3 20 371 https://staging.drfop.org/files/original/4adf69aec72e4ae9b5f3bf92fb6ac8b3.pdf e0839880f8ec1ac27ea3e70c4edbdfd1 https://staging.drfop.org/files/original/98fe795c88fad17b1d74cc108c160e00.jpg 6a34b2e11bcae6cff2d976d346aacbc6 https://staging.drfop.org/files/original/14cf27cb8f5d81a47a7cdb8e6e214bce.jpg 3e5046beb80d00399c476ce991aba40d https://staging.drfop.org/files/original/4e626be5b3789221a3412f6af707dc27.jpg d7655bf11d81815becaf73e0db4bf62c https://staging.drfop.org/files/original/2fd9c9228f2c808801f701cc1a7d7b4d.jpg 43a265c5f229dad91a709b0c2e9f55f4 https://staging.drfop.org/files/original/1d59bded42f11085ee1da15a0877dad4.jpg 212923d2b7ef13ff8f521e29fdd1f5c4 https://staging.drfop.org/files/original/0ade1458ed51fa5f108d5b082568fdab.jpg 69820b21e500e18a75685ae782e8bbce https://staging.drfop.org/files/original/35d6d2556399148c9040f819b52e0a3b.jpg 82fcf4c1287fe7b335a8ed1da803ffe6 https://staging.drfop.org/files/original/81650d70907f304a16ab8defe11f7f60.jpg 3eb5943b2e2f96e74e96a92daf651c64 https://staging.drfop.org/files/original/f08db7f605fcd5595c184552c44e456e.jpg 599058d9e0aacadff3ce8baef49af00e https://staging.drfop.org/files/original/1d67bc6ae3ad9cbc0f6efc141f40cb13.jpg b86b89038edb944943cd90a2d336b82a https://staging.drfop.org/files/original/13d1cabd8d9f654969ba2b555d3d8dbc.jpg 404c4855866586a67f87b86a472d8c4b https://staging.drfop.org/files/original/1c87598af401dbf72d1d1d6649168efb.jpg c22e01cc312817431faf39508cc6eb4c https://staging.drfop.org/files/original/2ad5c4af43e2a75bade795051925730d.jpg 1d026a103663cb520c6fa6258ee3016c https://staging.drfop.org/files/original/d30525d8fcd51ba1c3970ba3ab2d2341.jpg ff652c1d6b200c7720ed45b3b7d8e8f5 https://staging.drfop.org/files/original/ccc86a0851bcad4c2f6c5eb0c6aeaf60.jpg 8da98cb540c35edd945fd7d842777491 https://staging.drfop.org/files/original/59877e8b7291ec5abdf5713e6e331a77.jpg 0139dfaba0fae4e4298266965017153a https://staging.drfop.org/files/original/03ba66d1000443a30f2de37b2ae3c698.jpg 39756cb1dceb16189fffde46ca165728 https://staging.drfop.org/files/original/7448bd0d7c079138df3101f8ed65e8b4.jpg 374c47d5ffc47c6009dd51df02816f30 https://staging.drfop.org/files/original/0f0a175b1c6c3f79e4d2767c9c0ca6d9.jpg 5536596629ec9f258ad85c1291617a29 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1962_02_025.pdf Year 1962 Volume 6 Issue 2 Page Number(s) 25 - 73 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1962_02_025.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1962_02_025.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Construction of the Patellar-Tendon-Bearing Below-Knee Prosthesis</h2> <h5>Bryson Fleer <a style="text-decoration:none;">*</a><br />A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>The first and most obvious requirement of any below-knee prosthesis is to furnish a suitable extension of the stump to the ground in such a way as to provide adequate support for the body weight with as little involvement as possible of other parts of the residual anatomy. In the interest of appearance as well as of function, there is a need secondarily for some reasonably faithful simulation of the normal leg, otherwise known as the "shank." Each of these requirements may be met in either of two ways. In one the structural member may be endoskeletal (the pylon), in which case the skeletal form may be covered with some suitable camouflage designed to give natural appearance. In the other, the structural element may be exoskeletal (crustacean), in which case the shell-like supporting member may itself be so shaped as to provide the desired appearance of naturalness. In either case, there is needed some acceptable means of attaching prosthesis to stump in a way that will satisfy the additional requirements of weight-bearing, comfort, and stability both in standing and in the stance phase of walking. As has been found through several centuries of observation and experiment, this is best accomplished by attaching the prosthesis via the medium of a sleeve, or socket, so shaped and so fitted as to accommodate prevailing features of local anatomy and physiology and into which the stump may be inserted.</p> <p>Of all the methods, and variations of methods, that are available for the construction of sockets advantageously fitted to the irregular surfaces of the below-knee stump, most fall into one or another of three classes.<a></a> One of these involves the forming, or shaping, of materials (such as aluminum or other metals). A second involves the negative carving, or excavation, of some suitable material (such as wood). And the third involves the molding of some material (such as leather). Because the hand-shaping of metals, like the hand-carving of wood, is at best difficult and time-consuming, and also because the skill needed for doing either may be developed only through long periods of apprenticeship, metals and wood have in recent years both been on the decline as materials of choice in the fabrication of sockets. Although the molded leather socket has persisted owing to its comparative ease of fabrication, it too is being displaced because of undesirable properties (such as its tendency to deform under load and its inclination toward perspiration absorption and consequent odor). Profoundly encouraging this transition has been the advent of plastics technology and the introduction of plastic-laminating techniques into the field of limb prosthetics. The lighter, cleaner, stronger sockets of plastic laminate, much more easily made and with considerably more precision, have now all but replaced other types of sockets in new fittings of below-knee prostheses.</p> <p>Fabrication of the plastic-laminate below-knee socket involves the taking of a suitable impression (the negative cast) of the particular stump concerned; the preparation of a positive model (male replica) from the negative mold; modification of the model in such a fashion that in the final socket (to be made from the rectified model) the weight of the body will be distributed over the respective areas of the stump according to their relative tolerance, or lack of tolerance, for weight-bearing; and, finally, the layup, lamination, curing, and finishing of the plastic socket itself. Should liners or other special features be wanted for particular cases, they are incorporated in the layup, as will be seen later.</p> <p>While the method of construction described here is applicable in the fabrication of a variety of below-knee sockets, it is intended more specifically for the construction of the plastic below-knee socket in which the purpose is to utilize to fullest extent the patellar ligament as one of the principal weight-bearing areas.</p> <h4>Construction of Socket and Liner</h4> <p><b>Taking the Negative Cast</b></p> <p>Unlike numerous other below-knee sockets heretofore recommended, the socket for the patellar-tendon-bearing (PTB) prosthesis is intended to remain at all times in intimate contact with the entire surface of the below-knee stump. The stump is therefore contained firmly in the socket throughout its length, and accordingly the cast is taken not while the patient is bearing weight on the stump (as has sometimes been done in the construction of certain "open-end" sockets) but while he is seated, relaxed, the leg hanging naturally over the edge of the support (say a table), and the knee flexed naturally about 30 deg. Whatever special effects are induced by the hands of the operator as he takes the cast are intended not to produce a "weight-bearing shape" but to emphasize the special points of weight-bearing to be anticipated in a PTB socket.</p> <p>Although of possible impression materials there is available a substantial number, the most suitable, the least expensive, and the most workable for the present purpose is the old orthopedic standby, plaster of Paris. Judging from past practice, and from long usage in limb prosthetics generally, one may suppose that there are a number of satisfactory ways of taking a plaster impression, each perhaps with certain advantages and disadvantages peculiar to itself. Experience seems to suggest that for PTB sockets the most useful and practical means of cast-taking is to wrap the stump with plaster-impregnated bandage. Use of the bandage offers, among other things, the opportunity of regulating the tightness of the cast by controlling the tension applied to the bandage while it is being wrapped.</p> <p>With the amputee seated appropriately, somewhat as in <b>Fig. 1</b>A there is applied to the stump a thin cast sock of such size and length as to fit snugly and to come up well over the knee. To the top of the sock on either side of the thigh are attached, by harness clamps, the ends of a piece of 1-in. webbing passing around the patient's waist and just long enough to support the cast sock under comfortable tension. As in the cast-taking technique commonly used to produce other forms of below-knee sockets, the prosthetist must now identify and outline the bony prominences and other landmarks, both those known to be unusually sensitive to pressure (and hence requiring buildup in the model in order to give relief in the socket) and those especially well adapted to weight-bearing (those requiring reduction of the model and hence buildup in the socket), in this case particularly the patella and the patellar ligament (<b>Fig. 1</b><i>B</i>). To do so, the fitter moistens the cast sock and outlines the areas concerned with indelible pencil so that, subsequently, the tracings will be transferred first to the negative mold and then to the positive model.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Preparations for taking the negative cast. <i>A, </i>Patient seated with stump relaxed and knee flexed easily (about 30 deg.), cast sock applied and retained well above knee, prosthetist identifying (by palpation) bony landmarks and other pertinent features to be outlined by indelible pencil; <i>B, </i>the areas generally marked out for later use in modification of the model-some expected to be weight-bearing, some more or less pressure-sensitive and hence in need of relief. See text. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In all cases, at least nine areas are identified. These include the patella itself (<b>Fig. 1</b><i>B, a</i>), the mid-point (<b>Fig. 1</b><i>B, b</i>) of the patellar ligament (approximately at the level of the medial tibial plateau), the tubercle of the tibia (<b>Fig. 1</b><i>B, c</i>), the head of the fibula (<b>Fig. 1</b><i>B, d</i>), the anterior crest of the tibia (<b>Fig. 1</b><i>B, e</i>), the distal end of the fibula (<b>Fig. 1</b><i>B, f</i>), the antero-distal end of the tibia (<b>Fig. 1</b><i>B, g</i>), the medial flare of the tibia (<b>Fig. 1</b><i>B, h</i>), and the medial border of the tibia (<b>Fig. 1</b><i>B, i</i>). Marked only if they are prominent or sensitive to pressure are the anterior prominences of the lateral and medial tibial condyles, the lateral border of the tibia, and any other sensitive areas that might suggest the presence of bone spurs, adherent scar tissue, neuromas, or similar conditions.</p> <p>When the necessary marking has been completed, the patient having maintained his stump as much as possible in the original position of knee flexion without external rotation of the femur, a few rolls of 4-in. plaster bandage are laid out conveniently beside a basin of clean, cool water. As needed, each strip of plaster bandage is immersed in the water for about four seconds, squeezed to remove excess water, and applied to the stump over the marked cast sock. The wrap is begun with one or two layers of bandage running lengthwise (<b>Fig. 2</b><i>A</i>), beginning in front and just above the top of the patella, passing down and around the end of the stump, and continuing up the back of the stump to the posterior crease of the knee. Thereafter a series of circumferential wraps (<b>Fig. 1</b><i>B</i>) is begun at the upper border of the patella and made to spiral down, then up, the stump so that half the width of the bandage (2 in.) overlaps each successive layer. Each layer is smoothed carefully as it is applied, and the wrapping is continued until the shell thus formed has a thickness of about 1/8 in. in the proximal third. Additional layers are applied over the distal portions until about six rounds have been completed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Taking the negative cast. <i>A, </i>Beginning of the wrap with plaster bandage, strips extending well above knee, front and rear; <i>B</i> completion of the spiral wrap (see Fig. 3). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>While the amputee continues to maintain the original angle of knee flexion with relaxed musculature, the plaster is smoothed over the surface and worked in around the prominences and depressions by means of the hands until the plaster begins to harden. At this point, the fingers and thumbs of the operator are called upon to outline the patellar tendon and to compress the popliteal tissues, as shown in <b>Fig. 3</b>, and considerable experience and judgment are required to establish just how much pressure should be applied and in what direction. The thumbs are placed in such a position as to make a 45-deg. angle with the long axis of the tibia, and their ends are directed upward and inward midway between the lower edge of the patella and the tubercle of the tibia. Meanwhile, the fingers, wrapped around the knee, force the cast into the popliteal area, the forefingers being at the level of the posterior crease of the knee. Contact with the sides of the knee is maintained to prevent bulging, but distortion of the sides and pressure on the hamstring tendons are to be avoided. Pressure should be firm but not so great as to cause finger fatigue (a sign that too much pressure is being exerted). Both prosthetist and patient attempt to remain as motionless as possible while the plaster hardens beyond the possibility of permanent deformation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Use of the hands to shape cast while plaster is hardening. Thumbs compress bandage in and around patella, fingers force cast into popliteal area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Casting the Positive Model</b></p> <p>When the plaster has hardened completely, finger pressure is released, but the cast is allowed to remain in place for an extra minute or two, whereupon the harness clamps are released and the cast sock is reflected down over the cast, the amputee flexes his knee to 90 deg., and the prosthetist, with his hands in the same position as when forming the cast, removes the whole cast from the stump by an anteroposterior rocking motion induced while simultaneously pulling downward (<b>Fig. 4</b>). The cast sock, bearing the indelible markings, is allowed to remain in the cast, and the latter is then filled to the top with fluid plaster of Paris of the usual consistency. Into the center of the still-liquid plaster is inserted lengthwise (to a depth of not more than 6 in.) an 18-in. length of 1/2-in. iron pipe (approx. 1 in. O.D.) to serve as a mandrel in future bench operations. When the plaster has set for 20 to 30 minutes, the wrap cast is stripped off after it has been cut lengthwise down the posterior surface, and the model is ready for modification in accordance with the outlines originally marked on the cast sock.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Removal of the cast. Because of the depressions made in the cast purposely, a rocking motion is required to get cast off stump. Knee flexion helps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Modification (Rectification) of the Positive Model</b></p> <p>With the exception of those areas where the wrap cast was purposely distorted by the prosthetist's fingers and thumbs (around the patellar ligament, just under the lower edge of the patella, in the popliteal space, and so on), the positive plaster model now constitutes a faithful reproduction of the stump. It remains to revise the model in such a way that, when a socket is laminated over it, the shape of the socket will be that required to distribute the weight of the body over those areas best suited to weight-bearing while at the same time relieving sensitive areas from responsibility for bearing more weight than will be comfortable. This is accomplished by carefully carving away plaster where additional force transfer will be acceptable and by building up the model (with shaped patches of leather or other suitable material) in areas expected to be incapable of accommodating any appreciable part of the load. Guidance in this operation is to be had from the indelible outlines previously transferred first from cast sock to cast and then from cast to model.</p> <p>Although the original compression of the cast in the vicinity of the patellar ligament and around the tibial tubercle represents a preliminary step in shifting the anticipated load in the direction of the ligament midway between the lower border of the patella and the upper margin of the tibia, further modification of the model in this area is now required to intensify the effect. Accordingly, the model is cut away, as shown in <b>Fig. 5</b>, to form a channel at least 1/2 in. deep, on a radius of about 1 in., and extending horizontally across the front about 1 1/2 in., just short of the thumb prints on either side of the tibial crest. Smooth contours are obtained by sanding rough spots with a piece of wire screen.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Initial step in modification of the positive model - undercutting to enhance support on patellar ligament. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another stump area normally capable of bearing a portion of the body weight is the anteromedial flare at the proximal end of the tibia. As shown in <b>Fig. 6</b><i>A</i>, then, the model is shaved down in this area. At the deepest point of the resulting concavity, at least 1/8 in. should be removed (depending at least in part upon the amount of soft tissue overlying the stump in this area), and the edges should be smoothed out into continuous surfaces of gentle curvature. Since adequate vector forces cannot be exerted upon the anteromedial surface of the tibial condyles without corresponding vector forces on the lateral side, and since in any event the PTB socket is designed to provide, if possible, mediolateral stability without the necessity for sidebars, knee joints, corsets, and so forth, the lateral surface of the model is now also shaved down, as shown in <b>Fig. 6</b><i>B</i>. Depending upon the individual characteristics of the particular stump concerned, 1/8 in. to 3/8 in. of plaster is removed, beginning about 3/4 in. below the border of the head of the fibula and continuing to within 1/2 in. of the end of the fibula.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Successive steps in modification of the positive model. <i>A, </i>Reduction for enhanced support on medial tibial condyle; <i>B, </i>the same to provide lateral support against fibula; C, the same to avoid pressure on anterior crest of tibia. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Just as the PTB socket is expected to furnish adequate mediolateral stability, so it also must provide enough anteroposterior stability to come under full control of the knee of the wearer on the side of the amputation. Relatively comfortable and yet adequate fixation of the stump within the socket in the anteroposterior direction is effected by trimming down the anteromedial and anterolateral surfaces of the model almost throughout the length of the remaining tibia (<b>Fig. 6</b><i>C</i>). The result is a wedgelike support along both sides of the front of the tibia, which, then, must be backed up by corresponding but opposite forces to the rear of the socket in the popliteal area. As seen in <b>Fig. 7</b>, the popliteal area of the model is thus shaved down to the depth of the fingerprints, the upper portion of the model in this vicinity being rounded out to give a flare to the posterior brim of the socket. Finally, should it be the intention that the ultimate socket provide some amount of end-bearing, thin layers, up to about 1/4 in., of plaster may be shaved from the end surface of the model. If only the closed socket with no appreciable end-bearing is sought, the end of the model is simply smoothed with sandpaper, as is the whole model in any case to provide a finished job.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Further modification of the model. Popliteal area is shaved away to provide countersupport against forces from the front, thus improving anteroposterior stability of socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The model having been thus reduced to obtain the proper distribution of the loads to be anticipated in the socket, it is now equally necessary to build up those areas needing more or less relief from the pressure of weight-bearing. These ordinarily include the head and the end of the fibula, the prominent crests of the medial and lateral tibial condyles, the tibial crest throughout its length, and the antero-distal end of the tibia. In general they will already be outlined on the model from the indelible markings on the cast sock. Skived patches of leather carefully trimmed to fit (<b>Fig. 8</b>) are used to provide the modification needed. They are bonded to the plaster in the places needed, and the rectified model is then ready for use in fabrication of the plastic-laminate socket. The drawings of <b>Fig. 9</b> present for comparison the shapes of stump, original stump model, and stump model after rectification.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Build-up of positive model to furnish relief in pressure-sensitive locations. Skiving of the leather patches provides a smooth transition from plaster to build-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Contours at successive levels overlaid to show comparative shapes of stump, of stump model as made from the cast, and of stump model after suitable rectification (modification). The specific shapes vary from patient to patient, of course, depending upon individual differences. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>The Soft Insert</b></p> <p>To accommodate any inadvertent irregularities in the socket, or any minor incongruities between stump and socket, and because in general it has been found desirable to provide a comparatively soft and pliable liner in below-knee fittings, lamination of the socket itself is preceded by fabrication of an insert made of medium-weight horsehide (4 to 6 oz.) and 1/8-in. sponge rubber. Although the making of the liner and the lamination of the socket may be reviewed as two separate operations, they are, as will be seen, actually carried out as two successive steps in the layup, reinforcement, and lamination of the socket. Since the socket and its liner are both prepared <i>over </i>the rectified model, the innermost layers are the ones designed first, and hence the first step is to lay up the leather insert.</p> <p>The modified plaster model having been placed in the bench vise upside down and held there, in the vertical position, by means of the mandrel of iron pipe, there is cut from medium-weight horsehide a piece in the shape of an isosceles trapezoid such that the two parallel sides are 2 in. longer respectively than the proximal and distal circumferences of the model, the other dimension being about 2 in. longer than the model, and the direction of stretch of the leather being in the same direction as are the parallel sides (<b>Fig. 10</b><i>A</i>). With the smooth side in, the leather is fitted to the model, the intended seam line being so placed as to follow the posterior centerline. While the leather sheet is held in place by a suitable number of harness clamps (<b>Fig. 10</b><i>B</i>), the seam is marked with pencil. The sheet having then been removed from the model, it is sewed along the mark, the clamps being removed one at a time as the sewing proceeds. After the seam has been trimmed neatly throughout its length to within 1/8 in. of the stitching, the leather sleeve is replaced on the model, the work is removed from the vise, and the proximal extension of the leather is tucked and stapled to the top surface of the model (<b>Fig. 10</b><i>C</i>). An approximation of the final trim line of the socket is now drawn around the top of the leather-covered model (<b>Fig. 11</b>), and the whole is replaced in the vise, the mandrel again serving as the means of support.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Preparation and layup of the leather insert, or socket liner. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Proximal trim line of the leather liner. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To form an end pad for the socket, there is now cut from a 1/8-in. sheet of sponge rubber (Kemblo) a disc large enough to fit neatly over the end of the model, the diameter of the disc being usually equal to the average diameter of the stump (<b>Fig. 12</b><i>A</i>). The distal end of the liner and one side of the rubber pad are now coated with cement (Stabond T-161), allowed to dry until the cement is tacky, and then placed together so that the pad will conform to the shape of the end of the model. Unless the curvature of the model is extreme, the pad will conform when pressed into place. Should it not conform well, a dart or two will suffice to correct any difficulty in arriving at a smooth transition between rubber and leather. In either event, the periphery of the Kemblo end pad is now skived with a sanding drum (<b>Fig. 12</b><i>B</i>) so that the outer edge will be flush with the horsehide.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Construction of the socket end pad. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Padding of the sidewalls of the model is now undertaken by the successive application, beginning on the anterior surface, of a circumferential series of fitted strips of Kemblo running the length of the model. To begin, there is first cut a strip of Kemblo 2 in. wide and long enough to overlap the end pad 1/2 in. and to extend beyond the model about an inch proximally. The anterior surface of the leather liner and of the end pad are coated with cement,<a style="text-decoration:none;">*</a> as is also one surface of the first strip of Kemblo. When the surfaces are tacky, the Kemblo strip is placed in the position representing the anterior crest of the tibia and allowed to extend over the end cap about half an inch (<b>Fig. 13</b><i>A</i>). Carefully pressed into place so as to conform to all of the irregular areas, the edge of the first strip constitutes the pattern for one edge of the second. So that when finally cemented in place the second strip will fit as snugly as possible against the edge of the first, one edge of the applied first strip is marked with chalk (<b>Fig. 13</b><i>B</i>), and the second strip is laid along the model parallel to the longitudinal axis and so that one edge just overlaps the chalked edge (<b>Fig. 13</b><i>C</i>). The chalkline thus transferred to the new strip marks the trim line for tailoring to the contours of the model (<b>Fig. 13</b><i>D</i>). When the new strip has been trimmed as marked, it is cemented in place, and the process is repeated until the entire surface of the liner has been overlaid with a smooth covering of Kemblo. Where the strip ends overlap the end of the model, they are skived on the sanding drum, and a second end pad, like the first, is cemented over the end of the padded model. Skiving of the second end pad to be flush with the longitudinal strips of Kemblo completes the layup and fabrication of the soft insert (<b>Fig. 13</b><i>E</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Layup of the soft liner of sponge rubber (Kemblo). One edge of the first strip (<i>A</i>) becomes the pattern (<i>B, C, D</i>) for the second, and so on, until the entire model is overlaid with a smooth and neatly fitted covering (<i>E</i>). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>The Plastic Shell</b></p> <p>The next step is the lamination of the plastic shell over the soft liner but readily separable from it after construction of the shell is complete. As in the case of plastic-laminate sockets for other levels of amputation, use is here made of sleeves fabricated from sheeting of polyvinyl alcohol (PVA). Since in the construction of the below-knee socket it is desired to keep the liner separate from the plastic shell, two sleeves are used-the first to form a separator between liner and shell and the second, as usual, to enclose the whole layup-and-resin combination as a means of impregnating the reinforcing materials. Since neither sleeve need be more than an approximate fit for the model, two identical ones are fabricated to the dimensions shown in Figure 14. After the outer surface of the socket liner has been coated liberally with talc (to prevent sticking), the first PVA sleeve is stretched over the model and liner and trimmed around the distal end where it parts company with the surface of the liner (<b>Fig. 15</b><i>A</i>). A half-inch annular area of PVA adhesive is now painted around the cut edge (<b>Fig. 15</b><i>B</i>), and the open section is covered with another piece of PVA neatly bonded to form an end for the sleeve (<b>Fig. 15</b><i>C</i>). At the proximal end of the model the other end of the PVA sleeve is tied tightly about the mandrel, and any loose material is trimmed away to give a neat layup (<b>Fig. 15</b><i>D</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Application of PVA separator over socket liner and model </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The model and overlying liner, thus covered with the PVA separator, are now ready for layup of the laminations and reinforcing materials to be incorporated into the plastic shell, or socket. Three pieces of 1/2-oz. Dacron felt, cut to the same pattern as used for the leather liner (<b>Fig. 10</b><i>A</i>), are sewed as shown in <b>Fig. 16</b><i>A </i>and pulled over the model one after the other, the seams lying on the posterior aspect of the model. Then, under the last layer of felt, in the vicinity of the postero-proximal margin, there are placed five rectangular pieces of Dacron felt (<b>Fig. 16</b><i>B</i>) measuring 2 in. by 4 in., the purpose being to thicken and reinforce the posterior edge of the socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Layup of reinforcing materials for plastic socket. <i>A, </i>Layers of Dacron felt in place; B, extra material added in posteroproximal area; <i>C, </i>application of Fiberglas cloth and cast sock over Dacron. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A strip of Fiberglas cloth wide enough to cover the proximal half of the model is now wrapped around the Dacron so as to overlap itself by at least an inch, and a light cotton cast sock is slipped over the distal end of the model to hold the Fiberglas reinforcement in place (<b>Fig. 16</b>C). When the second PVA sleeve has been stretched over the whole and tied tightly about the mandrel, the layup is complete and ready for application of the resin-catalyst mixture.</p> <p>A quantity of the resin (200-400 grams, depending on socket size), prepared according to the recipe given in Appendix A, is poured into the open, distal end of the second PVA sleeve and thoroughly worked down into the fibers of the laminating materials. The open end of the sleeve is tied off, and working is continued to remove air and to complete impregnation by the familiar process of "stringing." To ensure that undercut areas and all other irregular contours of the model are reproduced in the final socket, the layup is now wrapped, as appropriate, with strips and pads of sponge rubber or with pressure-sensitive tape, whichever is more convenient (<b>Fig. 17</b><i>A</i>). Left thus undisturbed, the resin will cure at ambient room temperature in about 30 minutes, whereupon it is allowed to lose any heat of reaction and to return to room temperature.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Plastic lamination and initial finishing of the PTB socket. <i>A, </i>Layup encased in second PVA bag, impregnated well with resin, and undercut areas bound down by wraps of sponge rubber; <i>B, </i>removal of socket and liner from model after curing of resin is complete; C, specifications for trimming the top brim of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It remains now but to free the socket and liner from the plaster model. This is accomplished by trimming along the proximal edge of the layup (<b>Fig. 17</b><i>B</i>) at a 45-deg. angle until the underlying sponge rubber is just exposed. The shell is then readily slipped off the model, as the liner in turn may be slipped out of the socket. With liner removed temporarily, the proximal brim of the socket is now trimmed as shown in <b>Fig. 17</b>C.</p> <h3>Preparation of Socket for Alignment</h3> <p>The socket thus produced must next be properly aligned with respect both to the residual anatomy of its intended wearer and to the rest of the prosthesis, including the prosthetic foot and the shoe to be worn over it. Although the below-knee prosthesis may be so aligned, as it has been for a great many years, by the simple expedient of "aligning by eye" (that is, simply by trial and error and by observation of the static and dynamic behavior of the amputee-prosthesis combination), the whole procedure is made much easier (and the resulting relationships much more readily amenable to duplication if need be) by application of one of the more modern tools of prosthetics practice. Recommended for use in the present instance is the below-knee adjustable shank developed at the University of California. As may be seen in <b>Fig. 18</b>, the UC below-knee adjustable shank consists essentially of a steel plate perforated with a rather large number of countersunk screw holes and supported on a crossed-bar mechanism in which two identical and graduated bars cross each other back to back at a fixed angle of 90 deg. and in which each bar is capable of sliding across the other at the point of intersection, or of rotating about the longitudinal axis of the other, or of doing both simultaneously in an infinite variety of combinations of sliding and tilting. Each bar is held in position by a pair of opposing setscrews, such that loosening of any one screw permits both sliding of the bar to which that screw is attached and rotatory motion about the companion bar. The net result is a kind of universal joint in which, within the limits required, any combination of anteroposterior and mediolateral shifting horizontally may be had together with any combination of anteroposterior and mediolateral tilting. Included with the device is a pylon shank for temporary service during alignment, and a clamp on the shank portion provides for attachment of the foot and for adjustable foot rotation with respect to socket orientation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. The University of California below-knee adjustable shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Attachment of Socket to Adjustable Shank</b></p> <p>Since the below-knee adjustable shank is intended for use in combination with the socket shell, and since the latter is asymmetrical in all directions on the outside as well as on the inside, there is now required some practical means of attaching the socket rigidly to the shank. Experience shows that such an attachment is best arrived at by first sinking the socket into a hollow block of wood of suitable size and shape. For purposes of reference, here and throughout the remaining stages of construction, the socket is first marked with vertical centerlines representing, respectively, the anteroposterior and mediolateral planes. As shown in Figure 19, the lines are established by connecting, in side and rear views, the estimated center points of the top and of the bottom of the socket, the proximal center point for the anteroposterior plane (<b>Fig. 19</b><i>A</i>) being taken at the level of the posterior brim of the socket while the corresponding center in the lateral view (<b>Fig. 19</b><i>B</i>) is taken slightly above the indentation provided for the patellar ligament.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Anteroposterior and mediolateral center-lines of the socket, intended for reference in alignment. In each of the two views, the approximate "center" of the brim and the estimated "center" of the bottom of the socket are connected by straight lines, except that in the lateral view the proximal center point is taken just above the level of the indentation provided for the patellar ligament. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A cylindrical socket block of willow, about 6 in. long and about 6 in. in diameter, is now drilled through along the longitudinal axis of the cylinder (parallel to the grain) with a 2-in. bit, and one end of the tubular aperture is carved out so as to receive the lower end of the socket to a depth of 3 or 4 in. and in such a way that the socket will rest easily in the block with 5 deg. of adduction (<b>Fig. 20</b><i>A</i>) and 5 deg. of initial flexion (<b>Fig. 20</b><i>B</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Positioning of the socket in the socket block to give 5 deg. of adduction and 5 deg. of initial flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The distal surface of the socket shell, roughened to improve adhesion, is now bonded into the block in the predetermined position by use of a mixture of resin and sawdust (or other filler). When the bond has hardened thoroughly, the lower end of the socket block is sawed across squarely at such a level as to leave only about an inch of wood below the end of the socket shell.</p> <p>With the socket attachment plate and the slide-tilt unit of the below-knee adjustable shank (<b>Fig. 18</b>) centered and level, the socket block is now set upon the attachment plate in an orientation such that the mediolateral center plane of the socket (posterior reference line) lies in the same direction as the lower pair of setscrews of the slide-tilt unit (<b>Fig. 21</b>). Thereafter the socket block is moved upon the attachment plate in the anteroposterior direction until a plumb line dropped from the anteroposterior centerline of the socket at the level of the midpatellar tendon lies 1 1/2 in. in front of the centerline of the upper tube clamp (<b>Fig. 21</b><i>A</i>). Similarly, the block is then moved in the mediolateral direction until a plumb line dropped from the center of the posterior brim of the socket lies 1/2 in. lateral to the centerline of the upper tube clamp (<b>Fig. 21</b><i>B</i>). While the block is held in this position temporarily, a pencil line is drawn about the attachment plate onto the base of the block, the socket and block are removed from the adjustable shank, and excess wood is cut away from the block to produce the result shown in <b>Fig. 22</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Orientation of socket and socket block upon adjustable shank using socket centerlines for reference. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Socket and socket block after removal of excess wood from the latter. Circle on base marks position of socket-attachment plate for reattachment of adjustable shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the block thus partially trimmed, the adjustable shank is replaced against the bottom of the block in the same relative position as before, and the block is attached to the plate of the shank by means of not fewer than six 3/4-in. flat-head wood screws (No. 10), which, incidentally, will seat nicely into the countersunk holes in the attachment plate. The particular position chosen in the individual case is, of course, as already described and as shown in <b>Fig. 20</b> and <b>Fig. 21</b>, and the net spatial relationships of socket to adjustable shank shall be such that, to begin with, all of the adjustment setscrews are near the middle of their ranges of possible adjustment.</p> <p><b>Choice and Preparation of the Prosthetic Foot (With Shoe)</b></p> <p>Although in the construction of the patellar-tendon-bearing below-knee prosthesis use might be made of any one of a variety of foot-ankle units commercially available, the most satisfactory results are usually obtained with the nonarticulated SACH foot (Solid Ankle, Cushion Heel), in which a heel wedge of compressible but resilient material provides shock absorption and the equivalent of plantar flexion at heel contact while a solid wooden core (or keel) properly shaped at the ball of the foot furnishes needed support during roll-over and push-off in the stance phase of walking. <b>Fig. 23</b> presents schematically the familiar SACH foot as seen through a transparent shoe properly fitted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. The SACH foot, in transparent shoe, schematic. <i>A, </i>Heel contact; <i>B, </i>plantar flexion immediately after heel contact, heel wedge compressed. Rocker shape of keel at the ball of the foot gives support during roll-over and furnishes needed assistance at toe-off. Flexible toe piece permits normal toe-break in the shoe. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Generally, choice of SACH foot in the individual case depends on three factors: shoe size, height of the patient, and relative stiffness of the heel wedge. At present, oversize SACH foot blanks, left and right, are available in three ranges of shoe size (6-8, 8-10, 10-12) and two degrees of stiffness of the heel insert ("firm" and "medium"). As for heel stiffness, "medium" is generally recommended for below-knee amputees weighing up to 140 lb., "firm" for those exceeding 140 lb. As for Table 1, which presents the recommended size of foot blank as related to shoe size and height of patient, it should be noted that, as in most aspects of lower-extremity prosthetics, no hard and fast rules exist and that in any case borderline sizes have to be worked out as compromise. Ultimate choice of foot-blank size and heel-cushion stiffness should always be based on evaluation of the needs of the individual patient.</p> <p>Once the foot blank has been selected, it remains to shape the foot (<b>Fig. 24</b>) until it fits properly into the intended shoe. Although in the oversize blank the general contours of the foot are provided for by the manufacturer, so that in general only slight modifications are required, certain precautions need to be exercised. For example, the portion of the foot above the top of the shoe should not be reduced until the final wooden shank has been installed. Similarly, no material should be removed from the lower third of the heel contour lest the distance from heel to toe-break be made too small for a tight fit. Conversely, certain size reductions are usually essential, especially on the lower surface of the arch of the foot, in the toe area, and in the heel cushion above the lower third of the heel, all as shown in <b>Fig. 24</b>. In particular, the lower surface of the arch of the foot must be so reduced that it can never come into compression contact with the arch of the shoe (<b>Fig. 23</b>). Required here is a minimum clearance of 1/8 in., for otherwise motion may be restricted or the shoe damaged. In like manner, the dorsal surface of the arch of the foot should be reduced until the lacing gap of the shoe matches that of the shoe on the remaining normal foot, but not to the extent that fitting in this area might be loose.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Shaping of the SACH foot blank to the requirements of the shoe. Failure to maintain tightness in the areas indicated, or to provide relief in the others, leads to abnormal gait regardless of the care taken in construction of the rest of the prosthesis </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Just as the arch of the foot must be prevented from binding against the insole of the shoe, so the toe portion of the foot blank must be reduced so that expansion under compression will not restrict motion in the toe of the shoe. Finally, the upper two thirds of the heel insert must be shaped to give about 1/8 in. of clearance from the lateral, medial, and posterior brims of the counter of the shoe, a feature which permits the heel wedge to expand under compression without binding against the shoe (<b>Fig. 23</b>).</p> <p>A subtle feature in the shaping of the heel wedge is that the rearmost point of the heel should be fashioned to lie 1/4 in. lateral to the anteroposterior midline of the foot (<b>Fig. 25</b>) so that later, when the necessary toe-out is introduced, the point of the heel will automatically return to a position directly in the line of progression.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Shaping of the heel of the SACH foot to accommodate proper toe-out in the finished prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>All of these shaping operations are of course best carried out by means of a cone or drum sander, the sanding being done as much as possible in a direction parallel to the direction of the laminations at all points. A spindle speed of at least 1750 r.p.m. is desirable; and in the course of fitting, a thin sock should be placed over the boot whenever the foot is inserted into the shoe for trial.</p> <p>There remain now but two final adjustments-the first having to do with heel elevation (distance between bottom of heel and the surface upon which the ball of the foot rests when the top surface of the foot is parallel to the supporting surface) and the second with heel-cushion stiffness. Currently, SACH foot blanks are manufactured with a heel elevation of 11/16 in. If, when the shaped foot and companion shoe are held on a surface with top of foot parallel to that surface, there should be undue compression of the heel wedge, the heel elevation may be increased (by not more than 3/16 in.) by sanding the lower surface of the foam crepe shoe-sole material in the heel area. Should compression of the heel wedge be inadequate under the same circumstances, shims of crepe shoe-sole material, leather, or any other firm but flexible material may be shaped and bonded to the bottom of the heel.</p> <p>If needed at all, the second adjustment (heel-cushion stiffness) awaits attachment of the foot (with shoe) to the rest of the assembly (<i>i.e.</i>, to the bottom of the adjustable shank). Accordingly, the foot-attachment plug of the adjustable unit is now bolted to the flat, top surface of the foot, and the distance between foot and adjustable unit is established with an appropriate length of aluminum-alloy tubing 1.625 in. O.D., 1.510 in. I.D. Attachment of the proximal end of the tube is by insertion into the clamp at the bottom of the adjustable unit. To clamp the distal end of the tubing about the foot-attachment plug, the lower end of the tubing is split, the tubing is slipped over the plug, and the assembly is fixed together with the tube clamp furnished with the adjustable shank. Preliminary toe-out of the foot is obtained simply by loosening the tube clamp, rotating the foot so that the line of progression is parallel to the anteroposterior (bottom) slide bar of the adjustable unit, and resetting the tube clamp. Should the unit be too short when tried on the patient, the foot is removed, annular spacers are added, the foot is replaced, and the clamp tightened again. If the unit is found to be too long, the foot is removed and a shorter length of aluminum-alloy tubing is substituted.</p> <p>With the socket-and-block combination, the adjustable unit, the tubular pylon, and the foot-and-shoe combination thus assembled, the amputee dons the socket and stands upon it, weight distributed equally between heel and ball of foot. If all has been done well, the orientation in the parasagittal plane will be such that, when the prosthesis stands unloaded, the longitudinal axis of the shank will be inclined some 2 to 3 deg. anteriorly (<b>Fig. 26</b>, solid outline) whereas when the amputee stands upon the prosthesis the longitudinal axis of the shank will rotate posteriorly until it lies in a vertical plane (<b>Fig. 26</b>, dotted outline). The change in relative position brought about by addition of the wearer's weight represents of course an initial compression of the heel wedge. Over and above initial compression is that needed and acceptable at heel contact during the stance phase of walking. In general, the heel should compress about 3/8 in. at heel contact (<b>Fig. 23</b><i>B</i>). Should, in any particular case, any of these values prove to be appreciably larger or smaller than the recommended compression values, the heel cushion must be replaced by a stiffer or a softer cushion, whichever applies. The procedure for so doing is set forth in Appendix B.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Trial below-knee leg showing proper anterior tilt of shank (2 to 3 deg.) in the unloaded condition (without weight of wearer). Dotted outline shows return of the long axis of the shank to the vertical when amputee stands upon the prosthesis (initial compression of heel wedge). Should these relationships not prevail upon examination, a change in heel stiffness is indicated (Appendix B). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Making the Supracondylar Cuff</b></p> <p>All prior conditions having been met satisfactorily, the assembly shown in Figure 26 is now ready for preliminary alignment on the amputee. But before any alignment can be undertaken it is first necessary to fabricate the means of socket suspension-the supracondylar cuff fitting about the distal flares of the femur and resting in front upon the upper margin of the patella (<b>Fig. 27</b>). Though in some cases it may be necessary later to resort to jointed sidebars and thigh corset, with or without still additional paraphernalia, the simple cuff, with its side tabs attached to the socket posteriorly, commonly suffices in actual prosthetic use and, in any case, serves adequately the purposes of final fitting and alignment.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Finished PTB prosthesis using supracondylar cuff as only means of suspension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To make the cuff, including the tabs, a suitable piece of pearled elk leather is first cut out along the pattern labeled <i>a </i>in <b>Fig. 28</b>. Since ultimately closure of the cuff is to be by buckle on the lateral side, and since it is desired to have the smooth side of the leather outside, the orientation of pattern and material must be chosen properly. One side of the pattern is of course for right amputees, the other side for left amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Patterns (one half actual size) for preparing supra condylar cuff. a, Pattern for the cuff itself; <i>b, </i>pattern for the buckle billet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Rubber cement is now applied to the rough side of the leather part just cut, and two pieces of Dacron webbing 1/2 in. wide and 4-1/2 in. long are bonded to the leather tabs (<b>Fig. 29</b>) as insurance against excessive stretching. A piece of horsehide large enough to cover cuff and tabs is then selected, the rough side is covered with rubber cement, and the horsehide is bonded in place as a liner. When this laminate has set, the elk leather, Dacron webbing, and horsehide are sewed together along the edges, and the horsehide and webbing are trimmed flush with the elk leather.