4 20 371 https://staging.drfop.org/files/original/b21f639d8362d0faf7871fcd6b206981.pdf 00160730564941a88e1227cce0fc4cd6 https://staging.drfop.org/files/original/ae5fbb09b20594328d67143767a4b196.jpg 1f7187fd9cd02bd85bbacdc01a7d59b1 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_02_050.pdf Year 1963 Volume 7 Issue 2 Page Number(s) 50 - 52 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_02_050.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_02_050.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Limb-Deficient Child, a Review</h2> <h5>Charles H. Frantz, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p><i>The Limb-Deficient Child</i> is important as the first comprehensive summary of modern techniques in the relatively new field of child prosthetics. For until recent years, the consensus was that prosthetic fitting could wait "until the child is older"-an opinion based on the generally unsatisfactory attempts to care for the child amputee as if he were simply a small adult. The presentation made in <i>The Limb-Deficient Child</i> is based on the experience of the Child Amputee Prosthetics Project of the University of California at Los Angeles. The Project was started in 1955 and is supported by grants from the United States Department of Health, Education, and Welfare. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. <i>The Limb-Deficient Child</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Dr. Milo B. Brooks, who is the Medical Director of the Project, various members of the Project staff, and other persons closely associated with the Project are the contributors to <i>The Limb-Deficient Child</i>. The nine chapters of the book cover the role of the medical director, orthopedic considerations, psychosocial problems, preprosthetic evaluations, preprosthetic therapy, child prosthesis design and fitting, training, training the upper-extremity amputee, and lower-extremity training. There are numerous illustrations, the appendix contains various evaluation charts developed at the Child Amputee Prosthetics Project, and there is an index.</p> <p>Chapter I, "The Role of the Medical Director," describes the type of information desired from the referring physician and parents, stressing social information concerning the family organization, the child's general physical condition, and the type of amputation presented. A number of charts depict the normal development of children, with heights and weights for given ages. There is some discussion of the growth and development of limb-deficient children, the problems of limb dominance, and psychological adjustment. The etiology of congenital limb deficiencies is briefly discussed, and statistics are presented on cases studied at the Project. The thalidomide syndrome is briefly mentioned.</p> <p>Chapter II, "Orthopedic Considerations," discusses the relative importance of orthopedic management, the utilization of plas-ter-of-Paris cast techniques for correction, the use of braces, indications for surgical interference, the problem of scars, and the functional range of joints. Although very brief, the discussion on long bones, osteotomies, the problem of terminal overgrowth of long bones, neuromata, and the judgment and timing of surgical conversion of deficient extremities to more conventional types of stumps will be of interest to the orthopedist.</p> <p>This reviewer, however, is not in agreement with the attempt made in the discussion of the development of limbs to assign dermatome relationships to the limb buds.</p> <p>In general, this reviewer agrees with the brief classification of limb deficiencies, although it is incomplete from an anatomical standpoint. Perhaps future modifications may be in order to produce a more universal nomenclature, understandable to all who are interested in the limb-deficient child. The classification is followed by the prosthetics management of the terminal transverse deficiencies from wrist disarticulation (acheiria) up to amelia or shoulder disarticulation.</p> <p>Chapter III, "The Psychosocial Problems," gives a realistic discussion of parental guilt feelings and parental cooperation and emotional stability. There is discussion of the role of the physician in attempting to produce an environment of cooperation by the parents, an environment that is essential for success in treating the child amputee. The problems confronting the prosthetics team during the child's preadolescent and adolescent years are discussed, and the role of the social worker is clearly defined. This is an important chapter in the book.</p> <p>Chapter IV, "Preprosthetic Evaluations," discusses in detail the roles of the occupational therapist and the physical therapist. Reference is made to <i>The First Five Years of Life</i>, by Arnold Gesell and others, and it is highly desirable that therapists be well acquainted with this work. Chapter IV briefly describes the progress of motor kinesthetic development from the infant to the toddler. Techniques for determining the range of motion and the functional needs of the child are analyzed carefully. The chapter discusses the self-care needs of the child and relates them to the type of prosthesis indicated.</p> <p>In Chapter V, "Preprosthetic Therapy," the principles of joint motion, the correction of contractures, techniques of bandaging for shrinkage, the proper use of crutches, and skin care are elucidated and beautifully illustrated by photography.</p> <p>Chapter VI, "Child Prosthesis Design and Fitting," presents the important consideration of the growth of the child as contrasted to the adult. Materials for prostheses, such as plaster and polyester and epoxy resins, are discussed. The choice of terminal devices appropriate to the age and size of the child is clearly stated and well illustrated. Techniques for harnessing are demonstrated by photography. In addition, there are shown nonstandard types of prostheses for fitting upper-extremity phocomelic children. Unusual methods for operating elbow locks, by the phocomelic limb, buried in the humeral section of the prosthesis, are given special attention. The problems of upper-extremity amelia, both unilateral and bilateral, are discussed and shown in photographs, including cable systems and the various methods of hook-ups for the transmission of power. The problem of fitting a multihandicapped child is covered, together with some of the frustrating problems of finding power for terminal-device operation that is adequate in terms of the amount of energy expended. Stages of fitting lower-extremity amelic children from a small stationary bucket up to two prostheses are shown.</p> <p>In Chapter VII, "The Training Period," the training of the limb-deficient child is stressed, and rightly so. The child must know what the prosthesis will do for him. The chapter also emphasizes that one cannot go beyond the child's capabilities or his kinesthetic development for his years. One must not expect too much too soon in the avenues of function. There is a practical and well-illustrated discussion of clothing needs and modifications for ease of application. Illustrations also show how to reduce friction from the system through proper alignment of the cable-control assembly. Techniques to be employed by the unilateral and the bilateral amputee in applying and removing the prosthesis are excellently illustrated. The lower extremities are dealt with briefly with respect to the fitting of the socket, proper application-especially the fitting of a suction socket-and the problems involved with a patellar-tendon-bearing prosthesis and bilateral lower-extremity prostheses.</p> <p>Chapter VIII, "Training the Upper-Extremity Amputee," is well illustrated and goes into considerable detail. The environmental situation is discussed, and the necessary equipment is illustrated. In this reviewer's mind, there is some question about the discussion of training infants, because it is debatable whether one actually trains an infant or simply exposes him to experience in motor fields. There is discussion of the desirability of the presence of parents during training periods. Techniques for activating the components in stages by the young child are clearly presented, and action photographs show the functional capabilities of youngsters of various ages, both unilateral and bilateral types. Activities (aids to daily living) are well documented and very practical. This chapter should be especially interesting to occupational therapists.</p> <p>Chapter IX, "Training the Lower-Extremity Amputee," is much shorter than the preceding chapter. It gives a brief description of the progress of a youngster from infancy to an erect standing posture. Three phases of training are discussed with respect to the lower-extremity amputee. Comfort, fit, and skin tolerance are important during the first phase, with frequent inspection of the skin and prosthesis alignment. Independent ambulation is achieved during the second phase. During the third phase, faster ambulation, stair climbing, and walking up and down ramps and over uneven ground are mastered. This training is clearly illustrated by excellent photographs.</p> <p>Judging by its title, one would expect <i>The Limb-Deficient Child</i> to be a textbook on all facets of the child amputee. It is not such a text. It is a well-written presentation of the experiences of the Child Amputee Prosthetics Project of the University of California at Los Angeles. The problems of the limb-deficient child are much more far-reaching than this volume indicates.</p> <p>But the book is important as the first of its kind and should serve as a reference for physical and occupational therapists and for pros-thetists. It is a clear and very adequately illustrated narrative, with excellent photographs of children in action during their training periods, and photographs of prostheses. Harnessing patterns and cable operations are clearly depicted. There is much material here that should be of great assistance to therapists and prosthetists, particularly those who have broad experience with adult amputees. For with this text they can translate their past experience into the area of child amputees, especially those with congenitally malformed limbs.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles H. Frantz, M.D. </b></td></tr><tr><td class="clsTextSmall">Medical Co-Director, Area Child Amputee Program, Michigan Crippled Children Commission; Chairman, Subcommittee on Child Prosthetics Problems, CPRD, NAS-NRC, Washington, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_02_050/1963-Autumn-59.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Limb-Deficient Child, a Review Creator An entity primarily responsible for making the resource Charles H. Frantz, M.D. * https://staging.drfop.org/files/original/a6215b76e14080dd6c7ca38556f64bd7.pdf 4e4651dcdc97cadd4a5eb1206df0da68 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_001.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 1 - 4 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_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>An Evolution in the Care of the Child Amputee</h2> <h5>Charles H. Frantz, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>During the past twenty years the child amputee has emerged as a clinical entity requiring specialized medical and paramedical services. Prior to World War II, no precise methods of management existed. Common practice in fitting a child amputee with a prosthesis involved procrastination. </p> <p>The extent of the change that has occurred is well illustrated by two articles appearing in this issue of <i>Artificial Limbs: Recent Concepts in the Treatment of the Limb-Deficient Child</i>, by Cameron B. Hall, M.D., and the report of the Consultants to the Subcommittee on Child Prosthetics Problems on <i>Nomenclature for Congenital Skeletal Limb Deficiencies</i>. Dr. Hall's article presents an overview of current thinking on the subject, while the nomenclature focuses attention on the precise identification of congenital limb malformations. Many events have contributed to this evolution in thinking and practice. </p> <p>In September 1946, under the aegis of the Michigan Crippled Children Commission, an amputee training center was inaugurated at the Mary Free Bed Guild Children's Hospital and Orthopaedic Center in Grand Rapids, Mich. This project was inspired by the late Carleton Dean, M.D., who was then Director of the Michigan Crippled Children Commission. In the early 1940's, Dr. Dean had recognized that something was amiss in the habilitation of child amputees. He was vitally interested in the amputee program that had been developed by the Armed Services and the Veterans Administration. The science of prosthetics was advancing at a phenomenal pace. New mechanical components were being developed and were proving to be superior to anything heretofore available. Plastic protheses were supplanting the old conventional wooden limbs. Dr. Dean argued that there was no reason why these advances could not be used for child amputees. </p> <p>Little (if any) literature on the management of the child amputee was available, although Dr. Atha Thomas, of Denver, had written a very interesting and instructive chapter entitled "Prostheses for Children" in his book, <i>Amputation Prosthesis</i> <a></a>. In this chapter he advocated amputation in tibial hemimelia, foot removal in proximal femoral focal deficiency, and in pseudoarthrosis of the tibia. Dr. Thomas discussed overgrowth of the fibula as a complication of the child amputee and advocated osteoplastic procedures as described by Nikitin<a></a> and Barber.<a></a> Of singular significance is the fact that Thomas advocated "early fitting." </p> <p>Four years after the opening of the child amputee center in Grand Rapids, the professional personnel presented a formal paper on <i>The Juvenile Amputee</i> at the annual meeting of the American Academy of Orthopaedic Surgeons in February 1950. One hundred ninety-two cases were analyzed in detail. In addition to this presentation, a 28-minute motion picture depicted the problems of the child amputee and demonstrated fitting and training techniques. A scientific exhibit outlining the methods utilized in the care of the child amputee through the team approach was also displayed. Thus, for the first time, the child amputee was identified as an entity to the medical community. Five principles of treatment were stressed: </p> <ol> <li>Physical examination and stump evaluation. </li><li>Utilization of physical and occupational therapeutic methods. </li><li>Detailed coordination of prosthetic fabrication and fitting. </li><li>Inpatient prosthetic training. </li><li>Regularly scheduled outpatient follow-up in an organized child amputee clinic. </li></ol> <p>In January 1954 a workshop was held in Grand Rapids to review the total child amputee problem. Representatives of the Children's Bureau of the Department of Health, Education, and Welfare, the University of California at Los Angeles, New York University, and the Army Prosthetics Research Laboratory (now the Army Medical Biomechanical Research Laboratory) attended. The individual members of the conference enthusiastically endorsed the proposition that an organized program of treatment for child amputees in the United States was definitely indicated. An attempt was made to define the child amputee as compared to the adult amputee. It was agreed that the child amputee could be described as a growing, immature, dependent individual whose long bone epiphyses were still "open." </p> <p>In December 1955, in formal session, the Prosthetics Research Board appointed an <i>ad hoc</i> committee of seven members charged with developing recommendations relative to child amputees in the United States. The outcome of this effort was the formation of the Subcommittee on Child Prosthetics Problems. Its mission was to develop information, and to advise the Prosthetics Research Board on all aspects of the child amputee situation in the United States. </p> <p>During March 1956 the Subcommittee on Child Prosthetics Problems mailed questionnaires to 84 prosthetists and 25 orthopaedic clinics throughout the United States. The response was prompt and enlightening. Analysis of the returns indicated universal interest in child amputee treatment procedures. Shop practices were sharply individualized, and no precise criteria for training existed. At this time there appeared to be only four specialized juvenile amputee clinics in the United States.<a style="text-decoration:none;">*</a></p> <p>With this background of information, the Subcommittee proceeded to encourage the development of child-sized prosthetic components. This endeavor involved not only the miniaturization of adult-sized components but also the introduction of specially designed features so that the devices could be operated by young children. With the assistance of the Army Prosthetics Research Laboratory under the direction of Colonel M. J. Fletcher, the Child Amputee Prosthetics Project at UCLA under the direction of Drs. Craig Taylor and Milo Brooks, and the sound evaluation services of New York University under the direction of Dr. Sidney Fishman, components were gradually developed, fitted, and evaluated relative to their efficiency on child amputees. </p> <p>Stimulated by Dr. Arthur J. Lesser of the Children's Bureau (who was then a member of the Subcommittee on Child Prosthetics Problems), significant steps were taken to encourage the formation of specialized child amputee clinics as a means of standardizing practices in the management of juvenile amputees throughout the country. With the ultimate goal of having a clinic within reach of every child amputee in the nation, definite criteria outlining the requirements for the operation of a satisfactory amputee clinic were formulated. As qualified clinics were established, the cooperative investigation of difficult clinical problems was undertaken. Since these clinics were devoting their efforts exclusively to the child amputee, techniques, appliances, and practices could be introduced and critically evaluated through New York University. Over the years the findings of these studies, which have been analyzed and published, have resulted in the evolution of standards of management never before attained. The fruitfulness of these endeavors is well illustrated by the fact that the Committee for Care of the Handicapped Child of the American Academy of Orthopaedic Surgeons, in conjunction with the Children's Bureau, recently published a document entitled <i>Standards for the Care of the Juvenile Amputee</i>. These standards, which have had nationwide distribution, are essentially the same as those that have evolved through the cooperative research program. </p> <p>The growth in the number of child amputee clinics has been most gratifying. As of January 1966 they numbered twenty in the United States and two in the Dominion of Canada. </p> <p>During the early years of the child amputee program, clinical statistics indicated a ratio of two post-traumatic or postsurgical amputees to one congenital amputee. However, in a period of eight to ten years, a dramatic change has occurred: First, because of the publicity given to the treatment program, children began to appear in clinics at a much younger age than previously. At this very young age, the majority of patients have limb deficiencies that are congenital in nature. <i>Second</i>, the logical consequence was a tipping of the scales of etiological incidence to the congenital type. At present, the majority of clinics report a ratio of five congenital types of deficiencies to two acquired types. </p> <p>Thus the meaning of the term "juvenile amputee" has broadened to encompass post-traumatic amputees, postsurgical amputees, and congenital limb deficiencies and malformations. </p> <p>In 1961 another significant step was taken by the Subcommittee on Child Prosthetics Problems. In that year it initiated publication of the <i>Inter-Clinic Information Bulletin</i>. The first issue was published in October 1961, and the <i>Bulletin</i> has appeared monthly ever since with articles written by the clinic chiefs pertinent to the child amputee. The success of this project is attested by the figures of March 1966 when 1,700 copies were printed and 1,565 were distributed; 351 individuals and institutions received 630 copies. In addition 400 copies were sent to the World Rehabilitation Fund for distribution to its members and 535 to the American Orthotics and Prosthetics Association for distribution to its membership. </p> <p>The impact of the thalidomide tragedy in Europe (West Germany and England) in 1959-1962 focused attention again on the need to improve prostheses, especially when malformed limbs or the complete absence thereof made it difficult to fit conventional suspension and power and cable systems. </p> <p>Heidelberg University had worked with pneumatic power and applied its principles very successfully to these children. Since then there has been a concerted effort in the United States to exploit external power, utilizing compressed carbon dioxide and electricity as power sources. At the present time, a significant number of children throughout the country are wearing externally powered prostheses on an experimental basis. </p> <p>Laboratories are continuing to develop devices in an effort to decrease weight, provide easier application, and improve power sources. There is good reason to believe that as time goes on these endeavors will bear fruit in improved, practical prosthetic function. Interest in child amputees is growing steadily in all parts of the world. These children—many of them multihandicapped—now have a much greater hope for better appliances and services than they ever had in the past. </p> <p>In retrospect, it is evident that much has been achieved by the Subcommittee on Child Prosthetics Problems during the past ten years, but also that much remains to be done. Hopefully, the foundations have been laid for further advances. </p> <p><b>References:</b></p> <ol> <li>Barber, G. C. P., <i>Amputation of the lower leg with induced synostosis of the distal ends of the tibia and fibia</i>, J. Bone and Joint Surg., 13:68, 1939.</li> <li>Nikitin, A. A., <i>Comparative evaluation of late results of various amputations of lower extremities in children</i>, Ortop. i travmatol, Kharkov, (Nos. 4-5) 13:68-75, 1939.</li> <li>Thomas, Atha, and Chester C. Haddan, <i>Amputation prosthesis</i>, J. B. Lippincott, Philadelphia, 1945.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Area Child Amputee Center, Michigan Crippled Children Commission, Grand Rapids, Mich., George T. Aitken, M.D., and Charles H. Frantz, M.D. (1946); Kessler Institute for Rehabilitation, West Orange, N.J., Henry H. Kessler, M.D. (1949); University of Illinois Amputee Clinic, Chicago, Ill., Claude N. Lambert, M.D. (1952); Child Amputee Prosthetics Project, University of California, Los Angeles, Calif., Milo B. Brooks, M.D. (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Barber, G. C. P., Amputation of the lower leg with induced synostosis of the distal ends of the tibia and fibia, J. Bone and Joint Surg., 13:68, 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Nikitin, A. A., Comparative evaluation of late results of various amputations of lower extremities in children, Ortop. i travmatol, Kharkov, (Nos. 4-5) 13:68-75, 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Thomas, Atha, and Chester C. Haddan, Amputation prosthesis, J. B. Lippincott, Philadelphia, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles H. Frantz, M.D. </b></td></tr><tr><td class="clsTextSmall">Chairman, Subcommittee on Child Prosthetics Problems, December 5, 1955-June 30, 1966. When the Subcommittee was formed in 1955 it was a part of the Prosthetics Research Board, the predecessor of the present Committee on Prosthetics Research and Development. The Subcommittee became a standing subcommittee of CPRD when CPRD was formed in 1959. Dr. Frantz, an orthopaedic surgeon in Grand Rapids, Mich., is Medical Co-Director of the Area Child Amputee Program, Michigan Crippled Children Commission. On July 1, 1966, Dr. George T. Aitken, who also is an orthopaedic surgeon in Grand Rapids and Medical Co-Director of the Area Child Amputee Program, Michigan Crippled Children Commission, became Chairman of the Subcommittee on Child Prosthetics Problems.</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 An Evolution in the Care of the Child Amputee Creator An entity primarily responsible for making the resource Charles H. Frantz, M.D. * https://staging.drfop.org/files/original/06ff7c1b1ffe661ec3d52637ad1de5da.pdf d8e5e270866afbfeb1b0266021a3a456 https://staging.drfop.org/files/original/804147ec07f70a2ca9e68a7b5ad89752.jpg b8a5d08a40fc781da05fe270deedf973 https://staging.drfop.org/files/original/8060708851663a4e6b62705fd7673f48.jpg 48236d34b6e57e8fa3a8387180393966 https://staging.drfop.org/files/original/2621e70fa9f05b60c976cc6cd29949c0.jpg e16ad7168af90c3478c397208003756c https://staging.drfop.org/files/original/ea8672ccbfec15496887409c07bc2c68.jpg 4daa18a0bad84c931e0b84608e5180cb https://staging.drfop.org/files/original/ffda58be9b5b16824849380aef2798af.jpg df73e68e301073a206b5d54d322da7de https://staging.drfop.org/files/original/7dae03305294afa143bc899a07a7129e.jpg 81d0d6713066127f6689dd6f0bcef436 https://staging.drfop.org/files/original/9cba1e671bf7f65cc2aeac456c3cf265.jpg 25fa44df76c98369324d4692347573fd https://staging.drfop.org/files/original/0beb3fc2157b3219025430a21eb0f941.jpg bfc34be909d07c0f42d627d81681018e https://staging.drfop.org/files/original/c08f7b6c633291f9377ffe0a0662c0c7.jpg 8f0942b1cf85ffb6fd1e0cf158bf0400 https://staging.drfop.org/files/original/5ae9805eeac3afaf5817bc688515587d.jpg aaba8ada7145d82e8f00581e1b5f39cd https://staging.drfop.org/files/original/d24fb122adb3f7233341da58b557dd98.jpg a40ceb0ba4464673b1acc2d203cbe62e https://staging.drfop.org/files/original/5622b27f22b681d9faa779542276d256.jpg f3c6445361e54a612ebe16c8e7d71793 https://staging.drfop.org/files/original/e6be1213fe9bee96128e219d45e6bcf4.jpg 91ab67336ea16438dae2c542ec1a7d5d https://staging.drfop.org/files/original/839347574cabd58a2ec12adb88564d53.jpg 8504e432305c805881c15fe15c27eb1f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_02_025.pdf Year 1971 Volume 1 Issue 2 Page Number(s) 25 - 35 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_02_025.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_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>Ulnar Hemimelia</h2> <h5>Charles H. Frantz, M.D. <a style="text-decoration:none;">*</a><br />Ronan O'Rahilly, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Isolated deficits of the long bones form a well-recognized group of anomalies. They may be described as <i>terminal, </i>in which there are no unaffected parts distal to and in line with the deficient portion (<b>Fig. 1</b>); or <i>intercalary, </i>in which a middle part is deficient while those portions proximal and distal to it are present. (<b>Fig. 2</b>)<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Terminal longitudinal paraxial hemimelia, ulnar. There is absence of one or more digits (the absent parts have been ghosted in). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Intercalary longitudinal paraxial hemimelia, ulnar. Note that all five fingers are present. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Ulnar hemimelia is a postaxial longitudinal deficiency of the upper limb, wherein the ulna is completely or partially absent. Clinically, because of the multiplicity of forearm and hand deformities or contours, it may be very difficult to recognize precisely the deficiency without roentgen studies (<b>Fig. 3</b> and <b>Fig. 4</b>). The elbow joint may be in extension or in acute flexion. There may be fusion of the radiohumeral joint. The range of motion, if present, may be markedly limited. The proximal part of the radius may articulate with the underdeveloped capitulum, or it may be completely luxated. If the deficiency is incomplete, the ulnar remnant may vary in length and contour. The digits of the hand may vary greatly in number (<b>Fig. 5</b> and <b>Fig. 6</b>). At the shoulder girdle, one may observe considerable muscular atrophy, ligamentous relaxation, and a deep web in the axilla.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. <i>Left, </i>the short left upper limb is phocomelic. Note the severe atrophy of the left shoulder girdle. There are three digits in the hand. The right arm (ulnar hemimelia) demonstrates good shoulder musculature and motion. <i>Center, </i>abduction and forward flexion are limited by the axillary web. <i>Right, </i>X-rays reveal fused right radiohumeral joint (failure of cavitation). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. <i>Left, </i>bilateral ulnar hemimelia, with monodigital hands. <i>Right, </i>note the deep web at the cubital fossa (pterygium). <i>Center, </i>X-rays reveal the radiohumeral relationship. There is no true elbow joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. <i>Left, </i>bilateral ulnar hemimelia. The left is intercalary, since there are five digits; the right is terminal because there are only four digits. Patient has complete anonychia with distinctive pulp prints on the dorsum of the fingers. <i>Right, </i>X-rays reveal complete dislocation of the radiohumeral joints. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. <i>Left, </i>monodigital ulnar hemimelia, incomplete. <i>Right, </i>X-rays reveal proximal remnant of the ulna with a bowed radius. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In 1932, Kanavel<a></a> reported 60 cases of ulnar deficiencies. Comparison of Kanavel's findings with those of the cases presented here reveals the digit deficits as shown 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>O'Rahilly<a></a> presented a resume of 65 cases in the literature up to 1950. This deficit is seen much less frequently than is radial hemimelia, the literature indicating a ratio of 18:1. O'Rahilly's analysis revealed that 67% of the cases were unilateral, and 69% involved the right upper limb. The incidence in males was more common, with a ratio of 2:1. Radiohumeral fusion and/ or digital syndactyly were not mentioned.</p> <p>The absence of a radiohumeral joint (fusion) indicates the failure of cavitation of this structure. It is suggested that the lack of cavitation is an integral part of the total deficit seen in some cases of ulnar hemi-melia (38.5% of Frantz's patients).</p> <p>During the past 15 years, the staff at the Area Child Amputee Center has examined and managed 26 children with ulnar hemi-melia. An analysis of these cases reveals a follow-up of from 1 to 15 years. There were 16 males and 10 females.</p> <p>This deficit appears to be a sporadic lesion, in that there were 59 normal siblings of the 26 patients studied. One patient had a fraternal twin who had no skeletal deficits.</p> <p>Ten of the patients (38.5%) had unilateral ulnar hemimelia with no other skeletal deficiencies. Three children (11.5%) had bilateral ulnar hemimelia; seven also had lower-limb deficits. Six patients with unilateral ulnar hemimelia had varying deficiencies in the contralateral upper limb. These included terminal transverse hemimelia, phocomelia, absent thumb, and absent fifth finger. Ten patients (38.5%) had radiohumeral fusion accompanying the ulnar hemimelia.</p> <p>The involvement of carpals and metacarpals is complex. The triquetrum and capitate often are absent. There is an increasing frequency of metacarpal failure as one passes from the radial to the ulnar side of the hand.</p> <p>The frequency of digital absence is shown in <b>Table 2</b>. It is of interest to note that the three-fingered hand is preponderant, followed closely in occurrence by the mono-digital hand.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Management</h3> <p>In our experience, most of these children can be managed without surgical intervention. The goal, of course, is to improve function, with or without the use of a prosthesis. Whether surgery is indicated depends upon whether both arms are involved, and on the range of motion, the number of digits present, and the presence or absence of syndactyly (<b>Table 3</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Nonsurgical</h4> <p><i>No Fitting</i></p> <p>Some of these children had radiohumeral synostosis (<b>Fig. 3</b> and <b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. <i>Left, </i>ulnar hemimelia with three-digit hand (left). The right upper limb is phocomelic. <i>Right, </i>X-rays show radiohumeral fusion (failure of cavitation). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Opponens Post</i></p> <p>Children with one digit (monodigital hand) possessing good flexion power and lateral stability of the metacarpophalangeal joint were fitted to advantage (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. This boy was born with bilateral ulnar hemimelia with monodigital hands (see fig. 4). At 4 years of age the right upper limb was fitted with an opponens post. The left limb was managed by elbow disarticulation and prosthetic replacement. The elbow unit has 11 positions, allowing from 45degrees flexion to 180degrees extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Below-elbow Prosthesis</i></p> <p>Modified below-elbow sockets were sometimes prescribed (<b>Fig. 9</b>). However, range of elbow motion is significantly lacking.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. <i>Left, </i>monodigital ulnar hemimelia, with extension limited to 70degrees. Web release in the cubital fossa offered little additional motion. Initially the child was fitted with a below-elbow type of prosthesis <i>(center). </i>After a 2-year trial, the family expressed dissatisfaction with the limited motion and function of the arm. At 4 years of age an elbow disarticulation was performed and prosthetically fitted <i>(right).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Above-elbow Prosthesis</i></p> <p>This is a highly satisfactory method of fitting patients with unilateral, monodigital, ulnar hemimelia. The forearm segment is acutely flexed against and parallel to the humeral shaft and then encased within the humeral socket. The elbow-locking mechanism has a lever with which the single digit controls the elbow lock and unlock mechanism (<b>Fig. 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. <i>Left, </i>ulnar hemimelia with a monodigital hand. Note the acute flexion and the deep cubital web. <i>Center, </i>the radiohumeral angle is 20degrees. <i>Right, </i>the monodigital segment is encased in a fenestrated humeral socket in an elbow-disarticulation type of prosthesis. The digit operates the elbow lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Surgical</h4> <p><i>Elbow Z-plasty</i></p> <p>Z-plasty in the cubital fossa was performed in two instances in an endeavor to decrease the cubital web and in the hope of allowing a greater range of elbow flexion and extension. This procedure is somewhat advantageous in that it allows a better fit of the forearm socket, but it fails to offer any significant increased range of motion and therefore is not recommended (see <b>Fig. 9</b>).</p> <p><i>Elbow Disarticulation</i></p> <p>This surgical procedure is followed by fitting the limb with an elbow-disarticula-tion type of prosthesis. The surgeon should be meticulous in his technique so as not to disturb the distal humeral epiphysis during the disarticulation procedure.</p> <p>The application of the elbow-disarticulation type of prosthesis with an outside locking elbow offers 11 different positions of the elbow joint.</p> <p><i>Humeral Derotation Osteotomy</i></p> <p>Two children received a humeral derotation osteotomy of at least 90 degrees (<b>Fig. 11</b>). One was lost to follow-up after early union.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. <i>Left, </i>ulnar hemimelia, left; there is radiohumeral fusion (failure of cavitation) with 90degrees rotation. <i>Center, </i>derotation osteotomy of the humerus at 4 years of age. <i>Right, </i>arm position following derotation osteotomy. Note the three-fingered hand; the parents refused to have a syndactyly-release performed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Discussion</h3> <p>From this brief outline of management, it is obvious that the treatment of these children is highly individualized. The timing and procedure may be dictated by the age of the patient, the question of bilateral-ity, and the scope of the handicap. The decision as to whether or not to prescribe a prosthesis may be a difficult one. The approach to handling these children with ulnar hemimelia has been developed over the years by trial and error and by functional analysis.</p> <p>In <b>Fig. 3</b>, severe as the deformities may appear to be, the right shoulder functions normally, and the boy is able to abduct and forward-flex the shoulder, which allows him to prehend with his right hand. The left upper limb is phocomelic; however, he has a functional "pinch force" with the digits for close-in functioning. In the occupational therapy department, he demonstrated a very acceptable level of accomplishment in the activities of daily living and therefore was not fitted with prostheses.