all age levels of the child-amputee population.</li></ol> <h3>Cooperative Clinic Program</h3> <p>A significant early action of SCPP was to bring together in August 1958 a group of persons with a known interest in the treatment of the child amputee. Included were the chiefs of 11 existing child-amputee clinics who agreed to cooperate in studies seeking improved treatment for the limb-deficient child. The participants in this historic meeting were:</p> <ul> <li>Gen. F. S. Strong, Jr., Washington, D.C.</li> <li>Tonnes Dennison, Beverly Hills, Calif. </li> <li>George T. Aitken, M.D., Grand Rapids, Mich.</li> <li>Carleton Fillauer, Chattanooga, Tenn.</li> <li>Charles H. Frantz, M.D., Grand Rapids, Mich.</li> <li>Colin A. McLaurin, Chicago, HI.</li> <li>Charles Radcliffe, Ph.D., Berkeley, Calif.</li> <li>Harry Campbell, Los Angeles, Calif.</li> <li>Leon DeVel, M.D., Grand Rapids, Mich.</li> <li>Edward Hitchcock, New York, N.Y.</li> <li>Bertram Litt, New York, N.Y.</li> <li>Edward Peizer, Ph.D., New York, N.Y.</li> <li>Anna M. Bahlke, Albany, N.Y.</li> <li>Milo Brooks, M.D., Los Angeles, Calif.</li> <li>Capt. Thomas Canty, Oakland, Calif.</li> <li>Carleton Dean, M.D., Lansing, Mich.</li> <li>George G. Deaver, M.D., New York, N.Y.</li> <li>Sidney Fishman, Ph.D., New York, N.Y.</li> <li>Col. Maurice Fletcher, Washington, D.C.</li> <li>James Glessner, M.D., Newington, Conn.</li> <li>J. Leonard Goldner, M.D., Durham, N.C.</li> <li>Richard E. King, M.D., Atlanta, Ga.</li> <li>Claude N. Lambert, M.D., Chicago, HI.</li> <li>Arthur J. Lesser, M.D., Washington, D.C.</li> <li>Robert Mazet, Jr., M.D., Los Angeles, Calif.</li> <li>John R. Moore, M.D., Philadelphia, Pa.</li> <li>Frank Potts, M.D., Buffalo, N.Y.</li> <li>Frederick Vultee, M.D., Richmond, Va.</li> </ul> <p>Subsequently, other child-amputee clinics sought affiliation with the cooperative program, and, upon meeting the criteria or standards established by the subcommittee, additional clinics have been accepted into the cooperative research endeavor. Thirty clinics, broadly distributed, have now been accepted.</p> <p>A large proportion of the studies authorized by the subcommittee have been carried out by the participating clinics under the guidance of New York University.</p> <p>In addition to the 30 clinics currently enrolled in the cooperative program, contact is being maintained with 36 other child-amputee clinics.</p> <h3>Projects</h3> <p>By the mid-1960s, it had become apparent that significant advances had been made in prosthetics generally. Many of the improved fitting techniques that had been developed were found to be applicable to children, and numerous components of advanced design had been made available for use by the child amputee. As a result, children with less severe or with uncomplicated limb deficits, of either congenital or acquired origins, could be treated, and reasonably satisfactory results could be expected. However, the management of the child with severe losses, particularly those affecting both upper limbs at high levels, left much to be desired. The solutions to these problems were considered to be in the successful application and control of externally powered devices. Although available components and systems of this type were (and are) relatively crude, they are regarded as the hope of the future, and a major evaluation and redevelopment effort is being mounted. Already in progress or about to be initiated as a result of prior action by the Subcommittee on Child Prosthetics Problems are a number of studies of great potential value in the evaluation of improved devices and treatment procedures.</p> <p>Studies will be conducted by New York University, through the participating clinics, on the Ontario Crippled Children's Centre (OCCC) coordinated electric arm, an advanced model of the Michigan Crippled Children Commission feeder arm, the OCCC electric elbow, the Rancho Los Amigos Hospital electric elbows, the Otto Bock myoelectric hand, and the Viennatone myoelectric hand.</p> <p>At the request of SCPP, New York University has conducted an annual census of the child amputees who are being treated at the cooperating clinics. For 1969, the data indicated that the total population under treatment was 4,625-an increase of 236 over the prior year. An expanded census relative to the calendar year 1970 has been completed. <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 /> <h3>Specialized Fitting Centers</h3> <p>At its meeting on October 21, 1967, the Committee on Prosthetics Research and Development approved a proposal by the Subcommittee on Child Prosthetics Problems that an ad hoc committee be established to develop a detailed plan for the creation of specialized prosthetics fitting centers for severely handicapped children. At its meeting on June 12, 1968, CPRD received the report of the committee, which presented criteria for operation of the centers. This plan, which had been previously approved by the child-amputee clinics, was also approved by CPRD.