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Application of Dacron webbing to cuff side tabs to prevent undue stretching of the leather. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the cuff itself has been completed, a buckle billet is cut from a scrap of horsehide according to the pattern labeled <i>b </i>in <b>Fig. 28</b>, the ends of the piece are skived on the rough side, a slot for the buckle is cut out, a 5/8-in. buckle is inserted in the slot, and the billet is lapped back on itself, rough side in, and bonded together with rubber cement. The billet containing the buckle is then glued and sewed to the pearled elk surface of the cuff, as shown in <b>Fig. 30</b>. Finally, six or seven 3/16-in. holes are punched in the tabs at 3/8-in. intervals, and buckle holes of suitable size are punched into the strap of the cuff on 1/2-in. centers (<b>Fig. 27</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Installation of buckle and buckle billet on condylar cuff. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Attaching Cuff to Socket</b></p> <p>As will be noted in <b>Fig. 27</b>, one intention of the condylar cuff is that it shall bring about tension in the side tabs as the knee is extended throughout the range and that it shall permit the side tabs to relax as the knee flexes in sitting or in the swing phase of walking. Thus the points of attachment of the side tabs are pivots, the axes of rotation being behind the anatomical knee axis. Since the cuff must pull in against the patella over a full 60 deg. of knee flexion in the swing phase, while for comfort in sitting the tabs must relax throughout an additional 30 deg. to give 90 deg. of knee flexion (<b>Fig. 31</b>), the optimum points of attachment of tabs to socket must be arrived at by trial of the socket and cuff on the patient for whom they are intended.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Positioning of cuff side-tab attachments such as to provide tab tension throughout 60 deg. of knee flexion in the swing phase of walking and tab relaxation throughout an additional 30 deg. to accommodate comfortable sitting with knee flexed a full 90 deg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee first dons the cuff so that the tabs are on either side of the knee and fastens it comfortably. He then dons the socket over a stump sock, being careful to obtain proper seating of the stump, and stands on the prosthesis with weight evenly distributed on two legs. While this condition is maintained, the tabs are pulled down on either side of the knee and approximated to their natural position on the sides of the socket. The hole nearest the level of the tibial plateau but behind the average anatomical knee axis is selected on each side and the points marked through the holes with a pencil (<b>Fig. 32</b>). By means of self-tapping screws, the necessary buttons are attached temporarily at the points indicated, pending final alignment and walking trials. When all adjustments are complete, the buttons are attached permanently by means of rivets.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Attachment of side-tab buttons at position determined in Figure 31. The usual position, arrived at by trial and error, is behind the average anatomical knee axis at the level of the tibial plateau. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Preliminary Alignment</h3> <p>From the alignment established at the time of assembly of socket, adjustable shank, and foot (pp. 36-42) it is now necessary to arrive at the optimum alignment for the given case, a requirement demanding ultimately the participation of the amputee himself. Since the positioning of the socket in the block, the orientation of the adjustable unit, and the characteristics of the foot are all mutually interdependent in defining the "net" optimum alignment, it is imperative that no attempt be made to correct a fault at a given point without considering the possibility of thus upsetting position relationships at another. The whole process of alignment is in fact a series of checks and rechecks, and it is the responsibility of the prosthetist to determine the site of faults, if any, and to make appropriate corrections as the process advances in stepwise fashion. As has been seen, use of the below-knee adjustable shank makes it possible to orient a below-knee socket to any necessary combination of fore-and-aft positioning, side-wise positioning, fore-and-aft tilting, or side-wise tilting. But because each setscrew fixes not only the lengthwise positioning of its own bar but also the rotatory positioning of the companion bar, it is essential, in the course of successive adjustments, to reset the <i>same </i>screw as was first loosened (not its opposing counterpart) and to recheck any preceding adjustment to make certain that it has not been disturbed.</p> <p>The amputee having first donned the socket-shank combination (together with the condylar cuff for suspension and with the intended shoe on the prosthetic foot), a preliminary approach to alignment on the individual is made in four steps, as shown in Figure 33. While anteroposterior tilting is avoided, mediolateral sliding is accomplished. While anteroposterior sliding is avoided, mediolateral tilting at the desired angle is established. While mediolateral tilting is avoided, anteroposterior sliding is carried out to the extent desired. While mediolateral sliding is avoided, anteroposterior tilting is accomplished. To avoid any unintentional disorientation, each operation is followed by a check of the previous setting. Additional minor adjustments are made as needed until the alignment of the prosthesis upon the wearer is such that the toe-out of the prosthesis matches that of the normal foot, that the amputee can stand erect, hips level, with weight equally distributed between the two feet and with heels not more than 4 in. apart, and that in standing in one position between parallel bars (or with the aid of crutches) he can shift his weight comfortably with adequate control of both mediolateral balance and of knee flexion-extension.</p> <p>Of the principal faults sometimes encountered at the time of preliminary alignment of the trial prosthesis on the patient, some have to do with spatial relationships in the frontal plane (<b>Fig. 34</b>), others with relative positioning of parts in the parasagittal plane (<b>Fig. 35</b>). If, for example, there should be a gap at the brim of the socket on the lateral side, accompanied by undue pressure at the medial brim, the pylon of the adjustable shank may be found to be either vertical (<b>Fig. 34</b><i>A</i>, foot necessarily flat on the floor) or tilted laterally (<b>Fig. 34</b><i>B</i>, foot resting incorrectly on lateral edge of sole). In the first case, the remedy consists in shifting the socket medially by means of the adjustable unit (<b>Fig. 34</b><i>A</i>). In the second, elimination of the trouble is to be found in tilting the socket laterally, again by means of the adjustable unit (<b>Fig. 34</b><i>B</i>). When, in <b>Fig. 34</b><i>B</i>, the pylon shall have assumed a vertical position in the medio-lateral plane, the socket will have settled into a satisfactory fit near its proximal end. Similar, but opposite, corrections are made should undue pressure be found to prevail on the lateral brim of the socket, it being kept in mind that the long axis of the shank pylon must always lie in a vertical plane (foot flat on floor).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Two faults in mediolateral alignment sometimes found during initial trials of prosthesis on amputee. <i>A, </i>Pylon vertical (foot flat on floor) but socket too far lateral; <i>B, </i>same situation but with pylon tilted laterally so that foot rests on outside edge of sole only. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Faults in anteroposterior alignment sometimes found during initial trials of prosthesis on amputee. <i>A, </i>Knee forced backward, shank pylon tilted posteriorly so that too much weight is borne on heel; <i>B, </i>knee forced backward but with shank pylon vertical (foot flat); <i>C, </i>heel off floor, all weight borne on ball of foot; <i>D, </i>knee forced forward by virtue of too much anterior tilt in socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the parasagittal plane, a number of faults may be observed from time to time with individual patients (Fig. 35). For example, it may be found that application of the wearer's weight forces the knee backward, the shank pylon tilting posteriorly in one case (<b>Fig. 35</b><i>A</i>), standing vertical in another (Fig. 35<i>B</i>).</p> <p>Should a shift of the socket block forward on the adjustable shank prove not to correct the difficulty shown in <b>Fig. 35</b><i>A</i>, it may be that the heel cushion in the foot is too soft, in which case the heel wedge must be replaced by stiffer material according to the procedure outlined in Appendix B. When, on the contrary, the knee is forced backward while the pylon remains in a vertical plane (<b>Fig. 35</b><i>B</i>), then adequate correction should be obtained simply by tilting the socket-block combination anteriorly upon the adjustable unit. Occasionally, the weight of the amputee forces the socket forward while the pylon remains vertical (<b>Fig. 35</b><i>D</i>). When such a relationship prevails, it is usually corrected by tilting the socket posteriorly. And finally it may happen that, when the amputee stands erect in the prosthesis, the heel is not in contact with the base of support (<b>Fig. 35</b><i>C</i>), which of course means that all of the weight is borne on the ball of the foot instead of being distributed equally between heel and ball. Tilting the socket anteriorly usually corrects this undesirable arrangement.</p> <p><b>Fig. 35</b></p> <p>It should now perhaps be noted that, in the process of preliminary trials on the patient, none of the indicated adjustments should be more than a minor adjustment. The necessity for any gross adjustment at this point in the procedure reflects some inadvertence in the conduct of the preceding steps of construction, and in such a rare case it may be better for the prosthetist to start over, or at least to retrace his own performance from socket casting to assembly of the adjustable leg. In any event, it will be obvious that the orientation of the socket in the wooden block, the position of the block with respect to the adjustable shank, the orientation of the adjustable unit itself, and the design of the SACH foot are all interdependent and that each of these factors contributes to the final result, so that a change in any one feature affects the behavior of all the others. Accordingly, successful alignment of the PTB prosthesis is still partly a matter of art and thus calls for extraordinary skill and judgment on the part of the prosthetist. Throughout the preliminary tests it should be remembered that the wearer of the PTB prosthesis is expected to walk with the knee on the side of the amputation flexed some 5 to 8 deg. and with weight borne over the middle third of the prosthetic foot in midstance. If any major changes are made in the initial alignment, then over-all height should be checked, since an increase in anterior tilt reduces the effective length of the prosthesis while an increase in posterior tilt tends to increase it.</p> <h4>Dynamic Alignment</h4> <p>Despite the apparent implications of the nomenclature, dynamic alignment of the PTB prosthesis is less an actual alignment as such than it is a check to make certain that the alignment established in the static condition of standing is satisfactory when the amputee undertakes normal, level walking along a substantially straight line of progression. The features sought in dynamic alignment are essentially the same as those sought under static conditions, though the criteria are different. If, indeed, the requirements of static alignment have been met fully, and if the particular case involved presents no gross deviations from the characteristics of the average below-knee amputee, then the chances are that dynamic alignment will amount to no more than a confirmation, at most a minor revision, of the spatial relationships already existing.</p> <p>Since, however, no amputee-prosthesis combination, however carefully worked out, can be expected to perform in an optimum way without the active and cultivated participation of the wearer, no attempt at checking out the dynamic alignment of a PTB prosthesis is apt to be valid until the amputee has become familiar not only with what is to be expected from the prosthesis but also with what responsibility he, the wearer, has in the management of the limb. Accordingly, the patient is first encouraged to experiment (at first between parallel bars) with simple weight-bearing on the limb, with active knee flexion-extension, with standing and sitting, with short and simple steps including roll-over on the prosthesis, and finally, when he has gained some confidence, with straight and level walking without benefit of parallel bars or crutches. Meanwhile, the prosthetist and trainer continue to make such minor adjustments as seem indicated by observation of dynamic conditions. Thus, the indoctrination of the patient and the final details of alignment are carried out together, sometimes alternately, sometimes successively, until both patient and clinic team are satisfied that the best possible job has been done. Some of the problems that project themselves occasionally during dynamic alignment are depicted in <b>Fig. 36</b>, <b>Fig. 37</b>, and <b>Fig. 38</b>, and the final antero-posterior position of the socket with respect to the shoe is shown in <b>Fig. 39</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Check of foot and socket in mediolateral plane during walking. <i>A, </i>Proper alignment in front view; <i>B, </i>correction for undue pressure at medial brim of socket, rear view. Compare with Figure 34<i>A.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Check of anterior tilt of socket (and hence of initial knee flexion). Too much initial flexion, as here, may cause loss of knee stability at heel contact <i>(A) </i>or lack of support (drop-off) at the end of the stance phase (<i>B</i>), or both. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Check of posterior tilt of socket. Too little initial knee flexion (excessive posterior tilt of the socket) may cause early arrest of knee flexion after heel contact, or a prolonged period of unstable weight-bearing on the heel, or an excessive shift of the body weight to the ball of the foot accompanied by premature heel rise at midstance <i>(A). </i>Inadequate knee flexion may also give rise to scuffing of the toe during swing-through <i>(B).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Ultimate anteroposterior position of socket with respect to shoe. A plumb line dropped from the anteroposterior centerline of the socket at the level of the midpatellar tendon should pass just ahead of the breast of the heel of the shoe. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because in the practical matter of walking comfortably, effortlessly, and with acceptable appearance the details of alignment in the anteroposterior direction are more critical than those having to do with the mediolateral, it is recommended that the latter always be attended first, the anteroposterior adjustments being left until the very last. As in all other steps of alignment, each successive change should be followed at once by a check on the preceding one so that no correction coming later can upset another made earlier, except with the full knowledge of the prosthetist (as is sometimes necessitated in compromise situations where one advantage is to be gained only at the expense of another). In all cases, the patient should be allowed to walk upon the adjustable shank long enough (days, if need be) to demonstrate that all adjustments are at an optimum for the particular physico-anatomical circumstances then prevailing. When the prosthetist is convinced that he has attained the best possible set of conditions, the alignment is duplicated in the finished prosthesis by means of the UC adjustable alignment-duplication jig.</p> <h3>Alignment Duplication</h3> <p>The so-called "alignment-duplication jig" of the University of California, intended originally for duplication of the alignment of above-knee prostheses, consists of two adjustable, viselike clamps so mounted side by side upon a firmly fixed, tubular base as to be capable of being moved along the length of the base as required or of being fixed in any selected positions along the base in any chosen linear relationship to each other. One clamp is intended to position and hold the thigh portion and artificial knee of an above-knee prosthesis, while the other holds and positions the shank-foot combination. To be interposed between the two clamps, mounted on the same base, and movable along the base between the clamps, is a bracket intended as a guide for a miter saw whenever the saw is needed. When the bracket is in place, it is so oriented that the saw will make a cut normal to the long axis of the tubular base.</p> <p>Once the clamps have been set so as to accommodate as precisely as possible a thigh socket, adjustable knee unit, shank, and foot in the relative positions established in alignment trials, the component parts of the final prosthesis may be substituted for the adjustable devices without upsetting the prevailing alignment. Similarly, the alignment of an existing prosthesis may be duplicated in a new prosthesis simply by setting up the alignment jig to match the first limb and then making the second limb to match the setting of the jig. When the desired orientation of socket and knee block with respect to shank and foot has been attained, the saw is used to cut the planes representing the intended juncture of the two segments.</p> <p>Application of this device to the below-knee case, including the case of the patellar-tendon-bearing prosthesis, is readily accomplished by introduction of a special fixture called the "ankle bracket." Mounted on the base in the same way as the clamps, it is used in place of one of them, that one being simply shoved out of the way temporarily (<b>Fig. 40</b>). Drilled through the top of the ankle bracket is a 3/8-in. hole whose axis is such that, when the bracket is in place, the axis is parallel to the base tubes of the jig. When, in the below-knee case, static and dynamic alignment with the adjustable leg satisfy both prosthetist and amputee, the SACH foot is removed from the adjustable shank, and the distal end of the shank is attached to the ankle bracket by means of an Allen-head screw (<b>Fig. 41</b>). Since toe-out of the foot must be re-established after the final shank piece has been properly substituted for the adjustable shank, the prevailing relationship of the foot to the socket is keyed before the foot is removed from the adjustable leg. Using a straightedge and one of the bonding lines of the foot for reference, the prosthetist first marks points on the front and back brims of the socket (<b>Fig. 42</b>). Thus later, when the final shank has been aligned and cemented into place, the foot may be replaced in the same relative position of toe-out as established in the alignment trials on the adjustable shank.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. University of California alignment-duplication jig for above-knee prostheses, as adapted for below-knee alignment duplication through substitution of the ankle bracket (cross-hatched) for one of the adjustable clamps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Attachment of adjustable shank (with socket and socket block) to ankle bracket of alignment-duplication jig. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Recording toe-out of foot before removing foot from adjustable shank. Same toe-out must be reestablished later. See Figure 50. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since, when the ankle bracket is fixed to the base, the axis of the hole through the bracket is parallel to the long axis of the base, so also then is the long axis of the shank parallel to the base tubes when subsequently the shank has been bolted to the ankle bracket. The orientation of the socket being thus established, the socket clamp is brought up into position alongside the socket (<b>Fig. 43</b>), care being taken to see that the clamp is then not less than 10 in. from the end of the base tubes (so that later it can be backed out of the way). The socket clamp is there locked to the base tubes, and the clamping thumbscrews are run down carefully but firmly so as to clamp the socket without at the same time placing any distorting strains upon the shank. The relative positions of shank and socket are thereby established in the jig for later reproduction in the finished prosthesis. To establish the over-all length of the final prosthesis, the positions of the ankle bracket and of the socket clamp are then recorded from the scale running the length of the base tubes of the jig.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Setting of socket clamp to the orientation previously established by the ankle bracket. At least 10 in. should be allowed at socket end so that socket clamp and socket may later be moved out of the wav. See Figure 45. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the socket thus fixed in the clamp and with the clamp and ankle bracket secured to the base of the jig, the adjustable shank is now removed, first from the ankle bracket and then from the wooden base of the socket (<b>Fig. 44</b>). The saw guide is mounted near the base of the socket (<b>Fig. 45</b>), and a cut (not more than 1/4 in. from the end of the base) is made (<b>Fig. 46</b>) so as to produce a surface normal to the axis of the jig. The clamp holding the socket is moved out of the way, a partly hollowed, wooden shank block is now attached to the ankle bracket by means of the same Allen-head screw as before (<b>Fig. 47</b>), and a cut is made to produce a surface which, like the bottom surface of the socket base, will be normal to the long axis of the jig (<b>Fig. 48</b>). When the sawing is completed, the saw guide is removed from the jig, and shank and socket block are brought together by sliding the socket clamp back to its original position on the tubular base.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Removal of the adjustable shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Installation of saw guide on same base as other fixtures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Making saw cut on bottom of socket block. Remove not more than 1/4 in. at thinnest point about periphery. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Attachment of shank block to ankle bracket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Making saw cut on top of shank block. Length of block after cutting shall be such that it may be substituted for the adjustable shank and pylon without significant change in over-all length of the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If all has been done properly, the top surface of the wooden shank and the bottom surface of the socket block will now meet comfortably all around the periphery. When that is the case, the mating surfaces are spotted with glue, brought together firmly, and held in place by locking the fixtures to the base tubes (<b>Fig. 49</b>). To avoid inadvertent dripping of glue onto the equipment, the base of the jig may be draped loosely with scraps of paper, rag, or waste. When the glue has set firmly, the whole unit is removed from the jig, and the foot is attached to the shank (<b>Fig. 50</b>) in the same position (with respect to the socket) as before (reference lines match). Thereafter the leg is ready for final shaping and finishing (<b>Fig. 51</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Shank and socket block glued together in relationship established by jig fixtures. Dripping glue is caught by waste thrown over jig base. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Attachment of foot to shank with same relative toe-out as existed in trial leg using adjustable shank. Compare with Figure 42. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Assembled prosthesis ready for external finishing. Orientation of parts is that established in trials of static and dynamic alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Finishing the Prosthesis</h3> <p>Since it is inconvenient, if not actually impossible, to determine in advance exactly how the shank block and the socket block are going to line up in the finished prosthesis, and since ultimately, in the interest of weight-saving, it is desirable to carve out the shank block to the thinnest possible shell compatible with strength requirements, it is necessary to break apart the temporary attachment of shank and socket, but not until essential landmarks have been recorded for the purpose of later reassembly in the same relative positions as established in the alignment jig. Similarly, finishing the foot and ankle (distal part of shank) requires another removal of the foot, but not until the necessary reference position has been recorded on the work itself. To begin, the toe-out of the foot is marked with pencil, as shown in <b>Fig. 52</b><i>A</i>, and the foot is removed by unscrewing the attachment bolt. Because in the shaping of the distal end of the shank, and in its preparation for the lamination to follow (page 56), some material usually has to be shaved off the outside of the shank in the ankle area, the pencil mark on the anterior aspect is carried onto the base with a sharp tool, such as an awl or a penknife (<b>Fig. 52</b><i>B</i>). In order that the later plastic-laminate covering may form a smooth transition from shank to foot, a line is now scribed around the periphery of the bottom of the shank about 1/16 in. from the edge (<b>Fig. 52</b><i>C</i>), and the shank is ground down smoothly to the line.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. Preliminary steps in the finishing of the PTB prosthesis. <i>A, </i>Marking the established toe-out of foot with respect to shank; <i>B, </i>foot removed, reference mark transcribed to bottom surface of shank to avoid obliteration in next step; C, 1/16-in. annular ring marked about bottom surface of shank block as guide line for shaving down ankle area; <i>D, </i>ankle area shaved down, reference lines marked to record orientation of shank and socket block (after whole limb has been shaped on outside to match contours of the remaining leg of patient); <i>E, </i>shank block removed from socket block and routed out to form shell uniformly 1/4<i> </i>in. thick all around. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rest of the external surface of shank and socket block are now ground down to approximate the contours of the natural counterpart (preferably to match the shape of the remaining leg of the particular individual for whom the prosthesis is intended), and reference marks are made front and rear to indicate the established relationship of socket and shank (<b>Fig. 52</b><i>D</i>). The temporary, glued attachment of socket block and shank is now carefully broken apart by a sharp knife, and the inside of the shank is routed out (by routing machine or by hand) until the walls are uniformly only 1/4 in. thick (<b>Fig. 52</b><i>E</i>). Thereafter socket block and shank are glued back together, this time with intent of permanency, the front and back reference lines being made to match up as in the original attachment.</p> <p>To provide additional strength and at the same time to give the prosthesis a pleasant, perhaps even realistic, finish, the whole socket-shank combination is now covered with a suitable plastic laminate of Fiberglas cloth, nylon stockinet, and polyester resin, the latter appropriately tinted to simulate the color of the human skin. The technique is essentially the same as in other plastic-laminating procedures now in widespread use in prosthetics, for example in the making of the PTB socket itself (page 73).</p> <p>The socket-shank unit, less the foot, being supported on a mandrel held in a vise (F<b>Fig. 53</b>), a disc of Kemblo is first bonded to the bottom of the shank to protect it from resin and to close the foot-bolt hole. Then a sheet of Fiberglas cloth wide enough to extend from the foot base to within 2 in. of the socket brim is wrapped around the unit and is in turn covered with two layers of nylon stockinet, the first being made to spiral in the interest of increased strength (<b>Fig. 54</b>). A PVA sleeve made in the usual manner is now pulled over the layup, and the fibrous layers are impregnated with polyester resin in the fashion described earlier (page 36). When the resin has cured, the excess (including the ends of the PVA sleeve) is trimmed off at top and bottom (at ankle and at socket brim), and the foot is replaced with the same degree of toe-out as before.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 53. Application of disc of Kemblo to end of shank prior to layup and lamination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 54. Layup for lamination of socket-shank combination. <i>A, </i>First of two layers of nylon stockinet twisted over layer of Fiberglas cloth; <i>B, </i>second layer of nylon stockinet applied and tied off at both ends. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As a final finishing touch, the superior plane of the foot (which will now be somewhat larger than the end of the shank) is scored around with a pencil (<b>Fig. 55</b>), and the foot is sanded down in the vicinity of the ankle to give a smooth transition to the shank. The result is a finished prosthesis ready for trial on the amputee to determine, among other things, the necessity, if any, for further support, or added stability, or improved suspension in the form of conventional sidebars and thigh corset. Should the supracondylar cuff already prepared prove adequate, the amputee should be able to perform with an optimum of comfort, function, and appearance both in standing and in normal walking on a level surface. In the event it should <i>not </i>for any reason, the prosthetist proceeds with the construction of additional equipment.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 55. Scribing foot at ankle line for sanding to provide smooth transition between foot and shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The PTB Prosthesis in Special Cases</h3> <p>The design of the so-called "patellar-tendon-bearing" below-knee socket is such that, ordinarily, the socket itself provides adequate stability in both the anteroposterior and the mediolateral directions and is itself adequately suspended from the limb of the wearer by no more than the supracondylar cuff already described. With proper relief in the rear for the hamstring tendons, and with high enough side and front walls, there develops no insurmountable problem in knee flexion-extension, either in walking or in sitting, and the amputee is thus free of all impedimenta otherwise characteristic of the articulated below-knee prosthesis. In a comparatively small percentage of cases, however, special anatomical and/or physiological circumstances invalidate the simple cuff suspension and the equally simple means of support and stabilization typical of the true PTB prosthesis. In such cases there is no alternative but to resort to the thigh corset and metal sidebars, and sometimes even to the ischial seat and the waist belt, despite the known advantages of the PTB socket. Since improvement of weight-bearing characteristics and inherent stability as offered by the patellar-tendon-bearing socket in no way alters the problem of the moving center of rotation of the normal knee, and since single-axis mechanical knee joints are for various reasons still found to be the most satisfactory under all conditions of use, introduction of the thigh corset and sidebars to improve stability, or to assume some of the weight, or both, presents the same problems as have prevailed heretofore. To date the most useful approach to this problem, when corset and sidebars are unavoidable, has been the development of an improved and simplified method of arriving at the best compromise location of single-axis joints with respect to the moving axis of the normal knee.</p> <p><b>Use of Side Joints and Thigh Corset</b></p> <p><i>Theoretical Considerations</i></p> <p>Single-axis side joints must be aligned on the shank and corset of the below-knee prosthesis so that they effectively stabilize the prosthesis on the stump and allow the amputee to sit comfortably. This is a complicated problem, first because the anatomic joint is not a single-axis joint and, second, because the exact path of a series of "instant centers," degree by degree, during knee motion is impractical to determine in each specific case. Even an average anatomic center may be estimated only roughly in the posterior portion of the femoral condyles. Thus at any one position of the single-axis mechanical joints, the center of rotation of the joints and the center of rotation of the knee will inevitably be incongruent during part or all of knee flexion and will give rise to some relative movement between the stump and the components of the prosthesis as the knee and side joints move from full extension to flexion at 90 deg. The task is to place the joints in a compromise position that will offer the best function and eliminate discomfort resulting from this relative motion. This may be done either by reducing the motion or by having the motion relieve pressures which would otherwise cause discomfort.</p> <p>The effect of a particular position of the side joints with respect to the socket and corset can best be understood by investigating the effect of making a change from a position assumed to be the optimum one. Since movements result from a combination of several factors, total motion is a complex problem. In a hypothetical situation, it would be possible to have knee flexion occur either with the stump held tightly in the socket<a style="text-decoration:none;">*</a> and all motion occurring between thigh and corset or with the thigh fixed in the corset and motion occurring between stump and socket. Of these two extreme hypothetical situations, and the many possible variations in between, the one which will be considered is that in which the stump is fixed in the socket and in which relative motion occurs between the thigh and upper side arms of the joints. This condition most nearly approximates the real situation and forms the basis for the joint-location procedure described below.</p> <p><b>Fig. 56</b><i>A</i> shows a hypothetical situation in which the socket is held fixed and the stump is not allowed to move relative to the socket. In the fully extended position, the upper sidebar is parallel to the shaft of the femur, and the mechanical joint center is placed directly above the average position of the anatomic center. The anatomic center, although it actually varies in position from high in the thigh during hyperextension to near the center of the femoral condyles at 90 deg. of flexion, is assumed to maintain a single axis of rotation for comparison with the mechanical center during this analysis. Alternatively, one may consider the effect of a tiny range of motion and study the slight motion of the thigh corset on the thigh caused by a mechanical joint center higher than the instant center of rotation during this tiny knee motion. As the thigh flexes, the mechanical sidebar tends to move relatively anteriorly on the thigh (for 90 deg. of flexion, distance <i>A</i>) and to be drawn distally along the thigh (distance <i>B</i>). As a result, pressure is created between the thigh corset and the posterior aspect of the thigh because the stump is fixed in the socket. The stump might be forced against the anterior part of the brim (the patellar-tendon area of the stump), though by assumption the stump cannot move in the socket. Thus the conical thigh corset moves distally away from the conical thigh, thereby releasing pressure by allowing a greater perimeter of corset for a given level and perimeter of thigh.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 56. Relative motion to be expected between thigh and thigh corset (stump fixed in socket) during 90 deg. of knee flexion when single-axis mechanical joints are placed in any of six positions relative to a hypothetical average anatomic joint center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 56</b><i>B </i>shows the effects of placing the mechanical joint below the average anatomic center (or instant center for a tiny motion). With flexion, the sidebar tends to move posteriorly on the thigh (for 90 deg., distance <i>C</i>) and to move proximally on the thigh (distance <i>D</i>). As a result, pressure is created anteriorly between corset and thigh, or else by reaction forces the socket is pressed upward against the stump. In this case, the conical corset is forced proximally, engaging the thigh more tightly and thus further increasing pressure on the thigh. Because such motion is sharply limited, the reaction on the sidebars in effect attempts to push the socket forward and thus increases pressure on the posterior popliteal area of the stump. Clearly this situation is unsatisfactory.</p> <p><b>Fig. 56</b><i>C</i> shows the effect of placing the mechanical joint in front of the average anatomic center. With flexion, the sidebar tends to be forced posteriorly (distance <i>E</i>) and distally (distance <i>F</i>) with respect to the thigh. As a result, pressure tends to be created anteriorly between corset and thigh, but the corset is withdrawn distally down the thigh so that its fit is loosened and hence the anterior pressure on the anterior portion is partially or wholly relieved.</p> <p><b>Fig. 56</b><i>D </i>shows the effect of placing the mechanical joint behind the average anatomic center. With flexion, the sidebar tends to be forced anteriorly (distance G) and proximally (distance <i>H</i>) with respect to the thigh. As a result, pressure is created posteriorly between corset and thigh, and the conical corset is forced proximally until it can go no farther, whereupon reaction forces the socket forward to cause pressure in the popliteal area.</p> <p><b>Fig. 56</b><i>E</i> shows an interesting special case in which the mechanical joint is located on a 45-deg. anterior diagonal through the anatomic center. In this case, the sidebar is drawn distally downward on the thigh (distance <i>I</i>), but there is no tendency for the sidebar to move either anteriorly or posteriorly with respect to the thigh. Thus there is no anterior or posterior pressure between corset and thigh. The distal motion would indicate that the corset might pull the stump anteriorly and cause pressure on the patellar tendon. In practice, the conical corset merely moves distally so as to relieve pressure on the thigh.</p> <p>A similar analysis of the situation shown in <b>Fig. 56</b><i>F</i> would indicate that in this situation (posterior diagonal) posterior pressure between corset and thigh would be created by the substantial movement / (anterior movement of the sidebar). There would be no tendency for the stump to be pushed anteriorly or posteriorly against the socket brim or for the corset to move on the thigh.</p> <p><i>Optimum Mechanical Relationship Between Joint Axis and Average Knee Axis</i></p> <p>Relative movement in the mechanical joint position as compared with that in the anatomic joint position must first be understood. The prosthetist can then establish the best position for the joint axis by deciding what motions to suppress and what motions to allow. However, when the conical corset is attached to the upper side arms of the joints, proximal motion of the side arms will be suppressed so that reaction forces on the arms will cause commensurate forward movement of the socket against the stump and lead to pressure in the popliteal area. This factor must be borne in mind when the motions of the upper side arms of the mechanical joints are considered in establishing the best position. The hypothesis above of fixation of the stump in the socket may now be modified.</p> <p>There are two situations in which the mo-Lions between the prosthesis and the stump are of particular significance: when the amputee sits (a major fraction of the waking hours of most amputees) and when the prosthesis is swinging through during walking.</p> <p><i>Sitting. </i></p> <p>When the amputee sits, some motion between prosthesis and amputee will occur because of the inevitable incongruity. This being so, it is better to permit joint movement to draw the stump slightly out of the socket, and perhaps to move it forward so that roll formation and pinching between the corset and the back of the socket are reduced; yet forward motion should not press the rigid bony areas against the socket wall. In order to lift the stump, the mechanical joints must pull the corset up against the back of the thigh as the amputee sits. This will occur when the upper joint arms move anteriorly with respect to the thigh (as in <b>Fig. 56</b><i>A</i>, <i>D</i>, and <i>F</i>). To move the slump forward or avoid forcing the socket forward as the amputee sits, the upper joint arms should move distally with respect to the thigh (as in <b>Fig. 56</b><i>A</i>, <i>C</i>, and <i>E</i>). Thus, theoretically, a satisfactory position for the mechanical joints will be directly above the average anatomic joint axis, as in <b>Fig. 56</b><i>A</i>, if it is assumed that the amount of forward motion and upward motion should be approximately the same.</p> <p><i>Swing Phase. </i>For swing-phase control, and freedom from chafing, there should be little or no motion between the stump and the socket. Thus, the mechanical joint axis should be as close as practical to the instantaneous anatomic joint axis during the 60 or 65 deg. of knee motion in the swing phase. Because the instant center seems to move substantially during full extension, and especially during hyperextension, the alignment in slight initial flexion and the training of the amputee to maintain slight flexion at heel contact are considered to be important steps in reducing incongruities between axes and thus in reducing chafing.</p> <p>If the prosthesis is to function satisfactorily both during sitting and during the swing phase, the mechanical axis should be above the average anatomic axis but not so far above as to introduce too much relative motion between stump and socket during walking.</p> <p>All the foregoing analyses are based on consideration of the knee as if it could be averaged over 65 deg. of swing or 90 deg. between sitting and standing to behave as a single-axis joint. But, as is shown in the preceding article by Murphy and Wilson (page 4), the knee joint is actually made up of two complex bony surfaces-the femoral condyles and the tibial condyles. The femoral condyles are two convex surfaces separated by an anteroposterior groove, while the tibial condyles are two concave surfaces which fit their femoral counterparts. Further, these bony surfaces are separated by cartilages and fluids and are connected in complex ways by ligaments, so that analysis by x-rays alone may be inadequate.</p> <p>The femoral condyles roll and slide on the tibial condyles as the knee joint moves. The amount of sliding and rolling determines the axis of rotation of the knee joint at any instant. A shift in the axis of rotation may sometimes help and sometimes oppose required function. If the path of the knee axis were exactly known, the best position for the single-axis knee joint could be positively stated, and joints fully satisfying the functional requirements could be designed. As noted above, such refinements for each individual case seem impractical. However, experience has shown that the mechanical joints can be located accurately enough when use is made of the procedures proposed below, based on consideration of the knee as a single-axis joint at an average location.</p> <p>A typical relationship between socket, joints, and thigh corset in the finished prosthesis is shown in <b>Fig. 57</b>. The back brim of the socket will be trimmed to the patellar-tendon level. With the joints flexed 90 deg., the posterodistal edge of the thigh corset will be 1 in. behind the posterior brim of the socket and at the same level as or slightly above the posterior brim of the socket. The joints are approximately on a mediolateral axis parallel to the back wall of the socket, midway between the patellar-tendon protuberance and the posterior wall, and the axis is approximately 2-1/4 in. above the level of the mid-patellar tendon.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 57. Typical relationship between socket, joints, and thigh corset in a below-knee prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Side-Joint Locating Chart</i></p> <p><b>Fig. 58</b> is a chart based on the theoretical analysis given above. The chart can be used for correct positioning of the side joints on a below-knee prosthesis. It indicates the motion to be expected between the upper sidebar (the corset will be attached later) and the femur (<b>Fig. 59</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 58. Chart for determining location of joint axis of sidebars in below-knee prostheses. The motion referred to is that of the upper straps of the sidebars with respect to the thigh as the amputee sits from the standing position (Figs. 59 and 60). Outline of distal end of femur is considered to be mean actual size. The open circle, represents the average anatomic knee center; the closed circle is the optimum position for the mechanical joints. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 59. Compromise location of upper sidebar straps in optimum position for comfortable walking as well as for comfortable sitting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Procedure:</i></p> <ol> <li>After the socket is aligned on the adjustable leg and foot, the lateral lower sidebar is attached to the socket temporarily in the position indicated in Figure 57 so that the center of the joint is 2-1/4 in. above the midpatellar-tendon level and midway between the patellar-tendon protuberance and the posterior wall of the socket. Only one attachment point is used, namely, at the bottom of the sidebar, the bar being secured above by wrapping masking tape around the socket. The single attachment point at the lower end of the sidebar allows the joints to be moved back and forth during trials and simplifies a change in position up or down. The upper bar is not shaped or attached to the corset at this time. </li><li>The amputee stands and extends the mechanical joint. The position of the front and top edges of the sidebar on the thigh is marked with a skin pencil. </li><li>The amputee sits on a hard chair with his knee flexed 90 deg., and a check is made to see that the posterior brim of the socket and its lining are properly trimmed and that the stump is well seated in the socket. </li><li>While the amputee is sitting in this position, the upper sidebar is moved until the front edge is parallel to the line on the thigh marked in Step 2. A second mark is made on the thigh along the front and top edges of the sidebar. </li><li>The relative motion as evidenced by the difference in position of the marks in Step 4 as compared with Step 2 is measured. </li><li>On the chart (<b>Fig. 58</b>) is entered, in accordance with the scales shown, the data obtained in Step 5. This information will indicate in true scale the approximate location of the mechanical joint center with respect to the femur, as shown in typical true size by the dotted outline. </li><li>The direction in which to move the joint to improve its position is now estimated. The optimum compromise position is located a short distance above and slightly behind the average anatomic center. On the basis of experience with adult amputees, the upper sidebars of the mechanical joint should move distally on the thigh approximately 1/4 in. with 90 deg. of knee flexion. A motion between 1/4 and 1/2 in. is allowable. Motion greater than 1/2 in. results in the stump being forced forward excessively or the corset moving distally excessively after the sidebars are attached to the corset. The upper sidebars should move toward the front of the corset approximately 1/2 in. with 90 deg. of knee flexion. This motion is equivalent to a stump withdrawal with knee flexion after the sidebars are attached to the corset.</li></ol> <p>If the movements are not within the suggested limits, the joint is moved as indicated by the chart to bring them within these limits, and a recheck is made by the same procedures.</p> <p>When the joint has been properly located, both sidebars are riveted to the socket so that a line connecting the centers of the medial and lateral joints would coincide with the axes of the joints themselves and would be parallel to the floor and to the posterior wall of the socket. The upper sidebars are shaped to fit the thigh with the joints coaxial. Particular attention should be paid to the shaping of the upper bars over the femoral condyles because a close fit here helps to suspend the prosthesis. At this point the corset is cut to shape and is temporarily attached to the upper sidebars of the joints with binding screws.</p> <p><i>Example (<b>Fig. 60</b>):</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 60. Example of use of chart shown in Figure 58, chart reduced from actual size. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>Step 5 indicates a relative motion of 1 in. posteriorly and 1 in. distally along the thigh. </li><li>Enter data on chart as shown to locate point <i>A. </i>Point <i>A </i>represents the probable position of the mechanical joint relative to the femur. </li><li>The femur outline is actual size in <b>Fig. 58</b>. Therefore the movement required to relocate the joint in the assumed optimum position <i>B </i>may be scaled directly from the drawing in Figure 58 (not in the reduced example, <b>Fig. 60</b>). In this example, the joint axis shown is moved posteriorly a distance of 1-1/8<i> </i>in. and proximally a distance of 3/8 in.