</p> <p>This logic is in accord with the problem faced by the boy shown in <b>Fig. 7</b>. The ef-ficency of this four-year-old's performance in dressing, undressing, and toilet care is such that he needs no prosthetic aids. Utilizing the ulnar hemimelic limb, this boy is able to feed himself and care for most of his daily living demands.</p> <p>Bilateral ulnar hemimelia with monodi-gital hands is a severe handicap (see <b>Fig. 4</b>). One male in this group had the Cornelia de Lange syndrome. If a child is seen at an early age (i.e., before two years), one may be tempted to procrastinate. How long? The major question is whether one should fit one or both sides with a passive type of prosthesis (terminal devices with no cables, but with small rubber bands on the hooks) or whether to interfere surgically.</p> <p>It has been stated that a Z-plasty at the cubital fossa offers little improvement of the radiohumeral arc of motion.</p> <p>One approach may be to fit one side with an opponens post and the opposite side with a modified below-elbow prosthesis. Should the prosthetic side prove to be inadequate with a below-elbow type of prosthesis, one may then elect to perform an elbow disarticulation one year before kindergarten, allowing a year of prosthetic wearing before formal schooling. This was done in the patient shown in <b>Fig. 8</b>. At this writing, the boy is 14 years old. He is in junior high school and is the manager of the football team. Also, he is a fair bowler, for which he utilizes a special attachment to his prosthesis.</p> <p>Unilateral, monodigital, ulnar hemimelia with a normal contralateral upper limb is not as serious a handicap. The patient shown in <b>Fig. 9</b> was fitted at two years of age with a modified standard below-elbow pros- thesis. At the age of four years, the patient and her mother were dissatisfied with the function afforded, because of limited elbow motion. (The Z-plasty at the cubital fossa offered little additional motion.) The child received an elbow disarticulation and was subsequently fitted with a standard elbow-disarticulation prosthesis with a medially placed outside-locking elbow. At the time of writing, she is 18 years of age, ready to enter college, and is considered a very good prosthesis-wearer.</p> <p>The patient in <b>Fig. 10</b> was seen in 1964 at 15 years of age; she has a monodigital, left-sided, ulnar hemimelia. Her degree of radiohumeral flexion was more severe than that of the girl in <b>Fig. 9</b>. This patient was not particularly concerned with the cosmetic effect (and still is not). She was fitted with a prosthesis that encased the acutely flexed forearm within the humeral socket. The anterior, or ventral, wall of the socket was then fenestrated and a lever was attached to the elbow-locking cable, which permitted her to use the single digit to operate the elbow locking/unlocking mechanism. At this writing, she is in her second year in college and now wears a mechanical hand with a cosmetic glove. The upper arm is usually covered by a fluffy-sleeved blouse.</p> <p>To summarize, there are four approaches to treatment of the monodigital hand: op-ponens post; below-elbow prosthetic fitting; elbow-disarticulation prosthetic fitting, encasing the forearm in the humeral socket; or no fitting, which is the least recommended procedure.</p> <p>Rotational deformities occasionally are seen in which there may be up to 180 degrees of medial rotation of the forearm on the humerus. The hand rests at the side of the thorax, pointing dorsally. One patient was seen at eight months of age (see <b>Fig. 11</b>). There were three digits in the left hand with soft-tissue syndactyly. She received a derotation osteotomy of the humerus at the age of four years, and a fair result was ob- tained. Unfortunately, she was lost to clinic follow-up shortly after surgery.</p> <p>Dislocation of the radiohumeral joint is rare. One such patient was first seen at four years of age. He has five digits on the left hand and four on the right. There were no fingernails. It is of interest to note that this boy has distinctive prints on both the palmar and dorsal surfaces of his fingers. His radiohumeral joint anatomically is nonexistent (see <b>Fig. 5</b>). The intrinsic muscles of the hands are weakened, and the wrists are unstable. The forearms and hands have been encased in a half-sleeve of plastic attached to crutches (he also has bilateral amelia of the legs). He is now 18 years old and attends a trade school.</p> <p>Incomplete ulnar hemimelia occurred twice in this series. The proximal portion of the ulna is present, thus affording a normal-appearing elbow joint with an excellent range of motion (see <b>Fig. 6</b>). That child was seen at four years of age and fitted with a standard below-elbow prosthesis, which she is currently wearing.</p> <p>Syndactyly was encountered four times in 26 cases. Two cases have been corrected surgically.-<i>Charles H. Frantz, M.D.</i></p> <h3>Pathogenesis</h3> <p>The term "hemimelia" was introduced in 1836-37 by Isidore Geoffroy Saint-Hilaire <i>, </i><a></a> who also introduced the term "teratology". In 1877, Verneuil proposed subdivision (of "ectromelia") into longitudinal and transverse varieties <i>. </i><a></a> In addition to absence of the distal half (two of the four segments) of a limb, it became clear that, in some cases, only one side of the distal half was affected, and such instances were named (after the defective portion) "radial," "ulnar," "tibial," and "fibular" hemimelia. By 1903, a further distinction, that between terminal and intercalary varieties of hemimelia, had been made<a></a>. Finally, in 1951, O'Rahilly suggested the term "paraxial hemimelia" for the longitudinal variety, because either the preaxial or postaxial side of the limb is involved in such cases.</p> <p>It is not proposed to discuss here either the terminological basis<a></a> or the terato- genesis<a></a> of limb malformations in general, as these aspects have been considered recently elsewhere.</p> <p>Ulnar hemimelia was first reported in 1683 by Goller<a></a> and hence is probably the first of the paraxial hemimelias to be identified as such, there being some doubt about the true identity of the case of hemimelia described by Pare in 1573 <i>.</i><a></a> Although chronological tables of all the early cases of radial, tibial, and fibular hemimelia are available in the literature, no such list other than the bibliography provided by Rabaud and Hovelacque<a></a> seems to have been prepared for ulnar hemimelia.</p> <p>Among the hemimelias involving one of the four bones of the third limb segment, or "zygopodium" (forearm and leg), the ulnar type occurs the least. It differs from the others also in that a partial deficiency is more commonly found than complete absence. However, it resembles radial, tibial, and fibular hemimelia in that it is more frequently unilateral, more commonly seen on the right side, and more often observed in the male <i>. </i><a></a> Of particular interest are those cases in which thorough dissection has been possible <i>.</i><a></a> Several additional cases of ulnar hemimelia have been reported in the literature during the past two decades. The higher incidence of unilaterality and of right-sided involvement has been confirmed.<a></a> It is important to appreciate that the hemimelias may occur as isolated anomalies, or they may, as shown in this paper, be associated with other malformations. Ulnar hemimelia, for example, is sometimes a component of a sporadic syndrome that includes femoral and fibular defects.<a></a> The cause of the "FFU" (femur, fibula, ulna) syndrome is unknown; such factors as parental age and thalidomide have been ruled out, and familial occurrence has not been observed.</p> <p>A striking example of familial occurrence in several generations was recounted to Roberts<a></a> by a patient with ulnar hemimelia. Partial ulnar hemimelia of the intercalary type, together with hypoplasia of the thumbs and fibular hemimelia, has more recently been described and illustrated in two brothers <i>. </i><a></a> A different condition, ulnofibular dysplasia, characterized by shortening of the ulna and fibula, was found to be inherited as an autosomal dominant <i>.</i><a></a> Ulnar hemimelia accompanied by Polydactyly is not unknown <i>, </i><a></a> and the coexistence of Polydactyly and a long-bone deficiency in the same limb has been noted previously (e.g., heptadactyly and tibial hemimelia) <i>. </i><a></a> In such cases, it has been suggested that this seeming paradox of excess associated with deficiency may perhaps result from an excessive outgrowth, which occurs relatively late in the early embryonic period, "involved only the digital area, and attracts some of the tissue immediately proximal to the area of excess outgrowth" <i>. </i><a></a> In the human, the hand appears in mesenchyme at about 41 postovulatory days (stage 17), so that it may be expected that Polydactyly would be observable by about six weeks after fertilization. Indeed, an example of this as an isolated anomaly has been described <i>.</i><a></a> What are generally termed "fusions" of skeletal elements-that is, the occurrence as a single structure of something that is usually composed of two or more elements-may be found either as an isolated anomaly or in association with other disturbances. Carpal and tarsal fusions, for example, are not infrequent in the paraxial hemimelias, and, as emphasized in this paper, ulnar hemimelia may include humeroradial fusion. Normally, of course, certain bony fusions, such as those between the epiphyses and their diaphyses and between the neural arches and their centra, are of constant occurrence. Even in areas where synovial cavities might be expected, however, fusions are not infrequent, such as symphalangia between the middle and distal phalanges of the little toe. The histological development of phalangeal fusion has been studied in detail<a></a>, and it is of interest to note that carpal and tarsal fusions have been observed in both the embryonic and the fetal period.<a></a> That such fusions arise early during embryonic development as an absence of joint cavitation<a></a> is also suggested by studies of experimentally paralyzed chick embryos, in which articular cavities do not form.<a></a> The cartilaginous skeletal elements, which are at first united by mesenchyme, become, under these conditions, joined together by fibrous tissue or by cartilage. In other words, fusion takes place across the presumptive joint regions.</p> <p>That hemimelia occurs at a very early stage of embryonic life is indicated by the important, but neglected, observations of Hovelacque and Noel<a></a> on a strain of mice presenting tibial hemimelia. It was found that "the first manifestations of the anomaly are disclosed at a very early stage of development. They can be detected in embryos when the undifferentiated blastema begins to undergo change." In the tibial zone of the blastema, a "fibrous tract" appeared, and was connected to the fibula by the interosseous membrane. In some of these embryos, cartilaginous nodules developed in the area (especially proximally) where the tibia would normally form. Such nodules were in direct continuity with the fibrous tract; both constituted a unit that represented the tibia. The vascularization of the limbs was entirely normal. It was concluded<a></a> that "the tibia is never completely absent despite appearances; one can always find a trace of the element although it may be represented by only a nodule of pinhead size." There is no reason to believe that the above statements would not apply equally to the other types of paraxial hemimelia.</p> <p>To return to the human-the mesenchymal femur, tibia, and fibula appear at about 41 postovulatory days (stage 17), and the humerus, radius, and ulna appear at about 37 postovulatory days (stage 16). In other words, it may be expected that, in the light of the French workers' observations, paraxial hemimelia could be detected in the human before six weeks after fertilization.</p> <p>Prior to the first appearance of these specific skeletal elements, a sensitive period for teratogenic agents exists, as have been shown by correlations between the time of ingestion of thalidomide during pregnancy and the types of resultant anomalies.<a></a> Thus, tibial defects occurred mostly when ingestion began before the 46th menstrual day (perhaps about 32 post-ovulatory days). In one illustrated case, ingestion that commenced at 46 menstrual days resulted in bilateral radial hemimelia and malformations of the femur and tibia.</p> <p>Finally, it may be mentioned that ulnar hemimelia has been found sporadically in various animals, such as the pig.<a></a> It also has been produced experimentally by the inclusion of large doses of acetazol-amide (a carbonic anhydrase inhibitor) in the diet of rats during pregnancy <i>. </i><a></a> Of particular interest in these experiments is the circumstance that the ulnar hemimelia was practically restricted to the right side of the body.-<i>Ronan O'Rahilly, M.D.</i></p> <h3>Summary</h3> <p>The management of 26 cases of ulnar hemimelia has been discussed. This deficit is seen 18:1 less frequently than radial hemimelia. Bilaterality was present in 23% of the cases. Prior to determining the plan of treatment, a complete functional analysis should be carried out. Most of these children do not need surgery and may be treated by prosthetic fitting only. The pathogenesis of paraxial hemimelia and the embryogenesis of associated conditions, such as Polydactyly and joint fusions, are discussed.</p> <p><b>References:</b></p> <ol> <li>Drachman, D. B., and Sokoloff, The role of movement in embryonic joint development, <i>Develop. Biol. </i>14:401-420, 1966.</li> <li>Duken, J., Uber der Beziehungen zwischen As-similationshypophalangie und Aplasie der Inter-phalangealgelenke, <i>Virchows Arch. Path. Anat. Physiol. </i>233:204-225, 1921.</li> <li>Frantz, C. H., and R. O'Rahilly, Congenital skeletal limb deficiencies, <i>J. Bone Joint Surg. </i>43-A: 1202-1224, 1961.</li> <li>Gardner, E., D. J. Gray, and R. O'Rahilly, The prenatal development of the skeleton and joints of the human foot, <i>J. Bone Joint Surg. </i>41-A: 847-876, 1959.</li> <li>Hovelacque, A., and R. Noel, Processus embryo-logique de l'absence congenitale du tibia, C. <i>R. Soc. Biol. Paris </i>88:577-578, 1923.</li> <li>Kanavel, A. B., Congenital malformations of the hands, <i>Arch. Surg. </i>25:1-53, 282-320, 1932.</li> <li>Klippel, M., and E. Rabaud, Sur une forme rare d'hemimelie radiale intercalaire, <i>Nouu. Ponograph. Salpetriere </i>16:238-251, 1903.</li> <li>Ku'hne, D., W. Lenz, D. Petersen, and H. Schoneberg, Defekt von Femur und Fibula mit Amelie, Peromelie oder ulnaren Strahldefekten der Arme, Ein Syndrom, <i>Humangenetik </i>3: 244-263, 1967.</li> <li>Laurin, C. A., and A. W. Farmer, Congenital absence of ulna, <i>Canad. J. Surg. </i>2:204-207, 1959.</li> <li>Layton, W. M., and D. W. Hallesy, Deformity of forelimb in rats: association with high doses of acetazolamide, <i>Science </i>149:306-308, 1965.</li> <li>Lenz, W., Zur Genese der angeborenen Hand-fehlbildungen, <i>Chir. Plast. Reconstr. </i>5:3-15, 1968.</li> <li>Lenz, W., Der Zeitplan der menschlichen Organogenese als Massstab fur die Beurteilung teratogener Wirkungen, <i>Fortschr. Med. </i>87: 520-526, 1969.</li> <li>Malgaigne, J. F., <i>Oeuvres Completes d'Ambroise Pare, </i>vol. 3, Paris, Bailliere, 1841.</li> <li>Meckel, J. F., <i>Handbuch der pathologischen Ana-tomie, </i>Leipzig, Reclam, 1812.</li> <li>Murray, P. D. F., and D. B. Drachman, The role of movement in the development of joints and related structures: the head and neck in the chick embryo, <i>J. Embryol. Exp. Morph. </i>22:349-371, 1969.</li> <li>Nishimura, H., <i>Chemistry and Prevention of Congenital Anomalies, </i>Springfield, HI., Charles C Thomas, 1964.</li> <li>O'Rahilly, R., Morphological patterns in limb deficiencies and duplications, <i>Amer. J. Anat. </i>89: 135-193, 1951.</li> <li>O'Rahilly, R., The development and the developmental disturbances of the limbs, <i>Irish J. Med. Sci. </i>pp. 30-33, January 1959.</li> <li>O'Rahilly, R., The nomenclature and classification of limb anomalies, <i>Birth Defects: Original Article Series </i>5:14-17, 1969.</li> <li>Pfeiffer, R. A., and K. Reinhardt, Ulno-fibulare Dysplasie, Eine autosomaldominant vererbte Mikromesomelie ahnlich dem Nievergeltsyndrom, <i>Fortschr. Roentgenstr. </i>107:379-391, 1967.</li> <li>Rabaud, E., and A. Hovelacque, Etudes sur l'ectromelie, I. L'ectromelie longitudinale intercalaire hemisegmentaire, <i>Bull. Biol. France Belg. </i>57:401-468, 1923.</li> <li>Roberts, A. S., A case of deformity of the fore-arm and hands, with an unusual history of hereditary congenital deficiency, <i>Ann. Surg. </i>3:135-139, 1886.</li> <li>Stoffel, A., and E. Stempel, Anatomische Studien iiber die Klumphand, <i>Z. Orthop. Chir. </i>23:1-157, 1909.</li> <li>Stroer, W. F. H., Die Extremitatenmissbildungen und ihre Beziehungen zum Bauplan der Extremitat, <i>Z. Anat. Entwicklungsgesch </i>108:136-160, 1938.</li> <li>Trucchi, O., Ectromelie longitudinali estese e sistematiche in due fratelli, <i>Nunt. Radiol. </i>26: 1040-1054, 1960.</li> <li>Zwilling, E., and J. F. Ames, Polydactyly, related defects and axial shifts, a critique, <i>Amer. Naturalist </i>92:257-266, 1958.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Layton, W. M., and D. W. Hallesy, Deformity of forelimb in rats: association with high doses of acetazolamide, Science 149:306-308, 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>23.</b> </td><td class="clsTextSmall">Stoffel, A., and E. Stempel, Anatomische Studien iiber die Klumphand, Z. Orthop. Chir. 23:1-157, 1909.</td></tr><tr><td class="clsTextSmall"><b> 24.</b> </td><td class="clsTextSmall">Stroer, W. F. H., Die Extremitatenmissbildungen und ihre Beziehungen zum Bauplan der Extremitat, Z. Anat. Entwicklungsgesch 108:136-160, 1938.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Lenz, W., Der Zeitplan der menschlichen Organogenese als Massstab fur die Beurteilung teratogener Wirkungen, Fortschr. Med. 87: 520-526, 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>21.</b> </td><td class="clsTextSmall">Rabaud, E., and A. Hovelacque, Etudes sur l'ectromelie, I. L'ectromelie longitudinale intercalaire hemisegmentaire, Bull. Biol. France Belg. 57:401-468, 1923.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Hovelacque, A., and R. Noel, Processus embryo-logique de l'absence congenitale du tibia, C. R. Soc. Biol. Paris 88:577-578, 1923.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Drachman, D. B., and Sokoloff, The role of movement in embryonic joint development, Develop. Biol. 14:401-420, 1966.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Murray, P. D. F., and D. B. Drachman, The role of movement in the development of joints and related structures: the head and neck in the chick embryo, J. Embryol. Exp. Morph. 22:349-371, 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>17.</b> </td><td class="clsTextSmall">O'Rahilly, R., Morphological patterns in limb deficiencies and duplications, Amer. J. Anat. 89: 135-193, 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Gardner, E., D. J. Gray, and R. O'Rahilly, The prenatal development of the skeleton and joints of the human foot, J. Bone Joint Surg. 41-A: 847-876, 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Duken, J., Uber der Beziehungen zwischen As-similationshypophalangie und Aplasie der Inter-phalangealgelenke, Virchows Arch. Path. Anat. Physiol. 233:204-225, 1921.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Gardner, E., D. J. Gray, and R. O'Rahilly, The prenatal development of the skeleton and joints of the human foot, J. Bone Joint Surg. 41-A: 847-876, 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Nishimura, H., Chemistry and Prevention of Congenital Anomalies, Springfield, HI., Charles C Thomas, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Zwilling, E., and J. F. Ames, Polydactyly, related defects and axial shifts, a critique, Amer. Naturalist 92:257-266, 1958.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">O'Rahilly, R., The development and the developmental disturbances of the limbs, Irish J. Med. Sci. pp. 30-33, January 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Trucchi, O., Ectromelie longitudinali estese e sistematiche in due fratelli, Nunt. Radiol. 26: 1040-1054, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Pfeiffer, R. A., and K. Reinhardt, Ulno-fibulare Dysplasie, Eine autosomaldominant vererbte Mikromesomelie ahnlich dem Nievergeltsyndrom, Fortschr. Roentgenstr. 107:379-391, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Trucchi, O., Ectromelie longitudinali estese e sistematiche in due fratelli, Nunt. Radiol. 26: 1040-1054, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Roberts, A. S., A case of deformity of the fore-arm and hands, with an unusual history of hereditary congenital deficiency, Ann. Surg. 3:135-139, 1886.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Ku'hne, D., W. Lenz, D. Petersen, and H. Schoneberg, Defekt von Femur und Fibula mit Amelie, Peromelie oder ulnaren Strahldefekten der Arme, Ein Syndrom, Humangenetik 3: 244-263, 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>9.</b> </td><td class="clsTextSmall">Laurin, C. A., and A. W. Farmer, Congenital absence of ulna, Canad. J. Surg. 2:204-207, 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Stoffel, A., and E. Stempel, Anatomische Studien iiber die Klumphand, Z. Orthop. Chir. 23:1-157, 1909.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">O'Rahilly, R., Morphological patterns in limb deficiencies and duplications, Amer. J. Anat. 89: 135-193, 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Rabaud, E., and A. Hovelacque, Etudes sur l'ectromelie, I. L'ectromelie longitudinale intercalaire hemisegmentaire, Bull. Biol. France Belg. 57:401-468, 1923.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Malgaigne, J. F., Oeuvres Completes d'Ambroise Pare, vol. 3, Paris, Bailliere, 1841.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Meckel, J. F., Handbuch der pathologischen Ana-tomie, Leipzig, Reclam, 1812.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Lenz, W., Zur Genese der angeborenen Hand-fehlbildungen, Chir. Plast. Reconstr. 5:3-15, 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">O'Rahilly, R., The nomenclature and classification of limb anomalies, Birth Defects: Original Article Series 5:14-17, 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>7.</b> </td><td class="clsTextSmall">Klippel, M., and E. Rabaud, Sur une forme rare d'hemimelie radiale intercalaire, Nouu. Ponograph. Salpetriere 16:238-251, 1903.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Rabaud, E., and A. Hovelacque, Etudes sur l'ectromelie, I. L'ectromelie longitudinale intercalaire hemisegmentaire, Bull. Biol. France Belg. 57:401-468, 1923.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">O'Rahilly, R., The nomenclature and classification of limb anomalies, Birth Defects: Original Article Series 5:14-17, 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>17.</b> </td><td class="clsTextSmall">O'Rahilly, R., Morphological patterns in limb deficiencies and duplications, Amer. J. Anat. 89: 135-193, 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Kanavel, A. B., Congenital malformations of the hands, Arch. Surg. 25:1-53, 282-320, 1932.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Frantz, C. H., and R. O'Rahilly, Congenital skeletal limb deficiencies, J. Bone Joint Surg. 43-A: 1202-1224, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Ronan O'Rahilly, M.D. </b></td></tr><tr><td class="clsTextSmall">Director of the Carnegie Collection, Dept. of Embryology, Carnegie Institution of Washington, Baltimore, Md. 21210; Professor of Anatomy, Wayne State Univ. School of Medicine, Detroit, Mich.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles H. Frantz, M.D. </b></td></tr><tr><td class="clsTextSmall">Medical Codirector, Area Child Amputee Program (Mich. Dept. of Public Health), 920 Cherry St., S.E., Grand Rapids, Mich. 49506.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-28.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-29.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-30.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-31.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-32.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-33.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-39.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-40.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-41.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-34.jpg Figure 11 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-35.jpg Figure 12 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-36.jpg Figure 13 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-37.jpg Figure 14 http://www.oandplibrary.org/al/images/1971_02_025/ArtificialLimbs-Autumn1971-38.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 Ulnar Hemimelia Creator An entity primarily responsible for making the resource Charles H. Frantz, M.D. * Ronan O'Rahilly, M.D. * https://staging.drfop.org/files/original/f4a0dba11dbd83d1386ccb0e624bc090.pdf cdd8923abdae6f28e1a9d8d1fe8755c4 https://staging.drfop.org/files/original/681863a98ef8c1b69d476ca775d584e5.jpeg ae65dd03b074faa805393f2bb2cca1eb https://staging.drfop.org/files/original/b3f368a835f52e8d59db880235d53694.jpg 64a7ad3c59294b4014476742e34ee741 https://staging.drfop.org/files/original/bd5404308943c819bbb4f8cf4312b7c3.jpg 40b7c14dc32d98e7f4de52e02a7bd7aa https://staging.drfop.org/files/original/8377ac015b32853159b839d4e215bde5.jpg ebb48fe686c96a27f8944c39a7ea1994 https://staging.drfop.org/files/original/568455a545a488a7582cc67a53f4e0ff.jpg 39633f73e9a88bef0976b0d0d921dcb5 https://staging.drfop.org/files/original/bba2f04183e22d65f8b82db57ebb81de.jpg 56a7734fbe443f9e90a5a81715258054 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1977_03_005.pdf Text Any textual data included in the document <h2>Partial Foot Amputation - A Case Study</h2> <h5>Charles H. Pritham C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Traditionally amputations through the foot have been held in poor repute for a variety of reasons<a></a>, chief among them being the equinus deformity that can result from an imbalance between the intact triceps surae and the severed anterior muscles. In addition, the poor quality of socket fit that often occurs with older styles of fabrication can be cited as a contributing factor for the low esteem in which tarsal and mid-tarsal amputations are held.</p> <p>In recent years there has been an ever increasing emphasis on more distal level of amputation for peripheral vascular disease and the advantages to be accrued. Thus, today, below-knee amputations and disarticulations at the knee have supplanted to a large measure above-knee amputations. In a similar fashion Syme's and partial foot amputations are being performed by some <a></a> to ensure the patients the advantages of full limb length, distal end-bearing, retention of proprioception, and a long lever arm. The trend has gained impetus from such improved methods of predicting successful amputation levels as Xenon Radiography, and differential pulse ratios to predict accurately stump viability <a></a> as well as such improved methods of surgical technique as fixation of the pretibial muscles for Chopart and Lisfranc amputations, heel pad fixation for the Syme's, and the use of rigid dressings for all levels of amputation <a></a>.</p> <p>It, thus, seems correct to conclude that an increasing number of partial foot amputations for vascular insufficiency will be seen by prosthetists in the years to come. The challenge to the prosthetist, therefore, is to maximize the advantages cited by using the best products of the latest available technology. One example of this can be found in the use of a modified plastic ankle-foot orthosis with a toe filler distal to the stump in those cases where stump length is adequate to ensure proper control and fit of the shoe <a></a>. Numerous variations of the basic theme exist, and are well known. Karl Fillauer has reported recently on his experience with a prosthesis that totally encompasses the stump below the malleoli and permits free motion of the ankle <a></a>. To the extent of the author's knowledge, neither of these designs have ever been subjected to formal evaluation and while experience has been gained by many prosthetists with the first design, little is known objectively about the latter. Both designs appear to work well in selected cases, but neither design appears to provide for the broadest possible distribution of pressure (or in the case of a modified AFO, the most accurate distribution) to protect the fragile, sensitive, and often partially anesthetic skin over the dorsal surface of the remainder of the foot <a></a>. The purpose of this paper is to discuss one possible solution to this problem.</p> <h3>Case Report</h3> <p>W.M. is a 62-year-old male Caucasian, who sustained a right Chopart amputation in 1972, secondary to peripheral vascular disease and necrosis of the forefoot (<b>Fig. 1</b>). He was subsequently fitted with a prosthesis which he wore until April 1977 (<b>Fig. 2</b>). The prosthesis was fabricated of polyester lamination with a posterior opening and metal reinforcing elements. Because of subsequent failure an additional steel armature was added externally, and the weight of the unit when seen by us had crept to 5 lb. 4 oz. Over the years sufficient change had taken place in contour of the stump so that W.M. was experiencing pain on the distal-lateral and anterior aspects of the stump, and he walked slowly with the use of a cane. Our initial attempt to fit the patient was made with a molded ankle-foot orthosis with a toe filler, but the patient obtained no relief from the pain, and the situation was re-evaluated.</p> <strong><a href="/files/original/681863a98ef8c1b69d476ca775d584e5.jpeg">Fig. 1.</a> W.M.'s Chopart Amputation</strong><br /><br /><strong><a href="/files/original/b3f368a835f52e8d59db880235d53694.jpg">Fig. 2.</a> W.M.'s "Conventional" prosthesis</strong><br /> <p>After due deliberation, the patient was cast in the weight-bearing position, tracings were taken of both feet and vertical reference lines drawn (<b>Fig. 3</b>). With the tracing as a guide, a proper sized SACH foot was selected for the forefoot extension to the positive model of the stump, overwhich a polyethelene form of the heel and sole could be vacuum molded. The positive model of the stump was positioned inside the polyethelene form and the tracing and reference lines were used as guides to establish proper alignment. After plaster had been poured in the form and blended into the stump model, 1/4-in. thick polypropylene was vacuum formed about the extended model and subsequently modified to establish an AFO-type of socket with maximum rigidity about the ankle and anterior lever arm. A Plastizote interface was molded to the anterior aspect of the stump model and mated to a toe filler shaped from SACH-foot heel-cushion stock.<br /><br /><strong><a href="/files/original/bd5404308943c819bbb4f8cf4312b7c3.jpg">Fig. 3</a>. Outline of feet during weight-bearing to provide references for fabrication and alignment of the molded prosthesis.</strong></p> <p>The semi-completed prosthesis was fitted to the patient so that adequacy of fit and alignment could be checked. Ambulation by the patient revealed that he still experienced some pain, which was relieved by using adhesive tape to strap the shin firmly into the prosthesis and thus distribute the pressure over a broader area. While the patient was standing, strapped in the prosthesis, splints were used to cast the limb for an anterior shell that would match properly with the posterior element. Polyethelene was vacuum formed over the model to form an anterior shell that was lined with Plastizote. The two elements were then fitted to the patient and fastened proximally with "PTB-type" buttons in a fashion identical to the tibial fracture orthosis reported by Stills <a></a>. The finished prosthesis (<b>Fig. 4</b>, <b>Fig. 5</b>, <b>Fig. 6</b>) weighed 18 ounces and fitted more loosely in the shoe than the older prosthesis. The patient reported total comfort in the prosthesis during walking and considered the vastly decreased weight an important advantage.</p> <strong><a href="/files/original/8377ac015b32853159b839d4e215bde5.jpg">Fig. 4.</a> The molded prosthesis on the patient.</strong><br /><br /><strong><a href="/files/original/568455a545a488a7582cc67a53f4e0ff.jpg">Fig. 5</a>. Lateral view of the molded prosthesis.</strong><br /><br /><strong><a href="/files/original/bba2f04183e22d65f8b82db57ebb81de.jpg">Fig. 6.</a> Three-quarter anterior view of the molded prosthesis.</strong><br /> <p><b>References:</b></p> <ol> <li>Alidredge, R. FF, and E. F. Murphy, <i>The influence of new developments on amputation surgery</i>. In: Human Limbs and their Substitutes. New York, McGraw Hill Co., Inc. 1954.</li> <li>Anderson, M. H., J. J. Bray, and C. A. Hennessey, <i>The construction and fitting of lower-extremity prostheses</i>. In: Orthopaedic Appliances Atlas. Ann Arbor, ). W. Edwards, 1960.</li> <li>Bingham, J. <i>The surgery for partial foot amputations</i>. In: Prosthetic and Orthotic Practice. London, Edward Arnold Ltd., 1970.</li> <li>Condie, D. N. <i>Biomechanics of the partial foot amputation</i>. In: Prosthetic and Orthotic Practice. London, Edward Arnold Ltd., 1970,</li> <li>El-Sharkaw, A., H. Abdel-Farrar, H. El-Hadidi, and M. Abdel-Hafez, <i>A reconsideration of tarsal amputations with a new approach to the problem of equinus deformity</i>. In: Proceedings of the International Conference, Cairo and Alexandria, Egypt, May 1- 1 1, 1972. Sponsored by Social and Rehabilitation Service, DHEW, USA and International Society-tor Prosthetics and Orthotics.</li> <li>Eillauer, K. <i>A prosthesis tor foot amputation near the tarsal-metatarsal junction</i>. Orthotics and Prosthetics 30 (3): 9-11, September 1976.</li> <li>Rubenstein, H. J., G. J. Sweeney, P. Strong, and C. Durrett, <i>A foot amputation orthosis-prosthesis</i>. Inter-Clinic Information Bulletin 14(4), April 1975.</li> <li>Rubin, G., and M. Daniso, <i>Functional partial foot prosthesis</i>. Bulletin of Prosthetic Research 10-16: 149-152, Fall 1971.</li> <li>Rubin, C, and M. Daniso, <i>A functional Chopart prosthesis</i>. Inter-clinic Information Bulletin 11(6), March 1972.</li> <li>Stills, M. <i>Vacuum-formed orthoses for fracture of the tibia</i>. Orthotics and Prosthetics 30(2): 43-55, June 1976.</li> <li>Wagner, W. <i>Instructional Course in Amputation Surgery and Post-Op Care</i>. ISPO World Congress. New York, May 1977</li> </ol> <strong>*Charles H. Pritham C.P.O. </strong><strong>Staff Prosthetist, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, 12th St. &amp;Tabor Rri., Phila., Pa. 19141<br /><br /><br /></strong> Page Number(s) 5 - 7 Year 1977 Volume 1 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1977_03_005/1977_03_005-5.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/1977_03_005/1977_03_005-6.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 Partial Foot Amputation - A Case Study Creator An entity primarily responsible for making the resource Charles H. Pritham C.P.O. * https://staging.drfop.org/files/original/0eb0155fd4a6657c71f5a235373aa4bf.pdf a9eff5f0c0999d72953d88dc04f93154 https://staging.drfop.org/files/original/f158ce59a35747a9d9020e944269da53.jpg 757f7d66742eb5392ce4c317b6cb55db https://staging.drfop.org/files/original/67ca44d880b4aca5258caa2712db2aab.jpg 802b68c5445dacd6da77b74473d6a6c8 https://staging.drfop.org/files/original/4536555d7f66980c8ddffa5cb6fb6905.jpg 6662f3e43b363f5633707abfd523a5f6 https://staging.drfop.org/files/original/0c036efb96682517789da461a8caa5b1.jpg bd4bc6c6da7b8254b78d3a008146646b https://staging.drfop.org/files/original/4d1d11c52e9a10c1859a7c1aacce2376.jpg 0126ae23c2d2a6c7aa2f5ca6c0971c37 https://staging.drfop.org/files/original/55483c1f96ae1c766e8d18f2843826cc.jpeg 9355ee3a449698ab5e54d338aa49cdf3 https://staging.drfop.org/files/original/2c9444bd9873add9855c30b383b9b0ec.jpeg 7e7c6d801120cf56fba8c150439ee460 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_02_002.pdf Text Any textual data included in the document <h2>Concerning Suspension Alignment, and Control</h2> <h5>Charles H. Pritham, C.P.O.&nbsp;</h5> <p>In the prescription of any prostheses consideration is naturally given to the proper means of suspending the prosthesis and maintaining it in place. In contrast, not as much concern seems to be given to this crucial matter in the prescription of an orthosis.</p> <p>Paradoxically, this relative state of neglect is undoubtedly due to the very success with which suspension has been incorporated in most conventional orthosos. To cite but one example, the shoe that inevitably must be used with any ambulatory AFO, KAFO, or HKAFO provides for suspension of the device as well as providing support to the ground.