</p> <h3>Children's Orthotics</h3> <p>At its meeting on November 4-5, 1969, the Committee on Prosthetics Research and Development charged the Subcommittee on Child Prosthetics Problems with the responsibility for enlarging its sphere of activities to include children's orthotics. An ad hoc committee of SCPP was appointed to investigate the implications of this new responsibility and to make recommendations for its implementation. It should be noted that the Subcommittee on Design and Development of CPRD had already conducted a number of meetings and workshops on orthotics topics, particularly in the area of lower-extremity bracing, which was the first segment of the orthotics field to be investigated, and many items with possible applications to orthopedically disabled children were beginning to emerge from this work.</p> <p>Upon the recommendation of the ad hoc committee, a number of selected lower-extremity orthotics items that had emerged from the design and development effort and several bracing and ambulation aids that had been developed at the Ontario Crippled Children's Center were demon- strated at a meeting of amputee-clinic chiefs on June 11, 1970, and the clinic chiefs were polled as to their interest in clinical applications of the items demonstrated. Their responses were tabulated by New York University and revealed considerable interest in virtually all items. The Subcommittee on Child Prosthetics Problems reviewed these findings at its October 16, 1970, meeting and recommended that NYU undertake the recruitment of a nucleus of clinics interested in a cooperative research program on treatment devices for cerebral palsy, Legg-Perthes disease, and myelomeningocele. It was further recommended that orthopedic surgeons currently participating in the program be surveyed to identify clinics they knew to be interested in these problems. Subsequently, NYU reported that three clinics in the New York City area had indicated an interest in participating, and that discussions were being held with these clinics to develop a format for the initiation of a mutually useful program.</p> <h3>Education</h3> <p>A major requirement for participation in the cooperative clinical program has been that clinic personnel attend the appropriate upper- and lower-extremity courses at one of the three universities offering such programs. Moreover, since December 1961 at Northwestern University, and since 1964 at the University of California at Los Angeles, 26 courses in the management of the child amputee have been offered to 864 students, including 450 physicians, 238 therapists, and 146 prosthetists. New York University has offered special lectures in the management of the child amputee in its regular prosthetics courses. In connection with the evaluation of specific items where special application skills are required, courses of instruction have been given to the participants.</p> <p>All these educational activities have tended to provide an increasingly higher level of competence among physicians and others in the management of the child with limb deficiencies. Moreover, the Child Amputee Program has been a direct par- ticipant in, and contributor to, the general transition procedures governing the overall prosthetics research and education program. These procedures have served to bring new research-derived information directly and expeditiously to the consumer through courses of instruction and published materials.</p> <h3>Publications</h3> <p>In May 1961, at a meeting of the 12 clinic chiefs then participating in the cooperative program, the chairman of the Subcommittee on Child Prosthetics Problems proposed the creation of a bulletin or newsletter that would serve as a medium for the exchange of information between the clinics. The idea was received enthusiastically by the clinic chiefs, who undertook to provide articles on a scheduled basis. The first issue of the <i>Inter-Clinic Information Bulletin </i>was published in October 1961. It was six pages long, and 100 copies were distributed. Now, 10 years later, the <i>Bulletin </i>is a 16-page printed booklet with circulation in excess of 2,700 copies per issue.</p> <p>Initially, <i>ICIB </i>dealt solely with amputees and prosthetics management. In the past year, however, in line with the general trend, the scope of the <i>Bulletin </i>has been enlarged to include orthotics topics. Since 1967, <i>ICIB </i>has been catalogued in the Library of Congress (Catalogue Number 67-304).</p> <p>At the last four annual meetings of the chiefs of the cooperating clinics, a feature of the program has been a symposium on a selected area of child-amputee management. The proceedings of the symposia held in 1967 <i>(Normal and Abnormal Em-bryological Development), </i>1968 <i>(Proximal Femoral Focal Deficiency), </i>and 1969 <i>(Surgical and Prosthetic Management of Lower-Extremity Anomalies) </i>have been published and distributed to clinicians, medical schools, and other interested groups. The proceedings of the 1970 meeting <i>(The Child with an Acquired Amputation) </i>are being prepared for printing.