</li></ol> <p><i>Fabrication of Thigh Corset and Joint Cover</i></p> <p>Just as an encasement for any other part of the body must be made to conform to the shape of the part and must have enough elasticity and pliability to meet the requirements of necessary body activity, so the thigh corset of the below-knee prosthesis must be custom-cut to the particular size and shape of the thigh for which it is intended and it must be strong enough and yet flexible enough to meet the changing demands placed upon it. Because of its special combination of properties, leather has for many years been the material of choice in the construction of thigh corsets, almost to the exclusion of all other possible materials. Though from time to time in the history of prosthetics there have been introduced a good many variations intended to provide this or that beneficial feature, the basic construction of the modern-day thigh corset remains unchanged. It amounts to the custom fabrication of a comparatively long leather cuff, laced in the front, and furnished with the usual tongue to protect the thigh from local compression and constriction by the lacing. A common error is to make the corset too short, the amount of purchase on the thigh then being inadequate to provide the degree of stability required.</p> <p>In the method of corset fabrication currently recommended for use when corset and sidebars are needed with the PTB prosthesis, the first step is to prepare, from appropriate measurements of the patient, a suitable paper pattern of the surface of the thigh in the area between the lesser trochanter and the condyles of the femur. While the optimum length of the corset varies somewhat with the height of the individual, in general it may be said that the pattern should extend upward some 8 in. from about 2 in. above the midpatellar level on the lower end. Accordingly, the circumference of the thigh is taken at these levels, and the corresponding measurements are carried forward to the pattern step by step.</p> <p>A square of paper of suitable weight and texture (ordinary kraft wrapping paper, for example) and measuring 2 ft. on a side is first folded in half (<b>Fig. 61</b><i>A</i>). Along the fold are marked with pencil the two points corresponding respectively to the top and bottom margins of the corset (distance between points corresponds to intended length of corset). From one mark there is extended, parallel to the edge of the paper, a line of length equal to half the selected circumference of the proximal portion of the thigh. From the other there is extended a similar line of length equal to half the selected circumference of the thigh in the distal area. With the ends of these two lines as reference, a third line is now drawn to join them, all as shown in <b>Fig. 61</b><i>A</i>, and a line (broken line in <b>Fig. 61</b><i>A</i>) is then drawn to connect the points of bisection of the proximal and distal circumference measurements, the latter line representing the ultimate location of the upper straps of the jointed sidebars.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 61. Preparation of corset pattern. <i>A, </i>Paper folded in half, top and bottom margins of corset marked, lines parallel to edge projected to the extent of half the circumference of thigh at upper margin and half the circumference of thigh at lower margin respectively, ends of lines connected by straightedge, top and bottom circumferences joined by straightedge at points of bisection (broken line); <i>B, </i>paper opened at centerfold, reference lines transcribed to opposite side, proximal margin modified to match sine curve with maximum deviation of 1/2<i> </i>in. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The paper pattern is now opened at the fold to reveal the isosceles trapezoid shown in <b>Fig. 61</b><i>B</i>, and the proximal margin is cut roughly in the shape of a sine curve of 1/2 in. maximum deviation. Similarly, the distal margin is cut to the dimensions shown in <b>Fig. 62</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 62. Distal margin of corset pattern outlined to match requirements of popliteal space, location of upper straps of single-axis sidebars marked for future reference. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the pattern has been completed, it is laid upon a selected piece of 7-oz. cowhide (or English bridle) in such a fashion that, when the leather has been cut out, it will fit upon the thigh (left or right as required) with the rough side in, with opening toward the front, and with the high side of the proximal margin lateral. By means of a straightedge, the locations of the upper straps of the sidebars are transferred to the leather for future reference in the construction of the corset, and the leather is cut out along the lines of the pattern.</p> <p>The piece of cowhide, shaped as already described, is now applied to the thigh of the amputee smooth side out and held in place by pressure-sensitive tape or some other suitable means. The upper straps of the two sidebars are bent and shaped in such a way as to follow as closely as possible the external contours of the thigh (to assist in stabilization during the stance phase and in limb suspension during the swing phase), and the proximal ends are trimmed off as necessary so that the straps will extend to about 3/4 in. below the top of the corset (thus providing maximum leverage while leaving room for finishing the top of the corset). Then, for purposes of later attachment of the upper straps of the sidebars to the corset, each upper strap is drilled with three holes 1/8 in. in diameter and so spaced along the length of each strap that the first is 1/2 in. from the proximal end, the second is about 2 in. above the center of the ballbearing race on the distal end, and the third is half way between the other two (<b>Fig. 63</b>). The two upper sidebar straps, thus drilled to accommodate screw-type fasteners, are now placed against the corset, one on each side and each along one of the two guide lines outside the centerline, and the positions of the two top holes are marked through to the leather. The straps are removed, 1/8-in. holes are punched through the leather at the points indicated, and the two upper straps are attached, each by means of its top hole only.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 63. Preparation of upper sidebar straps for later attachment to leather thigh corset. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To set temporarily, subject to later revision if necessary, the bottom (distal) attachment holes of the straps, the amputee stands, the prosthetist positions each strap directly over the corresponding guide lines, and the bottom hole of each strap is marked through to the leather with pencil (<b>Fig. 64</b><i>A</i>). The amputee then sits with knee flexed 90 deg., the straps are once again positioned over the guide lines (<b>Fig. 64</b><i>B</i>), and the bottom holes are again marked through to the leather (at the new position). The holes for the bottom attachments are now punched through the leather at the proper height but midway between the two points marked on each side (<b>Fig. 64</b><i>C</i>). The process amounts to bisecting the angle between the positions of the bars in standing and their positions during sitting with knee flexed 90 deg. When the lower attachments have been completed, subject to final adjustment, the prosthetist proceeds with the remaining details of corset construction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 64. Tentative attachment of upper sidebar straps to corset. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>While the amputee stands upon the socket-shank-foot unit, the leather corset is wrapped about the thigh in the intended position, edges in front, and the edges are marked for trimming so that, thereafter, they will be 1-1/4 in. apart (<b>Fig. 65</b>). The corset is removed from the patient, the edges trimmed as marked, and 1/4-in. holes for the lacing are punched along each edge on 1-in. centers along lines 3/8 in. from the edges (<b>Fig. 65</b>). Now the amputee dons the corset and laces it up with a suitable length of nylon parachute cord singed at each end to prevent fraying. While he stands thus, any necessary adjustments are made in the trim lines at top and bottom, the intent being to have the front lower edge fit closely about the patella and just above it while in the back there is enough relief to avoid bunching of the flesh when the patient sits. Should the alignment of the sidebar straps prove to be faulty for any reason, re-alignment should be carried out before proceeding further.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 65. Trimming of front edges of corset, placement of lacing holes in proper position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the fitting is thus far satisfactory, a tongue is provided out of the same kind of leather (cowhide) as was used for the corset itself, and the entire component is lined with cream horsehide of medium weight (4 to 6 oz.). To form the tongue, a piece of cowhide is cut long enough to extend from top to bottom of corset and wide enough to extend 1 in. beyond the rows of eyelets on either side (<b>Fig. 66</b>). One of the long edges is then skived so that, when that edge is later sewed to the body of the corset, there will be a smooth transition from corset to tongue such as not to cause any unnecessary irritation when the unit is worn. To line that portion of the corset between the fixed side of the tongue and the edge on that side (<b>Fig. 67</b>), a piece of medium-weight horsehide is cut 2 1/2 in. wide and long enough to extend from top to bottom of lacer. One of the long edges is skived, and the strip is then bonded (with rubber cement) to the inside surface of the corset, smooth side facing in and skived edge lying 2 1/4 in. in from the edge (which leaves about 1/4 in. of surplus horsehide for later trimming).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 66. Relative size and shape of corset tongue. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 67. Lining of corset tongue area on fixed side of tongue. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The tongue of cowhide is now placed smooth side out (toward the front of the corset) over the horsehide lining of the edge of the lacer and with skived edge about 2 1/4 in. in from the edge of the corset. When a smooth transition has thus been attained by whatever local adjustment is necessary, both tongue and liner are sewed along the long side. The smooth side of the lacer and the corresponding smooth side of the tongue thus face each other to avoid any otherwise unnecessary bunching or wrinkling of tongue or corset.</p> <p>The next step is to line with medium-weight horsehide the entire remaining internal surface of corset and tongue. To do so, the corset (together with the tongue) is laid out flat on the bench, rough side down. Thereupon is placed, rough side up, a piece of medium-weight horsehide large enough to cover the entire piece of work. Thus horsehide liner and corset-tongue combination are placed smooth side to smooth side. When the liner has been cut out to correspond roughly to the shape of the corset, the two pieces are sewed together across the top, the seam line starting where the tongue joins the corset and ending about 1 in. short of the opposite side. Thereafter the whole piece is inverted (<b>Fig. 68</b>) so that the horsehide falls over the cowhide corset and tongue to form a smooth liner, smooth side of horsehide in, smooth side of cowhide out. The entire facing surfaces are then bonded together with rubber cement, the edges are sewed around carefully, and any excess is trimmed close to the seams. On the side opposite the base of the tongue, a final seam is sewed down the edge of the corset just inside the row of eyelet holes, and the latter are then cut through the horsehide liner. Into the punched holes are then installed the metal grommets for the lacing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 68. Lining of entire internal surface of corset and tongue. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To protect the clothing from excessive wear, specially designed leather covers are commonly placed over the upper flanges of the sidebars and over the housings of the ball-bearing races. For this purpose use is made of cowhide one third the thickness of the leather used to make the basic part of the corset. By appropriate use of the pattern shown in <b>Fig. 69</b>, one cover is made for each side of the corset, one medial and one lateral. When the sidebars have been riveted in place permanently through all three holes on each side (with 1/8-in. copper rivets), the covers are set in place, the distal portions being doubled back upon themselves and glued together with rubber cement. After the upper portions of the covers have been sewed to the corset on both sides, any excess is trimmed off, and a rivet is installed at about the point shown in <b>Fig. 70</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 69. Pattern for side-joint covers, half actual size. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 70. Installation of side-joint covers for protection of clothing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Finally, as protection against the effects of moisture and bacteria, all of the leather parts are coated with nylon solution according to the usual techniques <a></a>.</p> <p><b>Auxiliary Belt Suspension</b></p> <p>In below-knee prosthetics, the conventional thigh corset (and sidebars) may serve any of three purposes to varying extents and in varying combinations. It may be needed to provide necessary additional stability not to be had from the below-knee socket alone. It may provide needed suspension over and above that furnished by the supracondylar cuff. It may be needed to furnish additional weight-bearing over and above that provided by the PTB socket. Or it may be required for any of these purposes in one combination or another. Occasionally, additional suspension is needed for the PTB prosthesis with or without the thigh corset, and in such cases use is made of the pelvic belt in any of several forms. In all cases the belt fits about the iliac fossa on the normal side and extends downward on the side of the amputation to connect to the prosthesis itself. When, in addition to thigh corset and side joints, the pelvic belt is needed, it is attached to the prosthesis above the mechanical axes of the artificial knee joints. When the belt suspension is required on a limb without thigh corset or sidebars, it is attached to the limb either just below the brim of the socket or else to the supracondylar cuff, whichever is applicable. In general, the pelvic belt serves to reinforce the suspension provided by the supracondylar cuff, not the other way round. The supracondylar cuff is always tried first. Whenever it suffices, no pelvic belt is required.</p> <p>To prepare the pelvic belt and associated suspensory attachments for the below-knee prosthesis, use is made of the patterns shown in <b>Fig. 70</b> and usually of one or the other of those shown in <b>Fig. 72</b>. First there is cut from 2-in. cotton webbing a length 3 in. shorter than the waist measurement. It forms the belt component labeled "waistband" in <b>Fig. 73</b><i>A</i>. Next a 7-in. length of 2-in. elastic webbing is cut to form the tensile element of the vertical support (<b>Fig. 74</b>). Then there are cut from 6-oz. cowhide or pearled elk one piece according to pattern <i>A</i> (<b>Fig. 71</b>), two pieces according to pattern <i>B </i>(<b>Fig. 71</b>), and two pieces according to pattern <i>C </i>(<b>Fig. 71</b>). These form respectively the boomerang-shaped portion of the waistband (section <i>A </i>in <b>Fig. 73</b><i>A</i>), the buckle billets (5/8-in. buckles) to be installed on the belt (<i>B </i>in <b>Fig. 73</b><i>B</i>) and at the proximal end of the elastic suspensor (<i>B </i>in <b>Fig. 74</b>), and the two elements labeled "sections <i>C</i>" in <b>Fig. 73</b><i>C</i>. When, in addition to the thigh corset and sidebars, the pelvic belt is required, suspension is by virtue of the inverted Y-strap shown in <b>Fig. 74</b>, the forked section being fashioned according to pattern <i>D </i>of <b>Fig. 72</b> and the ends of the fork being attached to the prosthesis above the mechanical axes of the artificial knee joints, as already pointed out (page 61). When pelvic suspension is required in the absence of thigh corset and sidebars, section <i>D </i>(<b>Fig. 72</b>) is replaced by section <i>E </i>(<b>Fig. 72</b>), or the elastic vertical suspensor (<b>Fig. 74</b> and <b>Fig. 75</b>) may be attached directly to the anterior aspect of the supracondylar cuff (<b>Fig. 75</b>) without the necessity for sections <i>D </i>or <i>E </i>(<b>Fig. 72</b>). Details of fabrication technique for these several variations in auxiliary suspension are readily to be had from Figures 71 through 75.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 72. Patterns (one half actual size) for suspension straps when <i>(D) </i>thigh corset and sidebars are used and <i>(E) </i>when thigh corset and sidebars are not used. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 73. Details of assembly of the pelvic belt. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 74. Details of suspensor strap when pelvic belt is used in addition to thigh corset and sidebars. When thigh corset and sidebars are not required, section <i>D </i>(Fig. 72) is replaced by section <i>E </i>(Fig. 72). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 71. Patterns for construction of the pelvic belt shown in Figure 73, half actual size. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 75. Arrangement of suspensor strap when auxiliary support from pelvic belt is used in conjunction with the supracondylar cuff but without thigh corset and sidebars. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As for details of actual construction, section <i>A </i>(<b>Fig. 73</b>) is first bonded to the waistband with rubber cement with an overlap of 1 1/2 in. the bonded side being on the side of the amputation (<b>Fig. 73</b>C). The skived ends of the leather sections <i>B </i>(<b>Fig. 71</b>) are lapped back on each other, each piece is threaded with a 5/8-in. buckle, and the billets so formed are applied, one to section <i>A </i>(<b>Fig. 73</b>) and one to the proximal end of the elastic vertical sus-pensor (<b>Fig. 74</b>). The billets (<i>B</i>) having been fixed in place with rubber cement, the forked section <i>D </i>(or the U-shaped section <i>E) </i>is cemented to the distal end of the elastic webbing, as shown in <b>Fig. 74</b>, and the ends of the fork (or of the inverted U) are attached to the socket just below its brim on the medial and lateral sides. When belt suspension is intended simply to supplement the cuff-suspension system, less corset and sidebars, the vertical section shown in <b>Fig. 74</b> is attached directly to the anterior portion of the supracondylar cuff (<b>Fig. 75</b>). In every case all leather parts are backed with a lining of horsehide, and all segments are sewed around, excess horsehide being trimmed off close to the stitching.</p> <h3>Conclusion</h3> <p>In the construction or manufacture of any piece of apparatus or equipment, for whatever purpose, there may occur to the experienced craftsman any number of variations in technique to effect the same result-some in the interest of economy perhaps, some possibly with the intent of making the task easier, conceivably some with the idea of improving reliability in a stepwise procedure and hence of reducing the possibility for error, some perhaps for other reasons. Just so with the patellar-tendon-bearing, total-contact, below-knee socket. The particular method herein described for construction of the PTB socket, and of associated equipment for use in special cases, is not, therefore, the only possible method. It is simply the one which, in U. S. experience covering more than four years, has proved to be successful and the one most widely used. It is entirely possible that desirable changes in the recommended technique of construction, or with respect to the materials used, will be apparent at once to prosthetists and others. There is, indeed, nothing particularly sacred about the actual stepwise procedure described for fabrication, or about the actual materials suggested, so that it is reasonable to expect changes here and there as the application of the PTB prosthesis comes more and more into widespread use.</p> <p>Whatever changes in materials or fabrication technique may in the future be found to be useful, however, it is essential that the principles utilized in the PTB socket-in its design and in its application with respect to the wearer and to the rest of the prosthesis- be held inviolate if success is to be attained in the majority of cases. Features such as the ledge for weight-bearing on the patellar tendon, the high sidewalls for increased medio-lateral stability in standing and walking, the relief for the hamstring tendons during knee flexion in sitting and in the swing phase of walking, the firm but gentle contact of stump with socket throughout its length as well as at the terminal end, the soft liner and end pad for shock absorption, and the subtle aspects of alignment in slight adduction and slight initial knee flexion are all based on systematic analysis of physical and anatomical fact and are therefore indispensable to the usefulness of the true patellar-tendon-bearing below-knee prosthesis. If, in the otherwise average below-knee case, any one of these details is lacking, difficulty in one form or another will ensue, in which case other and undesirable expedients have to be devised and the inherent advantages of the PTB prosthesis-freedom from the restrictions imposed by additional equipment-are at best seriously discounted and may in fact be lost entirely.</p> <p>Although precision and meticulous workmanship are generally acknowledged to be essential requirements in the successful construction and fitting of any limb prosthesis, they are in the PTB limb especially in need of emphasis. Since the self-stabilizing, total-contact, patellar-tendon-bearing, below-knee socket is intended to be manageable by the wearer with little or no external assistance, all features of measurement, of fit, and of orientation are particularly critical, so that even a minor fault may result in gross deviation from proper performance. The eventual outcome of any PTB fitting is thus not only a matter of formal instructions but also of the exercise of sound judgment on the part of the clinic team in each and every individual case. General experience to date has indicated that the added investment in time and precaution almost always results in a satisfied and successful wearer. Failure to attend details almost always gives rise to failure and disappointment.</p> <h3>Appendix A</h3> <p><b>Formulation of Polyester Laminating Resin</b></p> <p>(for Each 100 Grams)</p> <p>Into 100 gms. of polyester resin mix thoroughly 2 gms. of ATC catalyst. Then mix in color paste according to manufacturer's recommendation. Add 10 drops of Naugatuck Promoter No. 3. Mix thoroughly.</p> <h3>Appendix B</h3> <p><b>Procedure for Changing Heel-Cushion Stiffness in SACH Foot</b></p> <p>In the event the amputee, standing on the socket-shank-foot-shoe combination, demonstrates proper heel elevation (11/16 in.) but too hard or too soft a heel cushion during walking, the heel wedge must be replaced with another, either softer or harder as the case may be. The amputee first steps out of the socket, the shoe is removed from the foot, and the remaining unit is placed on a level bench with a block of wood 11/16 in. deep under the heel (<b>Fig. 1</b><i>A</i>). By means of an ordinary carpenter's square, a vertical reference line is marked on one side of the socket block in the vicinity of the anteroposterior midline so that, after the wedge has been replaced, the prosthetist can be certain that the same orientation of the socket has been re-established.</p> <p>The edge of the sole around the heel is not marked in such a way as to locate the anterior point of the existing heel cushion (<b>Fig. 1</b><i>B</i>), the shank is clamped in a wood vise heel up, and the entire heel cushion is cut out with a sharp knife, the sole being peeled back first, the wedge itself later. Ant irregularities in the cut surfaces are smoothed with a fine file, and the new wedge is inserted, longest lamination next to the sole, and to such an extent that the point falls as nearly as possible into the position previously occupied by the point of the old wedge.</p> <p>Thereafter the whole unit is remobed from the vise and placed upon the bench with the 11/16-in. heel block under the heel as before. Movement of the new wedge forward or backward, as required, re-establishes the original alignment, as indicated again by the square (<b>Fig. 1</b><i>C</i>). When all is in order, the new wedge is cemented into place with Stabond T-161, and the heel is again shaped in the way previously recommended.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Pattern for preparation of the PVA sleeves. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Preliminary alignment of trial leg in four successive steps using the adjustment facilities of the UC below-knee adjustable shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Anderson, Miles H., John J. Bray, and Charles A. Hennessy, <i>The construction and fitting of lower-extremity prostheses, </i>Chap. 6 in <i>Orthopaedic appliances atlas, </i>Vol. 2, Edwards, Ann Arbor, Mich., 1960.</li> <li>DeFries, Myron G., and Fred Leonard, <i>Bacterio-static nylon films, </i>Appl. Microbiology, 3 (No. 4): 238 (1955).</li> <li>Leonard, Fred, T. B. Blevins, W. S. Wright, and M. G. DeFries, <i>Nylon-coated leather, </i>Ind. Eng. Chem., 45:773 (1953).</li> <li>Murphy, Eugene F., <i>The fitting of below-knee prostheses, </i>Chap. 22 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>University of California, Biomechanics Laboratory (Berkeley and San Francisco), <i>Manual of below-knee prosthetics, </i>November 1959.</li> <li>University of California, Biomechanics Laboratory (Berkeley and San Francisco), <i>The patellar-tendon-bearing below-knee prosthesis, </i>1961.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">DeFries, Myron G., and Fred Leonard, Bacterio-static nylon films, Appl. Microbiology, 3 (No. 4): 238 (1955).</td></tr><tr><td class="clsTextSmall"><b> 3.</b> </td><td class="clsTextSmall">Leonard, Fred, T. B. Blevins, W. S. Wright, and M. G. DeFries, Nylon-coated leather, Ind. Eng. Chem., 45:773 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Particularly if the socket wall were rigid and lacking a soft lining.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Application of cement within the 1/2-in. border around the estimated trim line is avoided at all times.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Anderson, Miles H., John J. Bray, and Charles A. Hennessy, The construction and fitting of lower-extremity prostheses, Chap. 6 in Orthopaedic appliances atlas, Vol. 2, Edwards, Ann Arbor, Mich., 1960.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The fitting of below-knee prostheses, Chap. 22 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Staff Engineer, CPRD, NAS-NRC, 2101 Constitution Ave, Washington 25, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Bryson Fleer </b></td></tr><tr><td class="clsTextSmall">Staff Editor, CPRD, NAS-NRC, 2101 Constitution Ave, Washington 25, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-15.jpg Figure 15 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-16.jpg Figure 16 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-17.jpg Figure 17 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-18.jpg Figure 18 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-19.jpg Figure 19 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-20.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Construction of the Patellar-Tendon-Bearing Below-Knee Prosthesis Creator An entity primarily responsible for making the resource Bryson Fleer * A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/69040961fa14eb3de1832ed0d1d448a5.pdf df098d8f74c3d28303ceedffbfd1dcaf DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_001.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_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>Canadian Candidate</h2> <h5>C. A. BELL, B.A.Sc, O.B.E., M.C <a style="text-decoration:none;">*</a><br /></h5> <p>Throughout the 200-odd years since its inception, the surgical procedure known as disarticulation of the hip has been fraught with danger and disappointment both medically and prosthetically. On few persons has the operation been performed, and fewer still have survived for any gratifying period. Because hip disarticulation is so severe a measure, and because in recent years it has for the most part been carried out only in the attempt to forestall fatal disease, the level of medical success thus far attained has been disturbing. Because the hip-disarticulation amputee presents such a difficult problem in anatomical deficiency, his successful rehabilitation prosthetically has proved particularly evasive.</p> <p>Although even in modern times postoperative mortality from residual systemic disease has remained alarmingly high, recent advances in surgical techniques and in medicine as a whole have done much to encourage hip disarticulation where it might not otherwise have been attempted. This circumstance, together with a growing tendency toward the use of radical amputation surgery as a curative measure in cases of malignancy, has been responsible for an increasing incidence of hip-disarticulation amputees. Meanwhile, the problem of providing a reasonably satisfactory substitute for a lower extremity amputated at hip level has over a long period of years continued to be most difficult for the limbmaker and most exasperating for the patient.</p> <p>To satisfy functional requirements in amputations at or about the hip, the prosthetist has not only to furnish a limb with three simulated anatomical joints, all of which have to be stabilized in the stance phase of walking, but he must do so with only the torso and associated structures as a source of activation and control. In the absence of an adequate thigh stump, reliable management of an articulated lower-extremity prosthesis calls for the use of various locks, or equivalent, and for the coordinated action of pelvis, trunk, and remaining sound leg. The saving grace in this situation is that weight-bearing can still be provided on one of Nature's chosen seats of election, the ischium.</p> <p>The hip-disarticulation prosthesis to which this issue of <i>Artificial Limbs</i> is devoted is the culmination of many years of practical work, later combined with present-day methods of organized research and the application of new materials. Canada has had much experience in the provision of orthopedic and prosthetic appliances in the aftercare of her veterans. Early in 1916, the government of the day was confronted with the matter of supply for members and ex-members of the Canadian Expeditionary Force. After thorough investigation, it was found that existing facilities were extremely limited and unable to cope with the problem. Further, although standardization of appliances was deemed essential to provide ready maintenance or renewal accessible to the veteran's place of residence over the breadth of the country, no such standardization existed throughout the Dominion. Government proprietorship was considered the best means for keeping in touch with latest developments in prosthetics from other countries and also seemed to offer the most expeditious way of initiating a domestic program of experimental work that would be productive of results in keeping with the policy of standardization.</p> <p>The agency thus established, which today is known as the Prosthetic Services Branch of the Department of Veterans Affairs, now consists of some twelve operating centres and six visiting facilities situated in or adjacent to Departmental hospitals in the principal Canadian cities from coast to coast. The largest centre, located at Sunnybrook Hospital in Toronto, serves as the central manufacturing facility for the production of standard parts and stores for supply to all other centres. Here also is located a research section technically staffed for the investigation of new designs, materials, and techniques. Situated close to the medical and production facilities, and with patient personnel from the largest veteran area, this unit provides ample opportunity for field-testing and final approval for manufacture in other District facilities across the country. It was here that Colin McLaurin and James Foort were inducted into the field of prosthetics research and here also that, early in 1954, McLaurin brought into production the hip-disarticulation leg now generally known as the "Canadian type."</p> <p>To produce an improved prosthesis for the hip-disarticulation case was already one of the problems confronting the design section organized in 1916. At that time, the choice of willow setups, wood or leather sockets, and heavy joints did not provide for a light limb or for good control. Later, in 1926, the Department adopted the J. E. Hanger English metal limb, which included a design known as the "tilting-table leg." This limb, although of lightweight construction and representing a decided improvement over former designs, did not eliminate locks, and, moreover, the location of the hip joint directly under the ischial seat created, when the wearer sat, a pelvic tilt that was tiresome over any lengthy period. Further design work was carried out after World War II using a lateral hip joint and folding-latch mechanism. But this device, while solving the "tilt" problem, necessitated heavy construction and gave little improvement in control. Because of this discouraging state of affairs, many hip-disarticulation and short-stump above-knee amputees had long preferred crutch ambulation rather than bother with the best prosthesis available.</p> <p>The current design of the Canadian-type hip-disarticulation prosthesis was evolved by McLaurin after some three years of work in which the scope of investigation was broadened to explore more features than the height of the joint under the seat. Included were a mechanical design of the hip joint to promote walking with a free hip, an alignment that provides stability through all phases of the walking cycle, and, finally, a new concept of a plastic socket-waistband. This all-plastic member embraces the pelvis and incorporates a rather rigid band which encircles the waist. When well fitted, it provides comfortable weight-bearing, a suspension that requires only the tightening of the front restraining strap, and a degree of control which permits the amputee to move the limb freely and confidently.</p> <p>Performance on the new device by a test amputee exceeded all expectations, despite the fact that in addition to an amputation at the right hip he had suffered amputation of the right arm above the elbow. Shortly after trials, he reported his ability to walk forty city blocks with less effort than he had formerly expended in two blocks with the old-style metal limb. The ease of donning and removing the new leg with the simple yet secure suspension was impressive. Further field-testing on a larger number of hip-level amputees justified the acceptance of the design as a standard of production, and by September of 1954, through instruction and training of District fitters, it was made available on a Dominionwide basis. Some thirty-two cases have been fitted to date, and twenty-five of these have been classified as successful.</p> <p>Following the results attained at Sunnybrook, the Prosthetics Research Group at the University of California at Berkeley undertook to assess the new device and to work out improved procedures for construction and fitting, and in the spring of 1956 the Committee on Prosthetics Research and Development of the Prosthetics Research Board approved the issuance of the Canadian-type hip-disarticulation prosthesis to veteran beneficiaries throughout the United States. Here, then, is a Canadian candidate for utilization by clinic teams everywhere in dealing successfully with one of the most troublesome prosthetic problems of all.</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>C. A. BELL, B.A.Sc, O.B.E., M.C </b></td></tr><tr><td class="clsTextSmall">Director of Prosthetic Services, Department of Veterans Affairs, Ottawa, Canada.</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 Canadian Candidate Creator An entity primarily responsible for making the resource C. A. BELL, B.A.Sc, O.B.E., M.C * 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/e678471a88e3fafdcc78502486bb9378.pdf 0c896873793ae2afd1dd418dddff6f7d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1956_01_001.pdf Year 1956 Volume 3 Issue 1 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1956_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1956_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>Lesson In Lesions</h2> <h5>C. Leslie Mitchell, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The human integument, with its complex structural and functional organization, is one of the most remarkable packaging materials in the world. Unlike inanimate wrappers however elaborate, it has under ordinary circumstances the extraordinary facility of regenerating itself, of adapting to the local environment, and of resisting attack by all kinds of agents-chemical, physical, and biological. The reason for this situation lies in the fact that living skin, as is the case with other living tissues, undergoes continuous metabolism, with consequent growth and decay.</p> <p>But in addition to its mechanical function-that of providing a tough, protective outer covering for the body-the skin has many important but little-recognized physiological properties, among these being its ability to function as a respirator in the exchange of oxygen and carbon dioxide; as a regulator of body temperature by means of sweat glands under control of the sympathetic nervous system; as an agent in the conservation of water and electrolytes; as a sensory organ to record heat, cold, pain, and touch; as a corridor for the reception of vitamins and hormones; and as a barrier against infection. Despite all these indispensable services, the integrity of the skin is so much taken for granted by almost everybody that usually no attention is directed to it until some deviation from the normal develops. Its numerous functions are poorly understood by most laymen, if not indeed by many physicians. Yet neglect of its proper care can result in serious consequences.</p> <p>Proper functioning of the skin is dependent on many factors, such for example as freedom from constriction and irritation, adequate exposure to air, prompt removal of waste products from its surface, and avoidance of extremes of heat and cold. Whenever the skin is subjected to abnormal insults, the problem of skin care is multiplied many times. Since the wearing of a prosthesis, particularly on the weight-bearing lower extremity, unavoidably creates most of the conditions-constriction, excessive moisture, increased heat, mechanical irritation, and undue pressure-conducive to poor skin health, it quite naturally places upon the skin of the stump a set of demands far in excess of the normal. And not only that. Having lost one of his principal heat-radiating "fins," and being at the same time required to exert in locomotion more energy than does the normal person, the leg amputee commonly perspires more freely than normal, and hence his needs for skin hygiene are more acute than are those for one who walks on two natural legs.</p> <p>The basic requirements of a lower-extremity prosthesis are to provide comfort, function, and appearance. Of these, comfort is unquestionably of chief importance, for without comfort the amputee will fail to obtain satisfactory function, or appearance, or both, and will ultimately either limit use of the prosthesis or else find it impossible to wear it at all. In a large percentage of cases of difficulty or failure, skin lesions of one type or another involving the stump are found to be the cause of discomfort, thus preventing the amputee from wearing the limb. Prophylaxis is, therefore, a <i>sine qua non </i>in this regard, and only through adequate knowledge of skin physiology can these disorders be anticipated and thus prevented.</p> <p>Although disabling skin lesions on the stump of the leg amputee have constituted a serious complication ever since prostheses were first used for the lower extremity, full appreciation of the problem and suggestions for solution have not been forthcoming until recently. As has been typical with most problems in medicine, little was accomplished until a concerted effort was made to understand normal function and to investigate reaction to the abnormal. It is encouraging to note that there is now well under way, with the sponsorship of the Prosthetics Research Board of the National Academy of Sciences-National Research Council, a systematic attack aimed at solution of the cutaneous problems of the leg amputee.</p> <p>Because even the most satisfactory lower-extremity prosthesis is of no avail if the amputee is deprived of wearing it, and because painful skin lesions in a leg stump have so frequently been the cause of inability to use an artificial leg properly, the then Prosthetic Devices Research Project at the University of California, Berkeley (now the Lower-Extremity Amputee Research Project), in conjunction with the Department of Dermatology at the University of California Medical School in San Francisco, organized in the autumn of 1954 a skin-study group to investigate the cutaneous difficulties of the lower-extremity amputee. In the course of the succeeding two years there has been accumulated a considerable body of new knowledge, not only on the nature and physiology of healthy skin but also on some of the specific clinical manifestations of skin disorders in amputees. Since the proper management of cutaneous disturbances is so essential to lower-extremity function, this issue of Artificial Limbs is devoted to a presentation of some of the information gathered thus far. In the first of two articles, a dermatologist discusses the anatomy and physiology of normal skin and what is to be expected when healthy skin is subjected to unfavorable conditions. In the second, another dermatologist characterizes the common skin maladies of leg amputees and offers suggestions for prevention and treatment.</p> <p>An interesting observation is that proper care of the stump skin is found to be the responsibility not only of the attending physician and the prosthetist but, and even more important, of the amputee himself. Nevertheless, simple attention to good practices of daily hygiene is not enough. A considerable number of skin disorders peculiar to the lower-extremity stump present themselves despite all precautions. Some are common to all leg amputees. Many are the result of individual skin idiosyncrasies or of climatic conditions. Some are so intractable as to be amenable to cure only by total excision.</p> <p>While the newer understanding has in recent years appreciably decreased the incidence of serious skin lesions in leg amputees and has made it more readily possible to deal successfully with some of those that do occur, it is obvious that much work remains to be done. For the complete etiology of many of the characteristic disease states yet remains to be elucidated. It is to be hoped that the initiative taken by the pilot study group at the University of California may prove to be a stimulus for similar investigative work at other centers of medical research throughout the world. The lesson is here for us to learn. Unless skin problems can be eliminated once and for all, there can be no true rehabilitation of the lower-extremity amputee.</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>C. Leslie Mitchell, M.D. </b></td></tr><tr><td class="clsTextSmall">Surgeon-in-Charge, Division of Orthopaedic Surgery, Henry Ford Hospital, Detroit; member, Prosthetics Research Board, NAS-NRC.</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 Lesson In Lesions Creator An entity primarily responsible for making the resource C. Leslie Mitchell, M.D. * https://staging.drfop.org/files/original/37c3fec692e2b57f47245df169887b35.pdf 4946ee134a3401f408e0f322622aa167 https://staging.drfop.org/files/original/cda236ac9cde9b85325e3b96250a8f34.jpg 26aeac3a42f4a49224918f719d96a7bf https://staging.drfop.org/files/original/61e5df6689a2f5df64d735ec336e8dd7.jpg 25e56e96ed63a1d92e654c1dfd5447c9 https://staging.drfop.org/files/original/fd0fd82498d9cf6124c858bd221e6da0.jpg ceb9e4d935e7a64a1a6b54d44300cd2f https://staging.drfop.org/files/original/d3c8b0e372904833805dd1044f5bb20f.jpg b836b034c8fba7dd52dcbf61c62f7557 https://staging.drfop.org/files/original/c807aa7a3fefd3330cb672958e4f9744.jpg cef35b057b604843a8fda814493e07bd https://staging.drfop.org/files/original/ef44f82ae71f82036a91bd66e369ab5f.jpg 0a8cf7b7df88f1f5875f99e02d60f2a1 https://staging.drfop.org/files/original/aae5019d6873ca6c365835a4c4706720.jpg ebaef7afe5ead98ddf0119032fb488da https://staging.drfop.org/files/original/00f96c383c511633e3f05f8c9f266f5b.jpg 17c8c67c8c1a64cd510eedfe1639eb79 https://staging.drfop.org/files/original/0b29948807ab4359f31ff27cd2112168.jpg 1cafb32b82c0b235dc700d48c8dcba50 https://staging.drfop.org/files/original/9500eb71d186ca76e567a337583202af.jpg e86c2a546d0bea141aba88885bd080ed https://staging.drfop.org/files/original/5644f8d878cf4491ab0b287029eb3741.jpg 0d76a9bdf9ccd33b508307f1bd262151 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_03_105.pdf Text Any textual data included in the document <h2>The Use of Surlyn and Polypropylene in Flexible Brim Socket Designs for Below-knee Prostheses</h2> <h5>C. Michael Schlich, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />A. Bennett Wilson, Jr.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The need for improved prosthetic socket designs to increase amputee comfort and function has long been recognized by prosthetists and other health care professionals involved in amputee rehabilitation. Reduction of the hardness and stiffness of wood and plastic laminate sockets has been addressed with various soft liners or inserts in an attempt to improve comfort and function. The subject is well covered in literature from Radcliffe's and Foort's initial description of leather and Kemblo® liners in 1961,<a></a> through Leon Bennett's work with gel liners in 1974,<a></a> to Tim Staats' description of multi-durometer liners in 1984.<a></a> Liners have no doubt been useful in below-knee prosthetics, but the proponents of soft liners seem to have overlooked the potentials offered by flexible brims.</p> <p>At least two engineers active in prosthetics research have for some time raised questions concerning socket brim stiffness as a negative factor with respect to socket comfort. Dr. Eugene Murphy first considered this theme as early as 1957<a></a> when he proposed, "minimize the stiffness gradient between the rigid socket wall and the flexible skin, i.e., taper flexibility of the socket brim." As Dr. Murphy<a></a> later relates:</p> <blockquote> <p>"This theme was eventually published as the introduction to an extensive series of theoretical and experimental papers by Bennett. The series ended with limited clinical trials of sockets with flexible brims made of plastic laminates. These sockets appeared to be helpful for patients previously troubled by chronic or recurrent cysts, but the mechanical durability of the laminate was so poor that the sockets often lasted only six months."<a></a></p> </blockquote> <p>In the course of developing the ultralight weight below-knee prosthesis at Moss Rehabilitation Hospital,<a></a> A. Bennett Wilson, Jr. recognized the possibilities afforded by the use of thermoplastics to achieve flexible brims that would be sufficiently durable. During the past year, we have been funded by the Veterans Administration Rehabilitation Research and Development Service to carry this idea further.</p> <p>After reviewing the theories set forth previously and considering the properties of new materials and techniques now available, a set of criteria for socket design was established:</p> <ol> <li> <p>Flexible brim</p> </li> <li> <p>Tapering flexibility of the socket in the brim area</p> </li> <li> <p>Flexibility options in other areas of the socket</p> </li> <li> <p>Light weight, but durable</p> </li> <li> <p>Thermoplastic and modular (i.e. no lamination, no epoxy, no glue, etc.)</p> </li> <li> <p>Compatibility with existing modular component systems</p> </li> </ol> <p>The resulting socket design (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-01.jpg"><b>Fig. 1</b></a>) consists of the following components: (1) a Surlyn® inner socket or liner; (2) a polypropylene frame for socket support and attachment; (3) silastic foam soft end pad for establishing total contact; (4) United States Manufacturing Company<a></a> adaptor hardware<a style="text-decoration: none;">*</a> for attachment to Otto Bock<a></a> modular systems; and (5) neoprene sleeve suspension.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-01.jpg"><strong>Figure 1. Complete prosthesis, except for cos-mesis and suspension, incorporating a socket with flexible brims.</strong></a><br /> <p>Fabrication of this socket system is as follows:</p> <ol> <li> <p>The cast is modified for a PTB-supracon-dylar socket design, and the distal end of the model is extended approximately one inch to allow for a silastic foam end pad and the modular adaptor (U.S. Mgf. Co.) for connection of the pylon to the socket (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-02.jpg"><b>Fig. 2</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-03.jpg"><b>Fig. 3</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-02.jpg"><strong>Figure 2. The modi-fled plaster model of the stump is extended to allow for location and alignment of the U.S.M.C. adaptor connector plate for the pylon.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-03.jpg"><strong>Figure 3. The modified plaster model complete with adaptor, ready for vacuum-forming of the Surlyn® inner socket.</strong></a></li> <li> <p>An inner liner of Surlyn® is vacuum formed using either 12" x 12" x 3/16" Surlyn® for light to regular duty sockets, or 12" x 12" x 1/4" Surlyn® for heavy duty sockets (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-04.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-04.jpg"><strong>Figure 4. Vacuum-forming the Surlyn® inner socket.</strong></a></li> <li> <p>One layer of thick stockinette and a nylon stocking are applied over the vacuum-formed Surlyn® liner to facilitate separation of socket frame and liner (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-05.jpg"><b>Fig. 5</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-05.jpg"><strong>Figure 5. Application of stockinette and nylon sock over Surlyn® inner socket to provide for separation of the polypropylene outer socket to be vacuum-formed over it.