</p> <p>In recent years with the expansion of new technology in the area of prosthetics and orthotics there has developed a corresponding interest in new techniques to overcome shortcomings in conventional devices. In the process, however, new problems can arise as a result of the intertwining roles played by various components of the device under consideration, and it would therefore appear worthwhile to attempt to sort out these various roles with special emphasis on suspension in order to clarify the picture, and possibly, as a result, to suggest new and unique applications for the various suspension systems available.</p> <p>For clarity a brief glossary has been prepared, and is included at the conclusion of this article.</p> <h3>Maintenance of Alignment</h3> <p>For any prosthesis or orthosis to provide the maximum benefit possible, it must be held in proper position relative to the body segments concerned. The prevention of inappropriate motion can be classified broadly as maintenance of alignment by either suspension or stabilization depending upon the direction of the motion. As it is defined, suspension is concerned with the prevention of linear displacement along the longitudinal axis, and it will be seen that no discrimination is made as to whether the direction is distal or proximal. Thus, the perineal straps that may be attached to a spinal orthosis to prevent proximal displacement ("riding-up") are just as much a suspension aid as is a suprapatellar cuff suspension strap on a below-knee prosthesis.</p> <p>Considered in this light, the weightbearing component of any given device naturally prevents proximal displacement, and, thus, may be confused as a suspensory component. The distinction must be made on the basis of intended function.</p> <p>Weightbearing is a primary characteristic of a lower-limb prosthesis or a weightbearing orthosis without which it cannot function. Suspension is a secondary characteristic inasmuch as it is but one of a number of different components intended to ensure proper weight bearing and thus function of the device. It can be seen, therefore, that the intended role of a weightbearing component is quite a bit different than suspension. However, the use of this same component as a non-weightbearing device for purposes other than weightbearing is not inconceivable. It is possible, if not practical, to use PTB brims about the knees of a patient to prevent proximal displacement of a corset, and the use of quadrilateral sockets as anchor points <a></a> for the powering of upper-limb prostheses comes to mind.</p> <p>Stabilization, as it is defined, is concerned with the prevention of displacement about the various rotatory axes of the body rather than along the linear axes. Motion does take place undoubtedly includes some linear motion, either laterally or anterioposteriorly, but in the author's opinion the rotary displacement is inevitably the predominant component. How then is stabilization to be differentiated from control which, as it is defined, is also involved, in part, with the prevention of motion?</p> <p>Two separate but interrelated definitions of the word control are given. In both instances control is to be considered as a primary characteristic. In the first definition control refers to the regulation of motion in one portion of the body segment relative to another portion, while stabilization (a secondary characteristic) refers to the regulation of the device relative to the body segment. In the second definition control refers to volitional regulation of motion in the device by the patient; while stabilization holds the device in firm contact with the body segment in order to maximize the efficiency of this volitional regulation.</p> <p>In any event, it can be appreciated that any given component of a prosthetic or orthotic device may play multiple roles in the function of that device. A hip joint and pelvic band fitted to an above-knee prosthesis while providing suspension also provides stabilization against lateral and rotary motion. The same component is likely to be fitted to an HKAFO to control motion about the patient's hip, and is unlikely to be used for suspension or rotary stabilization of the HKAFO since both of these functions are provided effectively by the fit of the foot in the shoe. Supracondylar wedge suspension in a below-knee prosthesis also provides effective stabilization against lateral thrust, while a cuff suspension strap fitted to a below-knee prosthesis does not. A figure-8 harness (<b>Fig. 1</b>) fitted to an above-elbow prosthesis not only provides suspension, but also stabilization against lateral or rotary motion of the socket and control of the elbow and terminal device, while a butterfly harness and Bowden cable (<b>Fig. 2</b>) fitted to a shoulder-driven WHO provides only control of motion in the metacarpal-phalangeal joints of the index and ring finger and neither suspension nor stabilization.</p> <strong><a href="/files/original/f158ce59a35747a9d9020e944269da53.jpg" target="_blank" rel="noopener">Fig. 1.</a> One Version of the Figure-8 Harness for Above-Elbow Amputees</strong><br /><br /><strong><a href="https://staging.drfop.org/files/original/67ca44d880b4aca5258caa2712db2aab.jpg">Fig. 2.</a> The "Butterfly" Harness</strong><br /> <p>These are but a few of the many examples that could be cited in designing or prescribing a device for a given situation. Consideration must be given to the many intertwining roles played by the many available design elements and selection be made of those elements that perform the intended function with maximum benefits and a minimum of adverse side effects.</p> <p>A particularly troublesome example of this dilemma is to be found in the design of an orthosis to control knee motion without involving the ankle-foot complex, the traditional source of suspension and rotary stabilization of devices to regulate the knee. If supracondylar suspension is used as with the IRM supracondylar knee orthosis (<a href="https://staging.drfop.org/files/original/4536555d7f66980c8ddffa5cb6fb6905.jpg"><b>Fig. 3</b></a>) or Iowa knee orthosis (to name but two examples of this class of orthosis) adequate suspension and stabilization may be gained initially from the critical fit about the knee, but the patient may not be able to tolerate it, and with compression of the soft tissues fit and, thus, suspension may be lost. The CARS-UBC knee orthosis (<a href="https://staging.drfop.org/files/original/0c036efb96682517789da461a8caa5b1.jpg"><b>Fig. 4</b></a>) avoids these problems by using a waist belt and suspension strap. Waist belts, however, are not well tolerated by many patients, and considerable effort must be taken in fitting the device to achieve adequate rotary stabilization.</p> <strong><a href="https://staging.drfop.org/files/original/4536555d7f66980c8ddffa5cb6fb6905.jpg">Fig. 3</a>. IRM Supracondylar Knee Orthosis</strong><br /><br /><strong><a href="https://staging.drfop.org/files/original/0c036efb96682517789da461a8caa5b1.jpg">Fig. 4.</a> CARS-UBC Knee Orthosis</strong><br /> <p>In any given instance it is necessary to weigh the pros and cons of the applicable suspension components available, and select the one that best fits the needs of the patient.</p> <h3>Classification of Suspension Types</h3> <p>In most instances, suspension is secured by obtaining a purchase above a flaring bony prominence (epicondyle, adductor tubercle) or other body segment (buttocks, shoulder). This general principle is the same regardless of type of suspension. Suspension may be classified into two major groups and a third miscellaneous one (<a href="https://staging.drfop.org/files/original/4d1d11c52e9a10c1859a7c1aacce2376.jpg"><b>Fig. 5</b></a>).</p> <strong><a href="https://staging.drfop.org/files/original/4d1d11c52e9a10c1859a7c1aacce2376.jpg">Fig 5.</a></strong><br /> <p><b>A. Extrinsic Suspension</b>: The means of suspension are not contained within the proper borders of a device, and must be gained by the addition of extraneous elements that pass beyond the borders of the device and may not be otherwise absolutely necessary for the function of the device. However, the extrinsic elements may also serve as means of stabilization or control.</p> <ol> <li> <p>Examples of extrinsic suspension are:</p> <ol> <li> <p>PTB cuff suspension strap</p> </li> <li> <p>Knee joints and thigh corset</p> </li> <li> <p>Waist belt</p> </li> <li> <p>Rubber suspension sleeve</p> </li> <li> <p>Hip joint and pelvic band</p> </li> <li> <p>Silesian belt f. Suspenders</p> </li> <li> <p>Perineal straps on a spinal orthosis</p> </li> <li> <p>Various harnesses used in upper-limb orthotics and prosthetics</p> </li> </ol> </li> </ol> <p><b>B. Intrinsic Suspension</b>: Suspension is gained by means of some elements) contained within the proper borders of the device. The elements) may also serve as a means of stabilization.</p> <ol> <li> <p>Examples of intrinsic suspension are:</p> <ol> <li> <p>All self-suspending prostheses</p> </li> <li> <p>All orthoses with few exceptions</p> <p>A shoe is necessary for the proper function of lower-limb orthoses while a waist belt used on a KO is not absolutely necessary for the function of the KO as suspension can be accomplished by other means. Therefore, an AFO is a case of intrinsic suspension while a KO is not necessarily an example.</p> </li> </ol> </li> <li> <p>Types of intrinsic suspension can be broken down as follows:</p> <ol> <li> <p>Supracondylar: purchase is obtained above any of the various condyles or epicondyles of the body.</p> </li> <li> <p>Flaring body segments other than bony prominences: purchase is obtained above any of the flaring body segments not covered in Item 1, such as the buttocks or shoulders.</p> </li> <li> <p>Suction, or negative atmospheric pressure: In general, suction suspension is used with amputation stumps that exhibit a high soft-tissue-to-bone ratio with few prominent subcutaneous bony prominences such as above-knee or above-elbow stumps; however, suction suspension has been used with below-knee prostheses in Europe and there is a current resurgence of interest in it in America.</p> </li> <li> <p>Muscular grasp: This is the often greatly overlooked ancillary of suction suspension and other suspension types. Rudolf Poets <a></a> has described briefly the principle of an "undercut socket" he attributes to Dr. Oskar Hepp, and every clinician is familiar with the admonition to the patient that he should use his stump muscles to hold the above-knee prosthesis on. Many below-knee amputees have reported being able to hold their prosthesis on with muscular contractions, and Dr. Ernest Burgess is currently studying how to capitalize on this phenomenon.</p> </li> <li> <p>Compression of soft tissue and friction: This means of suspension serves for such lightweight, elastic, and readily conformable devices as a spinal corset or knee support and may be used in conjunction with other means of suspension.</p> </li> </ol> </li> </ol> <p><b>C. Other Miscellaneous</b>: This serves as a catch-all division to contain those means that do not readily fit in the other divisions and are rarely used in prosthetics and orthotics.</p> <ol> <li> <p>Examples of the miscellaneous category are:</p> <ol> <li> <p>Medical grade adhesive used with rigid dressings, some cosmetic finger prostheses, facial restoration, and stoma appliances.</p> </li> <li> <p>Skeletal attachment. While under active consideration by some, this means of suspension is not currently in use.</p> </li> </ol> </li> </ol> <h3>Selection Criteria</h3> <p>As can be seen in <b>Fig. 6</b> and <b>Fig. 7</b>, selection of an appropriate means of suspension for a specific device can often pose problems. A variety of factors must be considered, a few of which are listed here.</p> <strong><a href="https://staging.drfop.org/files/original/55483c1f96ae1c766e8d18f2843826cc.jpeg">Table I.</a> Suspension Methods versus Orthosis Level</strong><br /><br /><img src="/files/original/55483c1f96ae1c766e8d18f2843826cc.jpeg" alt="Italian Trulli" /> <br /><strong><a href="https://staging.drfop.org/files/original/2c9444bd9873add9855c30b383b9b0ec.jpeg">Table II.</a> Suspension Techniques and Additional Auxiliary Function Possible.</strong><br /><img src="/files/original/2c9444bd9873add9855c30b383b9b0ec.jpeg" ul="" /> <ul> <li> <p>Medical contraindications</p> </li> <li> <p>Donning difficulties</p> </li> <li> <p>Clinic team preferences</p> </li> <li> <p>Patient preferences</p> </li> <li> <p>Maintenance</p> </li> <li> <p>Fitting difficulties and problems maintaining proper fit.</p> </li> <li> <p>Necessary related functions (stabilization or control) provided by a specific suspension system.</p> </li> <li> <p>Aesthetics</p> </li> </ul> <p>In any event the essential matter is to balance the pros and cons of the various suspension systems available and select the one that offers the most advantages with the fewest disadvantages. The matter becomes even more important when the emphasis is shifted from routine clinical prescription to the design of one-of-a-kind applications for a</p> <p>specific patient's unique problems or in research and development of a new style device.</p> <h3>Conclusion and Summary</h3> <p>Suspension is inevitably related closely to a wide variety of interrelated factors, all of which are involved in the determination of proper fit. An attempt has been made to logically sort out the various factors and concentrate on suspension. Further, suspension has been broken down into various categories and some of the inherent difficulties in selecting between a number of suspension techniques relevant to a specific patient or prosthetic or orthotic device have been suggested.</p> <h3>Glossary</h3> <p><i>Orthosis</i>: An externally applied device for the control of motion about the joints of a body segment.</p> <p><i>Prosthesis</i>: (Artificial Limb)-an externally applied device to substitute for a missing body segment.</p> <p><i>Suspension</i>: The method of maintaining a prosthesis or orthosis in proper place relative to the affected body segment and resisting linear displacement along the longitudinal axis.</p> <ol> <li> <p>Not weight-bearing</p> </li> <li> <p>Displacement due to:</p> <ol> <li> <p>gravity</p> </li> <li> <p>momentum</p> </li> <li> <p>"oozing" "creeping" (movement due to compression of a conical section)</p> </li> </ol> </li> </ol> <p><i>Weight-Bearing</i>: The transmission of a person's mass (or weight) to the ground from a relatively distant body segment by means of a prosthesis or orthosis.</p> <p><i>Stabilization</i>: The method of maintaining a prosthesis or orthosis in proper placement relative to the affected body segment and resisting angular or rotary displacement about one of the three axes.</p> <ol> <li> <p>Due to:</p> <ol> <li> <p>Moments created by the eccentric application of forces about the various axes or centers of rotation.</p> </li> </ol> </li> </ol> <p><b>Control</b>:</p> <ol> <li> <p>Orthotic: The maintenance of a body segment in a desired position or positions by an orthosis (also called correction or corrective control).</p> </li> <li> <p>Orthotic or Prosthetic: The voluntary activation of a prosthesis or orthosis (or of an artificial articulation thereof) by means of the body segment enclosed in the device or by a signal generated by a remote body segment and transmitted to the device or articulation by means of a mechanical, hydraulic, pneumatic, or electric linkage (also called volitional control).</p> </li> </ol> <p><i>Alignment</i>: The relationships that exist or are to be created between the components of a device or between the device as a whole and the affected body segment.</p> <p><i>Pistoning</i>: The cyclical linear displacement that takes place along a body segment with the cyclic application and removal of a load and due to inadequate suspension.</p> <p><i>"Bell-Clappering"</i> : Cyclical angular displacement in the A-P or M-L planes due to inadequate angular stabilization.</p> <p><i>Whipping</i>: A specific form of rotary instability that occurs in AK Prostheses.</p> <p><i>Primary Characteristic</i>: An absolutely essential property of a device if it is to carry out its intended function.</p> <p><i>Secondary Characteristic</i>: A property of a device necessary to facilitate one of its primary characteristics but not itself absolutely necessary to achieve the intended function of the device.</p> <p><b>References:</b></p> <ol> <li>Blakeslee, Burton (ed.), <i>The limb-deficient child</i>, University of California Press, 1963.</li> <li>Poets, Rudolfe, <i>The fitting of the above-knee stump</i>, Orth. and Pros., 28:1, March 1974.</li> </ol> Page Number(s) 2 - 6 Year 1978 Volume 2 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1978_02_002/1978_02_002-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1978_02_002/1978_02_002-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1978_02_002/1978_02_002-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1978_02_002/1978_02_002-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1978_02_002/1978_02_002-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 TABLE I http://www.oandplibrary.org/cpo/images/1978_02_002/1978_02_002-6.jpg Figure 7 TABLE II http://www.oandplibrary.org/cpo/images/1978_02_002/1978_02_002-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Concerning Suspension Alignment, and Control Creator An entity primarily responsible for making the resource Charles H. Pritham, C.P.O.  https://staging.drfop.org/files/original/0dd9f601769f60d4d41eff49c4f7e903.pdf 6083dd5dd381a8def8f92abd19065155 https://staging.drfop.org/files/original/67b2bb7011e7d4265c42e6b2743f583c.jpg 973338862e76956d2630ed5644e0145b 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_01_001.pdf Text Any textual data included in the document <h2>Endoskeletal Prostheses: Cause for Reflection</h2> <h5>Charles H. Pritham, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>American prosthetists have now accumulated a decade of experience with endoskeletal modular prostheses. In light of this experience, it seems logical to reassess the criteria and priorities that guided the development of this method of providing prosthetic care. If one were to choose two events more than others that marked the beginning of the "new era," they would have to be the introduction in the Fall of 1970<a></a> of the Otto Bock endoskeletal system and the convening in March 1971 by CPRD of a workshop entitled, "Cosmesis and Modular Limb Prostheses"<a></a>. Few are unfamiliar with the features of the Otto Bock system and they hardly need to be commented on here. Suffice it to say that the system undoubtedly represents the highest possible physical expression of the modular endoskeletal concept. The second development referred to, the CPRD workshop, is probably less familiar and merits closer attention, especially so since the report from the workshop states the philosophy of the endoskeletal modular approach to limb prosthetics.</p> <p>That philosophy finds its fullest and most concise exposition in the remarks of D.S. McKenzie, M.D.<a></a>, <b>Table I</b>. <br /><br /><img src="https://staging.drfop.org/files/original/67b2bb7011e7d4265c42e6b2743f583c.jpg" p="" width="503" height="296" />In other sections of the report, the CPRD workshop recommended improvements in cosmetic covers and prosthetic skins and development of endoskeletal upper limb prostheses employing center-pull cables and external power. Indeed, so sanguine were the attendees at the workshop about the future of endoskeletal modular limb prostheses that they essentially recommended that all future development be done in this context.</p> <p>Comparison of expectation with reality is very difficult in this situation as there is very little in the literature that describes field experience with endoskeletal modular prostheses. What information there is<a></a>, is largely anecdotal but it suggests that the problems encountered focus on weight and poorer durability than conventional exoskeletal prostheses. The upshot is that endoskeletal prostheses are fundamentally considered luxury items to be prescribed for light-activity, appearance-conscious wearers. Wider-spread acceptance has primarily occurred with hip disarticulation prostheses due to ease of fabrication and favorable weight competitiveness compared to conventional means of construction.</p> <p>It seems fair to conclude, therefore, that anyone who subscribed to the criteria developed in the CPRD workshop of 1971 would be disappointed with the rate of acceptance and continued improvements in endoskeletal prosthetic systems during the past decade. It is convenient to ascribe this failure to intransigent conservatism on the part of the third-party payers and of individual prosthetists. Perhaps a more proper explanation can be found in the precepts that shaped the development of the prostheses themselves.</p> <p>Endoskeletal modular prosthetic systems are intended by their very nature to encompass the needs of the vast majority of amputees. In effect, they represent a series of compromises: strong enough for all but the most punishing of patients and yet light enough for all but the most feeble of patients, etc. Anything or anyone who attempts to be all things to all men generally ends up satisfying no one. In this regard a fundamental fact about the nature of the amputee population needs to be acknowledged. The primary cause of amputation in western society is disease and this primarily affects the older age group. Comparison of amputee censuses<a></a> bears this out. Moreover, with declining birth rates and increased longevity, the age of the population in general is shifting to the higher decades. The one trend reinforces the other and we may confidently expect in the years ahead that even more of our patients will be 65 or over with circulatory disorders and multiple involvement. It is widely admitted that the needs of the geriatric amputee are different from the needs of the younger amputee. Sophisticated knee and ankle function become less important, and light weight, comfort, and ease of donning become more important. In effect, the nature of the amputee population and the precepts guiding development of prostheses have changed, but prosthetists and developers of prostheses have been slow to recognize the change. In part this is due to the fact that the needs of geriatrics are mundane and prosaic as compared to the challenge offered in designing a high performance, sophisticated prosthesis for a young vigorous user who uses a prosthesis maximally and thus offers maximum positive reinforcement to the designer.</p> <p>Another matter that deserves consideration is the concept that it should be readily possible by changing components or alignment to adapt the prosthesis to the changing needs of the amputee and that the same prosthesis that serves him 24 hours after surgery will still be suitable 24 months after surgery. Reference here is made to <b>Table I</b>&nbsp;where the different stages in the experience of an amputee are listed vertically and the various possible features of a prosthesis are listed horizontally. Advocates of the first viewpoint, such as D.S. McKenzie, would have it that at any given moment in the experience of an amputee, all possible features are present. Advocates of the second view would have it that for the sake of expediency, low weight, cost, durability, and other considerations, only those features absolutely necessary at any one stage of development would be present-in effect that form follows function. For example, while quick-disconnect of the pylon and foot from the socket is suitable and even necessary in an immediate post-operative prosthesis (I.P.O.P.), it is unnecessary and a possible source of trouble in a definitive prosthesis. An advocate of this second point of view might fill out the table much as it has been done.</p> <p>Central to this discussion is the question of what is an acceptable range of alignment adjustability at any one stage. Few would dispute that full range of alignment adjustability is necessary in I.P.O.P.s and temporary prostheses. Less unanimity greets the statement that it should be present in definitive prostheses. Some would maintain that it is not necessary in definitive prostheses and that, in any event, some range of adjustability (height, transverse rotation of foot, and in some cases, of the knee) is present and that this is all that is necessary in the vast majority of cases. They would further maintain that any increase in alignment adjustability represents an unacceptable increase in weight and decreases in reliability. Moreover, they would have it that should you have to change any of the other factors of alignment, something is so seriously wrong as to warrant starting over again completely from scratch. This second point of view is exemplified most strikingly in the Adaptive Fixation Prosthesis (A.F.P.) system of Medical Center Prosthetics of Houston, Texas.</p> <p>There is one final topic that merits discussion and that is the matter of cosmesis. Current techniques of providing cosmetic covers entail the carving of internal and external contours and are expensive and time consuming. Moreover, it is questionable as to whether or not the results merit the effort, as the covers for all levels of amputation are flimsy. For above-knee and higher, the one-piece covers inhibit function. Support hose currently used as prosthetic skins are even less durable, yet attempts to provide stronger skins have been defeated by the need to accommodate the extreme motion of the knee. (It remains to be seen whether it will be possible to devise successful one-piece cosmetic covers for above-knee prostheses with current technology or if we will eventually sacrifice some of the cosmesis of one-piece covers and adopt two-piece covers and improved durability.) Again, the work of Medical Center Prosthetics and their technique for foaming cosmetic covers in place are noted.</p> <p>In conclusion, it is possible to pose a number of questions:</p> <p>1.&nbsp;Do available endoskeletal prosthetic systems meet the needs of the majority of amputees as well as do exoskeletal prostheses?</p> <p>2.&nbsp;If they do, why are they not used with greater frequency than casual impression seems to imply that they are?</p> <p>3.&nbsp;Is it desirable to use a common family of endoskeletal components at all stages of an amputee's progress post-amputation or can an increase in desirable qualities be achieved by more specifically matching the available components and the individual's progress?</p> <p>4.&nbsp;Is it desirable and necessary to have full capability for alignment adjustability present in a definitive prosthesis or can some adjustability be sacrificed to decrease weight and heighten reliability?</p> <p>5.&nbsp;If cosmetic covers were better than they are, would more endoskeletal prostheses be prescribed? Or is it that if more endoskeletal prostheses were prescribed, better cosmetic covers would be developed?</p> <p>The present group of endoskeletal systems (with one exception) can be considered as first generation systems. Extensive experience has been gained with them and it seems reasonable to assess this experience with an eye towards developing criteria for second generation systems. Further, it seems only just that those personnel who have day-to-day experience be canvassed in developing these criteria.</p> <p><b>References:</b></p> <ol> <li><i>Below-Knee and Above-Knee Prostheses</i>, Committee on Prosthetic Research and Development, National Academy of Sciences, Washington, D.C. 1973, page 21.</li> <li><i>Cosmesis and Modular Limb Prostheses</i>, Committee on Prosthetic Research and Development, National Academy of Sciences, Washington, D.C. 1971.</li> <li>Wilson, A. Bennett, Jr., "Lower Limb Modular Prostheses, A Status Report," <i>Orthotics and Prosthetics</i>, Vol. 29, No. 1, pp. 23-32, March 1975.</li> <li>Kay, Hector W. and Newman, June D., "Amputee Survey 1973-74, Preliminary Findings and Comparisons,"<i> Orthotics and Prosthetics</i>, Vol. 28, No. 2, pp. 27-32, June 1974.</li> </ol> <div style="width: 400px;"><em><b>*Charles H. Pritham, C.P.O. </b> Formerly Director, Prosthetic and Orthotic Laboratory, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadelphia, PA. Presently Manager, Snell's of Louisville, Louisville, KY</em></div> Page Number(s) 1 - 3 Year 1982 Volume 6 Issue 1 Figure 1 TABLE I http://www.oandplibrary.org/cpo/images/1982_01_001/1982_01_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Endoskeletal Prostheses: Cause for Reflection Creator An entity primarily responsible for making the resource Charles H. Pritham, C.P.O. * https://staging.drfop.org/files/original/ae05e878bd64c3dbd3b2584c3a8af1c3.pdf 908af03ad8cb34c07750c64b92d97c44 https://staging.drfop.org/files/original/eff05f3ff73679cc3aa9f244a0b01ee1.jpeg edfa643666b367de3ccf1505947074ee https://staging.drfop.org/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg 673473bd1e41e590c4e9c60e9599e2fc https://staging.drfop.org/files/original/6e9b5d4a5957258a4958635acfc8fbda.jpg 682e526dd8cd44af055581f51d3543b0 https://staging.drfop.org/files/original/29254ec4552c6b302e11d7249167147b.jpg 5872069631752d0d3d9eb1f39bd37b76 https://staging.drfop.org/files/original/be009fdace4d2d0fce8a7757ab25edf7.jpg fc1c45950fcf019e826c6035112ac38e https://staging.drfop.org/files/original/a8017df2f33ae779bbc361ad9d87e7ee.jpg f72d46285c6e66bf702f8dc9c651e66b https://staging.drfop.org/files/original/51d4491374c4e678089f6cdf6c27afae.jpg f51626e0ef82b0a4dfb1ee8ab4693ced https://staging.drfop.org/files/original/822789265194f5be4e60727bb55d3108.jpg 4499acf3c75535c673217cfa36745c01 https://staging.drfop.org/files/original/20bbec62ad79b83acbdb384867dd8dfe.jpeg e67daa763e1a8051b264102cc6bd4c8b https://staging.drfop.org/files/original/df0e494105bf2580379ea0532148fd6e.jpeg 821ac6be13efc72dd02bf99301f354ec https://staging.drfop.org/files/original/56713088198c8c2e3e4a0e824e14d79b.jpeg efa1d6a37f55c3e4ec5ba5c6f99c1555 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/1981_04_005.pdf Text Any textual data included in the document <h2>Knee Orthoses: Biomechanics</h2> <h5>Charles H. Pritham, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>Derived from a lecture given at the ISPO Lower Limb Orthotics Course, Dallas, Texas, March 9-13, 1981.</i></p> <p>Irrespective of etiology, deformities of the knee can be divided into three broad categories: angular (genu valgum, genu varum, genu recurvatum), rotary (internal, external rotation of the tibia relative to the femur), translatory (anterior/posterior subluxation of the tibia relative to the femur). They can be further categorized as either flexible (secondary to flaccid musculature and/or ligamentous and capsular laxity) or fixed (secondary to spastic musculature and/or ligamentous and capsular tightness). For a variety of reasons orthotics has traditionally devoted the majority of its attention to cases of angular deformity and coped with instances of rotary or translatory deformity only secondarily as they arise as complications of angular deformity. For that reason, then, the majority of discussion will focus on this aspect of the situation.</p> <p>Viewed in the frontal plane (the case is the same in the sagittal plane) with the body aligned so that the weightbearing line coincides exactly with the mechanical axis of the leg (<a href="/files/original/eff05f3ff73679cc3aa9f244a0b01ee1.jpeg"><b>Fig. 1</b></a>), there is no tendency for the knee to bend into either genu valgum or genu varum. If the weightbearing line deviates to one side, a bending moment or torque is created (<a href="/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg"><b>Fig. 2</b></a>) that causes a change in angle (angle of deformity, 0) of the femur relative to the tibia. The bending moment can be quantified by multiplying the deforming force (body weight, W) times the perpendicular distance (x) from the line of action to the center of rotation. As body weight is essentially constant, any increase in angle of deformity will lead to an increase in distance x and an increase in the deforming moment. In real life this tends to create a vicious circle since the deformity is resisted by the capsular and ligamentous elements on the opposite side of the knee. The stress is greatest on those elements farthest away from the center of rotation, as they are best positioned by virtue of their longer lever arm to oppose the deforming force. When the stress becomes intolerable, they yield, and the load falls on elements less strategically placed. As the angle of deformity increases, distance x increases, the deforming moment increases, and a compromised knee is jeopardized further. To correct this situation and prevent further damage, it is necessary to introduce a corrective moment and reduce the angle of deformity.</p> <strong><a href="/files/original/eff05f3ff73679cc3aa9f244a0b01ee1.jpeg">Fig. 1</a>. Lower limb positioned so that weightbearing axis falls through the mechanical axis of the limb.</strong><br /><br /><strong><a href="/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg">Fig. 2</a>. As the weightbearing axis deviates to one side a bending moment or torque is created</strong><br /> <p>This corrective moment is created by a three-point pressure system (<a href="/files/original/6e9b5d4a5957258a4958635acfc8fbda.jpg"><b>Fig. 3</b></a>). For the laws of equilibrium to be satisfied, the forces acting on each side of the structure must be equal, and the clockwise moments acting about the center of rotation must be equal to the counterclockwise moments. The farther forces H and A are from the center of rotation, the smaller they can be, due to increased lengths of their lever arms a and b. Force K can seldom be applied directly at the center of rotation (<a href="/files/original/29254ec4552c6b302e11d7249167147b.jpg"><b>Fig. 4</b></a>), as the anatomical structures vary in their ability to tolerate the pressure. It may very well prove necessary to locate force K some distance from the knee and apply it as two sub-elements, S and I. K would be equal to the sum of the two and vary in point of application according to their relative strength. As K moves away from the center of rotation (<a href="/files/original/be009fdace4d2d0fce8a7757ab25edf7.jpg"><b>Fig. 5</b></a>), it increases the bending moment acting in one direction or another, and if the laws of equilibrium are to be satisfied, the opposing moment will have to increase in magnitude, leading to an increase in total force on the limb. <a href="/files/original/a8017df2f33ae779bbc361ad9d87e7ee.jpg"><b>Fig. 6</b></a> summarizes the discussion thus far. It should be noted that any orthosis fabricated to satisfy these conditions must be strong enough to do so without yielding or bending as the old pattern of the vicious circle (<a href="/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg"><b>Fig. 2</b></a>) will assert itself. Yet another factor to be taken into account is the familiar relationship of pressure, force, and area (<a href="/files/original/51d4491374c4e678089f6cdf6c27afae.jpg"><b>Fig. 7</b>)</a>. The need to satisfy these conditions and thus reduce the total force exerted must be, of course, balanced with the desire not to encumber adjacent joints, and to keep the orthosis as cool and light as possible.</p> <strong><a href="/files/original/6e9b5d4a5957258a4958635acfc8fbda.jpg">Fig. 3.</a> Three-point pressure system acting about the knee.</strong><br /><br /><strong><a href="/files/original/29254ec4552c6b302e11d7249167147b.jpg">Fig. 4</a>. Force K acting as two sub-forces, S and I.</strong><br /><br /><strong><a href="/files/original/be009fdace4d2d0fce8a7757ab25edf7.jpg">Fig. 5.</a> As force K moves away from the knee the total force on the limb increases.</strong><br /><br /><strong><a href="/files/original/a8017df2f33ae779bbc361ad9d87e7ee.jpg">Fig. 6.</a> A summarization of criteria necessary to minimize the force on the limb.</strong><br /><br /><strong><a href="/files/original/51d4491374c4e678089f6cdf6c27afae.jpg">Fig. 7.</a> The relationship of pressure to force and area.</strong><br /> <p>Another way to tackle the problem is to use a weightbearing brim (<a href="/files/original/822789265194f5be4e60727bb55d3108.jpg"><b>Fig. 8</b></a>). This, of course, reduces the deforming force and thus the deforming moment. What is not so apparent is that it might very well change the length of the lever arm x and reduce the bending moment. If some of the body weight is borne medially on an ischial seat, it would tend to shift the line of action of the body weight medial to its usual course through the head of the femur. This phenomenon is at work when a KAFO with a quadrilateral brim is used in cases of gluteus medium lurch. It might very well have implications in cases of genu varum and genu valgum. In the sagittal plane (<a href="/files/original/20bbec62ad79b83acbdb384867dd8dfe.jpeg"><b>Fig. 9</b></a>), a similar situation is identified in the UCLA Functional Long Leg Brace<a></a>. Moving the line of action of the weight line anterior by virtue of the load on the Scarpa's Triangle, a knee extension moment is generated. Knee extension is further aided by the intimate fit of the quadrilaterial brim and a firm fit of the foot in the shoe which produces a distractive effect on the leg, straightening it, as would pulling on opposite ends of a rope.