</p> <p>Effective communication with and between the clinics has been maintained by means of the <i>Inter-Clinic Information Bulletin, </i>the annual meeting of clinic chiefs, and personal contacts through CPRD and NYU staff. These factors have been critical elements in the extremely successful operation of the cooperative child-amputee research program. As the scope of the endeavor now expands to include conditions requiring orthotic assistance, the same elements may be used to develop an equally successful program for children with orthopedic disabilities other than amputation.</p> <h3>Subcommittee on Child Prosthetics Problems, CPRD</h3> <ul> <li>George T. Aitken, M.D., Chairman, Grand Rapids, Mich.</li> <li>Charles H. Epps, Jr., M.D., Washington, D.C.</li> <li>Sidney Fishman, Ph.D., New York, N.Y.</li> <li>Cameron B. Hall, M.D., Los Angeles, Calif.</li> <li>Douglas A. Hobson, P.Eng., Winnipeg, Canada</li> <li>Leon M. Kruger, M.D., Springfield, Mass.</li> <li>Claude N. Lambert, M.D., Chicago, 111.</li> <li>Robert E. Tooms, M.D., Memphis, Tenn.</li> </ul> <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>Hector W. Kay </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_02_006/ArtificialLimbs-Autumn1971-10.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 Children's Prosthetics and Orthotics Program Creator An entity primarily responsible for making the resource Hector W. Kay * https://staging.drfop.org/files/original/05797d097e7ea7bad20de2770f06ed76.pdf d699846094a3209fce59adbb13245529 https://staging.drfop.org/files/original/f98ef36fe95f94695881ac19925c87a9.jpg 30eb9bb0dc166fc3e4b3e982d869a061 https://staging.drfop.org/files/original/3f4b5b9d7c4f70854173c781c4481798.jpg 5ca81b27f54f0f31107e402d7d5b9cb2 https://staging.drfop.org/files/original/e349ce4b1ee6b4c02285e4909c234840.jpg 8de21023d178bf28467ea698c6b1c205 https://staging.drfop.org/files/original/4d87c9d67d81a8f92e52306ee2883f12.jpg b931c8ba3d44b6753e00a7f4493ef3af https://staging.drfop.org/files/original/d8ae7a1cea1830e2967b85b3afa776ab.jpg 1c823de12ebbf9e31f89866f0b07d59f https://staging.drfop.org/files/original/dbea119e932addf689fac9106cd0855e.jpg dc1f371a8c41a1e8da75e9ff08e496b6 https://staging.drfop.org/files/original/a6b7887debc002729c288b71ad391f6d.jpg de80f95e85cf71e745f38c6290765c9c https://staging.drfop.org/files/original/cefb99637af02427a4920d527a6cde80.jpg 4d5b9c08311b42d45b26abb4f1dfbeb9 https://staging.drfop.org/files/original/8570f07fd1f37cb83a54e7a55184cb89.jpg 107e71ad31ce064c650020317eb40e6e https://staging.drfop.org/files/original/ddde5450ec9bcccfc098853075b0d207.jpg 0e79c7eda7e3e3a0e5fa51bde27aa4f5 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_01_022.pdf Year 1971 Volume 15 Issue 1 Page Number(s) 22 - 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/1971_01_022.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_01_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>Elastic-Liner Type of Syme Prosthesis: Basic Procedure and Variations</h2> <h5>Maurice A. LeBlanc <a style="text-decoration:none;">*</a><br /></h5> <p>In the past few years, a number of pros-thetists have been fabricating elastic-liner types of Syme prostheses, and their procedures have been described in the literature. <a></a> This article presents the most commonly used procedure and some of the variations to it.</p> <p>The elastic-liner type of Syme prosthesis has the advantage of eliminating the door on the conventional prosthesis (<b>Fig. 1</b>), thereby allowing greater strength (with no openings) and a smoother cosmetic finish (with no straps) while maintaining total contact and suspension (<b>Fig. 2</b>). However, it cannot be used if the bulbous end of the stump is too large for satisfactory cosmesis of the cylindrical portion or for making the liner (not possible when the distal end is larger than the proximal brim).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Conventional Syme prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Elastic-liner Syme prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Basic Procedure</h3> <ol> <li>Felt patches are placed on the stump for relief of bony prominences and/or sensitive areas.</li><li>A plaster cast is taken of the stump with partial weight-bearing and with blocks making up the length discrepancy.</li><li>The largest diameter of the bulbous end of the stump is measured, and the proximal level of the stump model is marked where its largest diameter equals that of the bulbous end.</li><li>Using nylon stockinette, the inner socket is vacuum-laminated with Silastic (TM) elastomer #384 from the level marked in step 3 to the end of the stump (<b>Fig. 3</b>).</li><li>The remainder of the inner socket (the proximal brim down to the level of the elastomer) is laminated with Laminac (TM) #4110 polyester resin.</li><li>A wax build-up is made over the center portion of the inner socket between the bulbous end and the level marked in step 3 (<b>Fig. 4</b>). The build-up is cylindrical in shape to allow entry of the stump into the socket.</li><li>The outer shell of the socket is laminated with Laminac #4110. <b>Fig. 5</b> shows a cutaway view of the inner socket and outer shell of the prosthesis. Note that the end of the liner must be attached to the outer shell so it will not pull out with the stump.