</strong></a></li> <li> <p>The socket frame is vacuum formed of polypropylene directly over the inner socket. A piece 12" x 12" x 3/8" is suitable for light duty while a piece 1/2" thick is usually adequate for heavy duty (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-06.jpg"><b>Fig. 6</b></a>).<br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-06.jpg"><strong>Figure 6. The outer socket frame is vacuum-formed over the inner socket</strong></a></p> </li> <li> <p>After the final vacuum forming stage, the socket liner and socket frame are separated from each other and from the cast model (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-07.jpg"><b>Fig. 7</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-07.jpg"><strong>Figure 7. The inner socket and socket frame before trimming</strong></a></li> <li> <p>The Surlyn® liner is trimmed for a PTB-SC design and the polypropylene frame is trimmed for a PTB socket design and is fenestrated over the tibial crest anteriorly and the gastrocnemius area posteriorly (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-08.jpg"><b>Fig. 8</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-08.jpg"><strong>Figure 8. The socket frame and inner socket after trimming</strong></a></li> <li> <p>The Surlyn® liner is now inserted into the polypropylene frame (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-09.jpg"><b>Fig. 9</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-09.jpg"><strong>Figure 9. The socket frame and inner socket assembled.</strong></a></li> <li> <p>The U.S. Manufacturing Co.<a></a> adaptor hardware is used to attach the socket to the Otto Bock<a></a> titanium modular endo-skeletal components and an appropriate foot.</p> </li> <li> <p>During initial fitting, the distal end pad is foamed in place while the patient stands to provide total contact.</p> </li> </ol> <p>The Otto Bock modular system has sufficient range of adjustment to suffice for alignment of prostheses for most geriatric patients. However, the use of the Berkeley BK alignment device might be desirable for some of the more active patients (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-10.jpg"><b>Fig. 10</b></a>). A special adaptor plate is made of 1/8" aluminum sheet so the Otto Bock 4R22 adaptor component can be used between the socket and the alignment device.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-10.jpg"><strong>Figure 10. View showing adaptor needed when the UCB adjustable below-knee "leg" is used for alignment trials.</strong></a><br /> <p>Cosmetic finishing may make use of any of several foam cover systems available, such as the round styrofoam cover available from the U.S. Manufacturing Company (<a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-11.jpg"><b>Fig. 11</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-11.jpg"><strong>Figure 11. The completed prosthesis with cosmetic stocking pulled down to show the carved styrofoam cover.</strong></a><br /> <p>Below-knee patients fitted at the University of Virginia during the past two years, who voluntarily agree, are being refitted by their original prosthetist with the flexible brim thermoplastic system described here. Our initial conclusions are very positive. To date, eight flexible brim thermoplastic sockets have been fit on seven patients, with one patient having worn his for over one year. There have been six fittings since February, 1986. Only one socket failure has been noted, that of the Surlyn® inner flexible socket which split along the tibial crest on a patient weighing over 350 pounds. That particular socket lasted approximately four months. Though not indicated for use on someone of this weight, we were interested in determining its durability limits.</p> <p>Subjective evaluation includes patient questionnaires and comments, comparing their existing prosthesis with the new flexible brim thermoplastic socket system. Patient reaction, thus far, indicates enhancement of patient comfort and awareness of reduced prosthesis weight, especially with our geriatric subjects. Although not originally designed for geriatrics, this patient population has specific needs that can be met by this socket design, such as socket flexibility, less confining brim, reduced proximal shear forces, and extreme light weight. When used with Otto Bock titanium modular components and a "Lite" SACH foot, this system weighs between one and a half and two pounds.</p> <p>Current objective evaluation includes collecting heart rate and step count data in the patient's home environment, using a newly developed ambulatory physiological monitoring system. This includes physiological data with the patient's existing prosthesis in addition to that collected with the flexible brim thermoplastic socket system. This system of patient monitoring, or surveillance, electronically records heart beats (EKG), standing versus sitting posture, and step count, plotted against time up to 24 hours. The goal is to document any changes in activity level and energy expenditure that occur with use of new prostheses, such as the flexible brim thermoplastic socket system presented in this paper.</p> <p>In conclusion, a new socket design rationale and system utilizing existing thermoplastic materials has been presented. Patients fit with this system are currently being evaluated both subjectively and physiologically. Fittings and evaluations will continue until a significant number are completed and related data gathered. A follow up report will follow with final conclusions and statistical data presented.</p> <p><b>References:</b></p> <ol> <li>Bennett, Leon, "Gel liner effects," <i>Bulletin of Prosthetic Research</i>, BPR 10:21; Spring, 1974, pp. 23-53.</li> <li>Otto Bock Orthopedic Industries, Inc., 4130 Highway 55, Minneapolis, MN 55422.</li> <li><a href="cpo/1984_03_004.asp">Murphy, Eugene F., "Sockets, Linings, and Interfaces," <i>Clinical Prosthetics and Orthotics</i>, 8:3, Summer, 1984, pp. 4-10.</a></li> <li>Murphy, Eugene F., "Transferring Load to Flesh," <i>Bulletin of Prosthetic Research</i>, BPR 10:16; Fall, 1971, pp. 38-44.</li> <li>Radcliffe, C. W., and J. Foort, "The Patellar-Tendon-Bearing Below-knee Prosthesis," Biomechanics Laboratory, Dept. of Engineering, Univ. of Calif., Berkeley, and School of Medicine, Univ. of Calif., San Francisco, 1961.</li> <li>Staats, Timothy B., "Multiple Durometer Socket Liners for P.T.B. Prostheses," <i>Orthotics and Prosthetics</i>, 38:4, Winter, 1984, pp. 63-68.</li> <li>United States Manufacturing Co., 180 North San Gabriel Boulevard, Pasadena, Calif., 91107.</li> <li>Wilson, A. Bennett, Jr., "Ultralight Prostheses for Below-knee Amputees," <i>Orthotics and Prosthetics</i>, 30:1, March, 1976, pp. 43-48.</li> </ol> <div style="width: 400px;"><b>Footnote</b> USMC Part Nos. 41014, 42012, 43026, and 29316<br /><br /></div> <em><b>*A. Bennett Wilson, Jr. </b> The Department of Orthopedics and Rehabilitation at the University of Virginia.</em><br /><br /><em><b>*C. Michael Schlich, C.P.O. </b> The Department of Orthopedics and Rehabilitation at the University of Virginia.</em><br /> <div style="width: 400px;"><br /><br /></div> <div style="width: 400px;"></div> Page Number(s) 105 - 110 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-01.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 10 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-11.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1986_03_105/1986_03_105-09.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 Surlyn and Polypropylene in Flexible Brim Socket Designs for Below-knee Prostheses Creator An entity primarily responsible for making the resource C. Michael Schlich, C.P.O. * A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/0bbc53a6aa62aebf038a53dd53472ffc.pdf 54b8c595e4ec188d6a8b8159ebc5c71f https://staging.drfop.org/files/original/b31f453e857faf7e7c85a9dc242a2129.jpg 9df96fc4ee9a837d85bbaece371c46fc https://staging.drfop.org/files/original/0ee976b743595cde154bc870afa7a224.jpg a3b8fbd6a6cea81286d669f3a25bd448 https://staging.drfop.org/files/original/63c4901b6d5f332233ffdb0f2c00b116.jpg 1c1cb3009b38e53630bde0cda90c9c89 https://staging.drfop.org/files/original/37f7edd8f4b869d37f92eb967037f82a.jpg 117dc9625d7e146431f643fdb0d17f6d https://staging.drfop.org/files/original/79cc93918eb2d23f152ee4043b75be4e.jpg cc9511daf3e04fdecb2f5c18ed011951 https://staging.drfop.org/files/original/a3b0d6d764f90dc9b9f455667be76a39.jpg 27c4183a32ace08a6dfa6980ba988b0c Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_03_101.pdf Text Any textual data included in the document <h2>Experience with the Use of Alginate in Transparent Diagnostic Below-Knee Sockets</h2> <h5>C. Michael Schlich, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Tony Lucy&nbsp;</h5> <p>Transparent test sockets have been available in various materials for more than ten years,<a></a> but their use has not been as widespread or as routine as one would expect. Only recently has the emergence of new materials and new evaluation techniques, as well as third-party awareness and reimbursement, made the use of test or check sockets more appealing.</p> <p>The objective of this article is to present a refined technique for using test sockets and aliginate to guarantee that total contact exists between socket and stump. This technique has been developed as a standard procedure for each and every below-knee amputee fitted with a prosthesis at the University of Virginia. We consider it to be the single most important and recent technique for enhancing the fit of prostheses for our below-knee amputees.</p> <p>Robert Hayes, CP., described his alginate technique first in 1975 in <i>Orthotics and Prosthetics</i><a></a> and more recently in an updated version in <i>Clinical Prosthetics and Orthotics</i>.<a></a> In 1984, Timothy Staats, CP.,<a></a> described a technique for introducing alginate into the negative cast mold, which is used as a test socket after molding. No doubt there are other prosthetists using similar or variations of these techniques. However, the important point is not who or how many are using the technique, but how many still do not use this technique for refining below-knee socket fit.</p> <p>Equally important is the fact that any system of diagnostic socket evaluation should be more than just algination. The routine use of multiple, transparent, skin-fit sockets, evaluated both statically and dynamically as a progressive system, will provide assurance of optimum socket fit. It seems rather obvious that if amputees can ambulate successfully with a skin-fit, hard socket, then use of a definitive socket with a minimal number of prosthetic socks, with or without a soft liner, will be that much more comfortable and successful.</p> <p>A 12" x 12" sheet of 3/8" thick Durr-Plex<a></a> or Thermocheck<a></a> is used for the average below-knee socket. This material is transparent, strong and rigid, is easily vacuum formed (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-1.jpg"><b>Fig. 1</b></a>) using the frame and platen technique, and can be modified later by spot heating. Of course, any other transparent material that can be vacuum formed is equally suitable.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-1.jpg">Figure 1.</a> A transparent socket is vacuum-formed over a plaster cast that has been modified in the usual manner.</strong><br /> <p>Lubrication of the stump with petroleum jelly, or equivalent lubricant, is necessary for donning the check socket when it is used without a prosthetic sock. The patient then stands bearing weight in the test socket, which rests on a platform or stand that can be adjusted in height so that weight-bearing is the same on each side and the pelvis is level (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-2.jpg"><b>Fig. 2</b></a>). While the patient continues to stand, the stump in the transparent socket is evaluated by identifying changes in skin color. Blanching, or even whiteness, indicates that the pressure levels are acceptable. Excessive shiny blanching indicates increased pressure, which is perhaps excessive. Redness indicates voids or lack of total contact. If a patient complains of too much pressure when an area is surrounded by red, then algina-tion should provide relief by establishing total contact. If the patient complains of too much pressure when an area is surrounded by white and blanching, relief is provided by spot heating and stretching the socket in the area of complaint. A thin flat probe, like a corset stay, is often useful for specifically locating pressure areas for purging small pockets of trapped air, or gauging skin tensions within the socket (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-3.jpg"><b>Fig. 3</b></a>).</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-2.jpg">Figure 2</a>. The patient bears one half of his weight in the transparent socket for evaluation of fit by the prosthetist observing the color of the skin<br /></strong><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-3.jpg">Figure 3.</a> Evaluation of fit by observation can be augmented by use of a flat slender probe.</strong><br /> <p>A reliable technique for the evaluation and modification of the fit of below-knee diagnostic test sockets is available using the dental material, alginate. The viscosity and other properties of alginate makes it suitable for: (1) filling any voids between the socket and stump to insure total contact, or total surface bearing; (2) providing proper compression of soft tissues for better distribution of weight-bearing pressures.</p> <p>A mixture of 20 grams of powdered alginate<a style="text-decoration: none;">*</a> and 6 ounces of water provides the proper ratio and amount for most below-knee patients. The water should be lukewarm and dyed with food coloring to provide a definite contrast in color to the skin and socket.</p> <p>The socket is sanded lightly on the inside to promote adherence of the alginate, and escape holes are drilled medially and laterally approximately one inch proximal to the distal end. Small pin holes are also drilled over void areas to allow air to escape as the alginate fills. The water and powder are mixed with an electric drill and paint stirrer, and then poured into the test socket and slushed around the walls to completely coat the inside of the socket. The patient then enters the socket and stands with equal weight-bearing bilaterally. The alginate fills void areas, establishing total contact. The excess is evacuated, and gelling occurs in one to three minutes (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-4.jpg"><b>Fig. 4</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-5.jpg"><b>Fig. 5</b></a>). The patient is then seated and the socket is carefully removed, after breaking the suction seal. The alginate will adhere to the inside of the socket.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-4.jpg">Figure 4.</a> Alginate fills void areas while patient bears one half of his weight into the socket. Excess alginate flows through small relief holes drilled for this purpose.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-5.jpg">Figure 5.</a> Alginate solution cures between one and three minutes.</strong><br /> <p>When the socket is filled with plaster, a positive model that has been redefined by the alginate under weight-bearing conditions is obtained. When the plaster has set, the test socket is removed by cutting it off. The alginate will adhere to the cured plaster model (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-6.jpg"><b>Fig. 6</b></a>).</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-6.jpg">Figure 6.</a> Alginate is removed from new positive model before smoothing and vacuum-forming definitive socket or a new check socket.</strong><br /> <p>The new positive model is now evaluated. Information such as location and thickness of the alginate fill is useful feedback concerning the original casting and model modification. At this point the alginate is removed and the new positive model is smoothed using sand screen. The model is now ready either for use as a follow-up transparent test socket or for fabricating a definitive socket.</p> <p>If one chooses to proceed with the definitive socket, prosthetic socks are added over the model before the liner or socket is fabricated to allow for the thickness of socks desired in the final fit.</p> <h3>Results</h3> <p>Records were kept and studied for a series of 40 below-knee amputees fitted using the alginate test socket system. The data recorded were: (1) location of areas filled by alginate (i.e. voids in the prealginated socket); (2) thickness of fill with respect to location; and (3) results of dynamic and final fittings (i.e. adjustments required to improve socket fit at post-algination fitting sessions).</p> <p>Areas filled with alginate were very consistent and included the posterior distal soft tissue area, the tibial tubercle, the lateral tibial flare, and the anterior distal tibia. As the series progressed, the model modification technique changed based on this previous experience. As a result, the thickness of the alginate fillers gradually decreased, as did the plaster build-up over bony prominences on the original model. None of the 40 subjects required socket adjustments to improve comfort or fit at the time of dynamic alignment, delivery alignment, or delivery of the prosthesis.</p> <p>We have been involved, either directly or indirectly, with fitting more than 150 patients in this manner. The use of alginate with multiple transparent test sockets is a valuable tool in patient management and helps provide better below-knee sockets through improved weight-bearing pressure distribution.</p> <p><b>References:</b></p> <ol> <li>Durr-Fillauer Medical, Inc. 2710 Amnicola Highway, Chattanooga, Tennessee 37406.</li> <li>Friddle's Orthopedic Appliance, P.O. Box AR, Honea Path, South Carolina 29654.</li> <li><a href="cpo/1985_03_013.asp">Hayes, Robert F., "A Below-Knee Weight-Bearing Pressure Formed Socket Technique," <i>Clinical Prosthetics and Orthotics</i>, 9:3, Summer, 1985, pp. 13-16.</a></li> <li>Hayes, Robert, F., "A Below-Knee Weight-Bearing Pressure Formed Socket Technique, <i>Orthotics and Prosthetics</i>, 26:1, March, 1972, pp. 1-13.</li> <li>Mooney, V. and R. Snelson, "Fabrication and Application Of Transparent Polycarbonate Sockets, <i>Orthotics and Prosthetics</i>, 26:1, March, 1972, pp. 1-13.</li> <li>Staats, Timothy, "Advanced Prosthetic Techniques For Below-Knee Amputation," <i>Orthopedics</i>, 8:2, February, 1985, pp. 249-258.</li> <li><a href="cpo/1985_03_011.asp">Quigley, Michael, Jr., "The Role of Test Socket Procedures In Today's Prosthetic Practices," <i>Clinical Prosthetics and Orthotics</i>, 9:3, pp. 11-12.</a></li> </ol> <b>Footnote</b> Type II, Normal Set Alginate, Coe Laboratories, Inc. Chicago, Illinois 60658<br /><br /><em><b>*C. Michael Schlich, C.P.O. </b> C. Michael Schuch, C.P.O., and Tony Lucy are with the Department of Orthopedics and Rehabilitation at the University of Virginia.<br /><br /><br /></em> Page Number(s) 101 - 104 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-6.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experience with the Use of Alginate in Transparent Diagnostic Below-Knee Sockets Creator An entity primarily responsible for making the resource C. Michael Schlich, C.P.O. * Tony Lucy  https://staging.drfop.org/files/original/e2c61c59f3027ddb38ee4b0cad58918d.pdf 4858353a3eb0b95867caf9f1b1f0c2c5 https://staging.drfop.org/files/original/72d955fc50fde2bd2b5b4b1b61fa890d.jpg d1cb7af36eaa7f8d6fd1559e80442210 https://staging.drfop.org/files/original/2e7f596162524cefe76991581bbe8944.jpg c34932f2a3cf4306da2927cccbfd11f7 https://staging.drfop.org/files/original/6c08f5085c2f2e75abf1441c0fa75629.jpg 0da2cfe04fc70164f72489961e1c2d0e https://staging.drfop.org/files/original/6fc1780773a623d6bb12e14f72ae0de1.jpg 3f220ea36778d047dc8b3721a0987cc5 https://staging.drfop.org/files/original/5121ad2531312a946139f0f9fa81398c.jpg 20a8db15337befcfaebf9f8aa41d2bfc https://staging.drfop.org/files/original/7c209157d86272c7ca4678ada3e56a6d.jpg a2425d95830f7f8591ade9da25680e2a https://staging.drfop.org/files/original/37f4302ab2b2754b3775add6ca724672.jpg 77078b8c21f4ee471eeb1c731d3709c6 https://staging.drfop.org/files/original/49e03ca05a09b28f85c4d5ec8471ad81.jpg 8b088903d6682e433d8281cdb98047f7 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_051.pdf Text Any textual data included in the document <h2>Orthotic Management of the Arthritic Foot</h2> <h5>C. Michael Schuch, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>With ever increasing public exposure, orthotists are being requested more frequently to confront new challenges caused by physical disability. In the spectrum of orthotic protocols, management of the arthritic foot and ankle is a relatively new challenge. During the past five years, the Department of Orthopaedics and Rehabilitation, the Division of Rheumatology, and the Division of Prosthetics and Orthotics, all of the University of Virginia Medical Center, have comprised an Arthritis Rehabilitation Research and Training Center, providing a regional referral center for arthritis patients. Orthotic services for these patients have concentrated on the foot and the ankle, and this population of patients has been substantial enough to permit the development of a consistently successful protocol of management. The intent of this paper is to review the skeletal anatomy of the ankle and foot, discuss the types of arthritis and their relative pathophysiology and clinical manifestations, and finally to present our protocol for management of the various problems presented by the arthritic foot and ankle.</p> <h3>Review of Ankle-Foot Anatomy</h3> <p>The skeleton of the foot consists of three groups of bones: tarsal bones, metatarsal bones, and phalanges. The tarsal bones are further divided into two groups, the first group consisting of the talus and the calcaneus, together forming the hindfoot. The talus, which is the only bone to articulate with the tibia and the fibula, acts as a rocker by which the foot as a unit can be dorsiflexed and plantarflexed at the hinge of the ankle joint. In stance, the talus receives the entire weight of the lower limb; half this weight is transmitted forward to the bones forming the arch of the foot, and half of the weight is transmitted downward to the heel or calcaneous. The calcaneus, or os calcis, is the bone of the heel. It supports the talus, withstands shock as the heel strikes the ground, and transfers forward the portion of body weight it receives from the talus.</p> <p>The second group of tarsals consists of the five bones anterior to the talus and the calcaneus. The navicular, cuboid, and three cuneiforms increase flexibility of the foot, particularly in its twisting movements. These bones form the longitudinal arch of the foot, and are referred to collectively as the midfoot.</p> <p>The five metatarsal bones lie anterior to and articulate with the second group of tarsal bones described above. Each metatarsal consists of a base, a shaft, and a head, in respective order from proximal to distal. The distal-most bones of the foot are the five phalanges, which extend from the five metatarsals and form the bones of the toes. The metatarsals and the phalanges form the forefoot.</p> <p>The foot has three arches: the medial, lateral, and transverse. The normal medial arch rises through the calcaneous to the head of the talus, and from this high point it descends forward through the navicular, cuneiforms, and first three metatarsal heads. The lateral arch, which is lower than the medial, extends from the calcaneus to its high point at the cuboid, and down through the fourth and fifth metatarsals. The transverse arch rises across the width of the foot between the medial and lateral borders, primarily under the metatarsal shafts.</p> <p>The junctions of these various groups of bones form the joints that allow the functional motions of the ankle and foot to occur. The talocrural (ankle) joint consists of the medial and lateral malleoli and the trochlear surface of the talus. This joint permits the motion of plantar-flexion and dorsiflexion. The subtalar (talocal-caneal) joint is formed by the articulation of the talus and the calcaneus, and permits the heel to share in inversion and eversion. The transverse tarsal (midtarsal) joint is not an anatomic entity, but an important functional grouping of two joints which occur anterior to the talus. These two joints, the talocalcaneonavicular and the calcaneocuboid, permit much of the inversions version of the foot. The other tarsal joints, tarsometatarsal joints, and distal joints aid in flexibility of the foot from heel strike through mid-stance, and help the foot form a rigid lever during toe-off, or the propulsion part of the gait cycle.</p> <p>Each of the joints of the ankle and foot, including the joints between the sesamoids and the first metatarsal are lined with synovium so that when inflammatory conditions that affect the synovium are present, the foot and ankle may show dramatic changes clinically, radio-graphically, and pathologically.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-1.jpg"><strong>Figure 1. View of patient's feet afflicted with rheumatoid arthritis. Note, hallux valgus, claw toes, depressed longitudinal arch, and pronation or eversion at the subtalar joint.</strong></a></p> <h3>Types and Pathophysiology of Arthritis</h3> <p>While there are a half dozen or more differing types of arthritis,<a></a> we will limit our discussion to the types that have a tendency to involve the foot and ankle. The most commonly seen and most debilitating form of arthritis is rheumatoid arthritis.</p> <p><i>Rheumatoid Arthritis</i></p> <p>Rheumatoid arthritis is an inflammatory condition of unknown etiology that primarily affects the synovial lining of joints, tendons, and bursae. Secondarily, it may cause destruction to cartilage, bone, ligaments, and other soft tissue. Most people with rheumatoid arthritis have some degree of foot and/or ankle involvement.<a></a> The joints of the feet are initially involved more often than the joints of the hands.<a></a> Vaino showed that more than 88% of adults and 69% of children with rheumatoid arthritis have involvement of the feet during some phase of the disease.<a></a></p> <p>Guerra states that the earliest sign of rheumatoid arthritis is congestion of the synovial membranes with edema.<a></a> As the synovial inflammatory tissue and fluid within the joint accumulate, there is swelling of the soft tissue, and decreased range of motion of the joint. The inflamed synovium adjacent to the marginal bare areas causes destruction of bone, resulting in bony erosion at the margins. Because the inflamed synovium, known as the pannus, also proliferates, expansion occurs over the cartilage and destroys the cartilage through enzymatic action, producing symmetrical joint space narrowing. The pannus may also penetrate the unprotected bare bone and cause destruction of the cartilage from the marrow side. The reactive hyperemia, part of the inflammatory process, is implicated in the periarticular osteoporosis and the discontinuity of the subchondral bony plate.<a></a> Joint destruction and deformities occur and become fixed as the weakened support structure of the ankle and foot gives way to the normal mechanical stresses placed upon it; changes in alignment of joints allow muscles, tendons, and ligaments that cross the joints to exert different forces, and stiffness and pain in the joints prevent mobility.<a></a></p> <p><a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-2.jpg"><strong>Figure 2. Schematic view showing the effects of claw toes with subluxed MTP joints, resulting in metatarsal head prominences on the plantar surfaces of the foot.</strong></a></p> <p>Clinical manifestations can include all joints of the ankle-foot, collectively or individually. Ankle involvement in rheumatoid arthritis is not as common as involvement of other joints of the foot.<a></a> The clinical picture of ankle involvement is less dramatic than with the other joints, with swelling, stiffness, decreased range of motion, and pain being the indicators. Unlike the ankle, the hindfoot is often affected early in rheumatoid arthritis. The most common deformity of the hindfoot is pes plano-valgus, or more simply, valgus of the hindfoot and flattening of the longitudinal arches.<a></a> The midfoot-tarsal joints develop inflammatory changes that contribute to the pes planovalgus deformity of the hindfoot and midfoot.<a></a> In time, each of the tarsal bones seem to be equally involved, causing loss of pronation-supination and malleability of the foot in general. The forefoot shows marked abnormalities on clinical and radiologic examination. The altered forces created by hindfoot and midfoot deformities act with the inflammatory process, affecting the metatarsal-phalangeal (MTP) joints and proximal interphalangeal (PIP) joints to give the typical findings of hallux valgus, claw toes, subluxation and depression of the metatarsal-phalangeal joints, abduction of the forefoot, and splay foot. Involvement here as in other parts of the foot is symmetric and increases with disease duration.<a></a></p> <p><i>Osteoarthritis</i></p> <p>The next most commonly seen type of arthritis to cause foot problems is osteoarthritis, or degenerative joint disease. This form of arthritis is not a systemic inflammatory disease; rather it is a disease that is secondary to the wear and tear phenomena on joints. Disruption of the cartilagenous matrix occurs as a result of enzymatic action. Large weight-bearing joints of the body are particularly prone to dysfunction. The ankle joint and the first MTP joint seem most susceptible, with weight bearing, trauma, and footwear having all been implicated as causative agents. Radiologic examination reveals asymmetric narrowing of the joint space, the areas of stress demonstrating less interosseous space.<a></a></p> <p><i>Other Arthritis Types</i></p> <p>The arthritis patient population requiring foot orthotic management primarily falls into one of the above two categories of diagnosis. However, occasions will arise necessitating foot and or ankle management for patients with other arthritic diagnoses. The seronegative arthridities are ankylosing spondylitis, Reiter's syndrome and its variants, and psoriatic arthritis. Two additional types of arthritis that may affect the foot and/or ankle are gout and systemic lupus erythematosis. While differing in pathophysiology from rheumatoid arthritis and osteoarthritis enough to warrant separate diagnostic classification, the clinical manifestations of the ankle and foot are similar.</p> <h3>Orthotic Designs and Indications</h3> <p>As in all orthotic management, the scope of the problem dictates the complexity of the orthosis. We have been pleased with the simplicity of the decision making process that has been developed at the University of Virginia. Sophisticated evaluation processes are not necessary; patient communication concerning location of pain and routine physical examination of ankle-foot abnormalities are sufficient. Observation of gait irregularities usually reinforce communication/physical examination findings. Orthotic management conveniently falls into two levels of complexity: foot orthoses (FO's) and ankle-foot orthoses (AFO's).</p> <p><i>Foot Orthoses</i></p> <p>The objectives of foot orthoses for arthritic patients include, (1) maintainence and support of existing arches of the foot; (2) re-establishment of fallen arches when flexibility permits; (3) provision of inversion-eversion balance or stability; (4) distribution of weight bearing pressures; and (5) provision of soft tissue supplement.</p> <p>The clinical picture requiring this level of orthotic management can range from mild longitudinal arch depression with callous formation under the metatarsal heads to severe loss of the longitudinal arches, medial drift of the talocalcaneonavicular joint complex, subluxation of MTP joints with depressed and protruding metatarsal heads, hallux valgus, and claw deformities of the phalanges. Traditional foot orthoses for this type of clinical picture have been Plastizote® inserts, molded directly to the patient's foot. However, Plastizote® is not durable; it packs down quickly with wear. The more severe the deformity, the quicker the material loses its integrity and ability to meet the objectives of foot orthoses as described above. Occasionally, arthritic patients have presented or reported being fit with rigid foot orthoses, fabricated of Nyloplex (Rohadur), usually provided by podiatrists. While this material selection and orthotic design are ideal for many cases, we have found it to be highly unsuccessful with arthritic patients to the point that we consider rigid foot orthotics contraindicated for this patient population. Our experience has shown that this type of orthosis lacks the flexibility and soft tissue supplement necessary to promote acceptance by patients with arthritis. The choice of materials and design for arthritic foot orthoses at the University of Virginia has been PVC-Pelite™ foot orthoses, molded over positive models of the patient's foot or feet.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-3.jpg"><strong>Figure 3. View showing left foot impression taken in foam foot impression block. Note "X" identifying metatarsal head prominence.</strong></a></p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-4.jpg"><strong>Figure 4. Foot impression filled with molding plaster forming a positive model of the patient's foot.</strong></a><br /> <p><i>Description of Technique</i></p> <p>Negative impressions of the patient's feet are obtained using any of the commercially available foam impression blocks. This impression is taken with the patient seated, to capture the shape of the existing arches at their maximum height, free of weight-bearing loads. Care should be taken to balance inversion-eversion as the foot is pressed into the foam. Positive models are obtained in the conventional manner by pouring molding plaster into the impression forms. Modification of the positive model is necessary to meet the objectives of foot orthoses for arthritic patients as discussed above. The longitudinal arch is increased mildly, especially posteriorly, as proposed by Carlson, et al., in their technique for modification of the UCB foot orthosis.<a></a> This modification meets the objectives of maintenance and support of existing arches, provision of eversion or valgus stability, and distribution of weight bearing forces. The metatarsal or transverse arch modification is perhaps most important, and the degree of this modification in terms of size and depth parallels the severity of MTP subluxation and metatarsal head depression. It is frequently greater than 1/2" in depth. The shape of this modification should simulate that of prefabricated rubber metatarsal pads, which are commercially available in varying sizes and depths. Proper placement of this modification is critical; when an existing transverse arch can be identified, it should be exaggerated. If there is no identifiable transverse arch, the modification for this arch in the positive model falls under the metatarsal shafts, with the dome or apex of the plaster removal just posterior to the metatarsal heads, and the proximal edges blending gradually into the longitudinal arches. This modification provides support to uplift the depressed metatarsal heads and reduce trauma at the push-off phase of the gait cycle. It also meets the objectives of maintenance and support of existing arches in some cases, re-establishment of fallen arches in other cases, and better distribution of weight-bearing loads. The final modification to the positive model includes adding plaster to the plantar aspect of the PIP joints of the phalanges, which aids in providing a smooth transition from the MTP to the phalangeal area of the foot orthosis.</p> <p>The positive model is now complete and ready for molding of the base material, PVC Pelite™, which is available in 4' square sheets, 1/8" thick. PVC Pelite™ is ideal for foot orthoses because: (1) the PVC laminate (vinyl covering) assists the Pelite™ in maintaining its desired shape after heat molding; (2) the PVC laminate provides strength and durability, decreasing and even eliminating incidences of the Pelite™ packing down, and (3) the PVC laminate consists of closed cells and is waterproof, which makes it easy to clean and discourages the growth of bacteria and fungus. The size of the PVC Pelite™ sheet to be molded over the positive model is determined by closely tracing the positive model onto the PVC Pelite™ and allowing extra material to cover the longitudinal arch and extra material beyond the phalanges. Care should be taken to closely trace the lateral and posterior aspects of the positive model, because excess material here makes molding or vacuum forming more difficult, frequently resulting in bunching or folding of the material and, thus, an unacceptable orthosis. Heating the PVC Pelite™ sheet can take place in an oven, an electric skillet, or with a heat gun. The vinyl covering of PVC Pelite™ should not be subjected to high heat or heated directly since it can delaminate under these conditions and develop bubbles or blisters. When sufficiently pliable and moldable from the heat, the PVC Pelite™ sheet is molded in place over the plantar surface of the positive model using any of the following techniques:</p> <ol> <li> <p>Wrapping the PVC Pelite™ in place around the positive model with an elastic bandage.</p> </li> <li> <p>Vacuum formed in place using a vacuum hose placed inside a small airtight plastic bag.</p> </li> <li> <p>Vacuum formed in place using a commercially available foot orthosis vacuum-forming machine.</p> </li> </ol> <p><a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-5.jpg"><strong>Figure 5. Positive models of patient's feet, plantar surface facing up. Note identification of transverse (metatarsal) arch and prominent metatarsal heads.</strong></a></p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-6.jpg"><strong>Figure 6. Molded PVC-Pelite™ foot orthosis, with longitudinal and metatarsal arch support.</strong></a><br /> <p>Once the PVC Pelite™ is molded in place and cooled sufficiently for the molded shape to be maintained, a sheet of 1/2" thick medium density Pelite™ is cut to fill the transverse and longitudinal arch areas as a single piece. (To save time we have these precut in large numbers to a single large size that can be trimmed to fit a given positive mold.) This piece of 1/2" medium density Pelite™ is heated to a moldable state using oven, skillet, or heat gun, and is then molded or vacuum formed in place as was the PVC Pelite™. When sufficiently cooled, it is glued in place using Polyadhesive and sanded to a feather edge so that it will blend with the PVC Pelite™. Additional modifications to this PVC Pelite™ foot orthosis design may include either of the following:</p> <ol> <li> <p>For increased soft tissue supplement and shock absorption, 1/8" PPT can be glued to the bottom surface of the PVC Pelite™ foot orthosis.</p> </li> <li> <p>For maximum soft tissue supplement in cases of severe metatarsal head protrusion, nylon lined 1/8" PPT may be glued on top of PVC Pelite™ foot orthosis.</p> </li> </ol> <p>Either modification will require greater depth within the patient's shoes. With or without the above modifications, final shaping and fitting are done to the patient and his shoes.</p> <p>An additional point worthy of mention: soft tissue supplement, weight bearing pressure distribution, metatarsal head pain relief, and other plantar surface objectives can be attained with this foot orthosis system regardless of shoe integrity. However, when the objective is control of the inversion-eversion (varus-valgus) balance in the foot, or maintenance, support, or re-establishment of the longitudinal arch, the shoes become an adjunct to the foot orthosis and thus must have a firm heel counter with good integrity along the medial aspect of the longitudinal arch.</p> <p><a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-7.jpg"><strong>Figure 7. Rheumatoid arthritis patient wearing right molded, rigid copolymer AFO and left molded, weight-bearing, bivalve, rigid AFO.</strong></a></p> <p><i>Ankle Foot Orthoses</i></p> <p>Although somewhat rare compared to the numbers of patients we have encountered requiring foot orthotic management, there are those arthritics with severe enough involvement to warrant a higher level orthosis. The typical picture requiring AFO management is pain, swelling, and decreased range of motion located in the ankle (talocrural) joint, with frequent moderate to severe pes planus and subtalar (talocalcaneal) erosion. Although rheumatoid arthritis patients dominate this type of patient population, it is not unusual for patients with osteoarthritis to present at this level. Again, severity of involvement dictates the complexity of the orthosis. We have used two types or designs of AFO's in our management of these kinds of problems: rigid, molded plastic AFO's and bivalved, weight bearing, rigid, molded plastic AFO's (also known as PTB AFO's or axial load resist AFO's.) The distinction between the two is quite simple. When pain in the ankle or subtalar joint is due to the forces of walking or movement, i.e. if the normal movements of the ankle-subtalar complex in the course of walking causes or increases pain, yet standing stationary is comfortable and pain-free, the only need is elimination of motion which can be provided by a rigid, molded AFO. When pain is experienced in both standing and ambulation, the goals are to redistribute weight-bearing loads by reducing the amount of weight to be borne through the diseased ankle-foot complex and to eliminate range of motion. These objectives can be met with a bivalved, weight-bearing, rigid, molded AFO.</p> <p>As standard AFO's are commonplace items in any orthotic practice, detailed discussion in this context serves no purpose. However, the need for rigidity should be emphasized. The lower vertical trimlines need to be anterior to the malleoli, and carbon composite inserts can be used if necessary.</p> <p>Our chosen design for bivalved, weight bearing, rigid, molded AFO's is that described by Wilson, Stills, and Pritham<a></a> with the addition of a higher posterior trimline in the popliteal area, similar to that in a below-knee prosthesis. The reduction in the range of knee flexion as a result of this higher posterior trim is a minor sacrifice for a major gain in reduction in pain. We purposely try to avoid the use of the term PTB orthosis because of its erroneous weight-bearing implications. The patella tendon is identified by mild modification of the positive model in this anatomical region, similar to but much less aggressive than in a so called "PTB" prothesis. However, there is little concentrated weight-bearing in this area; the goal of weight-bearing is equal distribution throughout the entire part of the lower leg contained within the orthosis. Perhaps the most accurate prosthetic acronym describing the weight-bearing goals of the bivalved, weight-bearing, rigid, molded AFO, is the "total surface bearing" concept. In the case of an intact lower limb as is encountered in orthotics, modification of the term "to maximum surface bearing" seems appropriate.</p> <p>None of our patients requiring rigid AFO's has required SACH (solid-ankle cushion-heel) and rocker sole shoe modifications. We do recommend the use of shoes with soft soles constructed of Vibram® or crepe.</p> <h3>Shoes for Arthritic Patients</h3> <p>Proper shoes are a vital component of orthotic management of the arthritic foot. As was stated earlier, some foot orthotic objectives can be attained with shoes of poor quality or integrity. However, properly designed and fitted shoes can only enhance the best designed and fabricated foot or ankle-foot orthoses.</p> <p>Our large arthritic patient population at the University of Virginia has allowed us to recommend and fit a wide variety of accommodative shoes. As we gained experience, it became apparent that we could rely on a minimum inventory of shoe types or designs. I refrain from the use of the descriptor "style" because there may be several "styles" available within a shoe design category. The categories of "design" that I refer to could be listed and described as follows:</p> <ol> <li> <p>Thermo adjustable shoes</p> </li> <li> <p>Extra depth shoes</p> </li> <li> <p>Running shoes.</p> </li> </ol> <p><i>Thermo Adjustable Shoes</i></p> <p><a href="http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-8.jpg"><strong>Figure 8. View of various shoes useful in the management of patients with arthritis affecting the feet and ankles.</strong></a></p> <p>This shoe type or design is made primarily of Dermaplast®, which is a heat shrinkable Plastizote®. Known as Apex Ambulators®, there are two styles available: #1201, the simplest and most accommodative, and #1273, a more cosmetic version of the first style.</p> <p>Style #1201 is of black Dermaplast™ with a thin outer fabric covering, crepe wedge soles, Velcro® lap closure (eases donning for those arthritics with hand involvement), and removable Plastizote® insole. There is no heel counter reinforcement. The indications for this type of shoe is last resort, severe deformities, especially in the dorsal aspect of the foot, that are difficult or impossible to accommodate in shoes of firmer and less adjustable materials. Examples of such deformities are severe hammer toes, severe hallux valgus, and/or nodules on the dorsum of the feet or toes. This shoe is fitted slightly large and then heated while on the patient's foot (with protection by socks, of course). The application of heat causes the Dermaplast® to shrink and mold to the patient's foot shape, thus accommodating the severe deformity. The shoe upper material of Plastizote® and fabric is very soft and forgiving to such deformities. In all cases, we replace the removable Plastizote® insoles with molded PVC-Pelite™ foot orthoses.</p> <p>The other style of Apex Ambulators® thermo adjustable shoes, #1273, is very similar to that described above. The major difference is the outer covering of the uppers, which in this second style is thin, pliable leather. This shoe is more cosmetically appealing to most patients because the leather uppers allow the choice of four colors, (the catalogue number varies with color variations). It has slightly more integrity than the #1201 style, including a moderately reinforced heel counter. It also has a removable tongue, which is secured in place with Velcro®, a feature that enhances its adjustability. It is available with either lace or Velcro® loop back closure. Accommodation of deformities can be accomplished either by heating and shrinking a loose fit as with the #1201's above or by fitting the shoes to the proper size and then stretching the uppers with shoe stretching tools over areas of deformity.</p> <p><i>Extra Depth Shoes</i></p> <p>Extra Depth® shoes are offered by several manufacturers and provide greater depth throughout the entire shoe. This depth is ideal for accommodating molded foot or ankle foot orthoses designed for arthritic foot deformities. Extra depth shoes, like molded AFO's, are a familiar item in any orthotic practice, and therefore do not necessitate detailed discussion. However, there are two important considerations regarding their application to arthritic patients: (1) the shoe style selected should be made of very soft leather, preferably calfskin or deerskin, as these leathers are most easily spot stretched to accommodate deformities, and are the most forgiving to areas of inflammation; (2) adequate width in the forefoot or toebox of the shoe cannot be overemphasized.</p> <p>The extra depth shoes that we recommend for our arthritic patients are manufactured and distributed by Alden Shoe Company and P.W. Minor. The designs and styles vary in leather utilized, closure (lace or Velcro®), and amount of heel counter reinforcement. All have soft crepe soles and uppers that can be modified for deformities with relative ease using shoe stretching tools and equipment.</p> <p><i>Running Shoes</i></p> <p>Running or jogging shoes should be familiar to orthotists and patients alike. Their application to patients with arthritic foot problems stem from three of their characteristics: (1) they are acceptable to many patients who do not accept the "lack of style" of other appropriate shoes; (2) most utilize separate, removable insoles, which when removed, allow adequate room for use of molded foot or ankle foot orthoses; and (3) most are very light in weight. Problems we have encountered with running shoes include seams in the dorsal aspect of the toe box, making spot stretching difficult or impossible, and construction of vinyl or other synthetic materials which also make stretching difficult or less successful.</p> <h3>Conclusion and Results</h3> <p>An experience based protocol for orthotic management of the arthritic foot has been described. This experience is based on over 300 arthritic patients who required orthotic management by our service since 1985. Seven patients have been fit with eight bivalve, weight-bearing rigid, molded AFO's (one bilateral). One of these seven patients benefitted from a rigid, molded AFO on his lesser involved lower extremity. The remaining patients have been managed with custom molded PVC Pelite™ foot orthoses. Many of the patients fit with PVC Pelite™ foot orthoses were successfully converted from direct molded Plastizote® shoe inserts. Through routine follow up and chart reviews, we have found less than a three percent rejection rate; more important, we have found more active patients who enjoy a better quality of life.</p> <h3>Appendix</h3> <p>Alden Shoe Company, Taunton Street, P.O. Box 617, Middleborough, Massachusetts 02346.</p> <p>Apex Ambulators, Apex Foot Products, 330 Phillips Avenue, S. Hackensack, New Jersey 07606.</p> <p>PPT, The Langer Biomechanics Group, 21 East Industry Court, Deer Park, New York 11729.</p> <p>PVC Pelite™, Durr-Fillauer Medical, Inc., Orthopedic Division, P.O. Box 5189, Chattanooga, Tennessee 37406.</p> <p>P.W. Minor Extra Depth Shoe Co., 3 Treadeasy Avenue, Batavia, New York 14020.</p> <p><b>References:</b></p> <ol> <li>Carlson, J. Martin, and Gene Berglund, "An Effective Orthotic Design for Controlling the Unstable Subtalar Joint," <i>Orthotics and Prosthetics</i>, 33:1, March, 1979, pp. 39-49.</li> <li>Guerra, J. and D. Resnick, "Arthridities Affecting the Foot and Ankle-Pathology and Treatment. The Relationship Between Foot and Ankle Deformity and Disease Duration in Fifty Patients," <i>Foot and Ankle</i>, 2:6, 1982, pp. 325-331.