</p> <strong><a href="/files/original/822789265194f5be4e60727bb55d3108.jpg">Fig. 8.</a> Use of a weightbearing brim creates a proximally acting force, R, that counteracts weight, W.</strong><br /><br /><strong><a href="/files/original/20bbec62ad79b83acbdb384867dd8dfe.jpeg">Fig. 9.</a> Forces applied to the higher anterior wall of a quadrilateral brim tend to move the weightbearing axis anterior to the head of the femur, and the knee center.</strong><br /> <p>Subluxation of the tibia (such as might occur due to the pull of the quadriceps secondarily to ligamentous laxity in cases of genu valgum in arthritis, a situation described by Smith, et al.<a></a>), can be corn-batted by separate force couples acting on the femur and the tibia (<a href="/files/original/df0e494105bf2580379ea0532148fd6e.jpeg"><b>Fig. 10</b></a>). This is a feature of the University of Michigan Arthritic Knee Brace.</p> <strong><a href="/files/original/df0e494105bf2580379ea0532148fd6e.jpeg">Fig. 10.</a> Use of force couples acting on the femur and tibia to prevent anterior subluxation of the tibia relative to the femur. The force system would be reversed in an instance of posterior subluxation. A system of force couples is subject to the same sort of analysis and criteria as a three-point pressure system.</strong><br /> <p>In the absence of direct action on the skeleton, control of rotation is more problematical. As the proximal portion of the shin is triangular, considerable rotational control can be achieved as in the PTB prosthesis, the spiral ankle-foot orthosis (AFO), and the hemi-spiral AFO. Purchase about the condyles of the femur and the patella can be achieved, but is compromised by the necessity for unencumbered knee flexion. It is, of course, possible to use a quadrilateral brim to gain a purchase on the proximal structures, but any prosthetist will be glad to regale his orthotist companion with tales or rotary instability in above-knee prostheses. The last alternative is a frictional coupling between the soft tissue and broad elastic straps as in the Lenox Hill Derotation Orthosis (<a href="/files/original/56713088198c8c2e3e4a0e824e14d79b.jpeg"><b>Fig. 11</b></a>). As considerable slack must be taken up in the soft tissues, 20 degrees of motion at the surface may result in only 10 degrees of motion of the femur about its axis. Moreover, the efficacy of even the best such measures is called into question considering the magnitude of the bending moment generated by the action of the center of gravity about the long axis of the leg and comparing it with the moments that can be induced about the same axis by the maximum tolerable force acting at the surface of the leg.</p> <strong><a href="/files/original/56713088198c8c2e3e4a0e824e14d79b.jpeg">Fig. 11.</a> Schematic cross-section of a limb, on the left, with the skin (outer circle) connected to the bone (middle circle) by soft tissue (radiating rippling lines) and acting about the center of rotation (innermost circle). The broad vertical line is for reference. As rotary forces (arrows) are applied, on the right, the force is transmitted from the skin to the bone by the soft tissue. As slack in the soft tissue must be taken up it becomes apparent that the bone moves less than the skin.</strong><br /> <p>In conclusion, some of the biomechanical factors involved in the function of knee orthoses are reviewed. Due consideration of these factors, the anatomical structures involved, and the intended purpose of the orthosis at the time of prescription should inevitably lead to a more functional orthosis.</p> <p><b>References:</b></p> <ol> <li><em>Final Report, Functional Long Leg Brace Research</em>. University of California, Los Angeles. Prosthetics/Orthotics Education Program, March 30, 1971.</li> <li>Edwin M. Smith, M.D., Robert C. Juvinall, M.S.M.E., Edward B. Correll, M.S.M.E., and Victor J. Nyboer, M.D., "Bracing the Unstable Arthritic Knee," <em>Archives of Physical Medicine and Rehabilitation</em>, Vol. 51, No. 1, Jan. 1970, pp. 22-28, and 36.</li> </ol> <div style="width: 400px;"><em><br />*<b>Charles H. Pritham, C.P.O. </b> Formerly Director, Prosthetics and Orthotics Laboratory, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadelphia. Presently Branch Manager, Snell's of Louisville.</em></div> <div style="width: 400px;"><br /><br /></div> Page Number(s) 5 - 7 Year 1981 Volume 5 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-11.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Knee Orthoses: Biomechanics Creator An entity primarily responsible for making the resource Charles H. Pritham, C.P.O. * https://staging.drfop.org/files/original/dca562c934e6c03968ea74fbd3ff1f31.pdf 573718b9201606fcbfbf62993cef40b0 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/1983_02_001.pdf Text Any textual data included in the document <h2>Cervical Orthoses</h2> <h5>Charles H. Pritham, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Orthoses are fit for the control of motion about a joint or joints. By extension, cervical orthoses are fit to control motion of the cervical spine. Such orthoses are provided to patients for a wide variety of conditions ranging from the merely inconvenient on one end of the spectrum to the life threatening at the other end. In response to this need, a plethora of devices have been described; a review of the literature and of manufacturers' catalogs will reveal a positive galaxy of orthoses, all described as being of great efficacy and many differing from others in matters of only minor detail. What seems to be lacking is any systematic and quantitative assessment of the various orthoses' merits and a rational scheme for their use. While it may be overstating the case, it seems that most individuals in various parts of the country rely on two rules of three: selecting from the panoply available three orthoses graded as minimally, moderately, and maximally immobilizing; and fit in terms of small, medium, and large. Which orthoses are selected is shaped by local preference, training, and experience among other factors.</p> <p>In contrast to other areas of orthotics, the topic of cervical orthotics can be described as a stepchild or plain shoe. Since the end of World War II, other areas of orthotics have been radically reshaped (lower limb orthotics and spinal orthotics for scoliosis and kyphosis) by the application of new knowledge, new technology, and new philosophies of treatment. Upper limb orthotics occupies the middle ground: it's not that the effort has not been made, just that the results have been less than totally successful.</p> <p>It would, of course, be fallacious to suggest that no effort at all has been made to elucidate in some rational fashion the prescription of cervical orthoses. James D. Harris, D.O., in his review of cervical orthoses in Orthotics Etcetera, 2nd Ed. <a></a> cites a variety of references which used such means of measuring cervical motion as goniometry, cineradiography, and still radiography to assess the immobilizing affects of various orthoses. He further used these references and descriptions of effectiveness in his comparisons of a variety of orthoses. Rollin M. Johnson and his coworkers <a></a> used their original studies for a similar purpose. The impression remains, however, that while useful work has been done, the effects of it have been relatively small scale, and much remains to be done. This point of view is endorsed by the results of a workshop panel convened in 1977 <a></a>. It would seem that there exists a genuine need for research to be conducted comparing the efficacy of various orthoses with an eye towards developing a rational basis for prescription and for the results to be widely disseminated.</p> <p>The contrary point of view can, of course, be argued. Those instances that are truly life threatening are relatively few, usually promptly recognized, and are best managed aggressively with immobilization, confinement to bed and even surgery. For the rest, cervical orthoses are generally prescribed for episodic and short term relief of pain. Even if prescribed with an orthosis that does not perfectly match the need, patients limit their activities in response to pain and if necessary a new orthosis can be prescribed. Under the circumstances a basic measure of common sense illuminated by experience will serve to assess the competing claims of similar orthoses and match a particular orthosis with a particular situation.</p> <p>It would also be fallacious to argue that no improvements in technology have been made. While such developments as the Philadelphia Collar and the S.O.M.I. can be cited, the foremost example is the Halo. Originally a specialized device applied in specialized centers for relatively few indications, it has, in the guise of the Halo-vest, come to be widely used in instances where maximal immobilization and possibly distraction are needed. While intimidating in appearance and implications, the evidence is that the technique is readily mastered, and that the device is well tolerated by patients. However, the possibility of such complications as pin-site infections, penetration of the skull, and loosening do exist. As a result of these reasons and the generally felt need for something less drastic, if equally effective, calls have been made for a non-invasive halo <a></a>.</p> <p>In response, Wilson, Hadjipavlou, and Berretta <a></a> described "A New Non-Invasive Halo Orthosis ..." in 1978. Fundamentally, this is a S.O.M.I. orthosis modified by the substitution of a low temperature thermoplastic skull-cap for the occipital piece. The authors cited experience treating 20 cases of unstable fractures and cineradiographic studies to support their contention that "this orthosis is almost the treatment of choice whenever rigid immobilization of the cervical spine is indicated."</p> <p>In a similar vein, Rubin, Dixon, and Bernkopf <a></a> described in 1978 another modification of the S.O.M.I. In this device the mandibular piece was removed and two pads pressing in under the zygomatic arches where substituted. In addition, a "cranial vertex pad" rigidly fixed to the occipital pad and flexibly connected to the zygomatic pads was added. The authors showed radiographic and photographic evidence of near rigid immobilization of the cervical spine of one subject. However, they cautioned that the device was intended for relatively brief use, specifically for the removal of trauma patients to a hospital by trained paramedics, and they further speculated as to the unknown effects of long-term pressure on the zygomatic arches.</p> <p>Interestingly enough, both Harris <a></a> and Rubin, et al <a></a> refer to a device described by Boldrey in 1945. It is described as a rigid cap encompassing the posterior and lateral aspects of the skull with a forehead strap and sub-zygomatic pads. It was connected by a posterior steel upright to padded thoracic and lumbar bands with over the shoulder extensions and straps.</p> <p>None of these variations are commercially available. One further point needs to be considered: Harris <a></a> cites evidence of Hartman, et. al. that the Guilford Orthosis is 90-95% effective in restricting motion. Therefore, does the need for a non-invasive halo really exist?</p> <p>In any event, it is apparent that the subject of cervical orthotics is one that has received scant attention. What is not so apparent is whether or not such attention is vitally needed.</p> <p><b>References:</b></p> <ol> <li>Harris, James D., "Cervical Orthoses," <i>Orthotics Etcetera 2nd Ed.</i>, edited by James B. Redford, M.D., Williams and Wilkins, Baltimore, MD, 1980, pp. 100-122.</li> <li>Johnson, R.M.,; Hart, D.L.; Simmons, E.F.; Ramsby, G.R.; and Southwick, W.O., "Cervical Orthoses, A Study Comparing Their Effectiveness in Restricting Cervical Motion in Normal Subjects," <i>JBJS</i>, Vol. 59-A, No. 3, April 1977, pp. 332-339.</li> <li>Johnson, R.M.; Owen, J.R.; Hart, D.L.; and Callahan, R.A., "Cervical Orthoses: a Guide to their Selection and Use," <i>Clinical Orthopaedics and Related Research</i>, No. 154, Jan.-Feb. 1981, pp. 34-35.</li> <li>Edmonson, A.S.; et al., "Report-Panel on Spinal Orthotics" <i>Orthotics and Prosthetics</i>, Vol. 31, No. 4, pp. 67-71, Dec. 1977.</li> <li>Wilson, C.L.; Hadjipavlou, A.G.; and Berretta, G., "A New Non-Invasive Halo Orthosis for Immobilization of the Cervical Spine," <i>Orthotics and Prosthetics</i>, Vol. 32, No. 1, March 1978, pp. 16-19.</li> <li>Rubin, G.; Dixon, M.; and Bernknopf, J., "An Occipito-Zygomatic Cervical Orthosis Designed for Emergency Use-A Preliminary Report," <i>Bulletin of Prosthetics Research</i>, BPR 10-29, Spring 1978, pp. 50-64.</li> </ol> <div style="width: 400px;"><em><b>*Charles H. Pritham, CPO </b> Durr-Fillauer Medical, Inc., Orthopedic Division, Chattanooga, TN. Editor, Clinical Prosthetics and Orthotics-C.P.O</em></div> <div style="width: 400px;"><br /><br /></div> Page Number(s) 1 - 2 Year 1983 Volume 7 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 Cervical Orthoses Creator An entity primarily responsible for making the resource Charles H. Pritham, CPO * https://staging.drfop.org/files/original/d1fa99c68ccb7ad17715ef0dc1dd6825.pdf 2673ebe4132713a88e1fc6bbbefeea96 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/1983_04_007.pdf Text Any textual data included in the document <h2>Hydraulic/Pneumatic Knee Control Units A Prosthetist's Point of View</h2> <h5>Charles H. Pritham, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>As Mr. Wilson has demonstrated, the use of hydraulic and pneumatic control units had its genesis in the post World War II R &amp; D effort. The objective, of course, was to fit the returning veteran AK amputee with the best prosthesis technology could provide. Such amputees were young and physically fit, prime candidates to benefit from the advantages of advanced control units. The prime advantage, usually cited, is cadence responsiveness. As the patient walks at different rates, the control unit automatically adjusts to control heelrise and terminal swing impact. Constant friction knees can not duplicate this feature. All hydraulic and pneumatic units provide this feature and one, the Mauch S-N-S, provides stance phase control as well. This means that the unit provides enhanced knee stability in the early portion of stance phase to increase the patient's safety.</p> <p>In this mode, the S-N-S unit can be said to function in a fashion analogous to that of a conventional safety knee. In another mode, the function of the S-N-S can be likened to that of a simple manually locking knee. Two other knee control units, variants of Kingsley's Hydranumatic and USMC's Dynaflex, function in a similar fashion.</p> <p>The Hydracadence, in addition to swing phase control, also provides heel height adjustability and toe pick-up. Otto Bock has recently introduced a modular knee that includes a hydraulic swing phase control.</p> <p>As can be seen then, these are just a few of the variations available to the prosthetist and his patient. The principal advantages claimed for such control units are enhanced cosmesis and performance, and lower energy expenditure. Against these advantages, the disadvantages must be weighed. Bulk, size, and weight of some of the units preclude their use by many patients. The considerable expense of most, if not all, hydraulic and pneumatic control units rules out others. Moreover, the control units have been shown to be unreliable. Some patients derive satisfactory service from their units while other patients using the same brand unit are constantly having them replaced and repaired. As most of the units need to be factory serviced, the delay and expense of maintaining a unit under such circumstances can engender considerable frustration.</p> <p>Given these circumstances, the pool of available amputees for whom such advanced control units are suitable is a small proportion of the total AK population, and most closely resembles the patients for whom they were originally developed: young traumatic males; i.e. veterans. It must be borne in mind that this pool today represents a less important proportion of the amputee population than it did some 25 years ago. Statistics demonstrate that the majority of civilian amputees in the Western World are geriatrics who lose a leg due to arteriosclerosis and are as often as not female. Indeed, the very amputees who were originally provided hydraulic units by the VA are not getting any younger. The day will come for each of them when they, and the clinic teams who attempt to address their needs, must make a reappraisal of their prescription. So, the use of hydraulic/ pneumatic control units for a considerable portion of the amputee population can be ruled out. Not only that, but it is possible to be very skeptical in considering the suitability of such units for patients for whom it is theoretically ideally suited.</p> <p>Young, active traumatic amputees are probably, children aside, the hardest on their prostheses. Given the expense of purchasing and maintaining such a unit, does it make sense to fit an amputee with one if he is going to have more than average maintenance problems? Can he afford the time lost from work, interruptions in his daily life, and expense of repairs? Given the disproportionately rising cost of health care today, can society? Gait studies demonstrate that AK amputees walk slower than normal subjects and BK amputees because of increased energy expenditure. If this is so, is the prime advantage cited for hydraulic/pneumatic units, cadence response, relevant and worth the additional expense and problems? In another vein, given the aging nature of the population should further effort and money be devoted to developing newer and more sophisticated knee control units?</p> <p>In any event, it can be said that a prosthetist in attempting to formulate a solution to his patient's problems is confronted with a number of questions and a wide variety of devices all intended to perform the same function. It is also true that the prosthetist has little more than personal experience, hearsay, and the competing claims of the manufacturers to aid him in making his decision. The natural tendency on the prosthetist's part is to provide his patient with the most sophisticated unit possible, for all of us gain considerable satisfaction from doing so and from working with such units. The patient also wants the best prosthesis possible. The fact remains, however, that such tendencies must be resisted and both prosthetists and patient must make a realistic appraisal of the situation and logically weigh the pros and cons.</p> <b>*Charles H. Pritham, CPO </b> Technical Coordinator Durr-Fillauer Medical, Inc. Chattanooga, Tennessee Editor, C.P.O.<br /><br /> <div style="width: 400px;"></div> Page Number(s) 7 - 8 Year 1983 Volume 7 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Hydraulic/Pneumatic Knee Control Units A Prosthetists Point of View Creator An entity primarily responsible for making the resource Charles H. Pritham, CPO * https://staging.drfop.org/files/original/8c59087dd5defe8f43e0fb7935616737.pdf 8ce43640135a5c2fa157eb5fa345410e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_01_001.pdf Year 1957 Volume 4 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/1957_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_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>Getting Down to Cases</h2> <h5>Charles O. Bechtol, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>It is the common teaching of all experience that even the most carefully planned activities seldom follow the course originally laid out for them. Man tends to play himself through life by ear, as it were, in a series of false starts and fortunate recoveries. In all fields of endeavor, therefore, hindsight is more often than not the quality which, in the long run, keeps people going in the general direction of progress. That such is the way things are is perhaps nowhere more patent than in the evolution of the Artificial Limb Program.</p> <p>When, for example, in 1945, the Committee on Prosthetic Devices (now the Prosthetics Research Board) set out to improve the lot of the amputee population, it chose for itself the seemingly obvious, if also apparently simple, goal the design and development of new and improved artificial limb components. Because of the more or less widely held misconception, even among amputees themselves, that improved devices alone might well raise the level of the art of limb prosthetics to that existing in other fields of science and invention, the Committee established, through arrangements for contract research, a far flung program with principal emphasis on the fundamental investigation of human locomotion, on time and motion studies of the human arm and hand, and on what might by some be called professional gadgeteering.</p> <p>After a few years of organized effort on the part of engineers and prosthetists, with the consequent development of new and supposedly improved models and techniques, and after the application of experimental prostheses to amputees for initial tests of the new equipment, it became perfectly clear that, if genuine improvement in amputee service were to be had, something more would be needed. In retrospect came realization of the circumstance that no single design of prosthesis is ever apt to be superior for all amputees of a given type and, conversely, that every amputee presents in one way or another a special problem not amenable to mass treatment. Put in engineering language, the difficulty was seen to lie in the fact that dealing with the rehabilitation of amputees means dealing with a "nonstandard product," the human being. He comes in all sizes, shapes, and conditions. And his reaction to any given selection of equipment is almost always grossly influenced by his individual personal needs and characteristics—physical and mental—as well as by his activity requirements. Since most of the new devices and new methods were largely untried at the clinical level, there existed no valid criteria either for determining when components had been prescribed and fitted to best advantage in the individual case or for assessing the degree of utilization achieved by a given wearer. In the absence of demonstrable proof of successful application on a relatively broad scale, the limb industry was understandably reluctant to adopt the new ways and means with any ostensible enthusiasm. But at the beginning of the Artificial Limb Program in 1945 no one was in a position to predict such eventualities.</p> <p>Lacking, in brief, was the experience necessary for the construction of a general set of principles of amputee management. In recognition of this state of affairs, and in view of the especially challenging problems prevailing in the upper extremity, there was established in mid 1950, in the Department of Engineering at the University of California at Los Angeles, the so called "Case Study Program," with the purpose of investigating the application of prostheses to a wide variety of amputee types and of developing effective methods for evaluation of amputee service, not only with regard to the quality and applicability of the mechanical equipment but also with concern for the effect of training and of occupational, educational, recreational, and other personal factors on the final success of prescription and fitting. Intended to bridge the gap between fundamental work in the laboratory and practice in the field, and with excellent industry participation, the work continued until 1953. Analysis of the data thus accumulated continued until late in 1956.</p> <p>So fruitful was the case study work in upper extremities at UCLA that in the spring of 1953 there was organized at the University of California at Berkeley a similar investigation into the problems of the leg amputee, especially the above knee case, a matter that had already been the subject of fundamental research and engineering design at that institution since the beginning of the Artificial Limb Program eight years earlier. Again with the wholehearted cooperation of the limb industry, the so called "Clinical Study" in lower extremities has, like the UCLA Case Study, now garnered much valuable information on which to base some general principles.</p> <p>Because the experience gained at UCLA and at Berkeley represents the most reliable data available on what now constitutes good practice in limb prosthetics, the bulk of this issue of <i>Artificial Limbs</i> is devoted to a presentation of selected case histories, predominantly the histories of typical problem cases as contrasted with cases that responded readily and well to routine fitting. The balance is given over to a discussion, by one of the world's best known leaders in hand surgery, of the possibilities for surgical reconstruction of damaged hands and of the application of prostheses for the partial hand, an area which offers, if anything, even more highly specialized individual cases and which therefore has not yet been the subject of any major investigation within the Artificial Limb Program. Bunnell's contribution fills admirably what would otherwise be a noticeable gap in the coverage.</p> <p>As regards the broad implications of the case material, it is worth observing how many and diverse are the ways in which the problem of amputee rehabilitation must be attacked and how wide is the variety of skills necessarily brought to bear. In pursuit of clinical work it was found essential to enlist the participation of numerous specialists, each with his own particular interests and abilities. Functioning together, these people not only aided materially several hundred cooperating amputee subjects but at the same time contributed to their own self development and hence to the growth of techniques suitable for widespread dissemination to practicing clinic teams. Thus, in a larger sense, they laid the basis for the nationwide program of prosthetics education now so well under way. Because, in turn, the education program resulted in a vast increase in the number of available clinic teams, amputees in the United States are today reaping benefits that could scarcely have been visualized seven or eight years ago. Here then, in the results of the case studies, lies the key to continued advancement in the mastery of limb prosthetics.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles O. Bechtol, M.D. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Surgery and Chief of the Division of Orthopedic Surgery, Yale University; Orthopedic Consultant, Veterans Administration Hospital, West Haven, Conn.; formerly Assistant Clinical Professor of Orthopedic Surgery, University of California, and Western Area Consultant for Orthopedic and Prosthetic Appliance Clinic Teams, Veterans Administration; member, Committee on Prosthetics Research and Development, PRB, 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 Getting Down to Cases Creator An entity primarily responsible for making the resource Charles O. Bechtol, M.D. * https://staging.drfop.org/files/original/affc6aca870d2691c532bcb1de52320b.pdf 6da74b52fefbfd84763702e128d153bc https://staging.drfop.org/files/original/4855abea0e973f4417c0b317f993c386.jpg ef252a1fdf4eaa98400bc4eafd5598f5 https://staging.drfop.org/files/original/5f532646ed4a4826e06c36271fd690b0.jpg 86bd762152af57f1311a4b7bda41f25e https://staging.drfop.org/files/original/f10066429e8178e00674e849efd5ad63.jpg 035865f6b9ab5f776a3d2d22e9eaef11 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_009.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 9 - 14 Text Any textual data included in the document The Prosthetics Clinic Team <h5>Charles O. Bechtol, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>With the increasing complexity of medicine and its related sciences, the day is past when a single man can cope successfully with all the specialized problems in the treatment of injury and disease. The "horse-and-buggy" doctor did an excellent job considering the limited number of drugs and facilities avail-able to him. His results, however, can in no way compare with those obtained at a well-conducted, modern clinic, where a team of physicians as well as representatives of all the allied medical specialties are available. A comparable situation now prevails in the field of artificial limbs.</p> <p>The basic Prosthetics Clinic Team is composed of a physician, a therapist, and a prothetist. Workers in other fields, say a psychiatrist or psychologist, a social worker, a vocational counselor, or an engineer, should be available for consultation when the basic team considers that such services are required.</p> <p>Each member of the team has been trained to perform one particular job well, and, despite the considerable education and experience of each of these team members, no one man could be expected to carry out the entire procedure beginning with surgery and ending with the fitting and training of the patient. Although it is not generally stated, the patient himself is also a member of the team, since during the period of fitting and training he must cooperate by carrying out the instructions of the various team members and at the same time make and convey his own observations on the good and bad qualities of the prosthesis.<br /><br /></p> <h3>Function of Each Team Member</h3> <h4>The Physician</h4> <p>The physician acts as the chief of the clinic team. His particular training has prepared him to coordinate various ancillary services in the solution of all types of medical and surgical problems and to follow the progress of the patient until the difficulty for which medical care was sought has been corrected. In the past, this has been known as the "end result idea," more recently as <i>Rehabilitation</i>. The physician, in addition to his specific duties, is able to act in this same supervisory capacity in the prosthetics clinic team.</p> <p>First, the physician can evaluate the general medical status of the patient and either carry out any necessary surgery or, if he is not a surgeon, refer the patient to a properly qualified one. Immediate postoperative care in the hospital is under his direction. Then the prescription for physical therapy, whether preoperative or postoperative, is in his hands, and he is also the person who assumes ultimate responsibility for prescribing the prosthesis.<a style="text-decoration: none;">*</a> Moreover, the physician supervises evaluation of the prosthesis and renders final approval. And lastly, it is his responsibility to ensure that adequate training in use of the prosthesis is provided, to the end that the amputee may be able to gain the full functional advantages offered by a properly constructed, modern prosthesis.</p> <h4>The Therapist</h4> <p>The particular field of the physical and occupational therapists lies in preoperative and postoperative training and physical conditioning. The therapist is almost solely responsible for training in use of the prosthesis and usually for details of the checkout and evaluation procedures. These functions, however, are no more important than are those of physical conditioning and training in use of the prosthesis. And hence the therapist is a most necessary consultant in decisions relating to time of fitting, type of prosthesis, and type of post prosthetic training.</p> <h4>The Prosthetist</h4> <p>The special problem of the prosthetist, of course, is the actual fabrication and fitting of the artificial limb. Thus he is an indispensable member of the team. His consultation is particularly valuable at the time of prescription of the prosthesis. Using the medical data supplied him by the physician and the therapist, he can give excellent advice as to the relative degree of function that can be offered by different artificial-limb components. With cooperation in this respect, later changes in the prosthesis can be held to a minimum and possibly avoided entirely.</p> <h4>Other Consultants</h4> <p>In complex cases, the team will often feel a need for the services of others. It may be necessary to call upon a psychiatrist or psychologist to determine whether the mental attitude of the patient is such that a prosthesis can be used. Or a design engineer may be able to devise a mechanism or component that will be useful in special cases. Finally, the services of a vocational counselor or social worker may be needed in determining some of the future requirements of the amputee.</p> <h4>Administrative Personnel</h4> <p>In addition to the professional services involved, it is mandatory that someone assume the usual administrative responsibilities. An orderly clinic cannot be conducted without someone to schedule the patients' visits, to maintain individual records, and to carry out other administrative functions. This is of course true of any type of clinic operation, but it is perhaps even more important here because of the many factors involved and the numerous disciplines required.</p> <h4>Procedures in the Clinic</h4> <p>An amputee appears before the team a minimum of three times, as shown graphically in <b>Fig. 1</b>. The first visit is for the purpose of preparing the prosthetics prescription, the second to evaluate the amputee and his prosthesis before training, the third to evaluate the amputee and his prosthesis after training.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 1. Steps in the clinic--Team procedure.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h4>Visit No. 1</h4> <p>If, in the opinion of the team, the amputee is ready for fitting, a prescription is prepared. If for some reason—medical or otherwise—he is not ready, appropriate therapeutic measures are recommended.</p> <p>On hand is a preprescription form (<b>Fig. 2</b>) on which have been recorded such data as the cause of amputation, the patient's background, his physical limitations, and his desires for the future. Before attempting to prepare a prescription, each team member should be thoroughly familiar with the information given in the preprescription form. Unless the therapist is familiar with the case, it is desirable to check any existing physical limitations.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 2. Typical preprescription information form for upper-extremity amputation.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>The prescription is prepared through the cooperative effort of the team and is signed by the physician. Fitting is then carried out by the prosthetist in accordance with the prescription. A prescription form for upper-extremity amputees is shown in <b>Fig. 3</b>.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Typical prescription form for upper-extremity prostheses.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h4>Visit No. 2</h4> <p>Upon completion of the prosthesis, but before training, the amputee is brought before the clinic team a second time. Here emphasis is placed on "before training." Taken literally, this may mean that the amputee will have no conception of even the simpler control movements. In the final stages of fitting the upper-extremity amputee, however, it is necessary that the prosthetist instruct the amputee in basic control motions in order to ensure that the prosthesis is capable of function as fitted. Accordingly, the prosthetist must be thoroughly familiar with initial training procedures lest unnatural motions have to be unlearned.</p> <p>The primary purpose of the second clinic visit is to ensure that the amputee is ready for training. Included is an evaluation of his physical and mental condition as well as of the degree of comfort and function provided by the prosthesis. A simple but comprehensive series of tests has been developed to aid in evaluating functional aspects in upper-extremity cases, and a description of these appears elsewhere in this issue.</p> <p>When the team is satisfied that training is in order, the patient is referred to the therapist for this phase of the rehabilitation procedure. Although a patient and his prosthesis may meet all the criteria of the checkout procedures during the clinic session, quite often use of the prosthesis or changes of the stump during training make modifications necessary. Hence, the more familiar the therapist is with the functional aspects of the various components of the prosthesis the more quickly can he call such deficiencies to the attention of the team. Not only is time saved, but factors which tend to discourage many amputees are eliminated. The over-all result is added confidence in the prosthetics team.</p> <h4>Visit No. 3</h4> <p>Upon completion of training, the amputee is once more brought before the clinic team for a final evaluation of his ability to resume an active role in society. The patient should be encouraged to request the services of the team whenever required and also to report for follow-up examinations at regular intervals. The length of time between visits depends, of course, upon the peculiarities of each case, but as a rule it is best that the patient be examined at least once a year.