</li><li>Using reference lines established on the plaster cast, the socket is statically aligned following the attachment of a SACH foot which has been cut and shaped to receive the bulbous end of the socket. (There is normally about a three-inch height discrepancy with the Syme's amputation.)</li><li>The socket is then dynamically aligned to the amputee's gait. Depending on the method of attachment of the SACH foot to the socket, adjustment is usually provided by means of an alignment disc or by repositioning the socket with quick-setting epoxy resin.</li><li>The prosthesis is completed by laminating the socket and keel of the SACH foot and reattaching the sole (<b>Fig. 6</b>). Fiberglass reinforcement is usually used in the lamination.</li></ol> <h3>Variations</h3> <ol> <li>Alginate can also be used to make the negative impression of the stump. It gives better detail, and its elasticity allows easy stump removal. However, it is expensive, and one cannot see to position the heel pad while it is setting.</li><li>Modification can be accomplished on the plaster model instead of using the felt patches. Either way is satisfactory, but using the patches saves time and is equally effective if they are properly placed.</li><li> A combination of 80% of Silastic elastomer #384 and 20% of #386 (foam) for the liner can be used to increase its expandability. More than 20% of #386 foams too much and reduces durability. <a></a></li><li> One variation on the size of the liner is to laminate the liner down to the largest diameter of the bulbous end rather than including the entire end. It is then not necessary to attach the end of the liner to the outer shell (<b>Fig. 7</b>).</li><li> Another method of sizing the liner is to make an elastic window in the inner socket instead of making a whole inner bladder (<b>Fig. 8</b>). This allows entry by rotating the stump as it goes into the socket, and makes possible a very cosmetic prosthesis.</li><li> Instead of making a wax build-up, it is possible to use Silastic elastomer #386 foam for the space between the liner and outer shell and to leave it in the prosthesis. It is lightweight and can be compressed to allow entry of the stump. (This procedure is being used by William Sinclair, C.P.O., at Jackson Memorial Hospital in Miami, Florida.)</li><li>Another way to modify the SACH foot and attach it to the socket is shown in <b>Fig. 9</b> and <b>Fig. 10</b>.</li></ol> <p>A wooden block is fitted and fastened to the distal end of the socket, and the bottom is sanded so it establishes the flexion and adduction angles of the socket. The wooden block forms a socket base for attachment of the SACH foot with the hardwood base and plug which reinforce the keel.</p> <h3>Acknowledgments</h3> <p>The author wishes to thank Herbert W. Marx, C.P.O., and Robert Mazet, Jr., M.D., for lending several of the illustrations used in this article.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Eckhardt, Arthur L., and Harold Enneberg, The use of a Silastic liner in the Syme's prosthesis, Inter-Clinic Inform. Bull., 9:6:1-4, March 1970.</li> <li>Marx, Herbert W-, An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 1969.</li> <li>Mazet, Robert, Jr., Syme's amputation, a follow-up study of fifty-one adults and thirty-two children, J. Bone Joint Surg., 50-A:8:1549-1563, December 1968.</li> <li>Meyer, Leslie C, Harry L. Bailey, and Dewey Friddle, Jr., An improved prosthesis for fitting the ankle-disarticulation amputee, Inter-Clinic Inform. Bull., 9:6:11-15, March 1970.</li> <li>Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52-55, Spring 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Marx, Herbert W-, An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 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>1.</b> </td><td class="clsTextSmall">Eckhardt, Arthur L., and Harold Enneberg, The use of a Silastic liner in the Syme's prosthesis, Inter-Clinic Inform. Bull., 9:6:1-4, March 1970.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Marx, Herbert W-, An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 1969.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Mazet, Robert, Jr., Syme's amputation, a follow-up study of fifty-one adults and thirty-two children, J. Bone Joint Surg., 50-A:8:1549-1563, December 1968.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Meyer, Leslie C, Harry L. Bailey, and Dewey Friddle, Jr., An improved prosthesis for fitting the ankle-disarticulation amputee, Inter-Clinic Inform. Bull., 9:6:11-15, March 1970.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, Raymond E. Gilmer, Jr., and Alan Finnieston, A new surgical-prosthetic approach to the Syme's amputation, a preliminary report, Artif. Limbs, 10:1:52-55, 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>Maurice A. LeBlanc </b></td></tr><tr><td class="clsTextSmall">Staff Engineer, Committee on Prosthetics Research and Development, National Research Council-National Academy of Sciences.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_01_022/1971_01_022-10.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 Elastic-Liner Type of Syme Prosthesis: Basic Procedure and Variations Creator An entity primarily responsible for making the resource Maurice A. LeBlanc *