</li> <li>Portwood, Margaret M., "The Foot and Ankle in Rheumatic Disorders," <i>Principles of Physical Medicine and Rehabilitation in the Musculoskeletal Diseases</i>, Grune and Stratton, 1986, Chapter 19, pp. 489-513.</li> <li>Short, C.L., W. Bauer, W.E. Reynolds, <i>In Rheumatic Arthritis</i>, Harvard University Press, Cambridge, 1957, pp. 194-195.</li> <li>Tillman, K., <i>The Rheumatic Foot: Diagnosis</i>, Pathomechanics, and Treatment, Stuttgart, Georg Thieme Publishers, Boston, PSG Publishing Co., 1979, pp. 3-61.</li> <li>Vaino, K., "The Rheumatoid Foot: A Clinical Study With Pathologic and Roentgenological Comments," <i>Ann. Chir. Gynaecol. 45 (Suppl)</i>, 1956, pp. 1-107.</li> <li>Wilson, A. Bennett, Jr., David Condie, Charles Pritham, and Melvin Stills, <i>Lower-Limb Orthotics, A Manual</i>, First Edition, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Temple University, Drexel University.</li> </ol> <em><b>*C. Michael Schuch, C.P.O. </b> C. Michael Schuch, C.P.O., is an Assistant Professor in Orthopaedics and Rehabilitation and Associate Director of Prosthetics, Orthotics, and Rehabilitation Engineering Services at the University of Virginia Medical Center, Box 467, Charlottesville, Virginia 22908.<br /><br /><br /></em> Page Number(s) 51 - 60 Year 1988 Volume 12 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-7.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_02_051/1988_02_051-8.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 Orthotic Management of the Arthritic Foot Creator An entity primarily responsible for making the resource C. Michael Schuch, C.P.O. * https://staging.drfop.org/files/original/f19a203dc83608d15f834f83cded733e.pdf 6d2e37d1ab4e9eb40057c0b1eda9787a https://staging.drfop.org/files/original/626bec40f3c1712a163754c6407d8b7f.jpg 0889da54c981b532c0f7f9fca7ab7393 https://staging.drfop.org/files/original/4d23e4efd15dbd56d0d3c0d64d42a12c.jpg 235bf482c5bbd2d6df9a57a8e062d9f8 https://staging.drfop.org/files/original/84c1981f28fb0bd2b78a57f08cd3370e.jpg 29185ddb7cfae11354a16dd183354883 https://staging.drfop.org/files/original/be68f5014bf3e41306651775bb6aaa72.jpg 8728c5cf6a697fb1e11581b23e406435 https://staging.drfop.org/files/original/d47a2e29fc5ef0a8ed843d1a7dda7878.jpg db1eff3b83d2b60637bad4ef7307fada https://staging.drfop.org/files/original/5acc660a9991a044a33f6cdb80803607.jpg 3728771041c94d3d1d9b937fd099d600 https://staging.drfop.org/files/original/1f702da7b89a464c498010a1abcc516c.jpg 3dfc6a240ebdc1b4f044c9d2a70f29fc https://staging.drfop.org/files/original/350e92414c3f250e585c0c410483f05f.jpg e5cc9412d004ff923fa9cfe0116c8d67 https://staging.drfop.org/files/original/e0c8a2a383af1b8f73d88ad5a6e19878.jpg d135ed31bad70f44ed05da85fa80e938 https://staging.drfop.org/files/original/3d5ad29d6d20a80babbcb352572dc9c3.jpg 3dd7c369b1d5402e8bec9a1a13200601 https://staging.drfop.org/files/original/23e38cbe718dfe3bb7d85f6ed388efd9.jpg cfcb75970fefc5d722cd18ebb13f14af https://staging.drfop.org/files/original/83d73db1e1c4c310e0f458551ea5dbe8.jpg 41dc790f623b91b39085ce3145a0c1c4 https://staging.drfop.org/files/original/cbdfe4b7b4f81d816508d5add65aa3ed.jpg 6bd1b183c2bb185fdd17b2df9045e440 https://staging.drfop.org/files/original/0f06eae8e85a93d7810db6e5d53ec00d.jpg c2853522e2b04d169b43a87fb15b85e2 https://staging.drfop.org/files/original/a974bfac3181ff32c7452e179378f236.jpg 75455b1a6dc267f36a971693a75beeba Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_081.pdf Text Any textual data included in the document <h2>Report From: International Workshop on Above-Knee Fitting and Alignment Techniques</h2> <h5>C. Michael Schuch, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>An "International Workshop on Above-Knee Fitting and Alignment Techniques" was held in Miami, Florida, May 15-19, 1987. Conceived and organized by A. Bennett Wilson, Jr. and Melvin L. Stills, CO., the workshop was supported and sponsored jointly by the International Society for Prosthetics and Orthotics and the Rehabilitation Research and Development Service of the Veteran's Administration. Hosting the workshop was the Prosthetics and Orthotics Education Program of the School of Health Sciences, Florida International University, and more specifically, Dr. Reba Anderson, Dean of Health Sciences and Ron Spiers, Director of Prosthetic Orthotic Education. Approximately 50 invited professionals attended the workshop, representing the United States, England, Scotland, Denmark, Sweden, Israel, the Netherlands, and Germany. Invited professionals included physicians, engineers, educators, and researchers, as well as prosthetic practitioners, all known to be active in the field of prosthetics.</p> <p>The intent of the workshop was an organized sharing and discussion of information and experiences relative to the management of above-knee amputees. Above-knee socket design variables, specifically the accepted and established quadrilateral design and the newer ischial-con-tainment designs known by various acronyms (CAT-CAM, NSNA, Narrow M-L), were discussed in great detail. Goals were to determine differences/similarities, advantages/disadvan-tages, indications/contraindications, as well as to develop recommendations for future action with respect to the various socket designs. While many prosthetists and/or clinics may have considerable experience with the newer above-knee socket designs within the United States, it is true that there are still many questions and concerns on the part of consumers, prescribing physicians, third party paying agencies, and educators in the U.S., as well as a great curiosity on the part of our international colleagues abroad.</p> <p>After introductory remarks from Dr. Anderson, Dean of Health Sciences at Florida International University, Mr. John Hughes, President of ISPO, and Dr. Margaret Gianninni, Director of the Rehabilitation Research and Development Service of the Veteran's Administration, the program began with a presentation by A. Bennett Wilson entitled, "Recent Brief History of AK Fitting and Alignment Techniques." This paper began with the advent of the suction socket in the U.S. shortly after World War II and proceeded with the development of the total contact quadrilateral socket in the early 1960's. The audience was reminded that the total-contact quadrilateral socket, with or without suction suspension, was the socket design of choice from 1964 until very recently, when ischial-containment socket designs emerged. It was noted that, at present, the three senior prosthetic education programs in the U.S. (UCLA, Northwestern University, and New York University), in addition to teaching the application of the standard total contact quadrilateral socket, are offering special courses in what at first glance appear to be radical departures from the quadrilateral design. The technique at UCLA is known as CAT-CAM (Contoured Adducted Trochanteric-Con-trolled Alignment Method), based on work by John Sabolich, C.P.O., and inspired by Ivan A. Long, CP. The technique being presented at Northwestern University is said to be based more directly on the Ivan Long technique and is known as NSNA (Normal Shape-Normal Alignment). The technique taught at New York University is usually referred to as the narrow ML socket design based on a special tool designed by Daniel Shamp to facilitate casting. Mr. Wilson concluded his remarks by saying "unfortunately, none of these techniques has been subjected to an evaluation program independent of the development group, and a great deal of confusion exists among clinicians responsible for amputee care. I hope that this workshop can be helpful in clearing away some of the confusion, and point the way for action that will bring order to the present day practice of above-knee prosthetics."</p> <p>The next speaker on the agenda was Charles Radcliffe, Professor of Mechanical Engineering at the University of California, Berkeley. Professor Radcliff's presentation was entitled, "Review of UCB Quadrilateral Socket and Alignment Theory." Having been a member of the Prosthetic Devices Research Project of UC Berkeley in the 50's and 60's, Professor Rad-cliff is still a strong proponent of the quadrilateral socket. He presented a detailed review of the history and development of the quadrilateral socket and summarized this section of his presentation with the following comments. "The net result of all of this work in the 1950-1963 period was a better understanding of the complex interrelationships between the functional capability of the amputee, the rehabilitation goals, the prosthetic components required in the prescription, the gait of the amputee, the biomechanical forces generated, the socket shape, and the alignment. The socket was no longer described as a cross-section shape at the ischial level, but rather a three-dimensional receptacle for the stump with contours at every level which could be justified on a sound biomechanical basis. ... It should be emphasized again that the quadrilateral type of fitting is not just a socket, it is a complete system which includes the amputee as a most important component. The socket is the interface between stump and prosthesis, and its primary functions are to provide for weight-bearing in the stance phase, allow the use of the stump and hip musculature to control motion and posture of the upper body in the stance phase (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-01.jpg"><b>Fig. 1</b></a>), and to provide for control of the prosthesis in the swing phase of walking."</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-01.jpg"><strong>Figure 1. Biomechanical forces diagram, Above-knee amputee weight-bearing in the stance phase.</strong></a><br /> <p>The next section of Professor Radcliffe's presentation focused on biomechanical and alignment principles of a prosthesis with a quadrilateral socket. Here he related his feelings that many of the biomechanically related claims made by proponents of the newer non-quadrilateral socket designs are equally attainable in the quadrilateral socket if the original biomechanical principles are followed. "Regardless of the fitting method employed, the socket for any patient must provide the same overall functional characteristics, including comfortable weight-bearing, a narrow base gait, and as normal a swing phase as possible consistent with the residual function available to the amputee after amputation. It is possible to provide this with a quadrilateral socket and it is being done routinely in many facilities." Professor Radcliffe went on to say, "In most of the recent articles that I have read, statements have been made which indicate clearly that the author is comparing very poorly fitted quadrilateral sockets to the results obtained using the new technique. They show diagrams of typical fittings and gait deviations which can only be described as a complete list of horror stories describing what not to do in fitting a quadrilateral socket. Any prosthesis with the problems listed in these articles should never have been delivered. If the average pros-thetist in the United States is having the problems described by Long, Shamp, and Sabolich, then I must suggest that something is wrong with the methods being taught and used in daily practice. I am aware that the schools have made significant changes in the way that the principles are taught, with each school emphasizing different aspects of the problem. I suspect that there may have been a shift away from the fundamentals of teaching of overall objectives, including the interrelationships of amputee evaluation, components prescribed, biomechanics, and why sockets are fitted with particular contours."</p> <p>Following Professor Radcliffe was Tim Staats, Director of the UCLA Prosthetics Education Program. Mr. Staats' presentation was on the "UCLA CAT-CAM." UCLA began teaching CAT-CAM above-knee prosthetics with a pilot course in March 1985, which included both John Sabolich and Tom Guth as course instructors. Mr. Staats made it clear that the UCLA CAT-CAM philosophy of 1987 has departed from that of Sabolich, Guth, et al. and that the UCLA philosophy has now evolved to the point where a third edition of a teaching manual was published in March, 1987. To quote Mr. Staats as he spoke about this new manual, "the third edition of the UCLA CAT-CAM Above-Knee Prosthesis teaching manual integrates much additional material, covering the anatomy/socket relationship and how this is best achieved—material not yet fully understood and synthesized at the time of preparation of the previous edition. The UCLA CAT-CAM above-knee socket is a variation of the CAT-CAM design developed by John Sabolich, C.P.O., and Tom Guth, CP., and the NSNA AK prosthesis of Ivan Long, CP. Through countless hours of literature search, discussion, and intensive training given in this and nine foreign countries, and through the results of over 200 students who have fabricated and fit over 1,000 sockets under the guidance of our staff, a new insight has been developed. Our staff has refined the techniques of measurement, casting, and model modification to the point where it is a clearly teachable and viable above-knee fitting method. It is with great respect that we continue to recognize the published contributions of John Sabolich, C.P.O., Tom Guth, CP., and Ivan Long, CP., to the development and evolution of the UCLA technique. We would hope that this manual captures, blends, and enhances their philosophies. We recognize that our technique and CAT-CAM evolved from NSNA and we hope that these professionals can appreciate our efforts to refine and further evolve their clinical approach into a methodical step-by-step teaching manual."</p> <p>At this point I will briefly review the highlights of the UCLA CAT-CAM sequence, beginning with patient evaluation and measurement and proceeding through model modification and bench alignment. For the details, I suggest referencing the third edition of the UCLA manual.</p> <p>The recommended evaluation/measurement protocol is very complete and detailed, covering many of the procedures with which we should all be familiar. Adduction and flexion analysis of the residual limb are emphasized. Some new measurements and/or evaluations are introduced and illustrated:</p> <ul> <li> <p>Skeletal ML dimension, actually measured on patient (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg"><b>Fig. 2</b></a>)</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg"><strong>Figure 2. UCLA CAT-CAM medial-lateral diameter measurements.</strong></a></li> <li> <p>Soft tissue ML dimension, taken from Ivan Long's chart of circumferences and related ML values (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg"><b>Fig. 2</b></a>)</p> </li> <li> <p>Ilio-femoral angle, actually measured on the patient (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-03.jpg"><b>Fig. 3</b></a>)</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-03.jpg"><strong>Figure 3. Ilio-femoral angle, as measured for UCLA CAT-CAM.</strong></a></li> <li> <p>Public arch angle, evaluated by palpation and captured in the wrap cast (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-04.jpg"><b>Fig. 4</b></a>)</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-04.jpg"><strong>Figure 4. The pubic arch angle, as evaluated for UCLA CAT-CAM.</strong></a></li> <li> <p>Ischial inclination, evaluated by palpation and captured in the wrap cast (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-05.jpg"><b>Fig. 5</b></a>)</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-05.jpg"><strong>Figure 5. The ischial inclination angle, as evaluated for UCLA CAT-CAM.</strong></a></li> </ul> <p>The wrap cast is taken with the patient in a standing position, and all shaping of the cast is accomplished by hand molding. The goal is good definition and containment of the medial and posterior aspects of the ischial tuberosity and ischial ramus within the wrap cast and subsequent socket, as well as allowance for the pubic ramus to exit the socket near the midline of the medial wall (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-06.jpg"><b>Fig. 6</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-06.jpg"><strong>Figure 6. Medial view of pelvis-socket relationship, UCLA CAT-CAM.</strong></a><br /> <p>The initial trimlines for the resultant socket are as follows:</p> <ol> <li> <p>Anteriorly, just proximal to the inguinal crease. The anterolateral brim must clear the superior iliac spine when the patient is sitting.</p> </li> <li> <p>Laterally, the brim extends approximately 3" above the trochanter. The final height of this wall will be determined during fitting.</p> </li> <li> <p>Posteriorly, the trim line should begin at least 1" above the level of the inferior border of the ischial tuberosity. The curve that defines the posterior to lateral trim line normally begins at a point between the lateral third and the midline of the socket ML dimension at ischial level.</p> </li> <li> <p>The medial proximal brim will be "V" shaped, with the vortex of the "V" located at the point where the pubic ramus crosses the medial wall. This trim line projects upward from the vortex, posteriorly to encapsulate the medial aspect of the ischial ramus and tuberosity. (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-06.jpg"><b>Fig. 6</b></a>) A circumference reduction chart is used to attain suction suspension. The values used in this chart are slightly less than those normally used in quadrilateral suction sockets.</p> </li> </ol> <p>For bench alignment, the following references are used:</p> <ol> <li> <p>Posteriorly, bisect the socket at the level of the soft tissue ML, this reference line should fall as a plumb line to the center of the heel.</p> </li> <li> <p>Laterally, bisect the socket AP dimension at ischial level, this reference line should fall as a plumb line between 0" and 1" anterior to the foot bolt.</p> </li> <li> <p>Socket is set in measured adduction, and measured flexion plus 5°.</p> </li> <li> <p>The distal aspect of the medial wall should be on the line of progression.</p> </li> <li> <p>The knee bolt is externally rotated 5°.</p> </li> <li> <p>The top of the foot, as well as the prosthetic shank should lean medially 4°, or alternatively, the socket is hyper-ad-ducted 4° beyond measured adduction with the foot parallel to the floor and the shank perpendicular to the floor.</p> </li> </ol> <p>The UCLA CAT-CAM can be fabricated using rigid socket or flexible socket techniques. If a flexible socket or brim system is desired, the proximal medial trimline in the ischial area must be more aggressive during casting to allow for the linear shrinkage factor known in most thermoplastics.</p> <p>A final comment: the manual reflects the accumulated experience of the UCLA staff and includes a section on problem solving the difficulties that might be experienced in the CAT-CAM socket.</p> <p>Next to speak was Gunther Gehl, CP., Director of Prosthetic Education at Northwestern University in Chicago. Northwestern has been teaching the NSNA AK techniques of Ivan Long for several years now, and it was Mr. Gehl's task to report to the workshop on NSNA and Long's Line. He said that he and his staff taught NSNA as presented by Ivan Long with no changes. Ivan has been fitting Long's Line, now known as NSNA, for more than 12 years, and his approach has been consistent, with few changes. Perhaps changing the name from Long's Line to NSNA in July, 1985 is the most significant change. Mr. Long has published three technical papers describing his technique: "Allowing Normal Adduction of the Femur in Above Knee Amputees," (<i>Orthotics and Prosthetics</i>, December, 1975); "Fabricating the Long's Line Above Knee Prosthesis," (1981); and as a reprint of the Long's Line article with new title, "Normal Shape-Normal Alignment (NSNA) Above Knee Prosthesis," (<i>Clinical Prosthetics and Orthotics</i>, Fall, 1985). These articles were the basis for Gunther Gehl's presentation to the International Workshop.</p> <p>I will attempt to review and highlight the NSNA philosophy as I did the UCLA CAT-CAM. Again, within the limitations of this report, this will only be an overview. With the widespread availability of Ivan's publications, it does not seem necessary to go into details.</p> <p>NSNA is less detailed regarding evaluation and measurements, placing great emphasis on the wrap cast, subsequent model modification, and alignment, all based on Long's Line, which is defined as a straight line, starting approximately at the center of a narrow socket, passing through the distal femur, and on down to the center of the heel (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-07.jpg"><b>Fig. 7</b></a>). Long's Line is not always vertical because it shifts constantly when the amputee goes from a standing position to a walking position.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-07.jpg"><strong>Figure 7. Long's Line.</strong></a><br /> <p>The wrap cast is taken with the patient in a standing position. The important points about the wrap cast procedure are identification of the ischium and proper alignment. The hand will be held to indicate the medial and posterior surface of the ischium, but not forward of the ischium. The amputee then adducts as tightly as possible and extends his thigh to tighten the hamstrings. At this point a lateral reference line is established.</p> <p>The resultant cast model is oversized and will require considerable modification. Practically all modification will take place on the lateral wall. Following is a brief description of modification goals and resultant trimlines, taken from Mr. Gehl's presentation and from Mr. Long's publications.</p> <ol> <li> <p>The lateral wall is to be shaped to give support over a wide area, and particularly the lateral-posterior aspect of the socket.</p> </li> <li> <p>The medial wall will be lower than seat level, and the wrap cast will be the guideline as to how low.</p> </li> <li> <p>Depth of the socket will be the same as the measured length of the thigh.</p> </li> <li> <p>The seat will be at a right angle to Long's Line.</p> </li> <li> <p>Long's Line is drawn from the center of the seat level ML to the center of the distal femur. The distal femur will be very close to the lateral surface, probably only covered by skin.</p> </li> <li> <p>The top 1" of the medial wall will flare outward at 45°.</p> </li> <li> <p>The lateral wall extends above the trochanter.</p> </li> <li> <p>The ischium will bear on the flare of the socket, both medially and posteriorly.</p> </li> <li> <p>The cast is taken down in the ML as though the trochanter does not exist. In order to achieve the desired ML, many casts will be reduced 2" or more. The desired ML dimension is taken from Ivan's chart of ML values related to the thigh circumference just below the ischium (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-08.jpg"><b>Fig. 8</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-08.jpg"><strong>Figure 8. Table of M-L values determined from circumference just below ischium, used in NSNA.</strong></a></li> </ol> <p>Circumference reductions for suction suspension begin at 1" of tension proximally, reducing to 3/4", then 1/2", with the remaining tensions at 1/4".</p> <p>Mr. Long does not advocate use of an alignment device. Bench alignment is critical and is based on Long's Line. The center of the lateral wall is marked at seat level for TKA and the vertical reference line established during casting should parallel the TKA line. Long's Line is marked on the posterior of the socket. For the male, the socket is mounted with the inner aspect of the medial wall (which follows the pubic ramus angle) in 30° internal rotation to the line of progression (the outer edge of the medial trimline is on the line of progression), and with the knee bolt axis 4° higher on the lateral side. This is the same as adding 4° additional adduction to Long's Line. For the female, the socket is mounted with the inner aspect of the medial wall in 40-45° internal rotation to the line of progression (again, the outer edge of the medial trimline is on the line of progression), and with the knee bolt axis 7° higher on the lateral side (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-09.jpg"><b>Fig. 9</b></a>). Mr. Long emphasizes that it is not necessary to change the alignment. When the amputee is allowed time to adjust to the new prosthesis, then alignment changes will not be necessary.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-09.jpg"><strong>Figure 9. NSNA socket shape and alignment diagram, male and female.</strong></a><br /> <p>Following Gunther Gehl was Daniel Shamp, C.P.O., presenting, "The Shamp Brim, For the Narrow ML Above-Knee Prosthetic Socket." Mr. Shamp's system of brim casting and evaluation is currently the content of a special short course offered by New York University's Prosthetic and Orthotic Education Program.</p> <p>Long and Sabolich, as well as UCLA, advocate that the hand casting technique is the most successful in their experience with the narrow ML, wide AP, or ischial-containment socket for above-knee amputees. In response, Mr. Shamp stated, "Experience with the Shamp Brim system has proven to make the procedure more uniformly successful and more easily learned and applied by the practitioner who has spent years working with the brim method for quadrilateral socket casting and modification." Mr. Shamp went on to present detailed biomechanical rationale for the narrow ML socket. Biomechanical descriptions such as bony lock on the ischium, ischial containment within the socket, retention of normal adduction, etc., are consistently relevant to Mr. Shamp's socket system, as well as all of the latest ischial-containment socket designs. Two noticeably different aspects of Mr. Shamp's technique are (1) the brim forming system itself, which allows for evaluation of brim design under weight bearing conditions before proceeding with the wrap cast, and (2) what Mr. Shamp refers to as centralization of the femur. To accomplish centralization of the femur, during the casting procedure, the prosthetist pulls the distal medial tissue in a lateral direction while stabilizing the femur with the other hand by means of a 45° force against the lateral shaft of the femur (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-10.jpg"><b>Fig. 10</b></a>). Mr. Shamp stated that this centralization procedure is essential to prevent a large medial-distal bulge with resultant cosmetic problems when the femur is maintained in a position of maximum adduction in the AK prosthesis.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-10.jpg"><strong>Figure 10. Centralization of the femur, as proposed by Dan Shamp for Narrow ML Socket.</strong></a><br /> <p>Again, I will present an overview of the Shamp Narrow ML technique, summarizing from Mr. Shamp's presentation and from the "Manual for use of The Shamp Brim," which was provided for the workshop attendees. This manual was produced by Prosthetic Consultants, Incorporated of Akron, Ohio in cooperation with the Department of Prosthetics and Orthotics, New York University Post-Graduate Medical School, and is published by the Ohio Willow Wood Company.</p> <p>The measurement and evaluation procedure includes a careful observation and recording of the characteristics, lengths, and circumferences requested on the Narrow ML AK Information Chart. Review of this information chart will show the practitioner who is familiar with the technique for the quadrilateral socket that only a small number of measurements are different for the Narrow ML socket. It is important to note that three ML measurements must be taken precisely as follows:</p> <ol> <li> <p>Distal Ischial Tuberosity (DIT): firm ML measurement of the anatomy taken 1" to 2" distal to the ischial tuberosity (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-11.jpg"><b>Fig. 11</b></a>).</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-11.jpg">Figure 11. Distal Ischial Tuberosity (DIT), medial-lateral diameter measurement for Narrow ML Socket</a>.</strong></li> <li> <p>Oblique ML (OB): firm ML measurement taken from the medial side of the ramus of the tuberosity to a point just superior to the greater trochanter of the femur (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-12.jpg"><b>Fig. 12</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-12.jpg"><strong>Figure 12. Oblique ML (OB), medial-lateral diameter measurement for Narrow ML Socket.</strong></a></li> <li> <p>Ischial Tuberosity ML (IT): firm ML measurement taken from the medial border of the ramus of the ischial tuberosity to the subtrochanteric area of the femur (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-13.jpg"><b>Fig. 13</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-13.jpg"><strong>Figure 13. Ischial Tuberosity ML (IT), medial-lateral diameter measurement for Narrow ML Socket.</strong></a></li> </ol> <p>The Shamp Brim, which is compatible with the Berkley brim stand, is now set up and adjusted to the patient's measurements. As stated earlier, the brim allows for weight-bearing evaluation of the patient with regard to socket design before the actual wrap cast is taken.</p> <p>As with all of the ischial-containment socket designs discussed at the Workshop, the location of the ischial tuberosity in the socket is essential to both a comfortable fit and a stable femur in maximum adduction. For the Shamp technique, the ideal location is 1/2" inside the medial-proximal wall of the prosthesis and indicates the area referred to as the IT ML measurement. The medial wall has a 45° angle that assists the wedge effect in stabilizing the femur and so the location of the tuberosity on this slope is important. The trimlines are similar to both NSNA and the UCLA CAT-CAM, including the low anterior wall with clearance for the ASIS, the relatively horizontal posterior wall, and the high lateral wall, which extends generously above the trochanter. Although, not as exaggerated as the UCLA CAT-CAM, the medial wall is lowered as it approaches the anterior wall, allowing for the pubic ramus to pass from within the socket.</p> <p>Alignment follows generally accepted quadrilateral alignment principles for TKA and knee bolt external rotation. For alignment in the frontal plane (posterior view, ML plane), Mr. Shamp advocates the principles of Long's Line.</p> <p>Dr. Hans Lehneis, C.P.O., of the Rusk Institute of Rehabilitation Medicine was the next speaker and his presentation covered work done at the Rusk Institute and the New York Veterans Administration. Dr. Lehneis and associates are investigating anatomical, physiological, and biomechanical characteristics of geriatric above-knee amputees in an attempt to develop a set of design criteria for geriatric above-knee sockets. As this project is still in the developmental stages, I will not elaborate on this subject.</p> <p>Following Dr. Lehneis was Ossür Kris-tinsson of Iceland. As the developer of the flexible socket-rigid frame system, he was the first to speak on flexible sockets. Mr. Kris-tinsson reported that he was continuing development of flexible sockets, including walls and brims. He is conducting an extensive materials search in hopes of finding the materials that will make possible the ultimate flexible socket design.</p> <p>Mr. Kristinsson went on to say that we need some simple definition of flexible socket characteristics. "To label a socket as flexible, I would say that you should be able to deform it by your hands, and the material should not be elastic enough to stretch under the loads it will be subjected to." Concerning flexible socket design, Mr. Kristinsson stated, "When designing a flexible socket system, the most critical aspect for the comfort of the wearer is how the frame is designed. It has to be capable of supporting the flexible socket, preventing permanent deformation, and the socket-frame combination has to be structurally strong and stable enough to counteract the reaction forces." Mr. Kristinsson made a final, important point: "There may be doubt among professionals and users about the value of the flexible wall. I am, however, totally convinced that the flexible socket is here to stay. If anything, I think it will get more flexible as we gain access to more suitable materials than we are using today, and some obstacles on the way to proper understanding of the socket-stump interaction are overcome."</p> <p>Continuing the flexible socket presentations was Norman Berger of New York University's Prosthetic Orthotic Program. Mr. Berger's presentation was the ISNY (Icelandic-Swedish-New York) flexible socket design as taught by NYU. Mr. Berger described the socket and frame fabrication technique used in the ISNY. Three interesting points are worthy of mention:</p> <ol> <li> <p>The flexible socket is fabricated with polyethylene, which has a known shrinkage factor.</p> </li> <li> <p>The desired wall thickness of the flexible socket is 60/1000".</p> </li> <li> <p>Lateral distal support for the femur is not provided for by the frame.</p> </li> </ol> <p>The final presentor on the topic of flexible sockets was Charles Pritham, C.P.O. of Durr Fillauer Medical Company. A co-author and co-developer of Durr-Fillauer's flexible socket technique, Mr. Pritham described the biomechanical function of the flexible walled ischial-gluteal bearing quadrilateral socket as follows:</p> <ol> <li> <p>Ischial/gluteal weight bearing;</p> </li> <li> <p>Stabilization of the distal femur laterally;</p> </li> <li> <p>Total contact; and</p> </li> <li> <p>Flexible walls.</p> </li> </ol> <p>Note the mention of stabilization of the distal femur laterally; this is provided for by the frame design of the Scandinavian Flexible Socket. Mr. Pritham went on to say, "It will be appreciated that the design is actually not fundamentally different, flexible walls aside, from a similarly designed socket in the rigid walls. Indeed one of the factors that undoubtedly hastened its acceptance was the fact that previously learned methods of casting and fitting quadrilateral sockets were fully acceptable when fitting a flexible walled socket. While the advantages cited are formulated with the quadrilateral socket in mind, there is no reason to suspect that they are significantly different from non-quadrilateral above-knee sockets. Indeed, flexibility is often considered by the designers of one another of the various designs as an integral factor in their success."</p> <p>Mr. Pritham listed advantages of flexible walled sockets as:</p> <ol> <li> <p>Flexible walls;</p> </li> <li> <p>Improved proprioception;</p> </li> <li> <p>Conventional fitting techniques;</p> </li> <li> <p>Minor volume changes readily accommodated;</p> </li> <li> <p>Temperature reduction; and</p> </li> <li> <p>Enhanced suspension.</p> </li> </ol> <p>Indications for use of the flexible wall socket are:</p> <ol> <li> <p>Mature stumps (where frequent socket changes are not anticipated);</p> </li> <li> <p>Medium to long stump (where a significant portion of the wall will be left exposed and flexible); and</p> </li> <li> <p>Suspension is not a factor.</p> </li> </ol> <p>While the use of flexible wall sockets has been well accepted, Mr. Pritham pointed out that questions have arisen in at least three areas.</p> <p><i>Material</i></p> <p>Both Surlyn® and low density polyethylene (in a variety of types and name brands) have been used successfully and each has its advocates. Mr. Pritham and colleagues at Durr Fillauer prefer Surlyn® for three reasons: clarity, no shrinkage, and ease of rolling the edge.</p> <p><i>Thickness</i></p> <p>Originally socket walls of 30/1000" thickness were specified, however, this proved to lack durability. Subsequently, thickness in the neighborhood of 80-90/1000" were specified and are preferred. (Note: NYU prefers 60/1000".)</p> <p><i>Frame configuration</i></p> <p>At least three different configurations have been described for quadrilateral sockets. The differences center on the lateral wall and the amount of support considered necessary for the femur.</p> <p>A variety of designs have been put forth in order to achieve specific features in non-quadrilateral sockets, including the well known total flexible brim.</p> <p>Mr. Pritham concluded his presentation by saying, "the crucial point would seem to be that flexibility is independent of socket shape and can be modified to provide specific design features in a socket-frame system. The specific configuration depends upon the prosthetist's experience and fitting philosophy and the needs of the individual patient."</p> <p>Rounding out the first day of presentations was Dr. Robin Redhead, Senior Medical Officer at the Roehampton Limb Fitting Centre in London. Dr. Redhead's paper was entitled "Experience With Total Surface Bearing Sockets." This presentation centered more on weight-bearing distribution and biomechanics than on socket design or shapes. Dr. Redhead and associates maintain that regardless of socket shape or design, well distributed weight-bearing can eliminate the need for single point, bony weight bearing (such as ischial weight-bearing). This system of well distributed weight-bearing was referred to as a total-surface-bearing socket. It infers a hydrostatic type of socket fit utilizing the incom-pressibility of the fluids in an above-knee residual limb.</p> <p>This presentation brought a reaction from of Professor Radcliffe, who doesn't agree with the hydrostatic concept of weight-bearing in prosthetics. He stated that "you need a closed system for hydrostatics and the AK residual limb is not a closed fluid system. With an open fluid system, the fluids are pushed out."</p> <p>There was considerable discussion on this topic, both pro and con, and it was never resolved.</p> <p>Beginning the morning of the second day, John Sabolich, C.P.O., from Oklahoma City, and Glenn Hutnick, CP., from New York, presented another view of CAT-CAM. As stated earlier, Tim Staats, C.P.O. reported that the UCLA CAT-CAM is evolving independently of the CAT-CAM technique of the original developers.</p> <p>Sabolich and Hutnick report that the original CAT-CAM is continuing to evolve and develop. Sabolich stated that, "it took five to six years to develop the current medial wall design, which has become increasingly more aggressive in enclosing and capturing the ischial ramus." They advocate use of the total flexible brim. "The key is the flexible brim system—it is totally flexible in the proximal area, where most patients complain." Aside from 100% use of the total flexible brim, the Sabolich/Guth CAT-CAM differs from NSNA and the UCLA CAT-CAM by not advocating the 4° to 7° medial lean of the foot, pylon, and knee bolt in bench alignment as proposed by Long and UCLA. John Sabolich went on to say "this additional adduction or tilting of the knee bolt is a cover-up for lost stability due to inadequate ischial containment." Mr. Long's response was that this was incorrect. Probably the most noticeable aspect of design that separates the Sabolich/Guth CAT-CAM apart from the other recent ischial-containment designs is the earlier mentioned aggressive capture of the ischial tuberosity and ramus. Sabolich claimed that they are enclosing more and more of the ischial ramus, as much as possible and still allow pubic ramus comfort. This ramus enclosure provides two biomechanical functions: (1) a medial bony stop for ML stability, and (2) rotational control, especially on soft fleshy residual limbs. Other than these departures, the Sabolich/Guth CAT-CAM differs very little from the UCLA CAT-CAM, especially in terms of brim shape, trimlines, and biomechanics. Sabolich, unlike Long, does advocate the use of dynamic alignment devices.</p> <p>At this point in the Workshop, Professor Radcliffe returned to the podium in an attempt to present and clarify the comparative biomechanical principles of both quadrilateral and ischial-containment sockets. The following biomechanical analyses are taken from Professor Radcliffe's discussion and from the paper he later submitted reviewing his presentations.</p> <p>"It has been demonstrated that pressure against the medial aspect of the pubic ramus can be used to supplement the weight-bearing on the tuberosity of the ischium and contribute to medial stabilization in the upper one-third of the above-knee socket. In taking advantage of the weight-bearing potential on the medial aspect of the ramus, the prosthetist is creating a situation much like weight-bearing on the seat of a racing bicycle. To prevent the ramus from sliding laterally and downward into the socket, the prosthetist must exaggerate the counterpres-sure from the lateral side. This has been done by a reduction in the M-L dimension particularly in the area just distal to the head of the trochanter. The soft tissue must be accommodated. Therefore, the A-P dimension is correspondingly increased as compared to the quadrilateral socket. As compared to the quadrilateral fitting, the height of the anterior brim is typically lowered and flared and the gluteal area is filled in and fitted higher as a result of the ischium being encased deeper into the socket."</p> <p>"The medial brim of the socket must slope forward and downward to the point where the pubic ramus crosses the medial brim and emerges from the socket. The ischial ramus clearly is capable of providing medial counter-pressure which supplements the medial pressure on the adductor musculature. Since the socket slopes downward and inward along the entire medial brim, this contour is flared into the medial wall of the socket, which gives the impression of exaggeration of the medial coun-terpressure in the upper one-third of the socket."</p> <p>"The adduction of the socket and the use of lateral stabilization should not differ from that achieved by a properly fitted quadrilateral socket. There is an apparent exaggeration of the modification of the lateral wall, but this is primarily limited to the area just below the trochanter where the M-L dimension has been reduced to insure that the encased pubic ramus and ischium are maintained in the desired position on the medial brim. The exaggeration of the medial flare and reduction of the M-L dimension in the upper third of the socket leads to the impression of a greater angle of femur adduction, but the actual angle of the femur should be similar in both types of fittings if the quadrilateral socket is properly fitted and aligned."</p> <p>"Long's Line as proposed by Ivan Long is the anatomical axis of the lower extremity as described in anatomy textbooks. Placing the fe-mural stump in an advantageous position for normal use of the hip musculature by adduction and flexion of the socket has been a part of good prosthetic practice for at least 40 years in the United States and perhaps longer in certain European centers. Mr. Long's Line appears to be most useful in the cast taking procedure and subsequent modifications of the model rather than have any fundamental bearing on the alignment of the prosthesis. It appears to offer no new concepts useful in the bench or dynamic alignment of the prosthesis."</p> <p>Professor Radcliffe told the Workshop attendees that the use of "catchy names" should be avoided, and he therefore proposed the terminology of Ischial-Ramal weight-bearing socket, as well as Ischial-Gluteal weight-bearing socket.</p> <p>Professor Radcliffe continued his biomechanical analysis by saying "The biomechanics of the ischial-ramal weight-bearing socket are similar to the ischial-gluteal weight-bearing quadrilateral socket. The major differences are in the manner in which the ischium is maintained in position within or on the brim of the socket. In each case, there must be vertical support with a combination of lateral and anterior counterpressure to maintain the ischium in position" . . . "Some of the socket shape diagrams I have seen published are so crude and inaccurate as to be almost meaningless. The level of the cross section shown is often not indicated and a section at ischial level is sometimes compared to a section which is obviously higher or lower." Professor Radcliffe then sketched on the blackboard what he believed to be a more accurate comparison with emphasis on the three-dimensional shape both above and below the level of the tuberosity of the ischium. In each case, he showed a cross section of the socket at, (1) ischial level with the medial wall projected upward to this level; and (2) the outline of the highest points on the brim (<a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-14.jpg"><b>Fig. 14</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-15.jpg"><b>Fig. 15</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-14.jpg"><strong>Figure 14. Socket contours for an Ischial-Gluteal weight-bearing socket using the UC Berkeley Brims.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-15.jpg"><strong>Figure 15. Socket contours for an Ischial-Ramal weight-bearing socket of the NSNA type provided by Ivan Long.</strong></a><br /> <p>This concluded all presentations of current fitting techniques. The remaining presentations were concerned with evaluation techniques. Bo Klasson of Een-Holmgren Company in Sweden presented on "Socket Fit With Reference to Soft Tissue Force Transmission." Briefly, Mr. Klasson's theory is that we should attempt to design sockets with physical characteristics that match the physical characteristics of the residual limb. In other words, where the tissues of the residual limb are firm, so should the matching area of the socket material be; where the tissues are soft and flexible, so should the socket be. Mr. Klasson refers to this as "surface matching."</p> <p>The next speaker was Professor George Murdoch of Dundee, Scotland, presenting "A Method for the Description of the Amputation Stump." Professor Murdoch's paper was based on his premise that there is a need for an international classification system for residual limbs to be developed in order to compare one publication with another, one patient with another, one fitting technique with another.</p> <p>The final presentation was made by A. Bennett Wilson on "Physiological Monitoring Equipment in Evaluation of Lower Limb Prosthetic Components and Techniques." He reported on a system of physiological monitoring originally developed by MacGregor of the University of Strathclyde in the 1970's. Recently modified for use by the University of Virginia Division of Prosthetics and Orthotics, this system consists of a compact tape recording component worn on a waist belt that records electronically, step count, walking velocity, standing versus sitting, and heart rate, plotted against time up to 24 hours. The tapes are then analyzed by a special micro-computer program, which subsequently prints the information in digital and graphic format.</p> <p>Under some circumstances the heart rate data can be useful in providing an energy index, but probably more importantly, the step count, standing versus sitting, and velocity data provide specific information about the activity of the subject. Mr. Wilson and colleagues have recently developed a solid state device which is less costly and more reliable. The new system has 17 information gathering channels. Mr. Wilson concluded by saying, "At this point, we do not have sufficient experience to know how many subjects have to be monitored and how much data is needed to show significant differences, but it certainly appears that at last we have a breakthrough in instrumentation for evaluation of prosthetic devices and other treatments involving the function of the musculoskeletal system.</p> <p>With all presentations complete, the plenary group was divided into six panels of six to nine members with the following charges:</p> <ol> <li> <p>Determine similarities</p> </li> <li> <p>Determine differences</p> </li> <li> <p>What is the role of flexible walls?</p> </li> <li> <p>Indications and contraindications</p> </li> <li> <p>Recommendations for future action</p> <ol> <li> <p>Evaluation</p> </li> <li> <p>Education</p> </li> <li> <p>Application</p> </li> </ol> </li> </ol> <p>This first group of panels reported back on Sunday morning. The reports were quite consistent among the different panels. A synopsis of these reports will be presented in concluding this report.</p> <p>On Monday, new panels were formed to re-study the rationale for and possibly develop protocol for evaluation. The reports from this second group of panels was heard in plenary session on Tuesday morning.</p> <p>The meeting was adjourned Tuesday, May 19, 1987 at noon.</p> <p>What follows here is a synopsis of the conclusions and recommendations of the panel reports.</p> <ol> <li> <p><b>Similarities &amp; Differences</b></p> <ol> <li> <p>Biomechanics</p> <ol> <li> <p>Ischial Containment:</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>all ischial containment sockets advocate and utilize varying degrees of ischial containment</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>quads do not utilize ischial containment</p> </li> <li> <p>ischial containment sockets, amount of ischial containment</p> </li> </ul> </li> </ol> </li> <li> <p>Weight Bearing Distribution:</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>ischial containment sockets, combination of ischial tuberosity and ramus, and peripheral (soft tissue)</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>quads, ischial-gluteal weight bearing</p> </li> </ul> </li> </ol> </li> <li> <p>ML Stability—maintenance of adduction</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>goal of all AK socket systems</p> </li> <li> <p>greater success and maintenance in ischial containment sockets due to ischium acting as bony stop or lock</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>quad, soft tissue lock only, no bony lock</p> </li> <li> <p>less successful maintenance of adduction, thus less ML stability</p> </li> </ul> </li> </ol> </li> <li> <p>Socket Shape—ischial level cross section</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>ischial containment sockets, narrow ML, wider AP, concave post-trochanteric shape</p> </li> </ul> </li> <li> <p>differences</p> <ul> <li> <p>quad, wider ML, narrower AP</p> </li> </ul> </li> </ol> </li> <li> <p>Trimlines:</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>ischial containment sockets, generally; especially anterior, posterior, and lateral wall trimlines</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>quads, especially higher anterior, lower posterior and lateral wall trimlines</p> </li> <li> <p>medial wall of CAT-CAM</p> </li> </ul> </li> </ol> </li> <li> <p>Suspension:</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>all compatible with suction</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>ischial containment sockets, unclear about auxiliary suspension</p> </li> </ul> </li> </ol> </li> <li> <p>Alignment:</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>all but NSNA utilize alignment devices</p> </li> <li> <p>ischial containment sockets, medial wall not on line of progression</p> </li> <li> <p>NSNA &amp; UCLA CAT-CAM, tilting of knee bolt in bench alignment</p> </li> <li> <p>Shamp Narrow ML &amp; NSNA, use of Long's Line</p> </li> <li> <p>ischial containment sockets,TKA bench alignment, socket midline</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>NSNA does not use dynamic alignment device</p> </li> <li> <p>quad medial wall on LOP</p> </li> <li> <p>not all tilt knee bolt</p> </li> <li> <p>NSNA, varying degrees of knee bolt tilt, 7°, female, 4°, male</p> </li> <li> <p>quad, bench alignment, more stable TKA, T reference point is located at posterior l? of socket</p> </li> </ul> </li> </ol> </li> <li> <p>Rotational Control:</p> <ol> <li> <p>similarities:</p> <ul> <li> <p>ischial containment sockets, bony lock of Ischium and post-trochanteric concavity</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>quad, muscular-soft tissue cross-section</p> </li> </ul> </li> </ol> </li> </ol> </li> <li> <p><i>Method of Obtaining Cast</i></p> <ol> <li> <p>similarities:</p> <ul> <li> <p>quad and Shamp Narrow ML utilize a casting brim</p> </li> <li> <p>UCLA CAT-CAM &amp; Sabolich/Guth CAT-CAM, hand molding technique</p> </li> <li> <p>NSNA &amp; UCLA CAT-CAM, standing</p> </li> </ul> </li> <li> <p>differences:</p> <ul> <li> <p>CAT-CAM &amp; NSNA, hand molding technique</p> </li> <li> <p>Sabolich/Guth CAT-CAM, sometimes cast lying down</p> </li> </ul> </li> </ol> </li> <li> <p><i>Anatomical Considerations</i></p> <ol> <li> <p>UCLA CAT-CAM detail about pelvic differences:</p> <ul> <li> <p>ischial inclination</p> </li> <li> <p>pubic arch angle</p> </li> <li> <p>ilio-femoral angle</p> </li> </ul> </li> <li> <p>NSNA male, female alignment differences:</p> <ul> <li> <p>bolt tilt</p> </li> </ul> </li> </ol> </li> </ol> </li> <li> <p><b>Role of Flexible Walls</b></p> <ul> <li> <p>not linked to any one philosophy of designing an AK socket</p> </li> <li> <p>vital to the success of the Sabolich/Guth CAT-CAM</p> </li> <li> <p>improved sitting comfort</p> </li> <li> <p>improved proprioception</p> </li> <li> <p>better heat dissipation</p> </li> <li> <p>improved muscle activity</p> </li> <li> <p>reduced weight</p> </li> <li> <p>ease of socket change within frame, no loss of alignment</p> </li> <li> <p>enhanced suspension, if suction suspension</p> </li> </ul> <p>All participants agreed there is great need for improved flexible materials.