</p> <h4>Conclusion</h4> <p>The concept of the Prosthetics Clinic Team is not a mere theory. Under the direction of Dr. Augustus Thorndike, the Prosthetic and Sensory Aids Service of the Veterans Administration has established 30 such teams since 1949. Others are in operation in private clinics and within the Armed Services. The initial success of these teams, often under very difficult operating conditions, has led the Advisory Committee on Artificial Limbs to stimulate development of evaluation techniques that can be used under clinical conditions and to encourage the use of the clinic-team approach for amputee rehabilitation generally.</p> <br /> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Footnote</b></td> </tr> <tr> <td class="clsTextSmall">It must be emphasized that these prescriptions, even though they be signed by the physician, should correctly be the product of consultation by the entire team. It is perhaps in the preparation of these prescriptions that the knowledge of each team member is utilized to the fullest.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Charles O. Bechtol, M.D. </b></td> </tr> <tr> <td class="clsTextSmall">Assistant Clinical Professor of Orthopedic Surgery, University of California; Western Area Consultant for Prosthetic and Orthopedic Clinics, Veterans Administration; member of the Upper- and Lower-Extremity Technical Committees of ACAL.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_009/January-1954-2.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_01_009/ReplacewithFig2.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_01_009/ReplacewithFig3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Prosthetics Clinic Team Creator An entity primarily responsible for making the resource Charles O. Bechtol, M.D. * https://staging.drfop.org/files/original/cd2773276c38e31c5de8654b32560573.pdf 87b82fb3ff0928e5a56676a56b7cbdcf https://staging.drfop.org/files/original/a78493f4da7fe644e100ca7cd8f56d1e.jpg e073105d25ced27a5e34a054493e1b9b 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 Fig. 1. Common type of fitting stool in use as early as 1915. https://staging.drfop.org/files/original/08467dd5927652e3f141a24cfd88006d.jpg 6b207b6637a053feab492dfd5671d043 https://staging.drfop.org/files/original/70ce2e00269500442488030867f39c27.jpg 89f554cdd092a9be038f0d15dd877649 https://staging.drfop.org/files/original/dccd360bb421f24a14130d0561616df2.jpg 80c4e525bbf609f14fb7e4a1ab680320 https://staging.drfop.org/files/original/7fb4c0a612ed285e0c2e9087a7e28b62.jpg 76427ad85f7535e83fe3bfd90e193887 https://staging.drfop.org/files/original/0d84a2e1a512d5f9cb9193668acd65ae.jpg bed71c0fb716d2bdf7f019f1e9eb4b37 https://staging.drfop.org/files/original/97791855ac3600156a68a12b7c972dd5.jpg 2b164807888f99334218d0f7f47b8f17 https://staging.drfop.org/files/original/da317ff46ffe02bafb48463f608f475d.jpg 6810da6531996bb2b6c2be42269f130d https://staging.drfop.org/files/original/963ad811431eb69af334aa267224b273.jpg 1e1a95fac1029fec7c7f718ecb7e4a94 https://staging.drfop.org/files/original/2841d434985c67fafb98c4d6d708fb1d.jpg 674642f0b1ea2c951c02a34b642778c3 https://staging.drfop.org/files/original/4f883a6fd1a5b6708ec59964f8f2a42b.jpg 9c29c06be2efb1a6f591ec3270228eb0 https://staging.drfop.org/files/original/c80c09227dc29bd5b10a5c5d39e6a560.jpg 44accb51743d8c7c84cfc4df44fbde0b https://staging.drfop.org/files/original/c6663fb4bff4e66ca21d755e4fd2bce7.jpg 496e66c530a145b0109ce9a5596bc33e https://staging.drfop.org/files/original/d4d6515876785c9dc32270fdd4c7af27.jpg 1a33a5ea6da53b83e55a91265fa656e3 https://staging.drfop.org/files/original/4f02159f1f7aefd8f42f385c1a097c7a.jpg 9e0b9a2c892c1167b0652e3e195a4a8c DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_020.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 20 - 28 Text Any textual data included in the document <h2>Mechanical Aids for Alignment of Lower-Extremity Prostheses</h2> <h5>Charles W. Radcliffe, M.S.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>If a prosthetic device is to give optimum service to the amputee, it must always be properly fitted, regardless of its mechanical excellence. This is especially true in the case of the lower extremity, where the prosthesis must function continually and where poor fit or alignment will lead quickly to rejection of the device by the wearer. Among prosthetists there seems to be general agreement that by far the most important factors in the success of any artificial leg relate to fit and alignment on the subject. Fit and alignment are usually considered together, since they are mutually interdependent.</p> <p>Over the years many different mechanical devices to aid in fitting and alignment of lower-extremity prostheses have been developed to help in the application of one or another particular set of alignment principles in use by individual fitters. Others of these devices are more general in application and are adaptable for use by any prosthetist regardless of the particular alignment principles he advocates. In every case, however, an attempt has been made to improve the fitting and alignment technique by adopting one definite set of principles and using a mechanical device to aid in the application of those principles.</p> <h3>Historical Background</h3> <p>In 1919 Franz Schede<a></a> wrote <i>Theoretische Grundlagen fiir den Bau von Kunstbeinen, </i>a work generally considered to be one of the first important contributions in the field of prosthetic devices. In this volume Professor Schede established for the alignment of lower-extremity prostheses a set of principles based on application of known laws of mechanics. He was particularly concerned with alignment of the joints in a lower-extremity prosthesis so as to provide sufficient stability during the stance phase. As a result of the interest in his work, there was developed the so-called "plumb-line" method of alignment, a method which, essentially, assumes that the prosthesis carries weight along a vertical plumb line, the elements of the prosthesis then being arranged using this line as a reference. Still in general use throughout Europe and the United States, this system involves the problem of determining the location of the plumb line in the socket so that it can be extended down to the foot and used as a reference. For this purpose, many mechanical devices have been used.</p> <h4>The Fitting Stool</h4> <p>One of the oldest devices to aid in the fitting of lower-extremity sockets is the common fitting stool (<b>Fig. 1</b>). This device was well known as early as 1915 and is still in general use. When it is used to aid in establishing a "weight line," wedges are employed to tilt the socket block until the desired orientation is achieved. The hydraulic fitting stool of Habermann (<b>Fig. 2</b>) is a recent refinement. It requires that the location of one point on the weight line be assumed, usually at the socket brim, and that the plumb line be drawn vertically downward from this point.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 1. Common type of fitting stool in use as early as 1915.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 2. Modern fitting stool with hydraulic height adjustment. Manufactured in Germany by Habermann.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p><i>Pivot-Point Balancing Devices</i></p> <p>In an attempt to eliminate the necessity for the assumption of one point on the weight line of the socket, various modifications of the standard fitting stool have been tried.<a></a> <b>Fig. 3</b> is a schematic diagram of a fitting stool which uses a fixed ball as the lower contact point. The point of contact of the ball locates one point on the plumb line, which is then extended upward through the socket.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 3. Point-balance fitting stool with a fixed ball as the supporting point</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>In a further refinement of this technique, introduced into this country in 1947, the plumb line is located at the intersection of two vertical planes (<b>Fig. 4</b>). The lower edge of each plane is determined by use of a triangular block giving a line contact along the bottom of the socket.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 4. Line-balance fitting stool with triangular block as a support.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>Another pivot-point balancing device (<b>Fig. 5</b>) locates a similar point near the top of the socket block by supporting the socket in a clamp which pivots about a fore-and-aft axis and allows the pivot point to be moved medially or laterally as desired. Weight is transmitted to the floor through a connecting pylon.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 5. Pylon-type fitting stand with support at a point near the top brim of the socket.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p><i>Vise-Type Fitting Stand</i></p> <p>Another school of thought in the alignment of the above-knee socket believes that establishment of a plumb line is not as important as is establishment of the proper inclination of the socket in space. In the vise-type fitting stand (<b>Fig. 6</b>) of Habermann<a></a>, the socket can be adjusted in inclination to any position desired. Once the proper inclination and height have been established, the socket is clamped rigidly in space, and the amputee "marks time" in the socket. If necessary, changes are made until the amputee is able to bear weight comfortably and to use his stump efficiently in the control of body movements. After an arbitrary plumb line has been assumed, the optimum socket orientation is incorporated into the final prosthesis.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 6. Vise-type fitting stand.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>All of these mechanical aids have helped in the so-called "static alignment" of the prosthesis, a condition which determines the stability of the artificial limb in the stance phase. The "dynamic" factors, which affect the swing phase of the prosthesis, and which account for the differences between the static and dynamic conditions in the stance phase, are adjusted as necessary after the amputee is walking on the rough leg.</p> <h4>Schneider's "Gehmaschine"</h4> <p>Hans Schneider<a></a> of Nuremberg, Germany, has long advocated the use of an adjustable leg or "walking machine." Essentially, his method is to allow the amputee to walk on a trial prosthesis (<b>Fig. 7</b>), changes being made empirically until the alignment is considered satisfactory. Then, as the optimum alignment is being duplicated in the final prosthesis, various measurements are read from the adjustable leg and a measuring stand (<b>Fig. 8</b>). It is claimed that from these measurements the fit and alignment can be duplicated in additional prostheses ordered later.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 7. Schneider's "Gehmaschine."</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 8. Schneider's alignment stand.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h3>The University of California Above-Knee Adjustable Leg</h3> <p>A study of methods for alignment of the above-knee suction-socket prosthesis was started at the University of California, Prosthetic Devices Research Project, in the autumn of 1946. As one of the first phases of investigation, two adjustable prostheses were designed and constructed. These experimental devices (<b>Fig. 9</b> and <b>Fig. 10</b>) allowed adjustment of a large number of variables, and data were collected having to do with the effect of a change in one of the many alignment variables upon the behavior of the prosthesis<a></a>. It soon became apparent that devices of this nature were not only useful as research instruments but that they might also have some practical use as limbshop tools. Accordingly, there was designed and constructed for limbshop purposes a series of models of a simplified device in- corporating only those adjustments found most important, as determined using the research devices.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 9. Experimental adjustable above-knee leg used for research at the University of California.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 10. Experimental adjustable below-knee leg (University of California).</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>The initial effort was to develop a device for alignment of the above-knee suction-socket prosthesis. Out of this work came the above-knee adjustable leg shown in <b>Fig. 11</b>. Several units of this design were used in the experimental program at the University of California and were given shop trials in the San Francisco Bay Area. They were found very useful in the alignment of above-knee prostheses in the shops and, in addition, were widely used for demonstration of alignment principles. But use of the above-knee adjustable leg was then limited because of the difficulty in transferring the optimum relationships from the adjustable trial prosthesis to the final setup.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 11. The UC adjustable leg.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h3>The UC Alignment Duplication Jig</h3> <p>To fill this need, the designers produced the Alignment Duplication Jig (<b>Fig. 12</b>), which is essentially a rather specialized set of clamps and an associated saw guide to maintain the socket, knee axis, ankle axis, and foot in a fixed position, thus permitting the temporary adjustable knee to be removed and replaced with wood, plastic, or metal structural members and joints. Three models of the alignment duplication jig were constructed and loaned, along with models of the above-knee adjustable leg, to the representatives of the Orthopedic Appliance and Limb Manufacturers Association who were then serving as the Technical Advisory Committee to the Lower-Extremity Technical Committee of ACAL. The representatives of the limb industry were unanimous in their conclusion that use of these devices offered considerable advantage to the prosthetist for alignment of all above-knee suction-socket prostheses.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 12. The alignment duplication jig.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>On the basis of the experience gained, the above-knee adjustable leg was redesigned, as shown in <b>Fig. 13</b>, and drawings for both the adjustable leg and the duplication jig were made available to the artificial-limb industry.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 13. Revised design of the adjustable leg as released to the artificial-limb industry.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>Devices similar to those shown in <b>Fig. 12</b> and <b>Fig. 13</b> are now being manufactured<a style="text-decoration: none;">*</a> and can be purchased by limbshops.</p> <h3>The UC Combination Adjustable Leg</h3> <p>Because of the acceptance of the above-knee adjustable leg during its trial period of limbshop use, the Technical Advisory Committee of OALMA recommended that a similar unit be developed for alignment of below-knee prostheses. As a result, the combination above-knee/below-knee adjustable leg (<b>Fig. 14</b>) was designed and constructed at the University of California. Its use as a below-knee alignment device is indicated in <b>Fig. 15</b>. The principal advantage of this unit over previous designs is that no tools are required in making adjustments.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 14. Combination above-knee/below-knee adjustable leg in use as a trial above-knee prosthesis</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 15. Combination above-knee/below-knee adjustable leg in use as a trial below-knee prosthesis.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h3>Use of the Adjustable Leg and Alignment Duplication Jig</h3> <p>The basic difference in the use of the University of California alignment devices, as compared with Schneider's apparatus, lies in the manner of duplication of the optimum alignment. The adjustable leg is used in much the same manner as is Schneider's device. A set of guiding principles for filling and alignment has been established, and the adjustable leg is used as a means of applying these principles to the conditions existing with a particular amputee. But the devices serve as shop tools only, and any set of principles can be applied by the prosthetist.</p> <p>In the use of the alignment duplication jig, the (assumption is made that the optimum alignment will be influenced considerably by the fit of the socket. Since subsequent sockets for a particular amputee are not apt to be exactly alike, it is considered unnecessary to try to duplicate in all later prostheses the alignment of the first. Each socket is considered as a separate alignment prob- lem, and the alignment duplication jig helps in the construction of the final prosthesis rather than as a measuring instrument.</p> <p>In the prior art of lower-extremity limb-fitting, there has naturally been the tendency to stop making adjustments as soon as the prosthesis is just "good enough," especially so when a further change would mean breaking a glued connection or resetting a joint. The principal advantage of the UC alignment equipment is that, since all adjustments in the trial prosthesis are easily and quickly made, the prosthetist can make very small changes until both he and the amputee are satisfied that the best job has been done. The alignment of a leg prosthesis is especially critical in the swing phase and during the periods of transition from stance to swing. Very small changes in alignment can have very noticeable effects upon the performance of the prosthesis at these times. Since small adjustments can be made accurately using the adjustable leg, the prosthetist is able to obtain optimum performance where that is difficult, if not impossible, to achieve by trial-and-error methods. Besides this, the adjustable leg has found considerable use as an educational aid in teaching prosthelisls the fundamentals of limb alignment in suction-socket schools and in demonstration of alignment principles before groups of orthopedic surgeons, physical therapists, and others.</p> <p><b>References:</b></p> <ol> <li>Habermann, Alfred, <i>Mechanische Hilfsmittel fur denstatischen Aufbau des Kunstbeines, </i>Medizinische-Technik, 4(3) :60 (March 1950).</li> <li>Schede, Franz, <i>Theorelische Grundlagen fur den Bauvon Kunstbeinen; Insbesondere fur den Oberschenkel-amputierten, </i>Ztschr. f. orthopad. chir., Supplement 39, Enke, Stuttgart, 1919.</li> <li>Schnur, Julius, <i>BeinbelasiungsUnie und Schwerlinie,</i>edizinische-Technik, 5(3):54 (March 1951).</li> <li>Schnur, Julius, <i>Die Aquilibral-Kontakt Prolhese,</i>rthopadie-Technik, 4(2) :36 (February 1952).</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Functional considerations in fitting and alignment of the suction socket prosthesis, </i>March 1952.</li> <li>War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, <i>Report on European observations, </i>Washington, 1946. <b>p.92.</b></li> </ol> <br /> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Footnote</b></td> </tr> <tr> <td class="clsTextSmall">By the Plastic Fibre Limb Company, Minneapolis Minnesota.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; 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">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Reference</b></td> </tr> <tr> <td class="clsTextSmall"><b>6.</b></td> <td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946. p.92.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; 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">Habermann, Alfred, Mechanische Hilfsmittel fur denstatischen Aufbau des Kunstbeines, Medizinische-Technik, 4(3) :60 (March 1950).</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>References</b></td> </tr> <tr> <td class="clsTextSmall"><b>3.</b></td> <td class="clsTextSmall">Schnur, Julius, BeinbelasiungsUnie und Schwerlinie,edizinische-Technik, 5(3):54 (March 1951).</td> </tr> <tr> <td class="clsTextSmall"><b>4.</b></td> <td class="clsTextSmall">Schnur, Julius, Die Aquilibral-Kontakt Prolhese,rthopadie-Technik, 4(2) :36 (February 1952).</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Reference</b></td> </tr> <tr> <td class="clsTextSmall"><b>2.</b></td> <td class="clsTextSmall">Schede, Franz, Theorelische Grundlagen fur den Bauvon Kunstbeinen; Insbesondere fur den Oberschenkel-amputierten, Ztschr. f. orthopad. chir., Supplement 39, Enke, Stuttgart, 1919.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <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 W. Radcliffe, M.S. </b></td> </tr> <tr> <td class="clsTextSmall">Acting Assistant Professor of Engineering Design, University of California, Berkeley; member, Lower-Extremity Technical Committee, ACAL, NRC.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-10.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-11.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-12.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-13.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-14.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-15.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-16.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-17.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-18.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-19.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-20.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-21.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-22.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-23.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-24.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 Mechanical Aids for Alignment of Lower-Extremity Prostheses Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S. * https://staging.drfop.org/files/original/fcf5e10ffc3bff3cb89b517eb63ea5a2.pdf 0b8215ed539490f64e8cf75633dbb151 https://staging.drfop.org/files/original/5df5af90029daa1b7947c5ee33d08bc8.jpg 949b68f099a2ded1f6d45b1a93835af6 https://staging.drfop.org/files/original/e885e588918c3f3ed5fed4be446f6515.jpg 9c9edb182b521a4f3c55907aac2c12c4 https://staging.drfop.org/files/original/8ae9ef1f9e51a1ffe5839ee578fde9ec.jpg 3e30a207b5d92d01eaba842dbb9ce17e https://staging.drfop.org/files/original/dc315daacc177135b612f6d9d75dac9f.jpg 80cbacdea646e05d40116aa522d6538c https://staging.drfop.org/files/original/d6a0e71d869fdf811919200fc92af175.jpg 8af7b934c360f7d8be36455e7d27b56d https://staging.drfop.org/files/original/dcd15d5b2cb3600bbb9a16ceee230a8a.jpg b4bee6b427deadb2481ef102215ea90d https://staging.drfop.org/files/original/fbab7c843102fc1a6a56f0387d6474e7.jpg eecb06f6a79e8bf93b309fd4571aa73e https://staging.drfop.org/files/original/a36d8df923391175c131cc2503b2ad4f.jpg f12d7502edc79a9815ea0effa5a61252 https://staging.drfop.org/files/original/65c39b075e4ed74821b311f1425e07fe.jpg 33cdcc9406cbfccab6083b95a496cd32 https://staging.drfop.org/files/original/7ad63a3c7138be2c4aeadf85e67c3352.jpg 7f4f5ea9d217ef6cb6424c830141f675 https://staging.drfop.org/files/original/2c83de4880188f302b29099589602a5f.jpg c8b1c39cf8255f9580c8abf663fd469e https://staging.drfop.org/files/original/ae139375a47c70c260990878a1f0ae09.jpg 9e529d7b3beb3edc4fb97f0b018934f9 https://staging.drfop.org/files/original/dddd1109e0786871b6890b901ad89193.jpg f0c7d156e4cf6e475c16a3ffd9013a96 https://staging.drfop.org/files/original/43b8b6068ae6129c2d30f9f07c50ffce.jpg a10cd2406b8ed3c261645d2669705d61 https://staging.drfop.org/files/original/6fc43a0cc84ce447ae02214678f3688f.jpg f11a6615dd5d7161c615453a358094c1 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_01_035.pdf Year 1955 Volume 2 Issue 1 Page Number(s) 35 - 60 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_01_035.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_01_035.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>Functional Considerations in the Fitting of Above Knee Prostheses</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>In the fitting of any artificial limb, the goal of the prosthetist is simply to restore to the amputee the ability to perform everyday activities in an easy, natural, and comfortable manner. The basic requirements are therefore three in number-comfort, function, and appearance, the latter embracing both cosmetic appearance and appearance in use. Unless a prosthesis is reasonably comfortable, the amputee will be unable to wear it. Unless it performs the necessary functions with reasonable ease and dexterity, the amputee is not apt to find the device very useful. Unless it is reasonably acceptable cosmetically, and unless it can be operated in a natural manner, the limb is likely to be disagreeable both to the wearer and to his friends and associates. But this seemingly simple set of requirements is vastly complicated by the fact that the three are all mutually interrelated. That is to say, the degree of satisfaction attained in one condition is influenced greatly by the situation prevailing with respect to the other two. Cosmetic appearance, for example, is necessarily limited by details of mechanism, and vice versa. No matter how elaborate a prosthetic device may be, it cannot be made to function properly unless it can be manipulated with ease and without discomfort. And conversely, no device can be comfortable in use unless its functional characteristics are properly integrated with the residual biomechanics of the wearer. Any change aimed at improvement in one condition unavoidably affects the other two-sometimes favorably, sometimes unfavorably.</p> <p>In the lower extremity, cosmesis presents no serious problem. Since it is comparatively easy to fashion an artificial leg to an external shape and appearance more or less like that of its normal counterpart, and since in both sexes the lower extremity may be concealed beneath some sort of clothing, the actual cosmetic properties of a lower-extremity prosthesis amount to refinements to be added after all other requirements have been met. More critical in the lower extremity are comfort, function, and appearance in use. The leg prosthesis is in almost constant service, and it must provide both adequate support and a natural-appearing gait with as modest consumption of energy as possible. In fitting an above-knee limb, therefore, correct practices based on established biomechanical principles are mandatory if success is to be had.</p> <p> Because during all activities the suction-socket above-knee leg<a></a> is controlled by the amputee through the use of remaining hip musculature, every effort must be made to ensure that these muscles are used to the fullest possible extent without causing discomfort. The intent here<a style="text-decoration:none;">*</a> is to present the basic concepts that apply to the fitting of all above-knee prostheses, regardless of type of suspension, but which have particular application to the suction-socket above-knee leg. Although the details of fitting must necessarily be modified as dictated by the individual case, the basic features apply to all cases.</p> <h3>The Principles of Above-Knee Alignment</h3> <h4> Mediolateral Stability</h4> <p>When one watches the walk of a typical above-knee amputee, two characteristics of gait often are particularly apparent. First, sidesway, <i>i.e.,</i> lateral movement of the torso from side to side, is exaggerated. Second, the amputee usually walks with his feet farther apart than does a normal individual of similar build. The average individual walks in such a manner that the lateral distance between successive points of heel contact is from 2 to 4 in. In order for the gait of an amputee to appear as normal as possible, therefore, he must walk with a base equally narrow. The amputee with a walking base of from 6 to 12 in. never can achieve a normal gait appearance. If such an amputee is asked why he walks with a wide base, he usually gives as the reason that it is more comfortable or that he feels more secure with his feet farther apart. </p> <p>This circumstance is accounted for by the fact that, as an amputee attempts to walk with his feet closer together, certain functional requirements are placed upon the fit of the socket and upon orientation of the socket in space. In general, these requirements are not fulfilled in a prosthesis aligned for a wide-base gait. If an attempt is made to use such a prosthesis with a gait of narrow base, difficulties arise because certain forces come into play that cannot be accommodated by the stump in a comfortable manner. Although a poorly fitted prosthesis may be reasonably comfortable for many months provided the amputee walks so as to compensate for errors in fit and alignment, the same prosthesis may be very uncomfortable if the wearer attempts to change to a more normal-appearing gait. It is, however, possible to construct for the average above-knee amputee a prosthesis that allows a reasonably normal gait, that is comfortable in all normal activities, and that eliminates common points of stump irritation such as those in the crotch area and near the end of the femoral stump.</p> <h5> <i>The Weight-Bearing Line</i> </h5> <p>One of the most common terms used by the prosthetist in the fitting and alignment of an above-knee prosthesis is the "weight-bearing line." It serves as the guide for many phases of setting up the prosthesis, but its exact position is subject to considerable difference of opinion. One prosthetist may use a weight line drawn from the ischial tuberosity through the center of the ankle joint; a second may select a line falling along the medial side of the foot; and a third may advocate use of a line drawn from the geometric center of the socket at the ischial level to the center of the heel. It is possible to get many other definitions of the weight-bearing line. As a matter of fact, they probably are all equally helpful in the alignment of prostheses. In considering the manner in which the weight-bearing line is used, it becomes apparent immediately that such a line actually serves as a "reference line" or "construction line."</p> <p> In the discussion that follows, the term "weight line" is used to establish a mental picture of a theoretical line in space along which the force of the body weight acts. This concept differs from "weight-bearing line" in that "weight" is due to the gravitational attraction of the earth, whereas "weight-bearing" refers to the transmission of a force through the structural elements of the anatomy and the prosthesis. Although it would appear difficult to establish any one line which accounts for the net effect of the weight of the various and widely separated parts of the anatomy, that can be done in a theoretical, idealized way by defining a point within the body at which the effect of all body weight can be assumed to be concentrated. This point is usually designated as the "center of gravity" of the body as a whole. With all the weight assumed to be concentrated at the center of gravity, the body weight must then always be considered as acting directly downward from this point, as though it were a plumb bob suspended on a string hanging from the center of gravity. The string would represent the body weight line. A short definition of the weight line as shown in Figure <i>A</i> might read as follows: <i>The weight line of the body is a line through the center of gravity along which the body weight can be assumed to act vertically downward at all times.</i> </p> <h5> <i>Variations in Vertical Force</i> </h5> <p>Thus far we have considered only the effect of the body weight acting downward. For either an amputee or a person with two good legs, the body weight must be supported by the contact between foot and floor. For many reasons, the force of contact between foot and floor is very difficult to measure accurately because, for either foot, the contact force is extremely variable over the short time the foot is supporting weight. Shortly after the heel strikes the floor, the leg receives an initial load which, because of the slight reduction in the rate of progression of the body as a whole, quickly increases to a value greater than body weight. During the mid-portion of the stance phase, as the center of gravity of the body is reaching the lowest point in its path of motion, the load on the leg decreases to a value somewhat less than that of body weight. As the body is being elevated and propelled forward into the next step, the load builds up again to a value greater than that of body weight.</p> <h5> <i>Forces in Shear</i> </h5> <p>While all this is occurring, the person also is swaying from side to side and varying in speed slightly as he walks. This condition requires that the contact force must also provide some horizontal frictional forces along the floor, as everyone has realized after slipping on ice or when making a sharp turn. The forces acting on the foot during walking are, then, of two kinds-those acting perpendicular to the floor, which support the body weight, and those acting parallel to the floor, which are necessary to provide resistance to the impetus of the body moving forward, backward, or sideways.</p> <h5> <i>Floor Reaction and Load Line</i> </h5> <p> The total force exerted on the sole of the foot-the combination of all these effects-is known as the "floor reaction." It acts along the same line as does the total force exerted by the amputee on the socket of the prosthesis. The floor-reaction force is the load which the leg, whether normal or prosthetic, must transmit upward from the floor. In general, the line of these forces, known as the "load line" ( <b>Fig. 1</b> <i>B),</i> is not perpendicular to the floor but is directed upward, inward, and forward or backward with an inclination that varies continually during the time either foot is supporting the body. It is very definitely not a line drawn from the center of the hip joint through the knee and ankle joints. A line so drawn should, instead, be designated as the "mechanical axis of the lower extremity." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1. Definitions in alignment of the lower-extremity prosthesis. A, The "center of gravity" of the body is a point at which all body weight can be assumed to be concentrated. The effective body weight passes through the center of gravity and acts vertically downward along the "weight line." B, The "load line" is a line along which the force between the foot and the floor acts. In general, it is not perpendicular to the floor surface, since this force has two effects. First, it supports the body weight in a vertical direction, and second, it provides the horizontal forces necessary to cause motion of the body in the forward and medial directions. C, The "support line" is a vertical line along which the effective supporting force exerted between the rim of the socket and the stump of the amputee is assumed to act. In general, the support line does not pass through the center of gravity or through the center of foot pressure.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> <i>The Support Line</i> </h5> <p> An additional necessary concept is that of the "support line" (<b>Fig. 1</b>). In order to define the support line, it is necessary first to identify a "support point," which may be defined as the center of action of all the vertical supporting forces at the top rim of the socket, including the ischial-bearing force, support in the gluteal region, and support in other weight-bearing areas around the socket rim. Where such a point lies is very difficult to establish, its actual location depending largely upon the individual prosthetist's methods of fitting. In a typical ischial-bearing socket, the support point is probably somewhere anterior and lateral to the point of contact of the socket with the ischial tuberosity. The support line is defined as a vertical or plumb line, passing through the support point, along which the effective supporting force between the socket rim and the stump can be assumed to act. In general, the support line coincides neither with the weight line nor with the load line. </p> <h5> <i>Use of the Hip Abductors</i> </h5> <p> <b>Fig. 2</b> presents a rear view of an above-knee amputee, walking with a narrow base, at an instant during the walking cycle when the full weight is carried on the prosthesis. During the stance phase, the amputee, like the normal individual<a></a>, keeps his pelvis horizontal primarily by action of the hip abductors on the supporting side, as shown by abductor tension in <b>Fig. 1</b>. If, for one reason or another, the hip abductors are unable to exert the necessary force, the pelvis has a tendency to drop toward the unsupported side. When, therefore, the above-knee amputee stands upon his prosthesis, his pelvis may tend to drop toward the normal side owing either to inadequate hip abductors or to inadequate support on the lateral side of the stump-support which is necessary to stabilize the femur and to form a firm base for action of the hip-abductor musculature. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2. Use of the hill abductors for lateral stabilization of the pelvis.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Dropping of the pelvis toward the normal side generally results in an increase in pressure in the crotch area. It often allows the pubic ramus to come into contact with the medial wall of the socket and .an therefore be extremely uncomfortable. Anticipating this action, the amputee makes appropriate compensation. He maintains his balance either by leaning over the prosthesis, which results in the familiar amputee list, or by walking with a wide base and swaying from side to side. In the alignment of an above-knee prosthesis, then, one of the most important objectives is to construct the prosthesis in such a way that the hip abductors may be used in a normal and comfortable manner to prevent this tendency toward pelvic drop, torso list, or sidesway, and to allow a reasonably normal and comfortable gait.</p> <h5> <i>The Pelvic Lever</i> </h5> <p> As indicated in <b>Fig. 1</b> <i>A</i>, the center of gravity of the body is defined as the point at which the entire weight would have to be concentrated were it to have the same effect on the body as a whole as does the actual weight distribution. On the strength of this concept, the pelvis can be assumed to act as a lever in the stance phase while the amputee supports his weight on the prosthesis <b>Fig. 3</b>. Using the ischium as a supporting pivot or fulcrum, the pelvic lever supports the body weight (which acts vertically downward through the center of gravity and along the weight line) by the balancing action of the hip abductors, the process being similar to normal hip action in which vertical support is through the hip joint. If this lever action is to prevent dropping of the pelvis toward the unsupported side, the tension in the hip abductors must be sufficient to balance the body weight. The abductor muscle force can perform this function only if abduction of the stump is prevented by firm contact against the lateral wall of the socket. Otherwise the muscle action would simply cause abduction of the femoral stump inside the socket. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3. Lever action of the pelvis in stabilization of the torso.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> <i>Distribution of Lateral Pressure</i> </h5> <p> The necessary stabilization of the stump against the lateral wall of the socket can be accomplished comfortably if the stabilizing pressure is distributed widely over the lateral side. For a stump of average length, stabilization is achieved by fitting the lateral wall snugly over its entire length. A slight flattening of the lateral wall, with relief near the distal end of the femur, usually ensures that the stabilizing forces are not only comfortable but that they are directed medially as required <b>Fig. 2</b>. If, with the stump improperly supported against the lateral wall, an attempt is made to use the hip abductors for pelvic stabilization, the result may be a gap around the lateral brim and a painful concentration of pressure near the end of the stump. </p> <h5> <i>Considerations of Mechanical Advantage</i> </h5> <p> Two other factors enter into the lateral stabilization of the pelvis by the hip abductors. First, in balancing the body weight on the ischial fulcrum, the tension in the hip abductors has greatest mechanical advantage when the lever arm between the abductor tension and the support point is as long as possible. Support of a substantial portion of the body weight by the ischial seat and of a smaller amount by the gluteal musculature gives the abductor tension sufficient mechanical advantage to balance the body weight with little or no conscious effort on the part of the amputee. The characteristics of this lever system are shown in the schematic diagram of <b>Fig. 3</b> , where the required tension <i>T</i> is reduced by decreasing the distance <i>x</i> and increasing the distance <i>y.</i> </p> <h5> <i>Adduction of the Stump</i> </h5> <p> A second factor in making allowance for normal use of the hip abductors is the degree of stump adduction in the socket. The "rest-length" theory of muscle action<a></a> has shown that the muscles of the body act most efficiently when they are at approximately their normal rest length. To make the action of the hip abductors efficient, the stump, when fitted in the socket, must be adducted in such a manner that the outward movement of the femur within the muscle mass of the stump is anticipated and that the normal pelvic-femoral angle is maintained as closely as possible while the body weight is being supported on the prosthesis. For the average amputee, this requirement can be met in a practical way by aligning the medial wall of the socket perpendicular to the floor, the lateral wall being sloped definitely inward. Although exceptions are necessitated on the basis of stump length, the short stump being aligned with less adduction, every effort should be made to adduct the stump as much as conditions permit. </p> <p> An additional advantage of alignment in adduction becomes apparent immediately. As a result of the accompanying decrease in tension of the adductor musculature, pressure in the crotch area is decreased. As a result of this relaxation, the pressure in the crotch or medial area (<b>Fig. 2</b>) is then predominantly lateral rather than vertical and no longer causes painful pressure on stretched adductor tendons or in the region of the ramus. It should be emphasized here that a socket properly fitted and aligned carries little or no weight on the medial wall. </p> <h5> <i>Foot Position</i> </h5> <p> Alignment of the foot in a medial position, a fundamental consideration if the amputee is to walk without excessive sidesway or torso list, helps to ensure that the body weight will be borne chiefly on the ischial seat. The average amputee walks well with the centerline of the foot located directly below the ischium during the time the prosthesis is supporting the entire body weight. But this rule-of-thumb, illustrated by the reference line shown in <b>Fig. 2</b>, must vary depending upon the capacity of the amputee to use his hip abductors. If an amputee with a very short stump attempts to use it for lateral stabilization, he cannot tolerate the increased and usually localized pressure resulting from the short stump length and the concentration of force in a small area. He must, therefore, walk with more limited use of his hip abductors, and compensation is effected by leaning over the prosthesis to shift the weight line closer to the support line and by walking with a wider base, an expedient which increases lateral stability but leads to excessive sidesway. Because of these factors, and because of the probability in such cases of some degree of abduction contracture, the amputee with a very short stump should have his prosthesis aligned to accommodate a gait of wider base. </p> <h5> <i>Recapitulation</i> </h5> <p>In summary, mediolateral stabilization of the pelvis accompanied by a decrease in the amount of sidesway and list can be achieved by alignment of the foot in a medial position relative to the socket, by fitting the stump in an adducted position where possible, and by providing firm support for the stump against the lateral wall of the socket to allow efficient use of the remaining abductor musculature of the hip.</p> <h4>Knee Control</h4> <h5> <i>Involuntary Control</i> </h5> <p> Generally, the tendency of the articulated knee joint of the above-knee prosthesis to collapse under load is controlled involuntarily through alignment or by mechanical devices which lock or restrain flexion while the body weight is being transferred through the prosthesis.<a></a> Although involuntary control is desirable as an aid in achieving a smooth and natural-appearing gait, a proper balance must be obtained between the amount of involuntary and voluntary control of knee stability, taking into account the amputee's coordination and age and the condition of his stump. </p> <p>Involuntary control of knee stability during weight-bearing is made possible by so placing the knee axis that it is at all times posterior to the load line of the prosthesis<a></a>. A prosthesis with the socket placed well forward on the knee block or aligned in hyperextension and with the knee joint located posterior to the ankle joint is said to have a high degree of "alignment stability." That is to say, under load the knee joint is forced to extend until the extension stop makes contact and prevents further motion. This expedient often is necessary for amputees who have a fear of falling or when it is required because of age, insufficient stump power, excessive weight, or the prevailing terrain. But it has the disadvantage of making the prosthetic knee hard to flex under even a light load and thus results in poor gait and difficulty in negotiating stairs and slopes. </p> <h5> <i>Voluntary Control</i> </h5> <p> An attempt should therefore always be made to minimize the amount of involuntary alignment stability and to provide for a maximum of voluntary knee control by stump action because this type of functioning results in the smoothest and most effortless gait possible. The average above-knee amputee has a reasonable amount of strength remaining in his hip flexors and extensors and is able to extend and flex his stump throughout an appreciable range of motion, and it is important that the fullest use be made of this musculature in voluntary control of knee stability. That this control may be exercised in the most efficient manner possible, the stump should never approach the limits of its motion as the amputee performs normal activities. If, for example, the stump is able to extend a maximum of 20 deg. to the rear, then at push-off any forced extension in excess of the 20 deg. results in a forward rotation of the pelvis. To compensate for such a forward pelvic rotation, the amputee must arch his back, an expedient which leads to the development of lordosis. Alignment of the socket in a position of initial flexion, as shown in <b>Fig. 4</b>, eliminates much of this difficulty. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4. Influence of alignment on control of knee stability, socket aligned in initial flexion to avoid exces. sive pelvic rotation.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> <i>Initial Flexion</i> </h5> <p>When the socket is aligned with initial flexion, several other advantages become apparent. Since the length of the hip extensors is increased by the additional degree of hip flexion, the amputee has greater control of knee stability during the entire stance phase of the walking cycle. Since the extensor muscles are thus elongated slightly, they are able to develop the required tension easily. With much less conscious effort on the part of the amputee, therefore, the stump is able to exert the force necessary to keep the prosthetic knee back against its extension stop.</p> <p> Again, in an amputee with overdeveloped hamstring musculature there often is a tendency, as the stump extends at push-off, for the muscles to force the tuberosity of the ischium off the ischial seat, thereby causing pressure on the hamstring muscle and attachments and against the anterior brim of the socket. Initial flexion of the socket reduces this tendency and allows a portion of the body weight to be borne comfortably upon the hamstring attachments.<a style="text-decoration:none;">*</a> </p> <p>If the same degree of alignment stability is to be maintained, initial flexion of the socket must be accompanied by a shifting of the socket anterior to the knee axis. Merely changing the extension stop to decrease knee extension never can achieve the desired end-results. But less alignment stability is necessary under these conditions because of the increased voluntary control of the knee. Anterior positioning of the socket relative to the knee axis allows the prosthetic knee to be flexed a great deal more easily as weight is transferred from the prosthesis to the normal leg at the end of the stance phase. The result is a smoother gait. Although increased use of the hip extensors owing to their greater working length produces some decrease in the power available in the hip flexors, the loss is not serious since during ordinary activities the hip flexors never approach the limit of their range of flexion and since the force requirements are small as compared with those of the hip extensors.</p> <h5> <i>Ankle Position and Toe Break</i> </h5> <p> Another important factor in achieving the proper amount of knee stability is the fore-aft position of the ankle joint relative to the knee joint. For the active above-knee amputee, it usually is desirable to have the ankle joint directly below or slightly posterior to the knee joint, as shown in <b>Fig. 4</b>. Such an arrangement has several effects. First, as the foot is moved to the rear, the distance out to the toe break decreases to give the foot more of a "rocker" action and to allow the knee to flex easily at the end of the stance phase. Second, the major portion of the weight can be carried on the ball of the foot while standing. And third, the amount of toe clearance during walking is greater for a given angle of knee flexion. To move the ankle joint too far to the rear, however, results in instability at heel contact and excessive shortening of the stride. </p> <p> Many of these advantages can be achieved by use of a double toe break <i>(i.e.,</i> a flexible forefoot), which also gives the foot more of a rocker action and decreases the amount of vaulting over the prosthetic foot. But too much flexibility or too short a distance from ankle to toe break causes the leg to feel too short at the time of push-off. </p> <h3>Dynamic Alignment</h3> <p>For the major part of the time that the amputee is supporting himself on the prosthesis during the stance phase, the motions are relatively smooth, and the forces act on the prosthesis in essentially the same way as if the amputee were standing still with all weight carried on the artificial leg. During the swing phase, however, and during the times of transition from stance to swing and from swing to stance, the behavior of the prosthesis is influenced largely by dynamic forces varying rapidly with time. It is often relatively easy to fit an amputee so that he is comfortable in the stance phase, but in many cases it is more difficult to construct the prosthesis so that the amputee is able to walk with a smooth, natural-appearing, effortless swing-through. The first requirement for a smooth swing phase is a smooth transition from stance to swing, since, if the prosthesis is to swing properly, it must be given a good start.</p> <h5> <i>Knee Stability and Toe Break</i> </h5> <p>Of particular importance during these transition periods are knee stability, as affected by alignment and by the stiffness of dorsi-fiexion and plantar flexion at the ankle, and the combined effect of toe-out and orientation of the toe break in the foot. For security, the knee axis should be positioned far enough behind the hip-ankle line so that the amputee is conscious of a stable knee while standing. The amount of security desired depends upon the particular amputee. If, as the amputee attempts to walk, the knee feels insecure, the dorsiflexion position and stiffness in the ankle should be investigated as a possible additional cause of knee instability.</p> <p>In general, placing a stiff dorsiflexion bumper in the ankle and having the foot plantar-flexed in the neutral position, close to the point where the amputee has the sensation of "walking over a hill," produces the most desirable knee stability and allows smooth flexion of the knee at the start of the swing phase. The amount of toe-out usually is adjusted to the individual amputee. In all cases, however, the toe break should be at right angles to the line of progression to prevent insecurity resulting from the rapid shifting of the center of pressure during push-off.</p> <h5> <i>Whip in the Swing Phase</i> </h5> <p> One of the more obvious indications of poor dynamic alignment is the so-called "whip" of the prosthesis during the swing-through (<b>Fig. 5</b>). This lateral movement of the knee accompanied by medial movement of the foot, or vice versa, usually is caused by an incorrect amount of adduction for the particular socket being fitted, an improper angle of the knee axis with respect to the frontal plane, the natural tendency of the femoral stump to twist inward as it is brought forward, or a combination of these factors. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5. Common indications of incorrect alignment. A, Whip of the prosthesis during the swing phase. B, Mediolateral instability. C, Rotation at heel contact. For specific causes of these difficulties, see Radcliffe (10).</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An above-knee prosthesis often is "knocked" at the knee to position the foot laterally for greater stability while standing. Sufficient two-leg standing stability thus can be attained, but a stable, narrow-base gait is not then possible. The tendency of the prosthesis to whip also is aggravated because, as it swings like a pendulum, the leg has a natural tendency to swerve medially after toe-off and then to swerve out again just before heel contact. A prosthesis having the foot aligned medially for a narrow base during the stance phase need only move forward in a straight line from toe-off to heel contact.</p> <h5> <i>Rotation of Knee Axis</i> </h5> <p> Studies of normal human locomotion<a></a> show that the femur rotates an average of 3 to 4 deg. medially as the hip is flexed to bring the knee forward. Medial rotation of the femur causes a lateral displacement of the foot, as can be verified easily by observation of a person standing and flexing the hip while the shank hangs vertically. Accordingly, the knee axis in an above-knee prosthesis usually is rotated laterally to compensate for the tendency of the femur to rotate medially as the hip is flexed.<a style="text-decoration:none;">*</a> When the prosthetic knee axis is aligned in a position laterally rotated with respect to the socket, the foot moves somewhat medially with knee flexion, thus compensating for lateral movement of the foot caused by the medial rotation of the socket during the swing phase and allowing the foot to travel in a straight path. </p> <h5> <i>Ankle Stiffness</i> </h5> <p>The stiffness of plantar flexion at the ankle determines, to a large degree, the stability of the knee at heel contact. A stiff ankle does not allow the foot to rotate forward into the stable flat position and thus tends to cause the knee to buckle forward as the weight is transferred to the prosthesis. An ankle joint with insufficient plantar-flexion stiffness, however, allows the foot to slap at heel contact. A proper balance between these two effects must therefore be attained for the individual amputee. Proper swing-through is achieved by proper dynamic alignment, which, in turn, is effected by a comfortable, stable, and functional prosthesis in the stance phase; a smooth transition from stance to swing phase; proper ankle stiffness; and adjustment of the knee axis in lateral rotation to compensate for medial rotation of the stump during hip flexion.</p> <h4>Socket Shape and Orientation</h4> <p>Considered thus far are the means by which the amputee can make most efficient use of the remaining hip musculature to control body movements and to control the prosthetic knee during the stance and swing phases. There are, however, many functional details of socket shape and fit which make it possible for the amputee to derive these benefits comfortably.</p> <h5> <i>The Lateral Wall</i> </h5> <p>As already indicated, for the amputee having sufficient stump length and power, sidesway and leaning over the prosthesis during the stance phase can be eliminated almost entirely by making provision in the socket for full use of the remaining abductor muscles of the hip, primarily the gluteus medius. This can be achieved in two ways. First, the stump is adducted in the socket so that the lateral wall is sloped downward and inward, the medial wall remaining essentially vertical. Second, a slight flattening of the lateral wall, and undercutting for relief of pressure points where necessary, ensures a comfortable distribution of the pressure directed medially against the stump. The hip abductors then can develop tension as needed because the excursion of the femur is blocked comfortably against the lateral wall of the socket. If, after the fit of the lateral wall is considered satisfactory, the socket is too tight, relief should be provided along the medial wall of the socket to avoid disturbing the fit required to block excursion of the femur.</p> <h5> <i>The Anterior Wall</i> </h5> <p>The lateral pressures, acting with the horizontal counterpressures in the upper portion of the medial wall, tend to maintain the ischium on its seat medially. To hold the ischium in place still more firmly, it is necessary to provide stabilization at the front of the socket. Accordingly, the anterior wall of the socket should fit the stump firmly in the area of Scarpa's triangle, and a very accurate measurement should be made of the distance from the ischial tuberosity to the tendon of the adductor longus so that the anteromedial apex may be fitted snugly around the adductor tendons. The socket brim should be rounded and fitted high on the anterior side. If fitted properly, the anterior brim usually can be brought up to the level of the inguinal crease without producing discomfort when the wearer is seated. The actual height of the anterior brim varies with the individual and is limited by contact with bony prominences. It usually extends from 2 to 2-1/2 in. higher than the ischial seat, but it should extend at least high enough so that the brim will press into the abdominal muscles rather than pinch a roll of flesh near the top of the stump. Distributed over the upper portion of the entire anterior wall of the socket, such anterior counter-pressure easily can prevent the ischium from sliding into the socket and can prevent the discomfort that would result in the crotch area.</p> <h5> <i>The Adductor Region</i> </h5> <p>Incorporation of the proper distance from the adductor tendons to the ischial tuberosity, combined with a well-fitted, high, anterior brim, usually eliminates entirely any unwanted pressure in the crotch area. Some lateral counterstabilization by pressure in the crotch area is unavoidable, but it should be predominantly by lateral rather than by vertical pressure, and it can be tolerated comfortably if distributed over the widest possible area. Flattening the medial wall of the socket is one means of ensuring a comfortable distribution of pressure in the adductor region.</p> <h5> <i>The Anteroposterior Dimension</i> </h5> <p>Weight-bearing in the gluteal region makes it possible to reduce the size of the ischial seat. If the anteroposterior dimension is shortened, the socket may be widened in the mediolateral dimension, a feature having several advantages. First, it allows a greater area for gluteal weight-bearing on the posterior rim of the socket. Second, the ischium is moved laterally, allowing the ramus to be carried within the brim of the socket and thus easing a major source of irritation. Finally, because the ischium bears no weight in the posteromedial apex, there is less tendency for crowding of the adductor and hamstring musculature. Relaxation in this area owing to stump adduction also helps to relieve uncomfortable vertical pressures.</p> <h5> <i>Shape at Ischial Level</i> </h5> <p> As a result of these functional requirements, the socket shape shown in <b>Fig. 6</b> has evolved. When coupled with the proper alignment, it has proved to be extremely beneficial to the average amputee. As with any method of fitting, variations in shape must be made in accordance with the muscular development and condition of the individual stump. The influence of muscular development at the ischial level is shown in (<b>Fig. 7</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6. Anatomical features of an above-knee stump in weight-bearing, shown in cross section 1/2 in. below schial level.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 7. Influence of stump muscular development on socket shape at ischial level.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Entrances of the adductor tendons in the anteromedial apex, shown as <i>A</i> in <b>Fig. 6</b>, can be made more comfortable by a slight flaring of the socket brim in this region. Flaring of the socket brim in the hamstring area <i>B</i> has no function while the amputee is walking, but it contributes remarkably to his comfort while sitting. Many amputees experience a burning sensation while sitting because the hamstring attachments attempt to stretch over an ischial seat located high or medially, especially when the ischial seat has been placed diagonally across the posteromedial apex. The socket shape shown in <b>Fig. 6</b>, however, allows the ischial seat to be placed laterally to provide relief in the hamstring region and does not disturb the functioning of the limb during walking. </p> <h3>Construction of the Socket</h3> <h4>Stump Examination and Measurements</h4> <p>Before construction of an above-knee prosthesis is started, it is essential that a very careful evaluation be made of the amputee and his stump. A prosthesis may thus be planned and constructed to take full advantage of the individual patient's capabilities. Of particular importance is a thorough examination of the stump with regard to its functional characteristics. Answers to the following questions are helpful in planning the prosthesis, and they should be included in the examination data:</p> <ol> <li> What degree of stump flexion contracture is present? </li><li> What degree of stump abduction contracture is present? </li><li> Is the stump musculature soft, average, or hard? </li><li> Is the hamstring group soft, average, hard, or prominent under tension? </li><li> Is the gluteal group soft, average, hard, or prominent with stump extension? </li><li> Is the stump contour along the lateral side convex, concave, or essentially flat? </li><li> Is the rectus femoris muscle prominent with stump flexion? </li><li> Is the adductor longus soft, average, or hard? </li><li> Is the ischium toughened, pressure sensitive, padded with muscle, or prominent? </li><li> Has the amputee been accustomed to ischial-bearing? </li><li> What is the amount and location of redundant tissue? </li><li> What is the extent, location, and adherence of scars? </li><li> Are there areas of prior irritation as shown by blisters, boils, pimples, scars, darkened skin areas, and so forth? </li><li> Are there areas which are sensitive because of bone spurs or other prominences? </li><li> Is there any prior history of edema? </li></ol> <p> In addition to this general information about the condition of the stump, which can be recorded on a form such as <b>Fig. 8</b> <i>8A,</i> the series of measurements indicated in <b>Fig. 8</b> <i>8B</i> should be recorded carefully. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8A. Form used at the University of California for recording stump characteristics and measurements in above-knee fitting.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Planning the Socket Shape</h4> <p>After the information gathered during the examination is recorded, the limbfitter is ready to begin planning the prosthesis, a phase essential to proper fit. The socket contours and the over-all alignment to be incorporated into any lower-extremity prosthesis depend upon the interrelation of many factors. First, the amputee's general physical condition must be determined. Will the amputee be an active walker? Will ease of walking be more important than knee security, or vice versa? Has the amputee developed gait habits that require corrective training? Second, the stump must be evaluated on a functional basis. In terms of its potential usefulness in control of the prosthesis and of body movements, is it classed as short, medium, or long? Is there a normal range of motion in all directions? Are there any sensitive areas that restrict stump function? The answers to these questions affect the alignment of the prosthesis as well as the fit of the socket.</p> <p> It is important to plan for alignment before the socket contours are considered because the orientation of the socket on the stump and the alignment of the socket on the prosthesis may affect considerably the method of fitting the socket. Shown in <b>Fig. 8B</b> are some general features of alignment based upon the functional capacity of the stump-short, medium, and long. There are exceptions, of course, and these illustrations should serve only as a guide. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Figure 8B.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> After the general type of alignment has been decided upon, the necessary features can be incorporated into the orientation of the socket on the stump, a matter requiring a decision regarding the approximate amount of initial flexion and adduction to be anticipated in the final alignment. The socket contours are determined by reference to the information on stump muscle development recorded during the examination. <b>Fig. 7</b> shows a typical socket shape for an amputee of average musculature and indicates the variations possible with different types of stump muscle development. Undersize patterns for use in roughing out the socket contours are shown actual size in <b>Fig. 9</b> and <b>Fig. 10</b>. The dimensions shown along the medial side of the patterns are typical measurements of the distance from the ischial tuberosity to the anterior aspect of the adductor longus tendon. The perimeter measurements shown correspond to actual stump dimensions. But these patterns may require modification to provide for individual stump characteristics, an example of such a pattern modification being shown in <b>Fig. 11</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9. Variations in alignment to accommodate stumps of different functional lengths. With the short stump, the slow or hesitant walker, having limited use of the hip abductors and extensors, needs considerable alignment stability. The moderate walker, with stump of medium functional length, has average use of the hip abductors and extensors. Alignment for the long stump is for an active walker having good use of the hip abductors and extensors.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10. Undersize socket patterns (shown actual size) for stump with soft or average musculature,</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11. Undersize socket patterns (shown actual size) for stump with firm musculature.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Materials</h4> <p>The primary features required of a material to be used in making a suction socket are ease in forming to the proper shape, adaptability to a surface finish which is nonirritating and easy to keep clean, and ease in making alterations as required by changes in the stump. Wood and plastic laminates have, so far, proved to be the most satisfactory. But major changes in the size of the stump often take place during the first several months of wear. Hence, wood is recommended for the first socket because it is relatively simple to shape and allows alterations to be made as required. After the stump size is stabilized, a socket can be made of plastic laminates, which seem better than wood because of their flexibility, their ability to stand cleansing with soap and hot water, and their greater resistance to the action of perspiration.</p> <h4>Shaping the Wooden Socket</h4> <p> The three stages in shaping a typical socket are shown in <b>Fig. 12</b>. In the first, the posteromedial shelf is cut after laying out the socket pattern on the top of the socket block. The ischiogluteal shelf is cut in such a way as to be horizontal when the socket is oriented vertically in space. For the average socket, the medial wall is parallel to the vertical reference line ( <b>Fig. 2</b> ), and therefore the horizontal ischiogluteal shelf is cut at right angles to the medial wall of the socket. After the ischiogluteal shelf is cut, the missing portion of the socket pattern line is transferred down to the ischial level. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12. Modification of socket shape to accommodate individual stump characteristics.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The second construction stage shows the roughed-out socket, where considerable extra wood has been left above the ischial level to allow for the protrusion and flaring of the anterior brim in this area. The finished socket is shown in the third stage with all areas of the socket brim flared and rounded to prevent irritation of the stump, especially important in the anteromedial apex where the adductor longus tendon enters the socket.</p> <p> <b>Fig. 6</b> indicates the principle muscle groups and other anatomical features considered in preparing the patterns used as a guide in the preliminary layout of the socket outline. Because of the atrophy of certain muscle groups in the above-knee stump, and because the cross section shows the stump in the weight-bearing condition, the shape differs slightly from that of the normal. When the stump is bearing weight, it is necessarily compressed slightly in areas of relatively soft tissue which support load, such as the gluteal channel. </p> <h5> <i>The Lateral Wall</i> </h5> <p>The lateral side is always higher than the level of the ischial seat. In most cases, it is possible to extend it over the trochanter. To do so is especially important when the slump is short and when the height of the socket in this region may be required to maintain suction. If the muscular development requires it, the lateral side of the socket is, in some cases, undercut above the ischial level. Examination of the amputee determines the amount of undercut required, and, if it is necessary, it should be done with caution. The lateral wall should taper in acutely below the ischial level to provide adduction and lateral support for the femur upon weight-bearing above the distal end. Because the femur has been established as the body stabilizer during the stance phase, an undercut below the ischial level may distribute the pressure unevenly and thus allow most of the pressure to be taken at the top of the socket and near the distal end of the stump. The lateral wall should be shaped to fit the stump accurately and should, if necessary, be flattened to distribute the lateral-support pressure over a large area so that it can be tolerated comfortably.</p> <h5> <i>The Medial Wall</i> </h5> <p> The length of the crotch-line area that receives the adductor longus, gracilis, and adductor magnus muscles should be determined accurately by skeletal measurements. As indicated in <b>Fig. 11</b>, the measurement from the anterior aspect of the adductor longus tendon to the weight-bearing portion of the ischial tuberosity, less about half an inch, gives the approximate length of the medial side of the socket. In general, the upper third of the medial wall is flattened, and the superior brim is flared to prevent skin irritation. </p> <p>In almost every case, the crotch-line height varies with respect to the level of the ischial seat, but it should always be as high as is tolerable. In the typical socket, the crotch area is from 1/8 to 1/4 in. lower than the ischial seat. A pelvic tilt lowers the ramus of the ischium and may require a lowering of the medial side of the socket. In a properly fitted ischiogluteal weight-bearing socket, little or no weight should be borne on the medial side. From the ramus to the anteromedial apex, the medial brim can be raised as governed by comfort. If a medial adductor roll is present, the socket is enlarged slightly (never lowered) on the medial side to accommodate the excess tissue, which then is pulled into the socket and eventually diminishes.</p> <h5> <i>The Anteromedial Apex</i> </h5> <p> The socket shape at the anteromedial apex (<b>Fig. 6</b>) should conform to the contour of the adductor longus and gracilis muscles. The shape varies in each case, however, because these muscles form a cordlike tendon which must be fitted accurately. Tightness in this region, a common source of irritation in suction sockets, usually is caused by excessive length of the medial side of the socket. This condition allows the ischium to slide forward into the socket and to wedge the stump into the anteromedial apex. If tightness in the anteromedial apex persists, it is apt to be due to inadequate support of the stump across the anterior brim and down the anterior aspect of the adductor group. </p> <h5> <i>The Anterior Wall</i> </h5> <p>The primary function of the anterior brim of the socket is to maintain the ischium in place on the ischial seat so that ischial weight-bearing causes no discomfort. In many cases of amputees who are unable to tolerate ischial weight-bearing, the trouble can be traced to improper contact between ischium and socket. Ischial bearing on the edge of a flat ischial seat is especially uncomfortable. To maintain the ischium in place properly, considerable counterpressure from the front of the socket is required. Since, by and large, the portion of the stump in contact with the region of the anterior brim is soft tissue, some compression of the stump is necessary. This is accomplished by a flattening and inward protrusion of the anterior brim in the area of Scarpa's triangle.