</p> </li> <li> <p><b>Indications and Contraindications</b></p> <ul> <li> <p>there were no specific contraindications noted for any socket design</p> </li> <li> <p>some advocated not changing successful quad wearers</p> </li> <li> <p>quads are most successful on long, firm residual limbs with firm adductor musculature</p> </li> <li> <p>ischial containment sockets are more successful than quads on short, fleshy residual limbs</p> </li> <li> <p>ischial containment sockets are the better recommendation for high activity/sports participation/running</p> </li> <li> <p>lack of agreement on best recommendation for bilateral above-knee</p> </li> </ul> </li> <li> <p><b>Recommendations</b></p> <p>The panels' conclusions and recommendations were remarkably consistent. Most consistent was the recommendation for improved terminology, lumping what I have referred to as ischial containment into a single, workable term. Suggestions ranged from "Narrow ML" to Ischial/ Ramus Containment (IRC) and Non-Ischial Containment (Non-IRC). Due to time constraints, arguments about this recommendation were never resolved. It is hoped that all recommendations can be addressed in a future workshop or through some other form of action.</p> <ol> <li> <p><i>Evaluation</i></p> <p>There was unanimous agreement for formal evaluation of the newer above-knee techniques (NSNA, CAT-CAM, Shamp Narrow ML) as well as evaluation of implications of the inferiority of the quadrilateral technique.</p> <ol> <li> <p>A program for scientific/laboratory evaluation should be set up at a center or multiple centers, depending upon resources. This study might include: cinematography, force plate, motion analysis, gait mat and other "gait lab" studies as well as radiographical data on alignment and containment, physiological data, residual limb/socket force analysis, and/or any other relevant laboratory studies.</p> </li> <li> <p>A program of clinical evaluation, based on previous fittings and continuing fittings in clinics already utilizing new fitting techniques. This would be a more subjective study, and would require a greater effort for coordination and pooling of data.</p> </li> <li> <p>Complete manuals should be developed for each individual technique, unless the developers can find it mutually agreeable to work together and blend the new techniques. The panels found the latter option to be most desirable.</p> </li> <li> <p>Evaluation should be independent of the developers.</p> </li> <li> <p>Any evaluation needs to be coordinated by an authoritative group. ISPO and/or the U.S. Veterans Administration were recommended. The American Academy of Ortho-tists and Prosthetists should also be involved.</p> </li> <li> <p>Possible funding sources within the states include the Veterans Administration and the National Institute on Disability and Rehabilitation Research (NIDRR).</p> </li> </ol> </li> <li> <p><i>Education</i></p> <p>The post-graduate, specialized courses for experienced practitioners appear to be most appropriate for teaching these newer techniques at this time. Incorporation into entry level education programs should follow as well written, experience based manuals are developed. Any teaching course should include "hands-on", patient contact, fitting, and management as part of the curriculum.</p> </li> <li> <p><i>Application</i></p> <p>The application of these new techniques, while certainly not as widespread and accepted as the quadrilateral technique, or even the flexible socket technique, is occurring at this time. Growing acceptance and application will most certainly follow. It is hoped that this workshop, as well as future workshops, will aid in safe and proper application of these and future advances and developments in prosthetics.</p> </li> </ol> </li> </ol> <p><b>References:</b></p> <ol> <li>UCLA AK Teaching Manual, 1977-1978.</li> <li><i>UCLA CAT-CAM Above Knee Prosthesis</i>, Teaching Manual, Third Edition, March 1987.</li> <li><i>Fabricating The Long's Line Above-Knee Prosthesis</i>, by Ivan long, 1981.</li> <li>Ivan Long's business card.</li> <li><i>Manual for use of THE SHAMP BRIM for the Narrow ML Above-Knee Prosthetic Socket</i>, The Ohio Willowwood Co., 1987.</li> <li>By Charles Radcliffe. Re-drawn by A. Bennett Wilson, Jr.</li> </ol> <em><b>*C. Michael Schuch, C.P.O. </b> C. Michael Schuch, C.P.O., is Assistant Professor of Orthopaedics and Rehabilitation and Associate Director of the Department of Prosthetics and Orthotics at the University of Virginia Medical Center, Box 467, Charlottesville, Virginia 22908.<br /><br /><br /></em> Page Number(s) 81 - 98 Year 1988 Volume 12 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-14.jpg Figure 15 http://www.oandplibrary.org/cpo/images/1988_02_081/1988_02_081-15.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 Report From: International Workshop on Above-Knee Fitting and Alignment Techniques Creator An entity primarily responsible for making the resource C. Michael Schuch, C.P.O. * https://staging.drfop.org/files/original/3474e7ecce4c2562d559a2ef5a3224c3.pdf 752179c0caddf3dd354a38e5884fa076 https://staging.drfop.org/files/original/091d1855d334557fc5d055ca98125283.jpg 99405891fc0b427f417be5fcdd10911e https://staging.drfop.org/files/original/623d2eb93d60e3d4c25639ae39dbf858.jpg fa3d556e9fe28696987a8f633f4776bd https://staging.drfop.org/files/original/60653bedb7f2f194a3abf694e94b72d4.jpg 25e03e2ad856469b5230d75e9fbff306 https://staging.drfop.org/files/original/40d8e3d76404f9b60a1a92c7c194361a.jpg 4e59435fca4d2ecb3e37e2073e385370 https://staging.drfop.org/files/original/a673985d199872ddfb5ca0cf2df6a4c2.jpg 38aca28e8cd192cd8b5cb162dd8163fa https://staging.drfop.org/files/original/10477ecf47f98610dc14231a7fb101f2.jpg a738c99a5bd4d53e10f1c4bb9632e49b https://staging.drfop.org/files/original/1ae495556d9d18674597daab58f7343a.jpg f53f76de628d841c6b8c1c15925fc8c6 https://staging.drfop.org/files/original/5c970469f1caacd2dc19113bb317726a.jpg 4289918c2044368e7b9555ecf174aed6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_02_011.pdf Year 1971 Volume 1 Issue 2 Page Number(s) 11 - 15 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_02_011.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_02_011.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 CAPP Electric Cart: Recent Developments</h2> <h5>Carl Sumida, C.P.O. <a style="text-decoration:none;">*</a><br />Yoshio Setoguchi, M.D. <a style="text-decoration:none;">*</a><br />Julie Shaperman, M.A., O.T.R. <a style="text-decoration:none;">*</a><br /></h5> <p>Since the development of the first Child Amputee Prosthetics Project (CAPP) electric cart<a></a> the device has been completely redesigned. A limited number were produced in 1968-69, and a field test was conducted by New York University. This article describes the mechanical changes that have been made in the cart. The report of the field test is presented elsewhere in this issue.</p> <p>The changes in no way altered the basic concept of the cart, and the design is still consistent with the original criteria: (1) the cart should be a powered vehicle which provides mobility to severely limited, limb-deficient children; (2) the controls should be simple to operate; (3) the cart should be compact, highly maneuverable, yet very stable and transportable; and (4) it should require minimal maintenance, and be attractive in appearance without resembling a wheelchair.</p> <p>Earlier models of the cart are shown in <b>Fig. 1</b>, <b>Fig. 2</b>, and <b>Fig. 3</b>. These prototypes were built between 1962 and 1966. The changes made since prototype III have made the production of the 14 carts needed for the field test less costly. <b>Fig. 4</b> and <b>Fig. 5</b> show the cart produced in 1968-69 for the field test. The differences between this model and the 1966 prototype are described below.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Prototype I, CAPP electric cart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Prototype II, CAPP electric cart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Prototype III, CAPP electric cart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Field-test cart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Field-test cart folded. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Structural Changes</h3> <p>The chassis, redesigned to simplify construction, is built of 1-in.-square mechanical tubing. The seat frame is made of 1/4-in. square, chromed mechanical tubing. The front axle was redesigned to allow torsional or vertical movement by means of a central pivot stud that is located at the center of the axle, which allows the chassis to travel over an uneven surface and still maintain four-wheel contact and stability.</p> <p>A new folding-seat arrangement makes the cart more compact for transport and adds lateral support from the side arms. The arms are set back far enough to allow the cart to be placed close to a table, desk, or washbasin. The frame for the backrest can be folded flat by lifting it slightly out of its locking notch and allowing it to fold forward onto the seat cushion.</p> <p>A shell made of metallic-green fiber glass covers the chassis and power equipment. The upholstery for the seat cushion and backrest is black Leatherette (TM). The seat frame is slightly larger than the seat cushion, thus leaving a small space for storage behind the cushion. Eight-inch, spoked casters with one-inch, solid-rubber tires (wheelchair type) are used on all four wheels.</p> <h3>Power-System Changes</h3> <p>The two drive motors are positioned independently on each side of the chassis. Each motor drives a specially designed worm-gear reduction box. The rear wheels are mounted directly on the output shaft of the gearbox, which is bolted to the frame. Power is fed into the gearbox through a Browning gear belt.</p> <p>A third motor powers seat raising and lowering. This motor is mounted adjacent to the right drive motor and is connected to the two rear screw jacks by a Browning gear belt and to a single front screw jack by a flexible shaft. These screw jacks raise the seat platform nine inches.</p> <p>The battery is positioned between the rear wheels and is easily accessible from the rear of the cart. This arrangement is more convenient than the side opening in the previous model, but it necessitated repositioning the motors and gear boxes, which had been a single package at the rear of the cart in prototype III.</p> <p>The control box is a specially designed unit developed at CAPP. It has toggle switches for directional control and a separate switch to raise and lower the seat. A circuit breaker was added to prevent an overload of the drive system. The switch controls are housed in a compact cylindrical unit that is mounted at the end of an reshaped control arm, which is attached to the left side of the seat frame and extends to the child's chin. The control arm can be adjusted for height and distance from the seat back. The chin receptacle is positioned next to the seat-elevation-control lever and is foam-padded (see <b>Fig. 4</b> and <b>Fig. 5</b>). The control arm is held in position in front of the child by a ramp lock. When lifted slightly, the control arm swings out for seat folding, the child's use of the table top, or transfer.</p> <p>The specifications for the cart's power equipment, size, turning radius, etc., are shown in <b>Fig. 6</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Dimensions and specifications of CAPP electric cart. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Changes Since Field Test</h3> <p>In November 1970, two additional changes were made. (The modified cart, with the new wheels and control unit, is shown in <b>Fig. 7</b>.)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Cart with solid rear wheels and new control unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>A new solid-state proportional control unit, now available commercially, was selected to replace the previous control unit. This new unit (manufactured by the Motorette Corporation of Reseda, California) provides proportional (variable-speed) control and an on-off master switch. The manufacturer provided a control for raising and lowering the seat so that the unit could be used with the electric cart. The control box can be positioned for control by the chin or an extremity. The circuitry unit fits on the storage rack behind the seat.</li><li>The rear drive wheels were changed from spoke casters to specially designed cast-aluminum wheels to eliminate the possibility of breakage due to high torques, but they have the same solid-rubber tires as the front casters. Although the use of pneumatic tires is being considered, solid-rubber tires have been retained for the present because they provide less rolling resistance and thus prolong the life of the battery. Also, solid-rubber tires are more reliable for a testing program because no problems arise from variations in air pressure.</li></ol> <h3>Production</h3> <p>The gear box, control box, chassis, body, and seat-lifting mechanisms for the carts used in the field test were specially de- signed by Mr. Carl Sumida at the Child Amputee Prosthetics Project at UCLA. These items were manufactured by subcontractors, and other components were purchased from commercial sources. The fourteen carts were assembled for the field test at the CAPP (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Assembly of field-test carts. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>During the field test, all mechanical repairs were made at CAPP. At the end of the test, all the carts were rechecked, new control boxes were installed, and new wheels were applied. The carts have been returned to the children who participated in the field test, who will continue to use them as long as necessary.</p> <p>Attempts are now being made to find a commercial manufacturer for the electric cart because it has proven to be an extremely valuable aid to the mobility of the severely limb-deficient child.</p> <p><b>References:</b></p> <ol> <li><i>Artificial Limbs </i>8:2:42-44, Autumn 1964.</li> <li>Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees, <i>Eighth Annual Report 1962, </i>pp. 51-53.</li> <li>Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees: prototype no. II, <i>Ninth Annual Report 1963, </i>p. 20.</li> <li>Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees, <i>Tenth Annual Report 1964, </i>pp. 1-10.</li> <li>Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees: prototype HI, <i>Eleventh Annual Report 1965, </i>pp. 9-11. (Reprinted in <i>Inter-Clinic Inform. Bull. </i>5:9:12-14, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Artificial Limbs 8:2:42-44, Autumn 1964.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees, Eighth Annual Report 1962, pp. 51-53.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, A powered device for bilateral lower extremity amputees: prototype no. II, Ninth Annual Report 1963, p. 20.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees, Tenth Annual Report 1964, pp. 1-10.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Child Amputee Prosthetics Project, UCLA, An electric cart for multilateral amputees: prototype HI, Eleventh Annual Report 1965, pp. 9-11. (Reprinted in Inter-Clinic Inform. Bull. 5:9:12-14, 1966.)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Julie Shaperman, M.A., O.T.R. </b></td></tr><tr><td class="clsTextSmall">Mrs. Shaperman is a research therapist with the project.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Yoshio Setoguchi, M.D. </b></td></tr><tr><td class="clsTextSmall">Mr. Sumida is a research prosthetist.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Carl Sumida, C.P.O. </b></td></tr><tr><td class="clsTextSmall">Dr. Setoguchi is the medical director of the Child Amputee Prosthetics Project, University of California, Los Angeles.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-11.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-12.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-13.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-14.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-15.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-16.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-17.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_02_011/ArtificialLimbs-Autumn1971-18.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The CAPP Electric Cart: Recent Developments Creator An entity primarily responsible for making the resource Carl Sumida, C.P.O. * Yoshio Setoguchi, M.D. * Julie Shaperman, M.A., O.T.R. * https://staging.drfop.org/files/original/a32e7ddca38ac3658b7debb50c742a7d.pdf 94386f89329ed90de7d4de19d32ee144 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_01_004.pdf Text Any textual data included in the document <h2>From Research Lab to Consumer: The Manufacturers' Point of View</h2> <h5>Carlton Fillauer, CPO&nbsp;<a style="text-decoration: none;">*</a><br />Charles H. Pritham, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The matter of transferring new developments from the researcher to the consumer is one that has bedeviled the American prosthetic-orthotic establishment for years. The researcher, the agency that funds the research, the manufacturer, the clinician, and the patient are all, of course, interested in seeing new products brought to market, and all stand to benefit. Financially, the manufacturer is the one who stands to benefit the most from the successful introduction of a new product. Only by such means does a manufacturer expand his base and increase earnings. If the incentives are greatest for a manufacturer, the risks are also proportionately greater. In making a decision to produce a new product, the manufacturer must weigh the risks against the potential benefits and make a decision about committing his resources. It should be obvious that once resources of time, effort, and money are lost backing an unsuccessful product, they are lost forever. What is not so obvious is the fact that the loss is threefold.</p> <p>Potentially, at least, the resources expended for backing a losing product could have been invested in a successful one, turning a loss into a profit. Also, in making the decision to back a new product the manufacturer commits his prestige and credibility. A positive result resounds to his credit, attracting new attention to products currently being produced and assuring a positive reception for future products. A negative result has the opposite effect, tarnishing the image of other items in the manufacturer's product line and damaging his credibility. That the investment in a new product can be a high one should not be discounted, therefore.</p> <p>A small group of highly skilled and motivated individuals (or an inventor working alone) can, with a relatively low investment in machinery, produce complicated prototypes efficiently and with a low rejection rate. When the time comes to produce the same object in large numbers, the factors are fundamentally different. Production workers are seldom so skilled or motivated. Oftentimes, to overcome bottlenecks in production and to achieve consistent results, a product must be redesigned. The cost of this redesign must be borne by the manufacturer. To achieve productivity and consistent results, the manufacturer will develop tools, dies, and molds with which to produce a device. Resorting to such an alternative can enable relatively unskilled personnel using inexpensive materials to produce products of great appeal and excellent quality. While the material costs of such objects can be measured in the cents, the cost of the molds and dies can frequently run in the thousands of dollars each. If it is necessary to produce the device in a range of sizes and in right and left, the cost can be prohibitive. It should also be borne in mind that the researcher or inventor frequently has only partially tested the prototype and further testing and development must precede redesign for production. The direct expense of manufacturing an object, however, is only a portion of the cost.</p> <p>In order to sell a product it must be promoted and advertised. The total expense of attending a convention (often far from home), renting space to exhibit, and obtaining a suitable display is not cheap. Commissioning the art work and copy of an advertisement, and obtaining space for it in a journal are, similarly, of considerable expense.</p> <p>The organization that makes all this possible (research and development, production, and promotion) can frequently be quite large and demand a sizable indirect labor force to administer the resources and personnel involved. The total expense of all factors involved in developing a new product is a figure to be reckoned with and can be justified only if the product has the potential of selling in sufficient quantities to recoup the original investment and earn a favorable rate of return. It is in connection with this that the greatest stumbling block is encountered. Whatever the merits of a design may be, a manufacturer can not afford to devote the resources to its development if it will not sell in a large enough volume to enable him to sell it at a reasonable cost.</p> <p>Despite the optimistic expectations of a developer, the market for his new object is seldom as large as he hopes. All researchers and developers seeking federal research money are asked to project the number of individuals for whom their work will be applicable. As all involved will admit, it is a fundamental fact of the way that health care is funded in the United States and the way that health care statistics are gathered that the best of projections are crude estimates. What statistics are available point to the fact that the total market for any one product is small. This market is rendered smaller because not all members of that market are in the marketplace at one time, or even interested in the new product.</p> <p>A new product must compete for a share of the market with existing products that do the same thing. It should be kept in mind that few, if any, developments are so radically different as to have no potential competiton for market share. The price at which established products are sold limits the price for which a new product can be sold. For a new product to rapidly gain market share, it must be reasonably priced versus the competition, potentially much better than the competition, and current users must be very dissatisfied with the competing product.</p> <p>On a practical level, the people to whom a product must be marketed are not the ultimate consumer, but the prosthetist-orthotist who will render that product into a form suitable for a particular patient, and who must also frequently convince the physician to prescribe the device.</p> <p>At any one time, there are said to be about 2,000 practicing prosthetists-orthotists; that is hardly a mass market. Prosthetists-orthotists as a group are not the easiest group to introduce to a new product. Most of them have experience with one or more products that, despite the manufacturer's best efforts, were released before all the problems were worked out. Like the car buyer who chooses not to buy a car during its first model year, they prefer to wait and see. Others, while interested in trying a new product are "waiting for just the right patient." On the other hand, a disconcerting number are all too ready to rush in without thought.</p> <p>Battling for preeminence in every prosthetist-orthotist's lexicon of adages to live by are the two:</p> <ol> <li> <p>If all else fails, read the instructions.</p> </li> <li> <p>Don't force it, get a bigger hammer.</p> </li> </ol> <p>Every manufacturer can recount instances of practitioners who provided a device to a patient for whom it was specifically contraindicated, or who neglected one or more crucial precautions in fabricating the completed device. This can result in a wave of negative word of mouth publicity despite a manufacturer's best efforts to promote a new product and educate the profession about its proper use. The end result may be passive indifference, or active rejection whatever the positive merits of a new device are when it is properly prescribed and utilized.</p> <p>A developer of a new object has a vested interest in making it work successfully and will go to considerable pains to make it do so. It is a well recognized fact that a product, when transferred to even the best motivated and prepared practitioners, seldom works as well as it does for the developer.</p> <p>In summary, then, the following points can be made:</p> <ol> <li> <p>The following factors are sizable expenses:</p> <ol> <li> <p>Research and development of the original idea to a workable prototype</p> </li> <li> <p>Production design</p> </li> <li> <p>Tooling</p> </li> <li> <p>Manufacturing</p> </li> <li> <p>Quality control and testing</p> </li> <li> <p>Marketing</p> </li> </ol> </li> <li> <p>Considerable uncertainty surrounds the business of gauging market size and reception for a new product.</p> </li> <li> <p>However well an object sells, the field of prosthetics and orthotics can hardly be said to constitute a mass market of sizable proportions.</p> </li> <li> <p>Experience has repeatedly shown that it takes three years to achieve a profitable volume of sales once a new product is introduced.</p> </li> </ol> <p>The result of these facts is that the manufacturers of items for use in the prosthetic and orthotic market are confronted with the need to make sizable initial investments for a rather small market that is oftentimes slow to adopt new products of even the greatest merit. Considerable uncertainty surrounds the decision to make the investment and it can take many years for a return on the investment to be realized and the decision to be vindicated. Given these facts, it is understandable that manufacturers differ from developers and their backers about the utility and acceptability of many developments, and that they are slower to adopt new products than others might wish.</p> <em><b>*Charles H. Pritham, CPO </b> Technical Coordinator, Durr-Fillauer Medical, Inc.</em><br /><br /><em><b>*Carlton Fillauer, CPO </b> Vice President, Durr-Fillauer Medical, Inc., Orthopedic Division, 2710 Amnicola Highway, Chattanooga, Tennessee 37406.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 4 - 6 Year 1984 Volume 8 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource From Research Lab to Consumer: The Manufacturers' Point of View Creator An entity primarily responsible for making the resource Carlton Fillauer, CPO * Charles H. Pritham, CPO * https://staging.drfop.org/files/original/9f82190e18cf5ca09443da6fd68df3b9.pdf 43555eca290035ea7155e9a0312babce https://staging.drfop.org/files/original/41b75dea6e7a15877cc0a8243b4c4874.jpg b6438828e00e3ff265f4c6c3376559b7 https://staging.drfop.org/files/original/41ffa86db5a06c67178da1fe6aee4968.jpg 20d75a09605e3e2b68d200f44cc3f96a https://staging.drfop.org/files/original/402a3a26ceb04de8b1318dcabf4f5b30.jpg e1b78c19f91d79fac7635c1e04b7cb5b https://staging.drfop.org/files/original/5965cf7dfd7eb969f1a55b331bba978f.jpg 0f5897ea65b406960ef356aae8745014 https://staging.drfop.org/files/original/ce3704752c65bafb933002528b66de97.jpg 303919967c08f033368701a299f0dca1 https://staging.drfop.org/files/original/f3eaed68459cebb323caf8eac4f369f5.jpg b0b7b29cc73946063cd1cb85e8b07b5c https://staging.drfop.org/files/original/26d45afef759ecc508cb2fa1d00073fa.jpg def29cc322ce2288598609261fc453e6 https://staging.drfop.org/files/original/59d21c2e70e154cf05aebf3b2e8f05f2.jpg 3e4a48d0000f890a2ee4e1e639e6ca9f https://staging.drfop.org/files/original/058fa502bdf14434b5d3e4059b53c36b.jpg f86fdd1ac02b515fee07f9d0a83b6086 https://staging.drfop.org/files/original/15c2883e9508c92984a80cc01fb90f85.jpg 220753ac354d321682550677971639e4 https://staging.drfop.org/files/original/1599535e386e2026f4cc72d91bfd2cca.jpg 44adc9faa4fbe64b6d148b43dc5bacc2 https://staging.drfop.org/files/original/51e5edca62a38d9594e025c03ccac11b.jpg bb869d0a8ea128b30044b3213c4ca4fc https://staging.drfop.org/files/original/3598305f5c89bedf991c4f6548c90cf5.jpg 6d9b445e128c0fec74c50bf67157e15d https://staging.drfop.org/files/original/42655d7b96617f3031e4cfe4b384377a.jpg fca7110d2166127a2bad387fed992c5a https://staging.drfop.org/files/original/1637b57b9c0c9bd6f3aecc78d40064ba.jpg 28995acfac6dc5b1e438cc86f3f50219 https://staging.drfop.org/files/original/a28f64fb749dd90466694e6f74a7a7da.jpg 5405cbe2389ef56b993d6396a98106ac https://staging.drfop.org/files/original/d1f903fa6ec56d3011b93c35b07b5284.jpg be76fb64fc2e1785acd322b5062bda99 https://staging.drfop.org/files/original/0677d944077501669f0b3fdbb2af91fa.jpg 739231039457e940d8d4a1cb1bea9428 https://staging.drfop.org/files/original/799403b2935896e2bb5d55a38e9779f2.jpg 4739ce28a1715e3bf9ef1d2d7e7c9d51 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_01_027.pdf Year 1971 Volume 15 Issue 1 Page Number(s) 27 - 45 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_027.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_01_027.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Technique for Fitting Converted Proximal Femoral Focal Deficiencies</h2> <h5>Carman Tablada. C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>Proximal femoral focal deficiency (PFFD) is a congenital limb deficiency affecting the proximal end of the femur and, usually, the iliofemoral joint. The condition is characterized by shortness of the affected limb; flexion, abduction, and external rotation of the extremity; inadequate proximal musculature; and unstable proximal joints. <a></a> The condition may be unilateral or bilateral, and other anomalies may be present (<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>Aitken <a></a> has demonstrated four types of PFFD based on serial X-rays of patients before and after skeletal maturity:</p> <ul> <li><i>Class A: </i>Adequate acetabulum and femoral head. Short femoral shaft. Femoral head and shaft are joined at maturity.</li> <li><i>Class B: </i>Adequate acetabulum and femoral head. Short femoral shaft. Femoral head and shaft are not joined at maturity.</li> <li><i>Class C: </i>Severely dysplastic acetabulum. Femoral head never ossifies. Short femur.</li> <li><i>Class D: </i>No acetabulum or femoral head. Short, deformed femoral segment.</li> </ul> <p>At the Child Amputee Prosthetics Project (CAPP) in Los Angeles, the preferred treatment for children who have unilateral PFFD and functional upper extremities is conversion of the limb deficiency to an above-knee amputation. The surgical procedure consists of a Syme's amputation of the foot in all cases, and fusion of the knee in selected cases to give a single skeletal lever (<b>Fig. 2</b>). The children are then fitted as above-knee amputees, using a specially designed socket.</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>Since 1967, the prosthetists at CAPP have used a socket with a flexible inner wall to fit PFFD patients who have had the surgical conversion described above. This paper describes the total fabrication and fitting procedure as it is done at CAPP. Only its application to the patient with PFFD will be considered here, although we have used the same principle with success in fitting other amputees who have a stump with a bulbous end.</p> <h4>The Stump</h4> <p>The converted PFFD stump is relatively fleshy in the proximal area. The shape of the proximal portion is related to the patient's classification: In those with class A or B involvement, the shape is normal enough for the usual anatomic landmarks to be seen, and in those with class C or D involvement, the proximal stump is cylindrical.</p> <p>The shaft is usually narrow and bony, and the distal end is bulbous, with soft tissue padding its inferior surface. There are bony projections in the bulb which may not be seen but which can be located by palpation. These projections are sensitive to pressure.</p> <p><i>Telescoping</i></p> <p>When the structures in the hip region do not provide adequate articulation between the pelvis and the lower-extremity elements, upward pressure under the end of the stump causes upward displacement of the bony elements and apparent shortening of the limb. This motion is called "telescoping," and is frequently seen in patients with PFFD. As much as three inches of telescoping can be demonstrated in some patients.</p> <p>Telescoping can be a passive or an active motion. In varied cases, some patients can voluntarily retract their limbs and others cannot; they can, however, voluntarily lengthen it beyond the resting position by thrusting down. Traction on the stump also causes lengthening. This apparent shortening and lengthening of the stump in response to pressure and traction has important implications for measuring the stump length, for making the cast, and for weight-bearing (<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 /> <h4>The Socket</h4> <p>The socket consists of a rigid outer shell and a three-layered flexible inner wall, with an air space between the flexible layers and the hard socket. The flexible layers extend from the bottom of the socket to at least the level at which the bulbous end can pass through freely, comparable to the placement of the window in a standard Syme prosthesis. This arrangement provides room for expansion of the flexible wall as the bulb is inserted into the socket. Once the stump is fully inserted, the flexible wall closes around it, giving a total-contact fit without using a window and making it possible to use the bulb for suspension.</p> <p>Since the patient has a Syme's amputation, it would seem logical to fit him with an end-bearing socket. However, if this were done, pressure under the end of the stump during the stance phase of gait would cause telescoping and relative shortening of the leg. The patient would then have excessive lateral trunk bending during stance. For this reason, the socket is designed to be ischial weight-bearing, with the patient taking light contact on the end of the stump. The ischial weight-bearing minimizes the amount of telescoping and therefore decreases the lateral trunk bending. The light contact at the distal end gives him better control over the prosthesis.</p> <h4>Materials and Components</h4> <p>The hard outer socket is formed with 4110 polyester resin.</p> <p>Considerable thought was given to selecting the materials for the flexible layers. Our clinical experience has shown that, with continued use, RTV develops an odor and the material becomes fuzzy; nor will RTV bond to the rigid shell of the outside socket.</p> <p>Therefore, flexible polyester resin was selected for the layer closest to the skin. It is durable, is easy to keep clean and free of odor, and has a surface that is relatively friction-free. 384 RTV was used for the center layer because it laminates readily and will stretch and return to the same shape repeatedly. Flexible polyester resin was also used for the layer next to the outer socket, for it bonds to the hard material if the polyester resin is "roughed up" sufficiently. The polyester resin also protects the RTV from impregnation by wax during socket fabrication. In all the cases in our experience, the materials have retained these properties until the child outgrew the prosthesis.</p> <p>Primary suspension is provided by closure of the flexible layers over the bulbous end of the stump. A Silesian bandage, worn about an inch below the iliac crest, gives lateral support and secondary suspension.</p> <p>We have used a constant-friction knee and SACH foot for all children fitted with this type of prosthesis. The constant-friction knee is light in weight and has provided good function. All of the children have had adequate strength to lock the knee joint during stance.</p> <h4>Special Measurements</h4> <p>Before describing the fabrication procedure, a brief discussion of the measurements is in order, for much of the success of this method of fitting depends upon having ischial weight-bearing and a total-contact fit.</p> <p><i>Socket Brim Aand Ischial Seat</i></p> <p>In patients with class A or B involvement, the shape of the proximal thigh is normal enough to enable the prosthetist to make the A-P and M-L measurements as he would for a patient with a standard above-knee amputation. The socket will have a modified quadrilateral shape at the ischial level.</p> <p>In patients with class C or D involvement, the shape of the proximal stump is cylindrical, and there is no area comparable to the adductor-longus-tendon area of the standard above-knee amputee. In these cases, the M-L dimension is measured with outside calipers at the level of the adductor fold, and the ischial-seat measurement is made on a horizontal line from the ischium to the lateral edge of the stump at the ischial level.</p> <p>The inside measurements of the socket must be the same as the circumferential measurements of the stump. The prosthe-tist must reproduce the size and shape of the stump in the cast, positive mold, and socket to insure total contact without looseness or constriction.</p> <p>The stump length is measured from the ischium to the distal end of the stump with the stump at its greatest stretched length. The importance of measuring the length and taking the wrap with the stump fully elongated cannot be overemphasized, for two reasons: First, it helps ensure that the patient will take most of his weight on the ischium so that telescoping will be minimal; second, the length of the cast can be modified by only 3/8 in. in either direction.</p> <h3>Measurements</h3> <h4>Brim</h4> <p><i>Mediolateral</i></p> <p>In class A and B patients, take the M-L measurement as for a standard above-knee amputee.</p> <p>In class C and D patients, caliper the horizontal distance from the adductor fold to the lateral aspect of the stump (<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><i>Anteroposterior</i></p> <p>Take standard above-knee A-P measurements for classes A and B.</p> <p>For classes C and D, to measure the ischial seat, caliper the horizontal distance from the inferior edge of the ischium to the lateral aspect of the stump (<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 /> <h4>Socket Length</h4> <p>With the stump at its greatest length and vertical to the floor, measure from the ischium to the end of the stump (<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 /> <h4>Circumference</h4> <ol> <li>Measure the circumference of the largest part of the bulb, and from this point to the distal end of the stump (<b>Fig. 7</b>).</li><li>Measure the circumference of the narrowest part of the shaft, and from this point to the distal end of the stump (<b>Fig. 8</b>)</li><li>Beginning at the narrowest part of the shaft, measure the circumference at one-inch intervals to the adductor fold (<b>Fig. 9</b>).</li></ol> <h4>Bulb</h4> <ol> <li>Caliper the A-P and M-L dimensions at the largest part of the bulb (<b>Fig. 10</b>).</li><li>Palpate the bulb to locate the bony prominences and mark them with indelible pen.</li></ol> <h4>Overall Length</h4> <p>Measure the sound side as for a standard above-knee amputee.</p> <h4>Stump Sock</h4> <p>Make a tracing of the stump to accompany the measurements for ordering stump socks.</p> <h3>Cast Fabrication</h3> <h4>Materials</h4> <ul> <li>Fast-setting Johnson and Johnson plaster bandage</li> <li>Elastic plaster bandage (Johnson and Johnson Orthoflex)</li> <li>Cast sock</li> <li>Stockinette</li> <li>1-in. elastic webbing</li> <li>A-P caliper</li> <li>Yates clamp</li> </ul> <h4>Fitting The Cast Sock</h4> <ol> <li>Mark the shaft at the level where the A-P or M-L dimension is slightly larger than the A-P or M-L dimension of the bulb.</li><li>Measure the distance between the two points selected and cut one piece of stockinette that length (<b>Fig. 11</b>).</li><li>Cut five more pieces of stockinette, each 1/2 in. shorter than the last, and place them on the stump to fill in the narrow part. Place the shortest piece on the stump first, then the longer ones over it, <i>in reverse of what is shown in <b>Fig. 12</b>. </i>This facilitates removal of the cast.</li></ol> <h4>Making The Cast</h4> <p>The patient should stand with his stump vertical to the floor.</p> <ol> <li>Using the same technique as for a standard above-knee amputee, make the brim with the 4-in. elastic bandage, beginning at the lateral side of the stump at the level of the iliac crest (<b>Fig. 13</b>).</li><li>Complete the wrap with the 3-in. regular plaster bandage (<b>Fig. 14</b>).</li><li>Form the ischial seat while the bandage is still wet. With the A-P caliper set to the length measurement of the stump plus 3/16 in., place the short end under the ischium and line up the long end under the end of the stump. Then apply pressure under the ischium and have the patient thrust down until the stump end touches the caliper (<b>Fig. 15</b>).</li><li>At the same time, apply three-fingers' firm pressure to the proximal anterior medial aspect of the cast (<b>Fig. 16</b>). This prevents the socket from rotating internally on the stump.</li><li>The patient must remain in this position and the pressures must be maintained until the plaster sets.</li><li>Remove the cast.</li></ol> <h4>Checking The Cast</h4> <ol> <li>Check the M-L and ischial-seat measurements of the cast against those of the patient. Be sure that the ischial seat has a large enough surface for the patient to sit firmly upon it. If necessary, build up the seat with plaster before filling the cast (<b>Fig. 17</b>).</li><li>Check the length of the cast against the patient's stump length. They should be the same. If the cast is longer than the stump, pressure was not applied directly under the ischium. If the cast is shorter than the stump, the patient was not thrusting down to maximal stretch. If the difference does not exceed 3/8 in., the mold can be modified. If there is a greater than 3/8-in. difference, a new cast should be made.</li></ol> <h4>Modifying The Mold</h4> <p>To correct the length measurement:</p> <ol> <li>Measure from the ischial seat to the end of the mold.</li><li>Remove or add enough plaster (but no more than 3/8 in.) to the ischial seat to correct the length.</li></ol> <p>To correct the flexion or extension angle (<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 /> <ol> <li>Draw a line down the medial aspect of the mold, bisecting it into medial and posterior halves.</li><li>Set the goniometer at 90 deg.; hold one arm on the line described and the other arm at the level of the ischium. Draw a line at right angles to the line on the medial aspect of the mold.</li><li>Shape the surface of the seat along this line. The shaft should be at 0 deg. of flexion and extension.</li></ol> <p>To correct the abduction or adduction angle (<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 /> <ol> <li>Draw a line down the posterior aspect of the mold, bisecting it into medial and lateral halves.</li><li>Set the goniometer at 90 degrees ; hold one arm on the line described and the other arm at the level of the ischium. Draw a line at right angles to the line on the posterior aspect of the mold.</li><li>If the shaft is in <i>adduction, </i>remove plaster from the outside edge of the ischial seat. If the shaft is in <i>abduction, </i>add plaster to the outside edge of the ischial seat. The shaft should be at 0 degrees of abduction or adduction.</li></ol> <p>To modify the anterior brim (<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 /> <ol> <li>Form the height of the anterior brim: Draw a line at the ischial level across the anterior aspect of the mold from point A to point B. Divide the line in half at point C. From point C, draw a line at right angles to AB, extending it two inches proximal to point D. Line CD forms the height of the anterior brim.</li><li>To establish the anterior brim line, extend a line from point B one inch medially to point E. Point E should be in line with the ischial seat when viewed from the front. Draw a line on a smooth curve from point D to point E (<b>Fig. 20</b>).</li><li>Form a reverse curve along line DE to facilitate sitting and bending. Using a rasp or gouge, remove up to 1/4 in. of plaster from the area medial to line CD. This will ensure good contact along the anterior brim wall with the stump. If necessary, build up with plaster along line DE to form the reverse flare (<b>Fig. 21</b>).</li></ol> <p>To modify the lateral brim:</p> <ol> <li>Continue line DE from the anterior brim proximally to encompass two-thirds of the distance between the ischium and the iliac crest. Continue laterally, following the contour of the lip, then distally to the posterior-lateral corner of the ischial seat (<b>Fig. 22</b>).</li><li>Contour the lateral wall. Do not remove plaster below the ischial level (<b>Fig. 23</b>). Establish flare along the lateral brim line.</li></ol> <p>To modify the shaft:</p> <ol> <li>Correct the circumference measurements. Mark off the levels at which the circumference measurements were obtained. Note each measurement on the mold. Where it is necessary, the circumference measurements of the mold should be modified to be the same as those of the stump (<b>Fig. 24</b>).</li><li>At the brim area, blend the medial and posterior walls smoothly with the medial brim and ischial seat (<b>Fig. 25</b>).</li></ol> <p>To modify the bulb:</p> <p>Build up over the bony projections no less than 1/4 in. (These projections should be marked during the measurement and casting procedure.) <i>Be extremely careful while accomplishing this, as attempting relief in this area is extremely difficult </i>(<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>Recheck the mold measurements. Smooth the entire mold (<b>Fig. 27</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 /> <h3>Flexible-Socket Fabrication</h3> <h4>Materials</h4> <ul> <li>Ambroid varnish or the equivalent</li> <li>Five PVA sleeves (regular size and shape)</li> <li>Two 1-oz. fitted Dacron (TM) sleeves</li> <li>Four or five regular-length fitted nylon stockinettes (for fabricating the flexible layers)</li> <li>Three extra-long fitted nylon stockinettes (for fabricating the hard socket)</li> <li>Cast sock(s) (to equalize the stump sock)</li> <li>Flexible polyester resin #4134</li> <li>RTV elastomer Dow Corning #384</li> <li>Rigid polyester resin #4110</li> <li>150-A yellow wax (available from E. S. Browning Co., Los Angeles, Calif.) or any wax suitable for shaping</li> <li>Outside calipers</li> <li>Wood rasp</li> <li>Vacuum machine</li> <li>Oven with at least 200 degrees F temperature range</li> </ul> <p>Make the Dacron sleeves to fit the entire brim area. The Dacron must not be incorporated in the flexible layers.</p> <p>The number of stockinettes needed depends upon the size and activeness of the patient. Four are used on the less active patient, and five on the more active. These are separate pieces, sewn on one end and trimmed to 1/2 in. of the stitching. The width of the stockinette should be such that it stretches very minimally in what is to be the flexible wall.</p> <p>The three extra-length stockinettes must be long enough to double over in the brim area.</p> <p>One heavy and one lightweight cast sock are used for a 3-ply wool sock; two heavy and one lightweight cast sock are used for a 5-ply wool socket, etc.; or an old wool stump sock of the same weight can be used.</p> <p>The 150-A yellow wax is heated until it is soft enough to work with a spatula. With this type of wax, it is never necessary to melt it completely and pour it into a cone.</p> <h4>Procedure</h4> <ol> <li>With the outside calipers, measure for the area where the bulb can pass through freely. Mark this area heavily with a pencil (<b>Fig. 28</b>).</li><li>If the cast is wet, seal it with three coats of ambroid varnish.</li><li>Apply the appropriate number of cast socks (or an old stump sock) needed for stump-sock clearance. Tie them off securely on the mandrel.</li><li>Apply the first PVA sleeve, which will be the parting agent. Cap it on the end and tie it off on the mandrel.</li><li>Apply two Dacron sleeves, being sure not to overlap into the flexible walled area which starts at the mark made in step 1. It is advisable to leave at least 1 in. between the mark and the Dacron sleeves (<b>Fig. 29</b>).</li><li>Apply one layer of stockinette and tie it off on the mandrel. If necessary, separate and smooth the extra half-inch of material. With the outside calipers, measure again for the area where the bulb can pass through freely, and mark this area with a pencil.</li><li>With pressure-sensitive tape, make a full turn around the model at the mark made in the previous step (<b>Fig. 30</b>). This seals off the proximal end of the flexible wall.</li><li>Attach the vacuum line.</li><li>Apply the second PVA sleeve and seal it off on the mandrel, then repeat step 7.</li><li>Mix thoroughly enough 4134 flexible polyester resin to cover the area from the tape to the end of the model. Using vacuum, laminate this area <i>only. </i>(It is helpful if, at the end of each laminating step, the excess is tied off, thus saving the time of grinding it away.) Allow to set well (<b>Fig. 31</b>).</li><li>Remove the second PVA sleeve. Remove the pressure-sensitive tape around the model. With the wood rasp, roughen the bulbous end enough to raise the half-inch of stockinette. Do not break through to the parting PVA (<b>Fig. 32</b>). Apply two more layers of stockinette, again separating and smoothing down the extra half-inch of material. Tie them off on the mandrel, then repeat step 7.</li><li>Apply the third PVA sleeve, seal it off at the mandrel, and repeat step 7.</li><li>Mix thoroughly enough 384 RTV to cover the laminated area. Using vacuum, laminate this area only. Allow to set well (<b>Fig. 33</b>).</li><li>Remove the third PVA sleeve. Remove the pressure-sensitive tape around the model. With the wood rasp, roughen the bulbous end enough to raise the half-inch of stockinette beyond the stitching (as in <b>Fig. 32</b>).</li><li>Apply one or two more layers of stockinette, again separating and smoothing the extra half-inch of material. Tie them off on the mandrel, then repeat step 7.</li><li>Apply the fourth PVA sleeve, seal it off on the mandrel, and repeat step 7.</li><li>Repeat step 10.</li><li>Remove the fourth PVA sleeve. Remove the pressure-sensitive tape around the model.</li><li>For the wax build-up (<b>Fig. 34</b>), apply wax to the model from the proximal end of the flexible wall distally to the <i>largest </i>circumference of the bulb end. The thickness of the build-up should be sufficient to allow the bulb to expand the flexible wall through the narrow area. Use the outside calipers to measure the thickness of the build-up. Allow 3/16-in. thickness for the flexible-wall lamination. (Keeping in mind some goals for the finished prosthesis, such as cosmesis and lightness in weight, in most cases it is possible and advisable to "go overboard" on the wax build-up. Cosmetic build-up is kept to a minimum, and air space is weightless.) Allow the wax to cool and harden (<b>Fig. 35</b>).</li><li>Smooth the surface and taper the proximal and distal edges (<b>Fig. 36</b>).</li><li>Using the wood rasp, roughen the exposed tip of the bulb end enough to cut through to the RTV layer and to raise the half-inch of stockinette beyond the stitching on the final 4134 resin layers. <i>This step is extremely important, </i>as it will securely bond the flexible portion of the socket to the rigid outside shell (<b>Fig. 37</b>).</li><li>Apply the three extra-long nylon stockinettes, doubling the first two layers back at the brim (<b>Fig. 38</b>).</li><li>Apply the fifth PVA sleeve and seal it off on the mandrel. Mix enough 4110 polyester resin to cover the entire mold. Using vacuum, laminate the entire mold. Allow it to set (<b>Fig. 39</b>).</li><li>After the resin has set, cut a flap through it 3/4 in. in diameter at the distal edge of the wax build-up. Tape the flap back (<b>Fig. 40</b>).</li><li>Hang the entire laminated cast in the oven (heated to 175 degrees F) and allow <i>all </i>the wax to drain out.</li><li>Remove the laminated cast from the oven after the wax has drained. Allow the lamination to cool just enough for the rigid shell portion to harden. Mark the approximate trim line and cut along it with a Stryker saw. A strong tug, along with use of a hammer and piece of wood when needed, will separate the socket from the cast (<b>Fig. 41</b>).</li><li>To complete the socket, finish sanding the brim down to the trim lines.</li></ol> <h3>Fitting</h3> <h4>Materials</h4> <ul> <li>Fitting stool</li> <li>Talcum powder</li> <li>Stump sock</li> <li>Mandrel padded at the end with stockinette in the shape of a bulb</li> <li>Heat gun</li> <li>Silicone amputation-stump spray</li> </ul> <h4>Procedure</h4> <ol> <li>Set the socket in a wood block with the seat level.</li><li>Place the block on a fitting stool to get the correct ischium-to-floor length.</li><li>Lightly powder the socket.</li><li>Have the patient apply the stump sock and hold it firmly at the top as he pushes his stump into the socket (<b>Fig. 42</b>). (If the patient cannot push all the way into the socket, the flexible layers will need to be stretched as described in the next section.)</li><li>Check to see that the patient's ischium is firmly on the seat, and that he has light contact at the end of the stump. Do this by having him bear weight on the socket and by requesting him to "reach down into the socket" with his stump. If as he does this, he loses firm contact with the seat, the socket is too short. If he cannot feel contact on the bottom, the socket is too long. A sponge pad in the bottom of the socket may give the necessary light contact.</li><li>Have the patient lift his hip to take weight off the socket. There should be no more than 1/4 in. of piston action (<b>Fig. 43</b>).</li><li>Check for pressure areas in the bulb. With the patient standing, have him flex his hip while you apply resistance to the distal anterior end of the socket. Then have the patient abduct, extend, and ad-duct the hip, each time applying resistance to the distal end of the socket. There should be no pain from these maneuvers. (Pain may be caused by a wrinkle in the sock, by the presence of wax in the air space, or from inadequate relief over the bony prominences in the bulb.)</li><li>Establish the anterior and posterior trim lines. In the posterior lateral area, trim the socket so that it does not encase the gluteal area. Then have the patient sit in a chair and lean forward. Check for discomfort in the anterior area, and trim the socket to fit. There should be no gapping of the lateral wall. The anterior brim of the socket should be in firm contact with the skin, for looseness here would allow the socket to rotate internally on the stump when the patient walks.</li><li>To remove the socket, the patient should pull up on the top of the stump sock while pulling down on the socket. In a few cases, this was the only way in which the socket could be removed (<b>Fig. 44</b>).</li></ol> <p><i>Stretching the Flexible Layers</i></p> <p>If the patient cannot push his stump all the way into the socket, it will be necessary to stretch the flexible layers to allow the bulb to pass through the narrow part of the socket. This can be accomplished as follows:</p> <ol> <li>Place the padded mandrel in a vise.</li><li>Heat the inside of the socket to soften the flexible layers.</li><li>Work the socket back and forth on the mandrel, stretching the flexible layers.</li><li>Let the socket cool on the mandrel, with the padded end of the mandrel at the narrowest part of the socket.</li><li>Refit as in the preceding section, using silicone spray in the socket if necessary.</li></ol> <h3>Alignment</h3> <h4>Bench</h4> <p>The initial set-up is made with the ischial seat level. The posterior plumb line for the heel center passes between the center of the end of the socket and the point where the ischium rests on the ischial seat (<b>Fig. 45a</b>). The lateral plumb is taken from the center of the end of the socket and passes % in. anterior to the knee center (<b>Fig. 45b</b>). The socket is set in 15 degrees -30 degrees of internal rotation to the line of progression to compensate for the patient's tendency to internally rotate the pelvis to advance the prosthetic leg (<b>Fig. 45c</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45a. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45b. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45c. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Functional</h4> <p>The prosthesis is the correct length when the patient's spine is as straight as possible when he stands with his weight on both legs, i.e., in the finished prosthesis. The iliac crests of these patients are not always symmetrical, and it may not be a reliable reference point for judging the length of the prosthesis (<b>Fig. 46</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Dynamic alignment is done with the socket set on a child-size above-knee jig. Optimal dynamic alignment is based on standards set for the standard above-knee amputee.</p> <h3>Summary</h3> <p>This fitting technique can also be used on other stumps with bulbous ends: Syme's and above-elbow amputations and wrist disarticulations, for example.</p> <p>At CAPP, more than 20 patients have been fitted in this manner: 18 PFFD's, 2 bilateral Syme's amputations, 1 wrist disarticulation, and 1 above-elbow amputation. All of these patients' deficiencies were congenital in origin.</p> <p>The procedure described does require more fabrication time and material. Once the technique is mastered, it requires about three hours of the prosthetist's time, whereas a solid socket can be fabricated in an hour. However, the CAPP patients have shown a marked preference for this type of socket. It provides a very precise fitting, and in every case the child has expressed a feeling of greater security when wearing this socket (<b>Fig. 47</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another advantage is the apparent absence of skin breakdown. When the patient comes to the clinic for post-fitting examination, the characteristic blanching of the stump skin is absent, as are signs of rubbing, blistering, or callousing so often seen with use of the solid socket.</p> <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. 21. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. </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> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Aitken, George T., Proximal femoral focal deficiency-definition, classification, and management, in Proximal Femoral Focal Deficiency: A Congenital Anomaly, National Academy of Sciences, Washington, D.C., 1969.</li> <li>Marx, Herbert W., An innovation in Symes prosthetics, Orth. and Pros., 23:3:131-138, September 1969.</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>1.</b> </td><td class="clsTextSmall">Aitken, George T., Proximal femoral focal deficiency-definition, classification, and management, in Proximal Femoral Focal Deficiency: A Congenital Anomaly, National Academy of Sciences, Washington, D.C., 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, George T., Proximal femoral focal deficiency-definition, classification, and management, in Proximal Femoral Focal Deficiency: A Congenital Anomaly, National Academy of Sciences, Washington, D.C., 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Carman Tablada. C.P. </b></td></tr><tr><td class="clsTextSmall">Mr. Tablada is a clinical prosthetist at the Child Amputee Prosthetics Project, University of California, Los Angeles. This study was made under MCH Project No. 204, Division of Health Services and Mental Health Administration, Maternal and Child Health Service, Department of Health, Education, and Welfare. The photographs were taken by Mary Louise Histon.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-18.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-19.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-20.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-26.jpg Figure 11 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-27.jpg Figure 12 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-45.jpg Figure 13 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-46.jpg Figure 14 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-47.jpg Figure 15 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-48.jpg Figure 16 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-49.jpg Figure 17 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-07.jpg Figure 18 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-08.jpg Figure 19 http://www.oandplibrary.org/al/images/1971_01_027/1971_01_027-09.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 Technique for Fitting Converted Proximal Femoral Focal Deficiencies Creator An entity primarily responsible for making the resource Carman Tablada. C.P. * https://staging.drfop.org/files/original/dd8db7616001226c18971be2d8fcd283.pdf 1ad480aad4abe8298ef123b76f395b42 https://staging.drfop.org/files/original/d5b8d44b32ee77a3f0a1323a80a9afcc.jpg 2d03a3805b271567b07dc8e3a894f760 https://staging.drfop.org/files/original/beabbcc10d39750ad0df0029737fbb9a.jpg 2c4cecf0a116c3038089460eeeb1656d https://staging.drfop.org/files/original/eab5312062924db051a8886268065332.jpg 9a0e042d67cb98394cd3911b39aa9ef8 https://staging.drfop.org/files/original/6a6cd46dbbb7e7a257b0eb28b50d3729.jpg d75170a96119542a41e69cf1cdd9e7c9 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_01_038.pdf Text Any textual data included in the document <h2>Use of a Bivalved Thoracic Suspension Jacket in the Orthotic Seating Management of Severe Arthrogryposis Multiplex Congenita</h2> <h5>Carrie L. Beets, CO.&nbsp;<a style="text-decoration: none;">*</a><br />Louis Whitfield, R.T. (O)&nbsp;<a style="text-decoration: none;">*</a><br />Jan Minnich, L.P.T.&nbsp;<a style="text-decoration: none;">*</a><br />J. Leonard Goldner, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <h3><br />Introduction</h3> <p>The thoracic suspension orthosis<a></a> was developed to aid in the management of patients with neuromuscular disease and has been used primarily in individuals with myelodysplasia. The principle of the device is to use the rib cage as a weight bearing structure and thus provide improved seating posture for the patient while attempting to limit spinal deformity and relieve excess ischial pressure. Additional benefits include improvement of balance and mobility and freeing of the hands and arms for feeding and other activities of daily living. The body image of the patient is improved while seated in a wheelchair, and the patient may interact better with the environment.</p> <p>The thoracic suspension orthosis should be considered for those patients who cannot tolerate surgery or when surgery should be delayed until they reach maturity.</p> <p>The patient presented in this paper does not fit the usual criteria for use of a thoracic suspension orthosis. The needs of this patient went beyond those provided by usual orthotic seating devices and led to the adaptation of established techniques and development of a different design to provide a functional seating arrangement for a severely involved child who had failed with other custom seating devices.</p> <p>This seven year old girl with severe generalized arthrogryposis multiplex congenita had functional limitation in the upper extremities and no voluntary action in the lower extremities. Surgical releases of soft tissue contractures and proximal and distal femoral osteotomies had been performed to adapt the patient to a sitting position. Past attempts to provide molded seating inserts to allow a comfortable sitting position had failed. She was most functional supine in a custom designed and portable bed-like seating insert which permitted feeding.</p> <p>Examination of the child revealed severe muscle atrophy of both upper extremities. There was active elbow extension but no active flexion. She was able to get her left hand to within several inches of her mouth by abducting and forward flexing her shoulder and then allowing gravity to bring her hand to the mouth.</p> <p>The spine revealed right thoraco-lumbar scoliosis, thoracic kyphosis, fixed lumbar lordosis, and a fixed pelvic obliquity in which the left pelvic brim was higher than the right.</p> <p>The left hip had a range of motion from 30 degrees flexion to about 90 degrees for a total of 60 degrees of flexion, with an external rotation deformity. The right hip was fixed in +20 degrees flexion. Both knees had flexion contractures of 70 degrees with 10 degrees motion.</p> <p>In order to flex the right femur for sitting, a subtrochanteric osteotomy had been performed with creation of a silicone capped pseudoarthrosis. While this was relatively successful, pain occurred when the patient was placed in a sitting position with any weight bearing occurring on the right ischium. For this reason, she was evaluated for use of a thoracic suspension orthosis.</p> <p>The patient was initially placed in a plaster cast thoracic suspension jacket for a three week trial. During this time, the periods of suspension were gradually increased. Her skin was not accessible for monitoring; however, since she had normal sensation and was cooperative, we depended on her complaints of pain to assess the support. She tolerated the three week trial period and experienced no skin breakdown or abrasion. At that time, a cast impression was taken for the fabrication and fitting of a thoracic suspension orthosis.</p> <h3>Fabrication And Fitting</h3> <p>Due to the lack of spinal flexibility, the need for easy and accurate application of the orthosis, and the need to make the device as simple as possible for the parents; a bivalved design was chosen rather than the traditional single anterior opening. The bivalved design (<a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-1.jpg"><b>Fig. 1</b></a>) necessitated fabrication of two plastazote™ linings complete with conventional additional plastazote™ layers over the inferior costal margins. Special attention was needed to insure that the anterior and posterior halves of the two linings matched up accurately during the vacuum forming process (<a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-2.jpg"><b>Fig. 2</b></a>).</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-1.jpg">Figure 1.</a> Lateral view of bivalved thoracic suspension orthosis showing anterior shell trimlines.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-2.jpg">Figure 2.</a> View from above, the anterior and posterior linings match up to provide an even pressure just distal to the lateral and anterolateral inferior costal margins.</strong><br /> <p>The suspension spools were incorporated into the posterior shell, which was fabricated of low density polyethylene. High density polyethylene was chosen for the anterior shell, as it was felt that the additional rigidity provided by this material would be needed to maintain the integrity of the circumferential containment of the jacket under weight bearing. A large abdominal opening was provided in the anterior shell because the patient had experienced some distress in the plaster jacket, especially following meals, which had been relieved by the addition of an opening in the plaster cast (<a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-3.jpg"><b>Fig. 3</b></a>). The two half shells were held in place as a unit with Velcro® closures.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-3.jpg">Figure 3.</a> Anterior view of bivalved thoracic orthosis showing abdominal opening.</strong><br /> <p>Fitting of the orthosis was followed by an in-hospital program of gradually increasing wearing time both in the nonsuspended and suspended states. Her original supine positioning device was modified to permit her to lie in this with the thoracic suspension jacket on, eliminating the need to take off the jacket between periods of suspension. Since she could not tolerate any weight bearing on her right hip, the suspension brackets on the wheelchair were positioned for full weight bearing suspension. She tolerated the conditioning program well. At the time of discharge, she was wearing the jacket all day long and was tolerating uninterrupted suspension for periods of two and one-half hours. Her electric wheelchair was outfitted with a chin operated joy stick control (<a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-4.jpg"><b>Fig. 4</b></a>). While suspended, she could operate the wheelchair well. However, at the end of two and one-half hours in suspension, the patient would begin to complain of discomfort and would be transferred to her supine positioning device.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-4.jpg">Figure 4.</a> Patient sitting in suspension in wheelchair.</strong><br /> <h3>Conclusion</h3> <p>The application of a thoracic suspension jacket is a way of successfully providing a functional sitting position for a patient with severe arthrogryposis. In conjunction with a modified electric wheelchair, the patient was given an opportunity to interact actively with her environment, including a vertical position for eating.</p> <p>The bivalved design not only affords easy application and removal, but also permits visual monitoring of the skin. The crucial circumferential containment in the area of and just distal to the inferior costal margin was maintained satisfactorily with a bivalved design.<br /><br /><em><b>*J. Leonard Goldner, M.D. </b>J. Leonard Goldner, M.D., was former Chief of Orthopedics, Division of Orthopedic Surgery, Duke University Medical Center.<br /><br /><b>*Jan Minnich, L.P.T. </b>Jan Minnich, L.P.T., is with Lenox Baker Children's Hospital, Durham, North Carolina.<br /><br /><b>*Louis Whitfield, R.T. (O) </b>Louis Whitfield, R.T.(O), is with the Department of Prosthetics and Orthotics at Duke University Medical Center.<br /><br /><b>*Carrie L. Beets, CO. </b>Carrie L. Beets, CO., is with the University of Virginia. She was formerly with the Duke University Medical Center at the time of submission of this article.</em></p> <p><b>References:</b></p> <ol> <li>Drennan, J.C.; Renshaw, T.S., and Curtis, B.H., "The Thoracic Suspension Orthosis," <i>Clinical Orthopaedics and Related Research</i>, No. 139, March/April, 1979, pp. 33-39.</li> <li>Drennan, J.C., <i>Orthopedic Management of Neuromuscular Disorders</i>, J.B. Lippincott Co., Philadelphia, p.83.</li> <li>Fillauer, C.E.; and Pritham, CH., "The Thoracic Suspension Jacket-Review of Principles and Fabrication, <i>Orthotics and Prosthetics</i>, Vol. 38, No. 1. Spring, 1984, pp. 36-44.</li> </ol> Page Number(s) 38 - 41 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_01_038/1986_01_038-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Use of a Bivalved Thoracic Suspension Jacket in the Orthotic Seating Management of Severe Arthrogryposis Multiplex Congenita Creator An entity primarily responsible for making the resource Carrie L. Beets, CO. * Louis Whitfield, R.T. (O) * Jan Minnich, L.P.T. * J. Leonard Goldner, M.D. * https://staging.drfop.org/files/original/edc28974552d636fa1ea028aa0e21578.pdf 294e8f5e3a6397b4484601b6f361116c https://staging.drfop.org/files/original/781e2b223fa61880bf51b05c4edf135c.jpg 4ad590c6d183512433ec8b8f2b4b339c https://staging.drfop.org/files/original/c7377cf25aabe70d5cb23dd8de0aa0c4.jpg ee7fcf6b5720cb917c7db96963d9ad84 https://staging.drfop.org/files/original/f51761f1329161d2580197578d7d8689.jpg b74b09c28a7f96ffb049050980e2099b https://staging.drfop.org/files/original/66a30e039664be60082b9b8032b9c241.jpg 2557718fb6cbda2e9f4168069b87f242 https://staging.drfop.org/files/original/d399253c84caa386bc8be7d60bf1dd9f.jpg f587df89b78717e6bf8e8b8a8a6dc318 https://staging.drfop.org/files/original/1e2e1ad63b2195562c9cc2f2a67b6085.jpg ca43f84c54cd7bc3d4a8bb5f93af4b53 https://staging.drfop.org/files/original/182b0fc27916a29db2515bef2f1e987c.jpg a32b2f619602dbe88784e5017ad43476 https://staging.drfop.org/files/original/30ccdd27a6c8be6477d61535158ac7a2.jpg f9ae503cf342bcd9591a3274c694a082 https://staging.drfop.org/files/original/2dc72d2c032ba91c99f619f9238b0f6f.jpg 1eb6c0a2bcb4e2c27ff6fda53ffa817b https://staging.drfop.org/files/original/0709f936190c8cd43b0d3c61388f76c3.jpg 31339e09eb509368490509db7a7d804e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_095.pdf Text Any textual data included in the document <h2>The Anterior Shell Orthosis: An Alternative TLSO</h2> <h5>Carrie L. Beets, CO.&nbsp;<a style="text-decoration: none;">*</a><br />Tom Faisant, R.P.T.&nbsp;<a style="text-decoration: none;">*</a><br />Vernon Houghton, R.T.O.&nbsp;<a style="text-decoration: none;">*</a><br />C. Michael Schlich, C.P.O.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Postoperative spinal management has undergone progressive changes in recent years. The merits of early mobilization following spinal surgery are well documented<a></a> and it is now generally agreed that earlier mobilization leads to quicker and more successful patient recovery. The recent advent of DRGs and predetermined payment to hospitals, regardless of length of hospitalization, adds even more incentive to the concept of earliest possible mobilization.</p> <p>Traditional approaches to postoperative spinal immobilization have been plaster body casts,<a></a> Jewett hyperextension orthoses,<a></a> and Knight-Taylor orthoses.<a></a> More recent approaches include the use of total contact TLSO's (body jackets), either with an anterior or posterior opening, or a bivalved, clamshell design.<a></a> Each of the above orthoses has inherent deficiencies with respect to very early patient mobilization attempts. Briefly, plaster casts lack total contact, lack volume adjustability, and do not promote or allow acceptable skin hygiene. Metal frame type orthoses such as a Jewett or Knight-Taylor do not control motion in all three planes, which is necessary for immediate postoperative mobilization. The ability of these orthoses to control lateral trunk flexion and/or rotary motion of the trunk is questionable. On the other hand, total contact TLSO's provide excellent control, but are very difficult to independently don and doff and, more important, they require rolling the patient into a prone position, or use of a Stryker frame, for molding. An additional deficiency of total contact TLSO's is they are too restrictive or confining, and actually slow the rehabilitation/recovery process by limiting range of motion necessary for independence.</p> <h3>Development And Description</h3> <p>In late 1977, Richard Rosenberger, CP. (deceased March, 1985) and physicians with the Department of Orthopaedics and Rehabilitation at the University of Virginia Medical Center developed the "anterior shell" orthosis as an alternative TLSO, designed to address all of the above mentioned deficiencies found in these other orthotic approaches. As its name implies, the anterior shell orthosis is a TLSO that provides total contact coverage to the anterior three quarters of the trunk, with the anterior trimlines the same as those of any standard body jacket type TLSO, and the lateral trim-lines just posterior to the lateral midline of the trunk (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-01.jpg"><b>Fig. 1</b></a>). Suspension and immobilization are afforded by this total contact anterior section coupled with a Jewett type posterior pad with adjustable straps and a two inch wide Velcro® posterior strap across the sacral-coccygeal junction of the pelvis (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-02.jpg"><b>Fig. 2</b></a>). Although quite flexible upon first impression, this TLSO becomes sufficiently rigid when properly tightened on a patient (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-03.jpg"><b>Fig. 3</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-04.jpg"><b>Fig. 4</b></a>), deriving its strength and rigidity from the tubular principle. This orthotic design provides a three point pressure system which is effective from T5 to L5; however, a cervical extension can be added to the orthosis to extend its support to the upper thoracic region. Originally designed for postoperative spinal management following Harrington rod instrumentation secondary to traumatic injury, the anterior shell orthosis permits the cast impression to be taken with the patient comfortably supine without the need for proning or other patient movement.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-01.jpg"><strong>Figure 1. Anterior view of Orthoplast™ anterior shell orthosis.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-02.jpg"><strong>Figure 2. Posterior view of Orthoplast™ anterior shell orthosis.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-03.jpg"><strong>Figure 3. Anterior view of patient wearing orthosis.</strong></a><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-04.jpg">Figure 4. Lateral view of patient wearing orthosis. Note Jewett type posterior pad and strap arrangement.</a><br /></strong><br /> <h3>Advantages</h3> <p>In addition to the advantage of not having to move the patient while casting, the anterior shell orthosis is felt to be superior to the bi-valved and circumferential TLSO designs for postoperative management in other respects. Additional .advantages offered by the anterior shell orthosis include ease of donning and doffing the orthosis initially for the nursing staff and later, the ability to independently don and doff the orthosis by the patient while in the supine position (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-05.jpg"><b>Fig. 5</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-06.jpg"><b>Fig. 6</b></a>), ease of inspection of the surgical wound site without having to doff the orthosis, increased air circulation to the surgical wound site, and more efficient cooling due to less body containment within the orthosis. The anterior shell orthosis provides anterior, posterior, lateral, and rotary control, however, because there is no posterior section, the lateral aspects are slightly more flexible than in a circumferential design. This quality of slight flexibility facilitates maneuverability during transfers and activities of daily living, yet the orthosis provides sufficient external stabilization to protect the Harrington rod instrumentation.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-05.jpg"><strong>Figure 5. Patient in supine position donning orthosis.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-06.jpg"><strong>Figure 6. Patient, lying down, rolls to side and fastens the posterior pad and strap. Allowing for the posterior pad and strap to fasten on the same side facilitates donning and doffing in the lying position.</strong></a><br /> <h3>Indications</h3> <p>As the advantages of the anterior shell design were proven with experience with postoperative patients, opportunities were sought for its use with other spinal diagnoses (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-07.jpg"><b>Table 1</b></a>). Indications for use of the anterior shell orthosis now include various vertebral fractures, treated surgically or non-surgically; vertebral degeneration and pain due to diffused malignancy; progressive kyphosis due to osteoporosis, ankylosing spondylitis, and neurological conditions; degenerative joint disease; and postoperative management of spinal stenosis.</p> <h3>Experience</h3> <p>Over a period spanning 1979-1985, 232 patients were treated orthotically with the anterior shell; 137 of these patients were treated postoperatively (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-08.jpg"><b>Table 2</b> </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-09.jpg"><b>Table 3</b></a>). Over this seven year period, no postoperative patients experienced failure of surgical instrumentation while in the orthosis. During the initial development phase in 1978, only one postoperative patient experienced failure of his surgical instrumentation while in the orthosis.</p> <h3>Treatment Regime</h3> <p>Current treatment of thoracic and lumbar spinal cord injuries at the University of Virginia Medical Center includes molding and subsequent fit and delivery of an anterior shell orthosis within a few days post-surgery. Patients are usually maintained supine in bed until the orthosis is fit and delivered, with rehabilitation beginning immediately after fitting and delivery. At two weeks post-surgery, patients are allowed unlimited forward leaning in the orthosis for level and uneven surface transfers (wheelchair to bed, wheelchair to mat, etc.). Once the basic transfers are mastered, appropriately supervised advanced wheelchair transfers are permitted, including wheelchair to floor, floor to wheelchair, ascending and descending stairs in a sitting position, and in and out of a bathtub. At three to four weeks post-surgery, patients are taught independent donning and doffing of the orthosis in the supine position.</p> <h3>Technical Information</h3> <p><i>Material Selection</i></p> <p>At the University of Virginia Medical Center, the anterior shell orthosis is normally fabricated utilizing Orthoplast™. This thermoplastic material offers quick and easy fabrication that permits removal from the mold immediately after cooling without risk of shrinkage or other distortion. This allows for quick fabrication and delivery of the orthosis. Other noteworthy advantages of Orthoplast™ include pre-ventilation for air circulation, light weight, and due to its low temperature thermomolding properties, it is easily adjusted or modified in hospital and clinical settings. In cases where the orthosis is going to be used definitively, thermoplastics such as polyethylene or Vi-trathene are used in lieu of Orthoplast™.</p> <p><i>Patient Molding</i></p> <p>To cast a patient for an anterior shell orthosis, a piece of 12 inch wide stockinette is split lengthwise and placed over the patient with the edges of the stockinette tucked under the patient to prevent shifting during casting. A piece of narrow stockinette is passed carefully under the patient in the lumbosacral region of the back and through to the other side. The two ends are pulled tight over the iliac crests, tied off, and placed under tension as for pelvic traction (<b>Fig. 7</b>). Indelible anatomical markings are made and include the xiphoid process, sternal notch, costal margins, anterior superior iliac spines, and the superior border of the symphysis pubis. Plaster splints ase then applied making sure to cover from the symphysis pubis to the sternal notch anteriorally and down to the surface of the table on the sides, being sure to follow the patient's contours. When hardened, the plaster cast impression is removed and sealed and the positive model is poured.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-10.jpg"><strong>Figure 7. Patient, in supine position, is ready to be casted. Patient does not have to be rolled or turned to complete casting.</strong></a><br /> <p><i>Model Modification</i></p> <p>The positive model is modified in a normal TLSO modification fashion, including flattening the anterior lower thoracic and abdominal area for increased intraabdominal pressure and defining the area above the iliac crests for good suspension on the pelvis. Plaster buildups are added over the anterior superior iliac spines if the patient is thin. The lateral posterior border is extended two inches in the posterior direction from the iliac crests inferiorally, to cover the gluteals laterally and increase lateral stability.</p> <p>Because the anterior trimline of the orthosis extends to within an inch of the sternal notch, female patients require design variations in the model modification and the subsequent orthosis. For large busted female patients, an opening is frequently designed in the breast area to free the breasts. For smaller busted female patients, the breast area is built up on the plaster model to permit room for the breasts in the orthosis with the patient upright. In both situations, the area superior to the breast area is reduced on the plaster model to ensure good contact within the orthosis; also, the area superior to the breasts is reinforced in the fabrication process to ensure rigidity. When total contact for support and/or dispersement of pressure over a greater area is needed, as in cases of degenerative disease, such as osteoporosis, arthritis, and diffused cancer, the breast area is built up slightly on the plaster model and incorporated into a solid design in the orthosis.</p> <p><i>Fabrication Techniques</i></p> <p>When molded with Orthoplast™, reinforcement is provided by a double thickness of Orthoplast™ in appropriate areas: the anterior superior and the lateral posterior edges. The metal anchor plates for attachment of the posterior pad straps are sandwiched in between layers of Orthoplast™ and later drilled and tapped for 8-32 screws.</p> <p>If vacuum formed using a more durable thermoplastic, reinforcement can be provided with hybrid carbon composite inserts (available from Durr Fillauer). In this fabrication technique, the metal anchor plates for the posterior pad straps can be mounted on the plaster model for incorporation into the vacuum formed shell.</p> <p>In either case, the posterior pad is patterned after the Jewett orthosis posterior pad and has two sets of 1/2 inch dacron straps with 3/16 inch diameter holes, 1/2 inch apart in both ends for connection to the anterior shell. The posterior pad floats freely on the dacron straps, which are permanently attached to the metal anchor-plate on the left side of the orthosis with 8-32 screws and have roller buckles on the right hand ends of the straps. The right side straps, which are attached under 8-32 screw studs, pass through the roller buckles and double back on themselves for adjustable tension control and attachment to the stud-heads of the 8-32 screw studs. The roller buckle system acts as a pulley system, thereby reducing the mechanical force needed to properly tighten the posterior pad.</p> <p>The final component in the system is the two inch wide Velcro® sacral-coccygeal strap, which is permanently attached on the left side of the anterior shell, passes through a two inch stainless steel loop on the right, and doubles back on itself for a secure closure.</p> <p>This adjustable closure system is described as was originally designed by Rosenberger, et al. It is not necessarily deemed to be the simplest. Any of the adjustable closure systems utilized in the available prefabricated spinal extension orthoses should provide a suitable alternative to the above closure system.</p> <h3>Summary</h3> <p>The anterior shell orthosis provides quickly accessible orthotic support for early mobilization of patients with spinal cord injury and other diagnoses, allowing for independent donning and doffing with relative ease. Though sufficiently rigid to protect surgical instrumentation while boney fusion takes place, the anterior shell orthosis allows maximum maneuverability possible for a patient in a TLSO.</p> <h3>Acknowledgments</h3> <p>The authors would like to acknowledge Michael Smith for his efforts in the chart reviews.</p> <p><b>References:</b></p> <ol> <li>Albee, F.H., E.J. Powers, and H.C. McDowell, <i>Surgery of the Spinal Column</i>, F.A. Davis Co., 1945, pp. 213-215.</li> <li>Bauer, R., "Preoperative Correction and Post-operative Fixation Using Harrington Instrumentation," <i>Operative Treatment of Scoliosis</i>, George Chapchal, editor, 1973, pp. 82-85.</li> <li>Bradford, D.S. and R.C. Thompson, "Fractures of the Spine," <i>Minnesota Medicine</i>, 59:1976, pp. 711-720.</li> <li>Dickson, J.H., P.R. Harrington and W.D. Erwin, "Results of Reduction and Stabilization of the Severely Fractured Thoracic and Lumbar Spine," <i>Journal of Bone and Joint Surgery</i>, 60A:1978, pp. 799-805.</li> <li><i>The Unstable Spine</i>, edited by S.B. Dunsker, H.H. Schmidek, J. Frymoyer and A. Kaan, pp. 12-15.</li> <li>Edmonson, A.S. et al., "Report: Panel on Spinal Orthotics," <i>Orthotics and Prosthetics</i>, Vol. 31, No. 4, December, 1977, pp. 67-71.</li> <li>Edmonson, A.S., "Spinal Orthotics," <i>Orthotics and Prosthetics</i>, Vol. 31, No. 4, December, 1977, pp. 31-42.</li> <li>Flesch, J.R., et al., "Harrington Instrumentation and Spine Fusion for Unstable Fractures and Fracture-Dislocations of Thoracic and Lumbar Spine," <i>Journal of Bone and Joint Surgery</i>, 59A:1977, pp. 143-153.</li> <li><a href="http://www.acpoc.org/library/1976_01_007.asp">Friddle, W.D. and L.P. Brown, "Greenville Spinal Orthosis, Polypropylene," <i>Inter-Clinic Information Bulletin</i>, 15(9&amp;10):Sept.-Oct. 1976, pp. 7-12.</a></li> <li>Norton, P.L. and T. Brown, "The Immobilization Efficiency of Back Braces," <i>Journal of Bone and Joint Surgery</i>, 39A:1957, pp. 111-139.</li> <li>Van Hanswyk, E.P., H.A. Yuan, and W.A. Eckhardt, "Orthotic Management of Thoraco-Lumbar Spine Fractures With A Total-Contact TLSO," <i>Orthotics and Prosthetics</i>, Vol. 33, No. 3, September, 1979, pp. 10-19.</li> <li>Wallace, S.L. and K. Fillauer, "Thermoplastic Body Jackets for Control of the Spine After Fusion in Patients With Scoliosis," <i>Orthotics and Prosthetics</i>, Vol. 33, No. 3, September, 1978, pp. 20-24.</li> <li>Wharton, G.W., "Stabilization of Spinal Injuries For Early Mobilization," <i>Orthopedic Clinics of North America</i>, 9(2): April, 1976, pp. 271-276.</li> </ol> <em><b>*C. Michael Schlich, C.P.O. </b> C. Michael Schuch, C.P.O. is Assistant Professor in the Department of Orthopaedics and Rehabilitation and Associate Director in the Division of Prosthetics, Orthotics, and Rehabilitation Engineering Services at the University of Virginia Medical Center in Charlottesville, Virginia.</em><br /><br /><em><b>*Vernon Houghton, R.T.O. </b> Vernon Houghton, R.T.O. is an Orthotic Assistant in the Division of Prosthetics and Orthotics at the University of Virginia Medical Center in Charlottesville, Virginia.</em><br /><br /><em><b>*Tom Faisant, R.P.T. </b> Tom Faisant, R.P.T. is a Supervisor of Physical Therapy in the Adult Rehabilitation Unit at the University of Virginia Medical Center in Charlottesville, Virginia.</em><br /><br /><em><b>*Carrie L. Beets, CO. </b> Carrie Beets, CO. was formerly with the Division of Prosthetics and Orthotics at the University of Virginia Medical Center in Charlottesville, Virginia.<br /><br /></em> Page Number(s) 95 - 100 Year 1987 Volume 11 Issue 2 Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-06.jpg Figure 7 Table 1 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 Table 2 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-08.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-01.jpg Figure 9 Table 3 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-09.jpg Figure 10 FIGURE 7 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-10.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 Anterior Shell Orthosis: An Alternative TLSO Creator An entity primarily responsible for making the resource Carrie L. Beets, CO. * Tom Faisant, R.P.T. * Vernon Houghton, R.T.O. * C. Michael Schlich, C.P.O. * https://staging.drfop.org/files/original/dbe2ac19d37adf6c68bc2cc2d6d7a9ee.pdf bab704eb64cc2396fb9d10d50719dee6 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1982_03_001.pdf Text Any textual data included in the document <h2>Continuing Education: Past, Present, and Future for AAOP</h2> <h5>Charles H. Dankmeyer, Jr., CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>In 1978 the American Board For Certification in Orthotics and Prosthetics, Inc. (ABC) and the American Academy of Orthotists and Prosthetists (AAOP) reached an agreement which provided that AAOP would administer the continuing education program begun by ABC. The program is very similar to its original format developed by ABC, and remains a voluntary program. The Academy is responsible for processing applications, developing the standards to be met by the participants, and developing a recognition system for successful participants. ABC continues to accredit appropriate educational programs submitted to it and to designate the number of continuing education credits awarded for each program.</p> <p>The reason the organizations reached this agreement is two-fold. First, since the continuing education program that ABC was administering had no effect on certification outside of deciding the number of credit hours to be awarded for each program, ABC believed it should not be providing recognition to successful participants in a voluntary continuing education program. Second, AAOP believed that part of its responsibility was education. Since AAOP was directly involved in providing seminars, it seemed appropriate that AAOP should administer a continuing education program and provide recognition for successful participants.</p> <p>It should be remembered that both groups agreed to the continuing education program being administered by AAOP only to the extent that it did not affect certification. It should also be borne in mind that AAOP has no influence on the number of credits awarded or the approval of programs for credit.</p> <p>I stress that any continuing education program developed within the Academy does not affect an individual's certification by ABC. This emphasis is made because this is an area of grave misunderstanding by Academicians. Many members believe that if an individual does not participate in the continuing education program, he will lose his certification. Such is not the case. Any program developed by AAOP will affect only the membership within AAOP and not an individual's certification. The certification of an individual and the continuing certification of an individual remains the province of ABC.</p> <p>At the 1981 AAOP annual meeting the membership voted to convert the existing voluntary continuing education program to a mandatory program. This move by the membership has caused AAOP to search for an acceptable system for mandatory continuing education. Many approaches to converting the existing voluntary program to a mandatory one have been examined. None have been deemed acceptable.</p> <p>There are many problems within the continuing program which could lead to injustices for Academicians participating in a mandatory program. One of the things necessary, if we are to have a successful mandatory continuing education program, is the capability for an individual to plan ahead in meeting his continuing education requirements. Currently, there exists no publication which permits an Academician to sit down and look at all of the seminars and special programs being put on by other paramedical groups which may be acceptable for continuing education. Even if such a publication were available, there would be no listing of the number of credits allowed for each of these programs. Many programs which may well be suitable for credit are never even submitted to ABC to be approved. Program organizers are often not concerned about the need of orthotists or prosthetists to meet continuing education requirements and therefore never submit their programs for approval by ABC. Therefore, AAOP cannot recognize an Academician's attendance at many of the seminars and programs that are given locally by therapists and physicians groups. Additionally, there are extenuating circumstances which affect some Academicians' attendance at seminars.</p> <p>For example, I received a letter from an individual who was concerned that his membership in the Academy would be in jeopardy because he was unable to attend seminars on Saturday. As you know, most seminars are held on Friday, Saturday, and Sunday. This particular individual is a practicing Orthodox Jew and is unable to attend any seminars held on the Sabbath. It seems to me that it is in the best interest of the Academy to attempt to develop a program which will accommodate all individuals and not require them to travel in order to participate in the continuing education program. Such a program would allow individuals several choices to meet continuing educational requirements.</p> <p>I would suggest that reading of the AOPA Journal, <i>Orthotics and Prosthetics</i>, and clinical participation be the two mainstay requirements to maintain membership in the Academy. In fact under the current continuing education program, Journal reading is an acceptable means of obtaining credit. How does one know someone has really read the Journal? Journal reading could be verified by providing a group of questions at the end of a selected article within each issue. Academicians wishing to participate in a continuing education program would complete the questionnaire at the end of the selected article and return it to the National Office for approval. Although such a system appears to be a very minimal requirement, it would demonstrate that participants had at least read <i>Orthotics and Prosthetics</i>. There is currently such a system being used in a publication entitled <i>Contemporary Orthopedics</i>. This should satisfy the needs of those individuals who are unable to travel to seminars. Those individuals who decided to travel to seminars and meetings should be allowed to apply for credit for seminars attended. Therefore, they would not need the credits earned by responding to the questionnaires.</p> <p>An additional alternative could be a self-assessment examination. This could be required every three years of individuals who had not participated in a continuing education program designed around Journal reading or seminar attendance. Such a self-assessment examination could be structured in a manner which reported back to the individual his results without affecting his membership in the Academy. At the very least it would identify areas in which an Academician needed work. It is difficult to imagine that the Academy would be telling an Academician that he needed to bone up on a specific subject, because Academicians are currently practicing orthotics and prosthetics. To say that an Academician required additional work in a specific area is to say that orthotists and prosthetists are providing inadequate services. This is the same tack which therapists and physicians have taken with their mandatory continuing education programs. In essence, all of these programs state that practitioners who do not fulfill the requirements of the program are not maintaining competency.</p> <p>I do not believe that this is the case for orthotists and prosthetists. I believe that most orthotists and prosthetists have met the challenge of modern day orthotics and prosthetics practice. I further believe that if we are attempting to require continuing competency, and not continuing education, we should change our goals.</p> <p>The goal of all continuing education programs is to provide that practitioners maintain current standards which will benefit their patients. No continuing education program requires that a practitioner who attends a program utilize the material presented in that program. In other words, you can make someone sit down and listen to a different way of doing things, but you cannot make him practice it. This being the case, I do not believe that a mandatory continuing education program is in the best interest of the Academicians or the patients we serve. I suggest that continuing education not be a requirement for membership in the Academy. I further suggest that those practitioners who believe the ranks should be periodically reviewed for competency expend their efforts on obtaining a mandatory continued competency system.</p> <p>Continuing education is indeed the route that all other medical professions have followed. Continued competency remains the burr in every medical profession's side.</p> <p>To develop a continuing education program and to require that individuals participate in such a program appears to be the route that we must follow. I personally do not agree that this is the correct route. However, such a program has been requested by the membership. Academicians, I request that you submit to me your thoughts on such a mandatory continuing education program as a requirement for membership in the Academy.