</p> <p>The upper portion of the anterior brim is fitted 2 to 2-1/2 in. higher than the ischial seat and with a generous flare along the superior brim. When the socket is fitted with such a "high front," the anterior brim can hold the ischium in place comfortably. The high front does not interfere with sitting or with the amputee's ability to bend over far enough to tie his shoes. As the stump is flexed, the higher brim of the socket is accommodated by the abdominal musculature and does not pinch a roll of flesh on the upper portion of the thigh. The brim should be lowered only as necessary to prevent contact with bony prominences such as the anterosuperior spine. A channel should be provided below the brim for the rectus femoris muscle, which usually becomes prominent with stump flexion.</p> <h5> <i>The Posterior Wall</i> </h5> <p>The back of an ischial-bearing socket deserves particular attention. Channelization for the gluteus maximus muscle depends on the individual, but, in most cases where there has been little atrophy or distortion, this region of the socket should be kept on the same level as the ischial seat with a gradual enlargement in the posterolateral apex. The gluteus muscle should carry a considerable amount of body weight on a flared socket brim.</p> <p>Relief for the adductor muscles or the crotch line often can be made by relieving the gluteus maximus. Too tight a fit over the gluteus maximus can cause crowding of the adductor muscles in the crotch section. If the space for the gluteus muscle is lowered and widened, the ischial tuberosity can be moved posteriorly and laterally on the ischial seat of the socket. Lowering this section, however, increases pressure on the ischial tuberosity and should, therefore, be avoided. Should additional room be needed within the socket, the lateral side of the gluteal region can be made wider. The gluteal area should be widened instead of cut deeper posteriorly because a deeper section forms a hump or radius on which the leg rotates during sitting and thus causes a burning sensation of the skin over the ischial tuberosity.</p> <p>The outside shape of the socket in the posterior region is important to sitting comfort, but no attempt should be made to complete its shaping until the inside has been made comfortable and until the leg has been aligned properly and tested by walking. After these things are done, the back then is flattened for comfort and alignment while sitting.</p> <h5> <i>The Ischial Seat</i> </h5> <p>The ischial seat cannot be overemphasized. It should be located accurately under the ischial tuberosity, and, in the determination of its location, individual variations in anatomy must be taken into account. The seat should be adequate but not so wide as to cause discomfort while sitting. Slipping of the ischial tuberosity either to the inside or to the outside of the seat, conditions which create a great deal of discomfort, can be prevented by shaping the bearing surface in such a way that the seat slopes slightly toward the inside of the socket to render it more comfortable. Sloping increases the radius of the edge of the ischial seat and lessens the burning sensation of the skin in this region.</p> <p>If the ischial seat is too prominent, or if the ischium rides on the edge of the seat, a jabbing sensation or a marked increase in pressure is felt near the end of the stance phase. Lowering the ischial seat allows more weight to be distributed to the gluteal region and, if the ischial tuberosity is located properly on the seat, results in less discomfort and a shorter break-in period.</p> <p>Amputees with highly developed stump muscles may not require a well-defined ischial seat. In some cases, the muscles may push the ischial seat away from the tuberosity of the ischium and cause the weight to be carried by the muscles around the top of the socket. Such a condition is not objectionable, provided that the socket is designed with proper modification of the ischial seat. Indeed, such a design may be necessary in unusual cases, as for example those with end-bearing stumps.</p> <h4>Special Considerations in the Suction Socket</h4> <h5> <i>Tightness of Fit</i> </h5> <p> In the case of the suction socket, better results are obtained by having proper contours than by having a tight fit .<a></a> If, in the course of donning the leg, much difficulty is encountered in removing the sock, the fit is too tight. The superior brim of the socket should fit the contour of the stump while the muscles are tensed, and the fit should be so accurate that the socket can be suspended for short periods by skin friction without the aid of negative pressure <i>(i.e.,</i> without a valve). </p> <h5> <i>Free Space Below the Stump End</i> </h5> <p>The volume of unoccupied space at the lower end of the suction socket is not critical in obtaining sufficient suction. In most cases, it is convenient to have approximately 2 in. of space below the end of the stump to provide room for installation of the valve and for elongation of the soft tissue. In general, the smaller the volume in the end of the socket the less the excursion, but in itself the amount of free volume has no significant effect on the magnitude of the negative pressure.</p> <h5> <i>End Bearing</i> </h5> <p>If it can be tolerated, end-bearing is recommended because it relieves the load on the ischium. Felt or foam-rubber padding placed in the bottom of the socket permits comfortable end-bearing, the thickness of the padding governing the amount of weight carried on the end of the stump. Although little free space remains in the socket, adequate suction and control are not affected. For example, Gritti-Stokes amputations, which are principally end-bearing, have been fitted successfully.</p> <h5> <i>Inside Finish</i> </h5> <p>No single recommendation is made regarding adequate nonirritating finishes. Industrial and perspiration-resistant lacquers common to the limb industry are being used routinely. Some subjects have reported slipping of the socket because of perspiration. In some cases, perspiration also has caused the lacquer finish to deteriorate and to produce a roughness resulting in skin irritation. In general, however, these industrial lacquers have proved satisfactory when applied according to manufacturers' specifications. In cases of excessive perspiration, the socket may have to be refinished every few months. Whenever perspiration creates a severe problem, the amputee should be referred to a dermatologist for possible treatment.</p> <h5> <i>Bottom Seal</i> </h5> <p>The bottom of the socket should be sealed with a piece of hard wood 1/8 in. thick or more, cut so that the surface goes along the grain, and sealed with a waterproof glue. The bottom may be given additional protection by applying a thin coating of one of the thermosetting plastics common to the limb industry.</p> <h5> <i>Control of Negative Pressure</i> </h5> <p>Several different types of valves have been used in suction sockets with good results. A simple type of plug valve with a manual suction release is satisfactory. Automatic expulsion valves permit some change of air in the socket, a beneficial feature during hot weather and at times when the amputee perspires. They have proved successful in all cases and are now in general use.</p> <p>The valve opening should be positioned for ease in removing the fitting sock when the leg is donned and for convenience in operating the manual control, and it should be placed where the distal end of the stump is least likely to touch the inner face of the valve. The optimum location is toward the front on the medial side below the stump end.</p> <p> The magnitude of the negative pressure or suction required to hold a suction socket in place is only slightly greater than the value given by dividing the weight of the prosthesis by the cross-sectional area of the stump near the distal end-in most cases about 1-1/2 lb. per sq. in. With the additional support given by contracting the stump muscles during each step, a negative pressure of 1-1/2 lb- Per sq. in. is sufficient. Some amputees prefer somewhat greater suction, with its accompanying feeling of security, but excessive suction may cause edema. A negative pressure greater than 1-1/2 lb. per sq. in. indicates the presence of forces tending to pull or push the leg off the stump. This action may occur when the stump muscles are contracted, or it may be caused by an improper fit resulting in constriction of the muscles. Use of a gauge for measuring the maximum negative pressure at the time of the rough and the final fittings serves as a check on the quality of fit and is essential to good and consistent results. </p> <p> Accurate records should be made of the variations in pressure inside the suction socket during normal walking. With the automatic expulsion valve now in general use, these records should show a small positive pressure during weight-bearing and a negative pressure when the leg is in the swing phase. ( <b>Fig. 13</b> ) is a record of the pressure variations in a suction socket during two complete walking steps, the valve used during this test permitting automatic exhaust starting at a positive pressure of 1/2 lb. per sq. in.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13. Three stages in the construction of a wooden socket. A, Block cut to form posteromedial shelf. B, Roughed-out socket. C, Completed socket with inside finished and rawhide covering on outside.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The stiffness of the spring in the valve has, in itself, no direct effect on the magnitude of the maximum negative pressure. It does, however, allow a greater or lesser amount of air to be expelled with each step and thereby affects the amount of positive pressure developed during weight-bearing. Fairly high positive pressure within the socket during the stance phase generally is found desirable because it increases the pavex action of the socket on the stump, with consequent benefit to the circulation. High positive pressures help to control edema and to give the amputee a sense of "walking on air." But, as already mentioned, too great a positive pressure in the stance phase may tend to push the leg off or to increase the piston action of the stump in the socket. Springs permitting expulsion at a positive pressure of 1/2 <i>, 1-1/2</i> or 2 lb. per sq. in. now are commercially available. The choice should be based upon individual circumstances. Some leakage generally occurs either in the valve or between the socket wall and the stump. A regulated amount of leakage is, however, desirable because it relieves the suction during periods of inactivity. If the leak rate is too great, the leg may fall off or the piston action may be excessive and cause discomfort. If the leak rate is too small, however, edema may result. A good test for leak rate is to measure the time required for the negative pressure to drop to half its initial value while the prosthesis is suspended on the relaxed stump. If the time is 50 to 80 sec, the leak rate is satisfactory, but if it is greater than 100 sec, the manual release should be used during periods of inactivity. </p> <p>Conclusion In summary, then, it may be restated that, in the construction of an above-knee artificial leg, the objective of the prosthetist is to provide the wearer with optimum security in standing and walking, the best possible walking pattern, a minimum requirement for expenditure of energy in usual activities, and a generally comfortable leg that can be used more or less continuously without injuring the stump and without causing undesirable postural deformities. The above-knee prosthesis is called upon to replace as nearly as possible the functions of the normal leg, but it must do so under the influence of a residual motor mechanism deficient in power and sensory control. The necessary features are therefore to be obtained only by observance of certain functional rules established on the basis of anatomical, physiological, and mechanical considerations.</p> <p>Of first importance is that the prosthetist well understand the mutual interdependence of the details of alignment of the various components and of the fit and orientation of the socket. Since, unlike the normal limb, support in the above-knee prosthesis is not through the shaft of the femur but through some other axis, due cognizance needs to be taken of the new set of musculomechanical relationships and of the influence of these relationships on the static and dynamic characteristics of the artificial replacement. When proper compensation for these factors is made by the limbfitter, undesirable compensation by the amputee is avoided, while the requirements of comfort, function, and acceptable gait are satisfied. In no other way can so much satisfaction be afforded the above knee amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14. Typical pressure variation in an above-knee suction socket during level walking. Body weight: 145 lbs.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li> <p>Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949).</p> </li> <li> <p>Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Eberhart, Howard D., and Jim C. McKennon, Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United Stales, Artificial Limbs, May 1954. p. 29.</p> </li> <li> <p>Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and Joint Surg., 29:607 (1947).</p> </li> <li> <p>Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Libet, B., H. J. Ralston, and B. Feinstein, Effect of stretch on action potentials in muscle, Biol. Bull., 101:194 (1951).</p> </li> <li> <p>Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</p> </li> <li> <p>Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 23ff.</p> </li> <li> <p>Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Ralston, H. J., Mechanics of voluntary muscle, Am. J. Phys. Med., 32:166 (1953).</p> </li> <li> <p>Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110.</p> </li> <li> <p>Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947).</p> </li> <li> <p>Ramsey, R. W., and S. F. Street, Isometric length-tension diagram of isolated skeletal muscle fibers of frog, J. Cell. and Comp. Physiol., 15:11 (1940).</p> </li> <li> <p>Schede, Franz, Theorelische Grundlagen fur den Bau von Kunstbeinen; insbesondere fur den Oberschenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</p> </li> <li> <p>Schnur, Julius, Beinbelastungslinie und Schwerlinie, Medizinische-Technik, 5(3):54 (March 1951).</p> </li> <li> <p>Schnur, Julius, Die Aquilibral-Kontakt Prothese, Orthopadie-Technik, 4(2) :36 (February 1952).</p> </li> <li> <p>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</p> </li> <li> <p>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</p> </li> <li> <p>Wagner, Edmond M., and John G. Catranis, New</p> </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall"> Eberhart, Howard D., and Jim C. McKennon, Suction-socket suspension of the above-knee prosthesis, Chapter 20 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>Footnote</b></td></tr><tr><td class="clsTextSmall">The amount of medial rotation in the stump depends upon the inherent physiological characteristics of the hip joint and upon the loss of muscular function after amputation. Some amputees have even been observed to have lateral rotation of the stump upon hip flexion.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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"> Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall"> University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Too much initial flexion results in a decrease in stride length, which may be undesirable in some cases.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall"> Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall"> Wagner, Edmond M., and John G. Catranis, New </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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"> Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall"> Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall"> Libet, B., H. J. Ralston, and B. Feinstein, Effect of stretch on action potentials in muscle, Biol. Bull., 101:194 (1951). </td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall"> Ralston, H. J., Mechanics of voluntary muscle, Am. J. Phys. Med., 32:166 (1953). </td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall"> Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110. </td></tr><tr><td class="clsTextSmall"><b> 13.</b> </td><td class="clsTextSmall"> Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947). </td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall"> Ramsey, R. W., and S. F. Street, Isometric length-tension diagram of isolated skeletal muscle fibers of frog, J. Cell. and Comp. Physiol., 15:11 (1940). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall"> Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and Joint Surg., 29:607 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be understood that no new theory of alignment is intended, that the aim is simply to explain logically some of the problems facing prosthetists in the construction of above-knee legs and to provide rational solutions for those problems. The views presented are the combined result of experience gained at the University of California Prosthetic Devices Research Project during limbshop trials of the adjustable leg and alignment duplication jig(8,9,10) of a study of methods presently in use by the artificial-limb industry, and of a survey of information presented in the German literature.(15,16,17)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall"> Eberhart, Howard D., and Jim C. McKennon, Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall"> Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United Stales, Artificial Limbs, May 1954. p. 29. </td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall"> University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Acting Assistant Professor of Engineering Design University of California, Berkeley; member, Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-22.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-23.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-24.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-25.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-26.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-27.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-28.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-29.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-30.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-31.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-32.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-33.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-34.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-35.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-36.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 Functional Considerations in the Fitting of Above Knee Prostheses Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * https://staging.drfop.org/files/original/49c94e40d4d54801334c52a842ace4ed.pdf dfd86192aa56e645f99a7c566fa941e8 https://staging.drfop.org/files/original/cce24bee2b5fe0991388af212606ef74.jpg ef1c0dca41b0ab7c44300e6d6091dd63 https://staging.drfop.org/files/original/199ca305134e9005ef91d638f8f25894.jpg 4d0d5f177626a693aa2a260770eb3efe https://staging.drfop.org/files/original/3b360735bbb0fa0e3625db6dd8935a67.jpg 8bdbbe6dafaf8a396b30924bdd787d52 https://staging.drfop.org/files/original/dc137a63c334eca56c849eda853b7319.jpg 7b8647f7d925ec33f9fa8a9a30a7d76f https://staging.drfop.org/files/original/58a988e3c29cc1d77b5365f3b12fe7d6.jpg 11bfd9c94220dbf30ca3160cb92e64f0 https://staging.drfop.org/files/original/4104cbcff18b94957f89ad19c3538698.jpg 8f1672e6e9c7dcacb675b2c54346f4cf https://staging.drfop.org/files/original/f86a93f16d5cf433387b83c39de6baa1.jpg 1ba6d10dde2dbe083655de3498ff8947 https://staging.drfop.org/files/original/fe9962a5d48a6f8a2f401747a9d789e2.jpg 18e845753cbf9ac4c03f05dccf0a62a0 https://staging.drfop.org/files/original/a69de05bc1f9b589ef237d17add3a5ea.jpg 5423422d8380b01fc0c804ba17696ffa https://staging.drfop.org/files/original/bd3186304f87a62dee0927d9e017c4a7.jpg 323ef747f37e5e92fd66564ce31dd76b https://staging.drfop.org/files/original/221f45275c014c8446f733e660935c09.jpg 9104d70c79a83ac6f37205e2e6128e18 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_029.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 29 - 38 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_029.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_02_029.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 Biomechanics of the Canadian-Type Hip-Disarticulation Prosthesis</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>Establishment of a rational procedure for the proper fitting of a leg prosthesis to an amputee at <i>any </i>level of amputation requires careful consideration of many factors. The process of evolution of a new and satisfactory method of fitting of prostheses has generally been a lengthy one involving trials on amputees by a number of experimenters over a period of many years. Recently, both in the United States and in foreign countries this process has been accelerated through the efforts of research teams, which through a combination of the skills of personnel from the fields of medicine, prosthetics, and engineering have attempted to solve problems in a more logical, scientific manner. The Canadian-type hip-disarticulation prosthesis is an excellent example of an improved device that has resulted from the efforts of organized research in limb prosthetics.</p> <p>In a technical discussion of the principles of fitting of <i>any </i>prosthesis, it is often convenient first to describe the biomechanics involved, the term "biomechanics" referring both to the residual functional anatomy and to the mechanical implications of wearing a prosthesis applied to the stump. The biomechanical analysis establishes the pattern of force trans- mission between the prosthesis and the stump. Once the force pattern is known, physiological and anatomical factors must be considered in determining whether or not the proposed areas of force transmission are pressure-sensitive or unsatisfactory for other reasons. If there are no physiological contraindications, it then becomes the responsibility of the pros-thetist to fit and align the prosthesis in a functional and comfortable manner as dictated by the biomechanical and physiological requirements. Comfort is generally achieved by a distribution of any individual contact force over an area of the socket large enough to reduce the pressure on the stump to a tolerable magnitude.</p> <p>The biomechanical analysis of the Canadian-type hip-disarticulation prosthesis can be divided conveniently into two parts: first, an evaluation of the stump-socket forces required to support the torso in the stance phase and, second, a review of the dynamic behavior of the combined amputee and his prosthesis in level walking.</p> <h4>Principles of Mechanics</h4> <p><b>Force</b></p> <p>A "force" is the physical action of one body upon a second body which tends to change its position in space (<b>Fig. 1</b>). In interpreting the diagrams to follow, it will be necessary to consider the concept of force as a vector quantity. Force vectors, for example that shown in <b>Fig. 2</b>, must be specified by magnitude (indicated by length of a particular force arrow), sense or direction (indicated by the <!--Page 30--> arrow head), and the line of action (indicated by location of the shaft of the arrow).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "Force" defined. A "force" is the physical action of one body upon a second body. It may be either a push (compression) or a pull (tension). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The "force vector." The one shown here represents a 100-lb. force applied by a "second body." The force acts to the right, through point <i>A, </i>along a line inclined 10 deg. from the horizontal line <i>AB. </i>The scale factor for this force vector is 100 lb. per inch of length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>PRESSURE</b></p> <p>"Pressure" is a measure of the distribution of force over an area. Since pressure is defined as force per unit area, it is calculated by dividing the force by the area over which it acts. This would give an "average" pressure. Pressure is seldom uniform, and its variation is often indicated by a series of pressure vectors such as shown by the smaller arrows in <b>Fig. 3</b>. Where both force and pressure vectors are shown on the same diagram, the force vector indicates the "resultant," that is, the sum of the effects of the distributed pressures in a particular region.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. "Pressure" defined. "Pressure" is force supported per unit area. A broad area of support results in lower values of average pressure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>EQUILIBRIUM</b></p> <p>In force analyses, use is made of two fundamental principles of analytical mechanics: the concept of "force equilibrium" and the concept of "moment equilibrium."</p> <p><i>Force Equilibrium</i></p> <p>The principle of force equilibrium, first stated by Newton, can be interpreted in the following form: In order for a body to remain at rest (fixed, relative to a point in space) the vector sum of all forces acting upon it must be zero (<b>Fig. 4</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. "Force equilibrium" defined. In force equilibrium, the vector sum of all forces is equal to zero. The force diagram must form a closed polygon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <!--Page 31--> <p><i>Moment Equilibrium</i></p> <p>A "moment" is the product of a force acting through some perpendicular distance from a reference point or "moment center." A moment tends to cause a physical body to rotate. In the simple lever shown in <b>Fig. 5</b>, the force <i>F </i>exerts a moment <i>F </i>X <i>a </i>about the point <i>O. </i>In order for the body to have no tendency to rotate, the sum of all moments acting upon it must be zero, such as when a force <i>P </i>on one end of the lever, acting through distance <i>b, </i>balances a similar force <i>F </i>on the opposite end, acting through distance <i>a, </i>as in <b>Fig. 5</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. "Moment equilibrium" defined. For moment equilibrium, the moments acting about a center of rotation must be in balance. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>FREE-BODY DIAGRAMS</b></p> <p>Another useful concept is the "free-body diagram" used extensively in engineering mechanics. When a system or structure involves more than one distinct physical body, the parts are often shown separately, as in <b>Fig. 6</b>, and the effect of each mating part is accounted for by a vector representing the force exerted by it on the part being considered as a free body.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Free-body diagrams of the individual, isolated bodies, with the action of the second body represented by a force vector. Note that "action" on one body results in a "reaction" on the second. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Functional Description of the Canadian-Type Hip-Disarticulation Prosthesis</h4> <p>The functional features of the original design of the Canadian-type hip-disarticula-tion prosthesis are shown in <b>Fig. 7</b>, which is reproduced from the Canadian report of March 1954. Although there has since been minor modification of the methods for fitting and <!--Page 32--> alignment of the device, its functional features remain unchanged (<b>Fig. 8</b>). They include:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Original design of the Canadian-type hip-disarticulation prosthesis. From McLaurin <i>(1).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The Canadian-type hip-disarticulation prosthesis as modified at the University of California (Berkeley). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p><i>A continuous, laminated-plastic socket-waistband. </i>The socket-waistband is fitted so as to provide three reaction points (points of suspension), as shown in <b>Fig. 7</b>. The weight-bearing area of the socket is constructed of rigid plastic laminate, while the waistband is made flexible to permit easy donning of the prosthesis.</p> <p><i>Alignment stability. </i>A unique arrangement of joint locations results in improved security against buckling of the knee in any normal walking situation, the hip joint being located below and forward of the normal axis of the hip (<b>Fig. 7</b>). With the hip joint so located, the effective length of the leg is the same in both standing and sitting. A reference line extended through the hip and knee joints passes a minimum of 1 in. behind the heel, so that as long as the prosthesis bears weight the load transmitted between the foot and the hip joint always passes ahead of the knee joint, thus ensuring knee security. When required, flexion of the knee is initiated by contact of the elastic hip bumper (attached to the bottom of the socket) with a stop on the upper posterior portion of the thigh. As long as the hip bumper is not in contact, the knee joint is always completely stable.</p> <p><i>Full-width hip joint. </i>The full-width hip joint allows a much stronger connection between socket and thigh. The hip joint is similar to a prosthetic knee joint and is highly effective in resisting lateral bending at the connection between socket and thigh piece.</p> <p><i>Hip-joint motion. </i>In level walking, the hip joint allows approximately IS deg. of relative motion between socket and thigh. The amount of motion is limited by the hip-flexion control strap (shown as "elastic band" in <b>Fig. 7</b>). This arrangement allows the leg to assume a natural inclination at heel contact without backward tilting of the pelvis.</p> </blockquote> <!--Page 33--> <h4>Functional Sequence in Use of the Prosthesis</h4> <p>The manner in which the amputee walks on the prosthesis can be described by dividing the stance phase of walking into three parts: heel contact, mid-stance (roll-over), and push-off.</p> <p><i>Heel Contact</i></p> <p>As the leg swings forward preparatory to heel contact, the hip-flexion control strap limits the free hip-joint motion to approximately 15 deg. This hip-joint motion, in combination with a slight pelvic motion, allows the leg to assume a natural backward inclination as the heel makes contact. The amputee moves forward over the prosthesis, and the heel is planted on the floor without hesitation.<a style="text-decoration:none;">*</a> The weight-bearing prosthesis is extremely stable owing to the alignment of the hip, knee, and ankle joints, and the objective is to attain knee security by having an appreciable amount of force transmitted through the prosthesis at the instant of heel contact. Where additional security is desired, the amputee leans forward slightly at the time of heel contact. Doing so results in an increased tension in the hip-flexion control strap, which helps to hold the knee in full extension.</p> <p><i>Mid-Stance (Roll-Over)</i></p> <p>As the amputee rolls over the extended prosthesis during the mid-portion of the stance phase, knee security is increased as the weight-bearing line moves forward toward the ball of the foot. Hip-joint motion causes the hip-flexion control strap to relax, and the amputee rides forward with the socket balanced on the free hip joint. Pelvic stability is maintained by the momentum of the torso.</p> <p><i>Push-Off (Start of Knee Flexion)</i></p> <p>At the end of the stance phase, the prosthesis must be propelled forward into the swing phase. The amputee using a tilting-table prosthesis does this by a lifting and internal rotation of the pelvis on the side of the amputation. A normal individual achieves knee flexion at the time of push-off by combined hip and ankle action. The amputee using the Canadian-type hip - disarticulation prosthesis initiates flexion by a method somewhat similar to that used by an above-knee amputee wearing a suction socket. As the prosthesis inclines forward with the weight borne through the ball of the foot, the angle of hip flexion is reduced until contact is made between the elastic bumper system at the rear of the hip joint. As the socket continues to progress forward in a straight line (without pelvic rotation), continued forward inclination of the thigh causes an increase in the compression in the bumper system. The moment thus developed about the hip joint eventually disturbs the knee stability and causes the knee to flex forward into the swing phase. By proper adjustment of the stiffness and point of contact of the hip-bumper system, a very natural knee flexion at the time of push-off can be achieved. The amputee should never lift the pelvis and swing the leg forward by internal pelvic rotation. Rather, the recommended action is exactly the opposite. The amputee "sits hard" on the prosthesis in order to start the knee flexing. Where more rapid knee flexion is desired, a slight backward rotation <!--Page 34--> of the socket to increase the compression of the hip bumper will propel the prosthesis forward forcibly. If weight is transferred to the natural leg simultaneously, there should be no feeling of insecurity at this time.</p> <h4>Action of the Socket in Lateral Support of the Torso</h4> <p><i>Foot Position</i></p> <p><b>Fig. 9</b>, a series of free-body diagrams, shows, as viewed from the front, the rather simple force system which is acting when an amputee is walking on a Canadian-type hip-disarticulation prosthesis, the situation depicted being the period of mid-stance on the prosthesis when mediolateral dynamic effects are negligible. <b>Fig. 9</b>A shows the system of externally applied forces acting on the prosthesis alone. <b>Fig. 9</b>B shows the forces acting on the combination of the amputee and the prosthesis.<a style="text-decoration:none;">*</a> <b> Fig. 9</b>C shows the external force system acting on the amputee considered as an isolated free body.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Mediolateral force diagram of the Canadian-type hip-disarticulation prosthesis. <i>A, </i>Forces acting on the prosthesis (exerted by floor and stump); <i>B, </i>forces acting on combination of amputee and prosthesis (exerted by floor and gravity); <i>C, </i>forces acting on amputee (exerted by prosthesis and gravity). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 9</b>B involves the simplest force system and is therefore discussed first. Two forces are involved-the supporting floor reaction and the downward force of the body weight. The vertical component of the floor reaction is equal in magnitude to the downward force and hence just balances the body weight. The body can therefore be assumed to be in force equilibrium in the vertical direction. But the floor reaction, being inclined generally inward, has an inward component along the floor, which means that the entire body is being accelerated toward the sound side. This acceleration would result in a change in direction of motion of the torso, that is, in a movement toward the amputee's normal side. Such mediolateral oscillating motion of the body as a whole is characteristic of normal subjects as well as of amputees. To maintain mediolateral motion within normal limits in the amputee, the inclination of the floor reaction to the plane of progression must be minimized, and the hip-disarticulation prosthesis is therefore aligned to give a narrow walking base. Experience has shown that the walking base should be less than 4 in. from heel center to heel center.</p> <p><i>Stump-Socket Forces as Viewed from the Front</i></p> <p>The consideration of forces acting on the stump, which result in part from the requirement of a narrow walking base, is more complicated. As can be seen in <b>Fig. 9</b>C, four forces act on the combined stump and torso of the hip-disarticulation amputee-the downward force of the body weight acting through the center of gravity, the distributed vertical support pressures acting upward on the ischial-gluteal region, and distributed socket pressure between stump and socket-waistband acting on both normal and amputated sides. A single force vector is used when necessary to approximate the effects of the actual pressure distribution.