</p> <b>*<em>Charles H. Dankmeyer, Jr., CPO </em></b><em> Chairman, Continuing Education Committee President, Dankmeyer, Inc. Baltimore, MD<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 1 - 2 Year 1982 Volume 6 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Continuing Education: Past, Present, and Future for AAOP Creator An entity primarily responsible for making the resource Charles H. Dankmeyer, Jr., CPO * https://staging.drfop.org/files/original/d6ec4f4cef4fe2b96b5552ee4bba10a9.pdf 8f92cb1131cf047459895a5704ecc878 https://staging.drfop.org/files/original/998b11fabd198c71f6abd4bf6b516e92.jpg 315bfea7ae8512dca9b0928e26cca16c https://staging.drfop.org/files/original/a791344928dd5ce06a9dafb331b696fb.jpg 79ef2482afd24d2c7b2c8dd1b65284ec https://staging.drfop.org/files/original/4134d8561dbb4b9e1a573017e6502b8b.jpg 800248e585502a10a8018e210a065fa7 https://staging.drfop.org/files/original/9954f37265beca7bc0641bc84005faec.jpg a22bede040881a6d70bf53010ced6d35 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_020.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 20 - 24 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_01_020.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_020.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Experience with the Münster-Type Below-Elbow Prosthesis, a Preliminary Report</h2> <h5>Charles H. Epps, Jr., M.D. <a style="text-decoration:none;">*</a><br />John H. Hile <a style="text-decoration:none;">*</a><br /></h5> <p>The Münster technique, an attempt to obviate the traditional problems associated with fitting short and very short below-elbow amputees with split sockets and step-up hinges, has been described in some detail. <a></a> However, individual clinic experience in fitting Münster-type prostheses to patients has not been well documented. Following publication of a manual of instruction for the Münster-type below-elbow prosthesis by New York University in 1965, <a></a> the Juvenile Amputee Clinic of the District of Columbia General Hospital undertook the routine fitting of short below-elbow cases with these prostheses. The principles of construction and fitting outlined in the New York University manual were followed very closely. This article presents an analysis of patients fitted with the Münster-type prosthesis at the Juvenile Amputee Clinic.</p> <h3>Scope of the Study</h3> <p>Fourteen patients were fitted with a total of 24 Münster-type below-elbow prostheses between 1965 and 1967. The group comprised eight female and six male patients. The right upper extremity was involved in eight patients, the left in six. There were no bilateral cases. One ten-year-old boy had an amputation of traumatic etiology; the remaining 13 patients had congenital deficiencies. An 11-month-old infant is not included in the analysis because her family moved to another city shortly after her fitting, and no long-term follow-up data could be obtained. Stump length ranged from 1 1/4 in. to 7 in., with all but two stumps measuring less than 4 in. The distribution was as follows:</p> <table> <tbody><tr> <th> <p>Number of Patients  </p> </th> <th> <p>Stump Length (in.)</p> </th></tr> <tr> <td> <p>1</p> </td> <td> <p>1 1/4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>1 1/2</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>1 7/8</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>2</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>2 1/2</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>2 3/4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>3 1/4</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>3 3/4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>7</p> </td> </tr> <tr> <td> <p><b>Total: 13</b></p> </td> <td> <p> </p> </td> </tr></tbody></table> <p>Seven of the patients had been previously fitted by conventional means, and seven had never worn a prosthesis. It is interesting to note that only one of the previous prostheses had been of the split-socket type, the others being preflexed.</p> <p>During the study period, two patients received three prostheses, six received two prostheses, and six had single fittings. In the multiple fittings, the shortest period before replacement was five months, and the longest 26 months. The average for the entire 13 patients on whom adequate follow-up information was obtained was 11.8 months. The three patients requiring replacement at five to six months gained weight rapidly or experienced spurts in growth.</p> <h3>Fabrication and Fitting Procedures</h3> <p>Taking the wrap cast is one of the most critical steps in the preparation of Münster-type prostheses. Use of a proper molding grip is essential to the success of the technique. It was found that the stump of an infant is more difficult to cast than that of an older child because of the discrepancy between the size of the infant's stump and the hands of the prosthetist. Accentuation of the groove for the patient's ulna formed by the thenar and the hypothenar eminences of the pros-thetist's hand seems to be less critical in casting the infant's stump than in casting the stump of the older child or adult. The difference is probably due to the generous layer of subcutaneous fat so characteristic of infancy. No special efforts were made to relieve the olecranon during casting, but a buildup was added to the positive model of the stump. Important factors during casting are pressure at the posterior distal surface of the humerus above the epicondyle level and the two-fingered pressure on either side of the biceps tendon. On small patients, the prosthetist's middle finger is slightly bent because of the different lengths of the index and middle fingers (<b>Fig. 1</b>). A symmetrical socket brim which provides overall fit is the goal (<b>Fig. 2</b>). Aside from these minor differences, the casting and all the construction procedures followed the Xew York University manual exactly.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Molding grip. Note slight flexion of middle finger. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. End view of symmetrical socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The simplified harness system commonly referred to as the figure-nine harness, with the cable reaction point located on the proximal posterior portion of the socket, was used in the series. For the nine-month-old patient a small triceps pad with conventional figure-eight harness was used, in order to make the prosthesis more secure (<b>Fig. 3</b>). It was believed that the nine-month-old patient might be able to remove the prosthesis without the additional suspension provided by the triceps pad and the anterior forked strap.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Nine-month-old female infant (P.M.) with short below-elbow stump fitted with triceps pad and figure-eight harness for additional suspension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Evaluation</h3> <p>The value of the prosthesis was judged on two bases. First, the reactions of the patient and his parents were considered. Second, patient response and performance were compared with the checkout criteria published in the New York University manual.</p> <p>All patients and parents were pleased with the Minister-type prosthesis. The simplified harness and light weight were consistently mentioned as favorable features. It was interesting to note that the seven patients who had previously worn other types definitely preferred the Münster-type. The patient who had worn the split socket was even more emphatic in his approval, as were his parents.</p> <p>Standard checkout forms were used in the clinic. However, for purposes of this study, special attention was given to certain specific items: range of motion with and without prosthesis, stability, and control-system efficiency. These data are summarized in <b>Table 1</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Terminal-device openings were recorded for all patients within the limits of 30 deg. and 90 deg. of elbow flexion and were considered acceptable. The number of rubber bands varied between one-half a band to three, depending upon the functional requirements of the patients.</p> <p>The recorded ranges of elbow motion without the prosthesis illustrate the hyperextension so characteristic of upper-extremity terminal transverse partial hemimelia. Maximum flexion varied from 80 deg. to 100 deg. with the prostheses for most patients. In all instances, full terminal-device opening was obtained at maximum forearm flexion. The test of full terminal-device opening at the mouth did not apply, because the terminal device could not be brought to the mouth. However, since all the patients were unilateral amputees, the flexion ranges were considered acceptable.</p> <p>Retention of the prosthesis under axial load testing revealed suspension stability to be excellent, as most prostheses tolerated one-third of the child's weight without excursion of the socket. The greatest slippage recorded was one-half in.</p> <p>Control-system efficiency was better than 80 per cent in one-half of the prostheses, and in no instance was the percentage less than the 71 per cent recorded in one case.</p> <p>Perspiration has not been a problem even during humid summer days. All patients used cotton stockinette stump socks for insertion of the stump, with the ends tucked back into the forearm shell after donning. It is believed that the opening provided in the medial socket wall for this purpose may have been a significant factor in heat regulation.</p> <h3>Summary</h3> <p>An analysis of experience in fitting a total of 23 Münster-type prostheses to 13 patients has been presented. The prostheses were fitted, with very minor modifications in casting technique, according to the New York University fabrication manual. Actually, the differences were more quantitative than qualitative.</p> <p>It should be mentioned that the clinic prosthetist attended the pilot course in Münster-type fabrication technique at New York University. This technique is best acquired through firsthand instruction rather than by reading a manual.</p> <p>The results have been gratifying. The parents and patients found the prcsthesis acceptable, and in seven cases preferred it to other types that had been previously worn.</p> <p>Although the range of motion in the prosthesis did not always equal the expected 70 deg. of active flexion, function was acceptable. The stability achieved was excellent. In no case was there more than 1/2-in. displacement of socket on the stump with one-third of body weight in axial pull.</p> <p>The control-system efficiency was within acceptable limits in all cases, with one-half checking out at 80 per cent or better.</p> <p>On the basis of this limited experience, it is believed that the Münster-type prosthesis is the fitting of choice for the child with a unilateral short or very short below-elbow amputation.</p> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector W. Kay, <i>The Münster-type below-elbow socket, an evaluation</i>, Artif. Limbs, Autumn 1964, pp. 4-14.</li> <li>Kay, Hector W., Kevin A. Cody, George Hartmann,and Dominick E. Casella, <i>The Münster-type below-elbow socket, a fabrication technique</i>, Artif. Limbs, Autumn 1965, pp. 4-25.</li> <li>New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, <i>The "Münster" type fabrication technique for below-elbow prostheses</i>, June 1964.</li> <li>New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science,<i> A fabrication manual for the "Muenster" type below-elbow prosthesis</i>, April 1965.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the 'Muenster' type below-elbow prosthesis, April 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Münster-type below-elbow socket, an evaluation, Artif. Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Kay, Hector W., Kevin A. Cody, George Hartmann,and Dominick E. Casella, The Münster-type below-elbow socket, a fabrication technique, Artif. Limbs, Autumn 1965, pp. 4-25.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Münster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the 'Muenster' type below-elbow prosthesis, April 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>John H. Hile </b></td></tr><tr><td class="clsTextSmall">Clinic Prosthetist, Juvenile Amputee Clinic, District of Columbia General Hospital, Washington, D.C. 20003.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles H. Epps, Jr., M.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Juvenile Amputee Clinic, District of Columbia General Hospital, Washington, D.C. 20003; Chief, Division of Orthopaedic Surgery, Howard University College of Medicine, 520 W St., N.W., Washington, D.C. 20001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 2 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-04.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experience with the Münster-Type Below-Elbow Prosthesis, a Preliminary Report Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * John H. Hile * https://staging.drfop.org/files/original/12c366995fac640412262b97e21e05bc.pdf 5425bdb7fa0bf0a71fba5604a71cbe09 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_01_003.pdf Text Any textual data included in the document <h2>Prosthetic-Orthotic Research - A New Thrust is Needed: A Clinician's Perspective</h2> <h5>Charles H. Epps, Jr., M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Since the prime supporter of research, the federal government, has sharply reduced some areas of funding, the efforts of many established investigators and programs have been curtailed. Hardest hit has been the young aspiring investigator without a track record, who has found it virtually impossible to acquire funding for initial research efforts. Basic research as well as clinical research has suffered. Prosthetic and orthotic research programs which have never had abundant or even adequate funding also have been adversely affected.</p> <p>In the area of upper extremity prosthetics, much research remains to be done. For the patient who wears a prosthesis, cosmesis is still a major concern. Cosmetic acceptability must be improved and sensory feedback must be developed; sockets must be made more comfortable and suspension must be improved. Myoelectric control systems and other methods of external power must be made more functional, more compact, and more economical.</p> <p>In the lower extremity, newer materials and techniques must be developed to make prostheses lighter in weight, especially for the geriatric wearer. Although there seems to be less enthusiasm today for skeletal attachment of prostheses, the concept remains a challenge. The mechanical integrity and durability of knee devices can be improved along with fitting and alignment techniques.</p> <p>Because of basic lack of knowledge about the effects of forces on bone, ligaments and tendons, the need for orthotic research is even greater than in prosthetics. More needs to be known about the magnitude and patterns of forces that are necessary and safe to orthotic applications. Workers in kinesiology and gait laboratories around the country are endeavoring to find more answers to diagnostic problems and to collect useful data for orthopaedic assessment and even surgical treatment. New materials offer the orthotist new versatility. The pneumatic orthosis, a new concept, is ready for full development. Electrical applications are at an embryonic stage in the stimulation of paralyzed muscles, inducing therapeutic exercises, and providing afferent or feedback systems. New interest has developed to improve powered mobility devices to replace the conventional electric wheelchair for the high level spinal cord injured patient. Specially adapted vans can be operated safely by paralyzed, limb deficient patients and other severely handicapped. In view of the potential offered by computer applications and rapidly improving robot technology, environment control devices are on the threshold of great advances. So much remains to be done in prosthetic-orthotic research that even the casual observer must be concerned.</p> <p>At the same time that public research dollars have decreased, private research dollars have not increased sufficiently to fill the void. Obviously, research needs offer a challenge to orthopaedic surgeons who must increase the amount of personal time and funds given for research. At least one encouraging sign of private sector philanthropy exists. Bristol-Meyers/Zimmer U.S.A. has donated 1.2 million dollars to the Orthopaedic Research and Education Foundation (OREF) for the 1983-1984 Campaign. To date, more than 150 orthopaedic surgeons have given $1,000 each to OREF for the current campaign. This is in sharp contrast to the previous years' total of $200,000 from all sources. Other members of the industrial community should duplicate and even surpass the example set by the Zimmer group.</p> <p>If this instance of giving by the orthopaedic surgeons and a prime industrial supplier is replicated by prosthetic-orthotic practitioners and members of the corresponding industrial manufacturing community, the funding for prosthetic-orthotic research can be adequately raised to support needed research programs.<br /><b><br /><em>*Charles H. Epps, Jr., M.D. </em></b><em> Division of Orthopaedic Surgery, Howard University Hospital, Washington, D.C.<br /><br /><br /></em></p> Page Number(s) 3 - 4 Year 1984 Volume 8 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prosthetic-Orthotic Research - A New Thrust is Needed: A Clinician's Perspective Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * https://staging.drfop.org/files/original/6438c2935f8cb41a327a7110da0804b6.pdf fed62d2cec4e0a2356a7a35ce7281034 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1982_02_006.pdf Text Any textual data included in the document <h2>Editorial: Prosthetic and Orthotic Support - The 1982 Budget</h2> <h5>Charles H. Epps, Jr., M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The past year has seen a series of legislative successes by the Reagan Administration in its efforts to reduce the federal budget. The budget for the current fiscal year totals roughly $720 billion of which almost $270 billion will go for defense and interest on the national debt. It is estimated that almost four out of five of the remaining dollars will go for entitlement programs. The balance comprises the part often referred to as the controllable budget and includes items such as high wages, veterans hospitals and medical research.<a></a> The experts at this point have been unable to fully sort out the impact of the proposed cuts but it is estimated that almost $20 million will be in health and human service programs. The cuts will not stop here as the Administration in September proposed another 12 per cent reduction in human services to offset the extra $25 billion budget deficiency caused by the personal income tax cut.<a></a> One does not have to be an economist to realize that the proposed changes will fundamentally alter the scope of federal programs, particularly health and human services.</p> <p>It also becomes apparent that prosthetic and orthotic services as well as training, research, and development in those areas will be affected. Historically, the level of federal involvement and support has been substantial when one considers that laboratories engaging in prosthetic-orthotic research were operated by the Army, the Navy and the Veterans Administration. The Veterans Administration alone and in parallel with other agencies has supported a number of projects with universities, industrial laboratories, and in recent years has sponsored intramural projects in Veterans Administration Medical Centers. The office of Vocational Rehabilitation and its successor, the National Institute of Handicapped Research, (NIHR), supported Rehabilitation Engineering Centers and projects throughout the United States.</p> <p>The budget reconciliation process has been utilized in the Congress to fashion this new reduction of the federal role. Funds administered through the NIHR vitally affecting prosthetic and orthotic research and training have been exposed to this budgetary process. The Appropriation Committees of the House and the Senate have reviewed this aspect of the budget.</p> <p>The programs for crippled children, which reach many children requiring prosthetic and orthotic devices, have not escaped budget cuts. Maternal and Child Health (MCH) and Crippled Children's Services (CC) have been consolidated into a block grant to the states under Title V of the Social Security Act. Included in this particular block grant are: supplemental security income for disabled children; lead-based paint poisoning prevention; sudden infant death syndrome; hemiphelia treatment centers, and adolescent pregnancy. The House-Senate Conference agreement currently under the continuing resolution provides for an authorization of $347.5 million for fiscal 1982 for the MCH block grant. This amount is 25 per cent less than the 1981 appropriation of $456.2 million. It is hoped that support will continue for valuable programs presently funded at least in part at CAPP in Los Angeles, the Area Wide Amputee Center in Grand Rapids, and at New York University. Presently there are five projects funded at a level of $1.3 million. It is proposed to accomplish a reduction of 77 percent to a level of $300,000 in fiscal 1982. These projects, considered an aspect of technology transfer, constitute an activity of vital national concern. A reduction of this magnitude (77 percent) will substantially impair the programs.</p> <p>These are areas where private initiatives and voluntarism cannot replace the federal support. The private sector has been unwilling or unable to support totally even the more glamorous and highly visible activities such as symphony orchestras, art and scholarship support. Prosthetic and orthotic projects pale by comparison in their ability to attract private support when compared to other highly visible programs. It remains, therefore, the task of each of us to write or wire our Representatives and Senators requesting support of action in the Appropriation Committees of Congress that will insure at least a continuation of the present level of support, if not an increase in the funding for prosthetic and orthotic research and training. The present level of funding will deprive patients of needed services and cripple the research and training efforts perhaps beyond recovery.</p> <p><b>References:</b></p> <ol> <li>Editorial: "Who will Be Entitled?" <i>The Washington Post</i>, January 22, 1982, p. A14.</li> <li>England, M.J.: "The Health and Social Service Picture," <i>Journal AMWA</i> 36:350, 1981.</li> <li>"Health Programs Are Being Slashed," <i>The Nation's Health</i>, January 1982, p.1.</li> </ol> <em><b>*Charles H. Epps, Jr., M.D. </b> Professor and Chief, Division of Orthopaedic Surgery Howard University Hospital Washington, D.C.<br /><br /></em> Page Number(s) 6 - 6 Year 1982 Volume 6 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: Prosthetic and Orthotic Support - The 1982 Budget Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * https://staging.drfop.org/files/original/6f7e3f82472638ae5c7d6a8fe6502b0c.pdf aafc0735d891c3ca5b70c59e5b9e4dca https://staging.drfop.org/files/original/c8b4856c8000a6349f542a3fc1d9792b.jpg 155701ed19ed5a4cc064357783299d6f https://staging.drfop.org/files/original/f42bc1634981d3ce3923261609c448f0.jpg 86bbb24b5c5ea6d276b246de92acb3e4 https://staging.drfop.org/files/original/9e3ce64e754060714e02f7e869bb56c1.jpg bcc33ceb1a17e7d1665e8600710bf8c7 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1978_03_001.pdf Text Any textual data included in the document <h2>Externally-Powered Upper-Limb Prostheses: An American Dilemma</h2> <h5>Charles H. Epps, Jr., M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The discussion by A. Bennett Wilson, Jr., in Vol, 2, of the Prosthetic and Orthotic Clinic Newsletter is an excellent historical summary of the saga of externally powered upper-limb prostheses. Ben Wilson has brought to this forum an abundance of personal knowledge about the development of these devices that can only be known by one who has been intimately involved with the problem. I think it also raises the question, when one considers the present state of the art and the availability of American made components why more could not have been done and is not being done.</p> <p>As one who has been intimately involved in the treatment of patients with upper-limb deficiency for the past 17 years, I have experienced the frustrations that are unique to this area of medical delivery. In the Juvenile Amputee Clinic at the D,C. General Hospital, in Washington, D.C., we have cared for almost 300 children with one or more limb deficiencies, I remember, vividly, when I first began this work in 1961, telling parents that in five years we should have available for the child (bilateral upper amelia), a good set of externally powered arms. Much to my chagrin, five years later we were unable to deliver this needed service to a degree that satisfied the patient or the Clinic Team. After 17 years, there are still unfulfilled expectations.</p> <p><b><a href="/files/original/c8b4856c8000a6349f542a3fc1d9792b.jpg">Fig. 1.</a> This male was born with bilateral upper amelia and lower complete phocomelia. After acquisition of sitting balance, he was fitted with a shoulder disarticulation type prosthesis with nudge control for elbow lock and unlock and with terminal device and forearm lift control by chest expansion. At age five, a Michigan Feeder Arm was applied, and his feeding time and ease of eating were enhanced.</b></p> <p>One then has to ask the question, why has there not been greater progress in the United States? Research money has been available, to a limited extent and powered arms have been developed. These events have been developed historically by Ben and will not be reported in any depth here. I would mention the Michigan Feeder Arm, which was a very useful arm for the purpose of eating, in the young age group. Once the child became older, there was no model available. The Michigan Electric Hook was developed out of a similar need and can be purchased commercially today. We are using, at the present time, a number of these in our clinic. The Coordinated Arm, developed at the Ontario Crippled Children's Center, and which succeeded the feeding arm, can be purchased from a Variety Village in Toronto, Canada, but the problem is that this unit is suitable only for the younger child. There is literally nothing as good as the Coordinated Arm available for the older child or adult.</p> <p><b><a href="/files/original/f42bc1634981d3ce3923261609c448f0.jpg">Fig. 2.</a> A fourteen-year-old with partial transverse hemimelia fitted with a Otto Bock Myoelectric hand that is available in a kit as shown. The battery pack can be attached to the belt. The shirt covers the wire and the socket resulting in excellent cosmesis.</b></p> <p>Another approach we have utilized is the combination of the OCCC electric elbow with the Michigan electric hook, in what we have termed a "Hybrid" prosthesis. Today, our experience has been satisfactory, as we are able to combine both units to operate with a single electrical system, supplied by one battery. Even under these circumstances, it is very difficult to import the electric elbows from Canada. The cost is not inconsequential, when one considers that the purchase of both items will be close to $1,000 and then one has to consider the cost of fabrication.</p> <p>The net result is that unless one is extremely zealous, it is not possible to supply children with severe limb deficiencies with externally powered devices. When they are supplied, there are mechanical problems, electrical problems, and frequent repairs are necessary. The "down time" is considerable. For this reason, many clinicians and patients have been discouraged and have abandoned use of these devices.</p> <p><b><a href="/files/original/9e3ce64e754060714e02f7e869bb56c1.jpg">Fig. 3</a>. This youngster with right upper phocomelia and left amelia was given an opposition post early. A standard left shoulder-disarticulation prosthesis provided little function. A hybrid system utilizing an OCCC electric elbow and a Michigan Electric Hook, provides greater function. Both units are powered by one battery pack.</b></p> <p>It is ironic that the greatest development has been made for the patient with the below elbow deficiency. The Otto Bock System is available in a number of sizes and provides excellent cosmesis and function. Our experience has been satisfactory with this device. The cost, however, is considerable and this may be one reason that this prosthesis has not been applied extensively in this Country, in spite of the fact that there are large numbers of children with below-elbow level deficiencies. It is also a fact that below-elbow patients function quite well with body powered equipment. In either case, American industry has not been at the forefront. The majority of commercially available devices today have been developed in Europe or Canada.</p> <p>I recently had the opportunity to visit Doctor Rolf Sorbye, in Orebro Sweden, who in collaboration with Systemteknik has developed an excellent below-elbow self-contained self-suspended prosthesis, using myeoelectric control. This device has been fitted to a number of children as young as 18 months and the results are extremely promising. Two prostheses are fabricated for each patient so that there is no "down time" when one prosthesis becomes inoperative and needs bench repairs. The cost per patient therefore, is approximately $6,000 for the pair of arms. There is under development, at the present time, in Sweden, another multi-functional hand (also for the below-elbow level), which will provide powered function for grasp, release, dorsi- and palmar flexion of the wrist, and supination and pronation of the forearm. The project is funded by a joint effort on the part of the Swedish Government and private industry. It is unfortunate that we have not been able to have a similar effort in this Country. Dr. Dudley Childress, at Northwestern University has developed an excellent self-contained, self-suspended below-elbow system, using myeoelectric control. The fact of the matter is that this and similar devices, developed in this Country, have not found a manufacturing outlet for disbursement. It is, therefore, a financial matter that in the face of limited demand the manufacturers cannot produce these items at a cost that will make it profitable. It seems to me, therefore, that this is an area, where the Government should intervene and subsidize this effort. There are numerous precedents throughout industry in this regard. The railroads, the airlines, and the shipbuilders have been subsidized. The renal dialysis program is one health area where Government is presently providing a subsidy. The precedent is there. There also needs to be an effective lobbying effort mounted, not only by the profession, but by the affected individuals, that is, patients and their parents. I believe that this is the essence of the problem. The technical "know how" is available but what is lacking is sufficient funding to make these devices in sufficient numbers so that they can become available to patients. It is fortunate that there are not a large number of patients. Ironically, were there large numbers of patients and a large demand, then the cost, of course, would be reduced. In the absence of this unfavorable manufacturing circumstance, subsidies must be given to industry so that the necessary devices can be produced and made available at reasonable cost.</p> <p>Another aspect of the problem, which is paradoxical, is that there has been so much effort put into the below-elbow level, where the need, as I see it, is not nearly as great as it is in the above-elbow and the shoulder-disarticulation levels. The patients with more proximal limb deficiencies are greatly in need of externally powered devices. Yet the powered devices that are available for the proximal cases, are not the most efficient. The available commercial items, even at great cost, are not representative of the best technology available in this country, today. This can be partially explained by the fact that the numbers of patients affected at the higher level are substantially less than those at the below-elbow level. It is also natural to work on problems where success is more readily obtained. The challenge is there at the shoulder-disarticulation level and the above-elbow level, where these patients desperately need more function. There is need in this country for a concerted effort to develop and provide powered arms for patients with the more proximal limb deficiencies. It is a blight on our record as a nation, with such sophisticated technology and industrial and productive capacity, that this area of human need has been so long unfulfilled.</p> <h5><b>Charles H. Epps, Jr., M.D.<br />Professor and Chief, Division of Orthopaedic Surgery, Howard University, Washington, D.C.</b></h5> Page Number(s) 1 - 3 Year 1978 Volume 2 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1978_03_001/1978_03_001-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1978_03_001/1978_03_001-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1978_03_001/1978_03_001-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Externally-Powered Upper-Limb Prostheses: An American Dilemma Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * https://staging.drfop.org/files/original/aafea6cea49faeadc6dba48217d2ee06.pdf 1144c6f189f7e6d76ebed402cfb5d44c Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_017.pdf Text Any textual data included in the document <h2>Externally Powered Prostheses for Children: 1984</h2> <h5>Charles H. Epps, Jr., M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Not so many years ago children with upper limb deficiencies who appeared in our clinic with body powered prostheses asked for an arm like the one used by the six million dollar man. The television character routinely performed miraculous feats of strength and prehension that made the body powered prostheses look primitive by comparison. I was unable to satisfy such requests at that time. Now, at least for some patients, the long sought externally powered fitting is possible. The available arms do not approach that of the six million dollar man, but we have the means of fitting the below-elbow patient with a myoelectric prosthesis that is gratifying to patient and parents. In our own setting, two factors have converged to make this possible.</p> <p>First, the most important development in our clinic has been the affiliation of the local Variety Club, which established a Limb Bank. The concept is simple, the Variety Tent raises funds for myoelectric limbs, component parts and services. In some cases, the cost of the entire prosthesis is underwritten; in other situations Variety pays the balance not covered by insurance depending upon family finances. There are also components and spare parts available for repairs, courtesy of Variety. Such components keep the down time to a minimum and eliminate the need for two myoelectric prostheses. This arrangement developed between the Juvenile Amputee Clinic (Maternal and Child Health and Crippled Children's Services) at D.C. General Hospital and Washington, D.C.'s Variety Tent Number 11 is an example of how a public-private relationship can benefit the patient. Variety Tents are operational in Grand Rapids, Michigan; Memphis, Tennessee; Detroit, Michigan; Los Angeles, California; Toronto, Canada and other cities.</p> <p>Secondly, the technology has been available for a number of years, but we delayed because of the cost of myoelectric fittings and because the policies of many insurance carriers did not include such devices. It seemed undesirable to fit a child if one could not reasonably expect to continue with subsequent fittings and provide timely repairs. Sörbye in 1971 was among the first to apply myoelectrics to the young preschool amputee. His group operating in the government support health system in Sweden overcame these same problems by providing each patient with two prostheses. The second remained on the shelf as a back-up limb when the first needed repairs. In this manner, down time was eliminated and the child was not without the prosthesis.</p> <p>In the United States there has been a recent change in the policies of many third-party insurance carriers. Today, most will provide funds not only for the initial prosthesis but for replacements and necessary repairs, a not inconsequential cost. Some insurance companies pay total cost while others pay a fixed percentage.</p> <h3>External Power</h3> <p>Over the years, a number of battery powered switch operated devices have become available. The Michigan Feeding Arm was specifically designed to assistance in eating activities and was the first externally powered device developed in the United States for the pediatric age patient. In the early 1970's the Ontario Crippled Children's Center developed the OCCC Coordinated Arm. This was followed by the OCCC Elbow. Both were operated by switches and were designed for the 4-10 year age group. The Michigan Electric Hook (10x size) appeared in 1973 and was appropriate for the child approximately 2-10 years. Its successor, the Michigan Area Child Amputee Clinic Hook (MACAC) (10x size) was an improved version of the earlier hook designed for the same age group. In 1977 we saw the advent of a second elbow, the NYU Motor Lock Elbow, sized for a child six to a small teenager. This item remains experimental. To overcome the objectionable operational noise of the previous powered elbows, the NYU "Hush" Electric Elbow was developed in 1982. A versatile unit, it can be operated by push button or harness pull. Complimenting this armamentarium is the switch operated NYU Prehension Actuator (1982) which is applicable to any cable voluntary opening terminal device. More recently, the Utah Elbow was developed for the adult population but may be used with a child about age 12 years; it can be used with any terminal device and utilizes a dual site myoelectric system.</p> <h3>Myoelectric</h3> <p>The available myoelectric devices also offer a spectrum of choices. There is the University of New Brunswick System which is appropriate for ages 12 and up. This unit uses a surface electrode over one muscle. A small contraction is for closing and a strong contraction for opening. Relaxation of muscle contraction stops the hand at the current position. Sweden contributed the Systemteknik hand in two sizes; 2-6 years for the small child and 5-9 years for the larger child. The unit utilizes a single or double myoelectric electrode. The Steeper hand produced in England has the same size and age indication and similar choice of myoelectric controls. The German contribution is the Otto Bock System covering ages nine to adult with a dual myoelectric site system. These units are expensive but commercially available. The absence of a myoelectric unit developed in the United States is conspicuous.</p> <p>This array of devices presents a challenge to the physician prescribing external power for his patient. There are wide differences in the weight which may be crucial in the young patient with a short stump. However, all are heavy when compared to the body powered prostheses. The battery systems vary from 5 volt to 12 volt with varying useful life after charging. The prescription, therefore, is best written as a collaborative effort by the physician, the prosthetist, and the occupational therapist who has evaluated the patient and will provide the training.</p> <h3>Patient Benefit</h3> <p>After witnessing the satisfaction of the patient and parents after a successful fitting has been accomplished, there is no doubt that external power is preferred over body power in most instances. Function seems more natural when hand opening and closing are controlled by forearm extensor and flexor muscle activity. It is obvious that the psychological benefit of the cosmetic effect is profound on patient and parents alike. The dramatic change can be seen even with the initial application of the arm. External power and myoelectric applications are now state-of-the-art in below elbow cases and should be made available to all who have the interest and proper indications.</p> <h3>The Challenge</h3> <p>There is still much to be done for the amelia and the high above elbow amputee. Efforts must continue to bring the maximum degree of function to patients who are less well served at present. The numbers of patients in this category are small and there are not the normal incentives to manufacturers to expend funds for research and development in this area. The Federal Government may have to support the requisite research to accomplish the necessary break-through. It is ironic that the below elbow patient who enjoys reasonably good function with conventional prostheses would benefit most from the new technology. This is explicable when we realize that this level of limb deficiency makes the task easier. Although the numbers of high level deficiency patients by contrast is small, the need is great. We must continue to work for solutions for these patients who remain underserved at this time.</p> <em><b>*Charles H. Epps, Jr., M.D. </b> Charles H. Epp, Jr., M.D. is Professor and Chief at the Division of Orthopedic Surgery at Howard University Hospital, 2041 Georgia Avenue, N.W., Washington, D.C. 20060.<br /><br /><br /></em> Page Number(s) 17 - 18 Year 1985 Volume 9 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Externally Powered Prostheses for Children: 1984 Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * https://staging.drfop.org/files/original/b07addbca7cb05cba5493373ba37e4d5.pdf beaed1b03564c538ee3e1e8ec6019f68 https://staging.drfop.org/files/original/3315a246e37eef6187bbc4b8ea89f1ba.jpg 2cd16c71b05ac05e1bf1a8dec6934bc5 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1982_04_005.pdf Text Any textual data included in the document <h2>Editorial: Special Prostheses Enhance Rehabilitation</h2> <h5>Charles H. Epps, Jr., MD&nbsp;<a style="text-decoration: none;">*</a></h5> <p>In the case of a child, conventional wisdom has held that success of prosthetic rehabilitation can be measured by the ability of the child to play, as play may be considered child's work. In the adult, ultimate success was evidenced by the patient's return to his former job or to some other gainful employment. Special acclaim and attention have been given to amputees like Pete Gray, who succeeded as a professional baseball player. Today another criterion can offer a more valid assessment of success. The ability of the patient, child or adult, to participate in life's activities is a better measure. This assessment should include sports and athletic activities, especially those activities formerly enjoyed in the case of an acquired amputee. Fortunately, today's prosthetic armamentarium includes special techniques, components and prostheses that make participation possible in a variety of activities. On the basis of the experience gained in treating more than 700 juvenile amputees, R.C. Hamilton<a></a> formulated the conclusions about their role in competitive sports as shown in <b>Table I</b>. Most amputees are not interested in competition, but desire to engage in recreational athletic activities.</p> <strong>Table I. Suggested Areas of Athletic Participation by Unimembral and/or Uncomplicated Amputees</strong><br /><img src="/files/original/3315a246e37eef6187bbc4b8ea89f1ba.jpg" p="" width="399" height="473" /> Beginning in Europe in the late 1940's, skiing was one of the first sports to be "adopted" for amputees. In the United States there has been a great interest in this activity, as manifested by the formation of the National Amputee Ski Association. Special ski boots and outriggers have been developed. The unilateral below-knee amputee can ski with or without a prosthesis. The bilateral below-knee uses the four track technique with two prostheses, two skis and outriggers. The unilateral above-knee usually must ski on the intact leg using the three track technique. The bilateral above-knee can use short prostheses without knee mechanisms. Cross-country skiing is recommended solely for the below knee amputee. According to Bernice Kegel, the average amputee can learn to ski intermediate and expert slopes in one fourth the time an abled-bodied skier needs, and with a far greater degree of proficiency.<a></a> <p>Swimming is an activity that can be enjoyed by amputees of all ages. If the swimmer is able to stay afloat safely without a prosthesis, opportunities are plentiful as swimming facilities are fairly common in our society. For the amputee who wishes to enjoy aquatic activities, several options are available:</p> <ol> <li> <p>Swimming without a prosthesis</p> </li> <li> <p>Peg legs for use on the beach and possibly swimming</p> </li> <li> <p>Sockets attached directly to swim fins</p> </li> <li> <p>The utility or beach prosthesis used to ambulate on the beach but not for swimming</p> </li> <li> <p>The swimming leg worn while in the water<a></a></p> </li> </ol> <p>Water skiing is another activity that can be enjoyed by amputees.</p> <p>Wheelchair sports have been organized for amputees, also. A rather detailed classification of degrees of disability has been developed to maintain fairness in competition for men and women. Competition is now commonplace in wheelchair basketball, marathon races, bowling, field events, table tennis, and archery; there are even international events.</p> <p>Special prosthetic adaptations have been developed for the lower extremity amputee who is interested in participating in the following activities.</p> <ol> <li> <p>Golfing—a rotor in the shank<a></a></p> </li> <li> <p>Flying—portable hand controls and a special SACH foot<a></a></p> </li> <li> <p>Boating<a></a></p> </li> <li> <p>Horseback riding<a></a></p> </li> </ol> <p>In the upper extremity, special adaptations may be necessary for certain activities. The standard terminal device may be used for given activities, especially in the case of the unilateral amputee. For other activities the amputee may find it more convenient to remove the prosthesis completely. By and large the ability of the bilateral upper limb amputee is dependent upon the strength and mobility of the residual limbs. For the upper limb amputee, M.D. Robb<a></a> has grouped activities into those requiring closed or open skills. When the environment or activity is highly unpredictable and constantly changing, open skills are needed to adjust to and/or regulate the environment. Closed skills are those such as swimming, bowling, and golf activities which are performed in a comparatively stable environment. Among the recreational activities for which adaptive devices have been developed are:</p> <ol> <li> <p>Rein bar for horseback riding<a></a></p> </li> <li> <p>Special terminal device for fishing<a></a></p> </li> <li> <p>Terminal device for bowling<a></a></p> </li> <li> <p>Fletcher-Motis adapter for archery<a></a></p> </li> <li> <p>Universal joint terminal device for golf<a></a></p> </li> <li> <p>Additional devices adapted for hockey,<a></a> skiing,<a></a> and driving<a></a></p> </li> <li> <p>Baseball glove terminal device for the unilateral below elbow (this has always been a popular item among teenage boys in our clinic)<a></a></p> </li> </ol> <p>Swimming can usually be accomplished without prostheses and special appliances. However, it may require minor adaptations of stroke techniques, kick modifications and a special breathing pattern.<a></a></p> <p>It should be apparent even to the casual observer that there are benefits to be derived from the use of secondary prostheses or adaptive devices by amputees. The physiological benefits will flow to the cardiopulmonary system as the result of the physical activity.</p> <p>However, there is another even greater benefit—the psychological uplift—realized by the patient who achieves new heights of pleasure, pride, and increased self esteem by participation in physical recreation and/or competition. This aspect is so important to the total treatment and rehabilitation of the amputee patient that we must educate clinicians and third party carriers so that ordering such devices will become routine for all who have the ability and desire to use them. Furthermore, third party carriers should pay for them as routinely as the standard prostheses. In this manner we can give our patients the opportunity to participate in and enjoy life more fully—the essence of rehabilitation.</p> <p><b>References:</b></p> <ol> <li>Hamilton, R.C.: The juvenile amputee in athletics. Inter-Clinic Info. Bull., 6(1):1, 1966.</li> <li>Kegel, Bernice: Prostheses and assistive devices for special activities. Chapter 29, Atlas of Limb Prosthetics, American Academy of Orthopaedic Surgeons, St. Louis, C.V. Mosby, 1981.</li> <li>Racette, W., and Beraken, J.W.: Clinical experience and functional considerations of axial rotators for the amputee. Orthot. Prosthet. 31(2): 29,1977.</li> <li>Hughes, H. N. and Helmuth, G.: A modified prosthetic foot for pilots. Orthot. Prosthet. 29(1): 33,1975.</li> <li>Robb, M.D.: The dynamics of motor skill acquisition. En-glewood Cliffs, N.J., Prentice-Hall, Inc., 1972.</li> <li>Larkins, C: Horsemanship for the physically handicapped. Inter-Clin. Info. Bull., 9(7): 4-11, 1970.</li> <li>Sabolich, L.J.: An adapted fishing rod for arm amputees. Inter-clin. Info. Bull., 12(2): 13-15,1972.</li> <li>Kay, H.W.; Lewis, S.L.; and Steward, W.A.: A bowling device for bilateral arm amputees. Inter-Clin. Info. Bull., 9(7): 13-16, 1970.</li> <li>Bender, L.F.: Prostheses and rehabilitation after arm amputation. Springfield, Illinois, Charles C. Thomas, 1974.</li> <li>Redford, J.B.: Prostheses for hockey-playing upper limb amputees. Inter-Clin. Info. Bull., 14(6): 11-15,1975</li> <li>Stanek, W.F.: Report of the juvenile amputee ski program. Inter-Clin. Info. Bull., 8(9): 1, 1969.</li> <li>Wuttke, W.: New German foot-control system enables armless persons to drive. Rehabilitation World, pp. 12-13. Winter 1978-79.</li> <li>Shearer, J.D.; Buckner, M.L.; and Bowker, J.H.: Prostheses and assistive devices for special activities. Chapter 16, Atlas of Limb Prosthetics, American Academy of Orthopaedic Surgeons, St. Louis, C.V. Mosby, 1981.</li> </ol> <div style="width: 400px;"><em><b>*Charles H. Epps, Jr., MD </b> Professor and Chief Division of Orthopaedic Surgery, Howard University Hospital, Washington, DC<br /><br /><br /></em></div> <div style="width: 400px;"></div> Page Number(s) 5 - 6 Year 1982 Volume 6 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1982_04_005/1982_04_005-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: Special Prostheses Enhance Rehabilitation Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., MD *