</p> <p><b>Fig. 9</b>A shows the forces acting on the prosthesis considered as an isolated free body. It is to be noted that the body weight, that is, the effect of the downward pull of gravity, does not act on the socket <i>per se. </i>The effect of the body weight is made apparent by the opposite reaction (acting downward) of the vertically upward ischial-gluteal support seen acting on the stump-torso in <b>Fig. 9</b>C. If the body weight and ischial-gluteal support forces were the only two forces acting on the torso, the body would have a tendency to rotate about the point of support and to drop toward the unsupported normal side. This tendency is counteracted by the moment of the couple formed by the two mediolateral forces <i>H </i>and <i>S. </i>For moment equilibrium, taking the summation of moments about point 2 equal to zero, <i>W </i>X <i>b = H </i>X <i>a. </i>Or,<br /> <b>H=(b/a)W</b><br /> Thus the magnitude of the reaction against the normal hip, or the tension in the waistband, or both, can be reduced by increasing the distance <i>a. </i>Moving the concentration of lateral forces on the stump to a lower level by alteration of fit is practical only within certain limits. Too low a position would result in shear forces along the bottom of the stump and in considerable relative motion between stump and socket. It is also apparent that, owing to the limitations on increasing dimension <i>a, </i>the lateral forces <i>H </i>and S are of the same order of magnitude as the vertical forces <i>W </i>and <i>I</i>, since dimensions <i>a </i>and <i>b </i>would be approximately equal.</p> <p><i>Stump-Socket Forces as Viewed from the Side</i></p> <p><b>Fig. 10</b> shows the pattern of forces acting on the amputee and/or his prosthesis as viewed from the side during level walking. <b>Fig. 10</b>A indicates the force system acting on the prosthesis isolated as a free body at heel contact. <b>Fig. 10</b>B shows the forces exerted by the socket on the stump-torso, plus the action of the body weight, during the three major divisions of the stance phase in level walking-heel contact, mid-stance, and push-off. <b>Fig. 10</b>C is a free-body diagram of the isolated prosthesis at push-off. Again the use of free-body diagrams allows a clear distinction between forces acting on the amputee and forces acting on the prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Anteroposterior force diagram of the Canadian-type hip-disarticulation prosthesis. <i>A, </i>Forces acting on prosthesis at heel contact; <i>B, </i>forces acting on stump at heel contact, mid-stance, and push-off; C, forces acting on prosthesis at push-off. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At the time of heel contact on the prosthesis, the normal leg is completing push-off. The force acting on the normal foot is then transmitted through the normal leg to the pelvis. This thrust of the normal leg is shown in <b>Fig. 10</b>B acting on the normal side of the pelvis. Shown in addition to the force from the normal leg are the force of body weight and the distal, posterodistal, and anteroproxi-mal stump-socket forces. The floor-reaction force is not transmitted directly to the stump but results in the system of stump-socket forces shown acting on the socket in <b>Fig. 10</b>A and <b>Fig. 10</b>C. For example, the isolated prosthesis must be in equilibrium under the action of stump contact forces plus the floor reaction. The same system of stump contact forces <i>react </i>to appear as forces applied in the opposite sense in the diagrams of <b>Fig. 10</b>B. Because of the offset lever arm between body weight and the line of vertical support through the ischium, as shown in <b>Fig. 10</b>B, a counter- acting stabilizing force is required in the anteroproximal region. The thrust of the normal leg tends to increase the unbalanced moment about the distal point of support and hence to increase the need for anteroproximal counterpressure in the inguinal region.</p> <p>In the mid-stance phase, the normal leg is off the floor, and the four forces shown in the middle diagram of <b>Fig. 10</b>B are acting. The anteroproximal pressure on the stump is reduced as compared to that existing in the heel-contact phase. This circumstance indicates that errors in fitting would be more noticeable at the time of heel contact than in the succeeding mid-stance phase. If the dynamic effects of acceleration are ignored, two forces are acting on the combined amputee and <!--Page 37--> prosthesis during the mid-stance phase- the body weight and the upward floor-reaction force on the sole of the foot. This situation prevails until the normal foot again contacts the floor ahead of the prosthesis.</p> <p>At about the same time that the normal foot strikes the floor, the hip-bumper system in the prosthesis makes contact and tends to flex the knee forward. During this push-off phase, there is again a thrust on the pelvis from the normal leg, this time from the front, as shown in <b>Fig. 10</b>B. The thrust of the normal leg counteracts the offset body weight and further reduces the need for anteroproxi-mal support from the socket. This feature gives the amputee a greater degree of perceptive control of the prosthetic knee, since the stump-socket forces are reduced and the effects of the hip-bumper force acting on the bottom of the socket are therefore more readily distinguishable. With a properly adjusted hip-bumper system, the amputee is able to exercise a more than adequate control and timing of knee flexion even though some of the body weight is still being carried by the prosthesis at this time.</p> <p>Owing to the ever-changing nature of the stump-socket force system as viewed from the side, it is necessary to fit the distal portion of the socket snugly in the posterior region in order to prevent relative motion between stump and socket in the more highly stressed areas of vertical support under the ischial tuberosity.</p> <h4>Surgical Implications</h4> <p><b>Fig. 11</b>A and <b>Fig. 11</b>B show front and side views of a typical hip-disarticulation stump. Cross-hatching on the surface of the stump indicates those areas where biomechanical analysis shows a functional need for supporting or stabilizing contact pressure between stump and socket. Clearly indicated are those areas where surgical incisions should be avoided, in particular the ischial-gluteal, inguinal, and lateral-distal areas. The incision and resultant scar should be located along the anterodistal portion of the stump, as shown in <b>Fig. 11</b>A. This area is not required to tolerate localized pressure and is generally relieved during the fitting process in order to avoid pressure-sensitive areas over bony prominences in the pubic region.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical dynamic pressure distribution on the hip-disarticulation stump when wearing the Canadian-type hip-disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Implications for Fitting</h4> <p>Biomechanical force analysis shows certain regions over the stump where particular attention must be paid to socket fit. They include the ischial-gluteal, inguinal, and waistband contact areas.</p> <p>In the ischial-gluteal area, functional pressures must be developed on a bony prominence and a neighboring area of atrophied gluteal musculature. This requirement calls for careful location and fitting of the bony prominence of the tuberosity. In order to develop pressure on the soft tissues, considerable modification of the cast is required. This displaces the soft tissues upward in the socket, and the necessary functional contact pressure is achieved. The pressure in the gluteal area is an absolute necessity in order to stabilize the distal end of the stump on the bottom of the socket. Otherwise chafing due to shearing motions between stump and socket will result.</p> <p>The inguinal region must provide a major contribution to the anteroposterior stabilization of the torso. An inaccurate fit in this region will result in concentration of pressure at a lower level in the generally sensitive pubic areas. The soft tissues of the inguinal and abdominal areas must be displaced inward if the proper functional stump-socket pressure is <!--Page 38--> to be achieved. This is most easily accomplished by wrapping the cast in this region while the patient is supine.</p> <p>The mediolateral force which must be transmitted by the waistband extending around the normal hip approaches the body weight in magnitude. The waistband must be fitted very carefully to avoid local concentration of pressure on bony prominences.</p> <h4>Training Implications</h4> <p>Training a hip-disarticulation amputee to walk on a properly fitted, aligned, and adjusted Canadian-type prosthesis is not a difficult or time-consuming process. If the therapist is thoroughly acquainted with the functional principles of the prosthesis and with the methods of fitting and adjustment, a well-coordinated amputee should walk unaided, without a cane, after less than 10 hours of training. Proper adjustment of the hip bumper, hip-flexion control strap, and ankle-foot characteristics is absolutely essential for efficient use of the prosthesis. For this reason, therapist and prosthetist should work together during the initial training sessions.</p> <p>Particular points which should be stressed by the therapist in working with the amputee are:</p> <ol> <li>Develop confidence in the stability of the knee at heel contact. Emphasize the necessity for a confident placing of the prosthetic heel and simultaneous weight-bearing. Show that the knee stability will increase in direct proportion to the amount of force transmitted by the prosthesis.</li><li>Show the action of the three-point mediolateral support of the torso. Do not allow the amputee to bend his trunk over the prosthesis. If painful pressure develops over a bony prominence, have the prosthetist provide relief or padding.</li><li>Place considerable emphasis on the timing and use of the pelvis to propel the prosthetic knee forward. Remember that the amputee "sits" to flex the knee while the prosthesis continues to bear a portion of the body weight. The amputee should not lift the prosthesis off the floor and then propel it forward by internal rotation of the pelvis.</li></ol> <h4>Summary</h4> <p>A biomechanical analysis is presented for the forces involved when an amputee stands and walks with a Canadian-type hip-disarticulation prosthesis. The results of the analysis are applied to the specialized topics of stump surgery, socket fitting, and training of the amputee.</p> <p><b>References:</b></p> <ol> <li>McLaurin, C. A., <i>Hip disarticulation prosthesis, </i>Report No. 15, Prosthetic Services Centre, Department of Veterans Affairs, Toronto. Canada, 19 March 1954.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In Fig. 9B contact forces between stump and socket are internal forces which cancel out when the combined system of amputee and prosthesis is considered.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The foot should not swing up and then snap back into contact with the floor.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Engineering Design, University of California, Berkeley; member, Committee on Prosthetics Research and Development, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_02_029/aut57c-011.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 Biomechanics of the Canadian-Type Hip-Disarticulation Prosthesis Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * https://staging.drfop.org/files/original/6a14887dccb6af6e9e26ce87123196dd.pdf 9c0426c05e766c9fea1f2d8fdf087e6b https://staging.drfop.org/files/original/842bf0cf5047f21bfbb1f5b67b405d57.jpg c5929c69483ba3a3674295e9c05e2798 https://staging.drfop.org/files/original/b69258705c1c1029fea89e959a20461f.jpg 8d3adecc23bb719325e7f3b757b2bbfb https://staging.drfop.org/files/original/44354ad5672e786cb22286eed8615f9a.jpg 4be40ceee37e10c8210384107aa5a06c https://staging.drfop.org/files/original/ee5d5da90ccb3fbaba84f056609ca61a.jpg 2d5d7cd8183cb4aefac4c723e16fd1d7 https://staging.drfop.org/files/original/840cc38fe69fc89973c3ca0430b6b333.jpg de4df5209df76fb80f081dc30f4a582d https://staging.drfop.org/files/original/ec31e35fa05e26ac2dc2d20061e34567.jpg 0643a7a42d9b832e42cb92f8de360af7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_076.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 76 - 85 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1961_01_076.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_076.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Biomechanics of the Syme Prosthesis</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br /></h5> <blockquote><p>*A contribution from the Biomechanics Laboratory, University of California, San Francisco and Berkeley, aided by U. S. Veterans Administration Research Contract VAm-23110.</p> </blockquote> <p>The purpose of any limb prosthesis is to replace, to the reasonable satisfaction of the wearer, as much as possible of the normal form and function lost through amputation. To provide a suitable prosthesis in any particular case, therefore, the several cooperating professional persons-physicians, prosthetists, therapists, others as appropriate-must have an intimate knowledge of just what losses have been incurred and just what new circumstances, if any, have accrued as a result of the losses. Among these are the losses of structural elements, of joint motion, and of muscle function; the decrease in proprioceptive sense as well as in sensory perception; the development of persistent or recurrent pain in one form or another; the impairment of circulation; and the losses of what in the normal would be the weight-bearing areas; not to mention numerous other matters purely medical and not necessarily associated with the amputation. Any one of these factors, or any combination of them, may influence the way in which an amputee will use a given type of limb prosthesis-that is, a device intended as a limb substitute.</p> <p>In the case of the Syme amputee, where the patient has suffered loss of the foot and ankle while retaining essentially the full length of the shank and more or less of the typical weight-bearing characteristics of the normal heel, the obvious problem is to restore foot and ankle function (or to supply the equivalent of foot-ankle function), to extend the stump so as to accommodate the loss of the tarsus and of the calcaneus, to furnish adequate support for the body during standing and during the stance phase of walking, to provide suitable suspension for the prosthesis during the swing phase, and to do all these things in such a way that the final result is acceptable to the wearer under both static and dynamic conditions. As with prostheses for other levels of amputation in the lower extremity, determination of the requirements of the Syme prosthesis takes its departure from a review of the normal pattern of locomotion and proceeds toward assessment of the means through which such a pattern may best be reproduced by application of inanimate devices. Discussion is here limited to the pertinent features of straight and level walking in the normal person and to the corresponding circumstances in a Syme amputee enjoying good general health, using a prosthesis, and having a stump itself free from any inherent medical complications such as excessive scar tissue, or neuromas, or skin disorders, or sensitive joints, or other conditions ordinarily beyond control of the limb designer.</p> <h3>LOCOMOTION PATTERNS</h3> <p>In any analysis of bipedal locomotion such as that of man, it is common practice to divide the walking cycle into the two obvious phases through which the lower limbs pass alternately-the stance phase and the swing phase. <b>Fig. 1.</b> and <b>Fig. 2.</b>, based on averages from tests on four normal young males during straight and level walking,<a></a> show five different kinds of data-angular motion at the knee and ankle joints, moments about the knee and ankle joints as a result of muscle activity, muscle activity as measured by electromyographic techniques, energy level at the knee and ankle joints at a given instant, and change in energy level. Correlation of the energy data <b>Fig. 2.</b> with motions of the joints <b>Fig. 1.</b> provides an insight into knee-ankle interaction in normal human locomotion and is useful in determining the compensation required to make up for the losses incurred by Syme's amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Correlation between joint action and muscular activity in normal locomotion in man. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Energy levels and work done at knee joint and ankle joint during normal, level walking. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The terms "work done on/' "work done by," "input," and "output" used in describing energy requirements can best be defined by citing examples. In the simplified sketch of musculoskeletal joint action <b>Fig. 3.</b>, the musculature exerts an internal moment <i>M </i>which resists the load <i>W. </i>If the load <i>W </i>is sufficient to overcome the moment <i>M </i>and thus to cause the joint to rotate in opposition to the muscle action, then work is done <i>on </i>the joint, <i>i.e., </i>the joint absorbs energy. If the moment <i>M </i>is sufficient to cause the joint to rotate in the same direction as the muscle action and thus to move the load <i>W </i>in a direction opposite to its sense, then work is done <i>by </i>the joint, <i>i.e., </i>the joint provides an energy output.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Energy input and output at a typical joint. Left, equilibrium; center, energy in at knee joint, i.e., work done <i>on </i>the joint; right, energy out at knee joint, <i>i.e., </i>work done <i>by </i>the joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>THE STANCE PHASE</h4> <p>Comparison of the stance phase of the normal with that of the Syme amputee wearing a prosthesis reveals an excellent example of compensation by one joint (the knee) for loss of a second joint (the ankle) in the same extremity.</p> <h4><i>Shock Absorption</i></h4> <p>During the subphase designated "shock absorption" (<b>Fig. 1.</b> and <b>Fig. 2.</b>), the ankle in the normal subject undergoes plantar flexion while the knee flexes, both under load. Thus, an energy input results at both knee and ankle (work is done <i>on </i>both joints during the first part of the stance phase). As summarized in the bar graph of <b>Fig. 2.</b>, the work done on one joint is approximately equal to that done on the other. It could therefore be stated that in bipedal walking the knee and ankle contribute equally to the cushioning of the shock transmitted to the body at the beginning of the stance phase when the leg first assumes its function of support.</p> <p>In the Syme amputee, ankle function has-been lost and some way of compensating for it must be found. Because of the inherent space limitations in conventional Syme prostheses,. use of articulated ankle joints and elastic compression members has been for the most part unsuccessful. It is known that, in order to keep stresses in elastic bumpers within reasonable limits, the bumpers must contain a certain minimum volume of material. Otherwise the energy-absorption requirements per unit volume are excessive, and overheating and fatigue occur rapidly. The alternatives are to increase the volume of shock-absorbing material so as to reduce the unit stresses, or to transfer shock absorption to some other area, or both.</p> <p>The volume of shock-absorbing material can be increased by eliminating the articulated ankle joint and using in the heel the greatest possible volume of suitable sponge-rubber cushion-as in the SACH foot.<a></a> In general, function may be improved over that supplied by an articulated joint, but owing to the space limitations the Syme amputee cannot be given the same degree of shock absorption as can be afforded the above-knee or below-knee amputee wearing a SACH foot.</p> <p>To compensate for the lack of adequate function in the artificial foot, the knee joint on the side of the amputation must assume a greater proportion of shock absorption by increasing the amount of knee flexion under load just after heel contact. If the knee does not assume this function, the amputee must tolerate a definite impact force from prosthesis to stump and must also accept the deviation from normal gait that might be expected to accompany such a circumstance.</p> <h4><i>Roll-Over</i></h4> <p>The roll-over portion of the stance phase in normals may in turn be subdivided into three parts corresponding to the direction of knee motion. During the first part, the knee continues to flex under load and thus prolongs the period of its function as a shock absorber for the initial support of the body weight. The ankle, acting as a controller, is required to supply energy during this time, as indicated by the rising curve of energy level and the positive bar for the ankle <b>Fig. 2.</b>. In the Syme amputee, the heel cushion of the modified SACH foot contributes some of its energy of compression and thereby simulates normal ankle action, but again the knee joint must compensate for the shortcomings of the prosthetic foot-ankle unit. Because of the lack of active plantar flexion in Syme amputees, maximum knee flexion during this subphase is in general less in persons wearing a Syme prosthesis than it is in normal persons.</p> <p>While in normal locomotion the body continues to roll over the foot, which for the time being continues in full contact with the floor, the knee begins a second period of active extension, a circumstance that results in work being done on the body as a whole (<i>i.e., </i>the knee exhibits energy output). Meanwhile, the ankle absorbs about half the energy output of the knee. In a typical Syme amputee wearing a prosthesis, the foot-ankle unit is neither absorbing nor supplying energy during this period, and the energy requirement of the knee during this interval is thus reduced as compared with that of the normal person.</p> <p>During the third part of normal roll-over, the knee is forced into full extension and maintained there by the external forces acting upward on the ball of the foot. The ankle continues to absorb energy as the tibia rotates forward over the stationary foot. To compensate for the inability of the prosthetic ankle to absorb energy during the last part of rollover, the prosthetic foot must be designed so that the forward point of support corresponds to the ball of the foot, an arrangement which maintains the knee along a path corresponding to that of the normal. In other words, the knee should move forward smoothly, and no sensation of vaulting over the fore part of the foot should be experienced. In the amputee wearing a Syme prosthesis with a properly aligned SACH foot, knee action at the end of roll-over should be almost the same as it is in a normal person.</p> <h4><i>Push-Off</i></h4> <p>The push-off portion of the stance phase begins when the heel is lifted from the floor. During the first part of this subphase in normal persons, both knee and ankle contribute energy-the knee by virtue of energy that has been stored by passive stretching of the hamstring ligaments and the ankle by virtue of active plantar flexion which continues throughout the push-off phase. In the Syme amputee, the ankle substitute cannot contribute energy by active plantar flexion, and accordingly other means must be found to maintain a smooth path of the center of gravity of the body. In the SACH foot, a comparatively simple keel contour, with a cylindrical or spherical surface on a 2-in. radius at the end of the keel, has been found practical for most adults. Under these circumstances, the hip and knee joints serve as the active elements in the kinematic chain which controls the pathway of the center of gravity.</p> <p>In the second part of push-off, the normal knee absorbs about half as much energy as is supplied by the normal ankle joint, energy absorption by the knee being associated with the maintenance of a smooth path for the center of gravity of the body as a whole. At toe-off, for example, the knee in normal persons has flexed 40 deg. of the total of 65 deg. achieved at the point of maximum knee flexion. Energy absorption by the normal knee continues at about the same rate after active plantar flexion of the ankle has started to slow down. Since the foot-ankle unit in the Syme prosthesis must maintain the pathway of the knee by proper keel contour rather than by active plantar flexion of the ankle, the amount of energy absorption required of the knee is less in the Syme than it is in the normal. The need to initiate knee flexion before the end of the stance phase remains, however, and the socket must therefore be designed to permit maximum control of knee motion by the stump in preparation for the swing phase.</p> <h4>THE SWING PHASE</h4> <p>Since in the patient with Syme's amputation the knee and hip joints are usually undisturbed, it might be assumed that the swing phase of the Syme amputee would always appear relatively normal. But the role of the ankle joint at the end of the stance phase must be considered. In normal locomotion, the knee starts to flex before the foot leaves the ground, and the controlled knee-ankle interaction provides a major source of energy for the forward propulsion of the knee. If this motion is smooth and precisely controlled, the thigh-shank-foot combination enters the swing phase normally. Anything that tends to disturb this smooth transition from stance to swing has a noticeable effect throughout the swing phase.</p> <p>For the patient who has undergone Syme's amputation, poor function in the prosthetic foot and pain in the weight-bearing areas of the stump are the two most common sources of unstable or erratic action during transition from stance to swing phase. When, however, the prosthetic foot has been properly designed, aligned, and adjusted to allow the knee and hip to provide normal-appearing control of knee motion at the end of the stance phase, the amputee should, in general, have the ability to exercise complete control of his prosthesis during swing phase.</p> <h3>SOCKET DESIGN</h3> <h4>ANALYSIS OF STUMP-SOCKET FORCES DURING THE STANCE PHASE</h4> <p>Analysis of the distribution of contact pressures between stump and socket at various times during the stance phase is useful in the design of a socket that will be comfortable for the amputee. Since pressure distribution varies during each of the three subphases-shock absorption, roll-over, and push-off-each must be analyzed separately.</p> <h4><i>Shock Absorption</i></h4> <p>If it be assumed that body weight is supported at the distal end of the stump, it can be seen clearly from <b>Fig. 4.</b>A that during the shock-absorption subphase the major functional forces between stump and socket occur in the anterodistal and posteroproximal areas. During roll-over, the need for posteroproximal pressure decreases, and the contact pressure at the end of the stump shifts toward the center of that area. If the force system is to be in equilibrium, the paths of the forces <i>P, D,</i>and <i>F </i>must intersect at <i>M </i>and their vectors must form a closed polygon. Use of this principle makes it possible to estimate the relative magnitudes of the three forces.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Stump-socket forces during the stance phase. A, Shock absorption; B, push-off. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4><i>Push-Off</i></h4> <p><b>Fig. 4.</b>B shows the force system that develops as the Syme amputee rolls over the ball of the foot in the push-off subphase. At the instant shown, the hip joint is being used to help flex the knee against the force acting upward on the ball of the foot. Again, the principle of force equilibrium can be applied to estimate the magnitude of the forces. A posterodistal and an anteroproximal contact force between stump and socket are seen to be necessary to resist the floor reaction against the ball of the foot. It is essential that the anteroproximal force against the tibia be kept at as high a level as possible. Shortening of the distance <i>a </i>results in increased inclination of the line of the posterodistal contact force and in a transfer of the force away from areas surgically prepared for end-bearing.</p> <p>Since some change in the inclination of the distal stump-socket force is unavoidable, it must be anticipated during the fitting procedure. If the line of the floor reaction is kept in a particular position relative to the knee, the amputee can use some voluntary control in shifting the distal contact point. Moreover, the anteroproximal force at push-off will be several times the posteroproximal force at heel contact. For this reason, the prosthesis must be strong enough to resist the large bending moment in the ankle region during push-off. Suppose that in a 180-lb. man there is an increase of 30 percent (as compared with body weight) in the dynamic force against the ball of the foot during push-off and that dimension <i>b </i>is 4 in. Then the structure must resist a bending moment of 1.30 X 180 X 4 = 936 lb.-in.</p> <h3>SOCKET MATERIALS</h3> <p>Because of the bulbous form of the typical Syme stump, any prosthesis devised for it will be bulky in appearance. To provide the least bulky socket requires that the thickness of the wall be kept to a minimum commensurate with structural demands. Plastic laminates with high strength-weight ratios that can be molded easily over a plaster model seem ideally suited for construction of sockets for the Syme prosthesis.</p> <p>Since a snug fit throughout the length of the stump is necessary if proper function is to be expected, a cutout must be provided in the narrow section of the socket to permit entry of the bulbous end of the stump. The question arises as to where to locate a cutout, which in any case obviously should not interfere with the functional characteristics of the prosthesis nor affect its structural properties unduly. Several possibilities have been suggested. Among others are the posterior cutout used at Sunnybrook Hospital in Toronto and the medial cutout proposed at the Veterans Administration Prosthetics Center (page 57). Some predictions as to the relative structural strengths to be had from the several approaches may be arrived at through the techniques of engineering stress analysis.</p> <p>From a review of data on normal human locomotion it has been determined that in level walking maximum forces are brought to bear on the shank at the time of push-off. At this point in the walking cycle the center of pressure is eccentric with respect to the shank. Obviously the highest unit stress will occur at the level of the shank where the cross-sectional area is smallest. The relationship at push-off between the center of pressure acting upward on the ball of the foot and the minimum cross-section at the ankle is indicated in <b>Fig. 5.</b>, where the ankle is approximated by a circle of radius <i>R </i>and where all dimensions are expressed in terms of <i>R. </i>If the same loading conditions be assumed to be present when a Syme prosthesis is worn, the result is a combination of three different types of stresses in the structure of the prosthesis: compression stresses resulting from the direct thrust load carried by the structure, bending stresses resulting from a tendency for the structure to bow laterally, and bending stresses resulting from a tendency for the structure to bow posteriorly. If the loading conditions and the dimensions of the cross-section are known, the magnitudes of the stresses can be calculated, as indicated in <b>Fig. 6.</b>A. In such calculations, a plus sign indicates that a fiber of the material would be in tension at the point being investigated. A minus sign shows that the fiber would be compressed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Center of pressure as related to minimum cross-section of the ankle. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Summary of stress calculations for various socket cutouts. <i>A</i>, Sample stress analysis for Canadian-type posterior cutout, ø = 210 deg. <i>B, </i>Comparison of stresses at edge of cutout for varying degrees of cutout at three locations about the circumference; <i>P, R, </i>and <i>t</i> constant. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Summarized in <b>Fig. 6.</b>B are the results of a number of calculations based on stresses in a hypothetical Syme prosthesis with a circular cross-section of radius <i>R, </i>with a material thickness <i>t, </i>carrying a load P, and with a constant eccentricity. An interesting feature is that, even when the values for direct compression as a result of proximal weight-bearing are included, in general the posterior cutout results in tensile stresses at critical points whereas the medial cutout results in compressive stresses at critical points. The posterior cutout with <i>ø = </i>210 deg. and the medial cutout with <i>øT = </i>270 deg. are perhaps most nearly representative of actual conditions.</p> <p>These results would indicate that, when Syme prostheses are constructed with a posterior opening in the socket (tensile stresses at critical points), a material with the highest possible tensile strength should be used. A laminate of Fiberglas cloth with epoxy resin, such as is used by Canadian makers of Syme prostheses, would be an efficient material, particularly when reinforced with roving along the edge of the cutout. A laminate of Fiberglas cloth and polyester resin would also be satisfactory if fabricated carefully. Either material would provide great strength and minimum thickness with more than sufficient tensile strength. Nylon stockinet with polyester-resin laminates has lower tensile strength, and the lamination would have to be thicker.</p> <p>When the stresses at critical points are compressive, such as in the case of medial opening, a material with the greatest compressive strength should be used. In situations involving compressive loading of thin-walled columns (as in a proximally loaded Syme prosthesis), failure may be due either to failure of the laminate at the area of direct compression or to buckling of the material in a localized area, such as near a free edge carrying a compression stress. The sides of the cutout in the Syme socket with medial opening would constitute free edges of this type. To increase resistance to local buckling, the wall thickness of the laminate should be increased. Doing so will also increase resistance to direct compression because the area of the cross-section will be increased proportionally.</p> <p>Since in practice it is more convenient to use nylon stockinet as a laminating material, and since the thickness must be increased to overcome the effects of buckling, nylon stockinet is probably the material of choice for the medial opening. Although theoretically Fiber-glas laminates would have sufficient direct compressive strength even with thin walls, resistance to local buckling would be lower than in the case of a thicker nylon laminate. Moreover the compressive strength of a structure made of thin-walled Fiberglas laminate depends mainly on the quality of the laminating technique.</p> <p>It should be pointed out that in Syme prostheses direct end-bearing has been used more often in Canada than in the United States. Since end-bearing tends to increase the critical tensile stress in the posterior-opening socket by eliminating the direct compressive stresses due to proximal loading, the need for an extremely strong laminate such as one of Fiberglas cloth, Fiberglas roving, and epoxy resin is obvious. When direct end-bearing is used with the medial opening, the critical compression stress is reduced, sometimes to the extent that it is converted into tension of some low value. Nylon stockinet and polyester resin should be an adequate material for the medial-opening socket, although such a socket is more bulky in appearance.</p> <h3>CONCLUSIONS</h3> <p>To ensure a satisfactory period of use, the ankle of any prosthesis must be so designed that the elastic members resisting dorsiand plantar flexion have adequate volume to provide sufficient fatigue strength. Furthermore, the foot must be designed to permit the knee and hip joints to move smoothly through space during the roll-over and push-off phases. The SACH-type foot, with its sponge-rubber heel wedge and a keel of proper proportions, has proved useful in meeting most of the requirements for use in a Syme prosthesis, but, like all other known foot-ankle units, its inability to provide energy at push-off requires that the remaining musculoskeletal system compensate for functions lost in amputation.</p> <p>To satisfy the requirements of a comfortable transmission of functional stump-socket contact forces, the socket must provide the following features:</p> <ol> <li>Comfortable support of the body weight on the distal end of the stump or on the proximal part of the socket brim or both.</li><li>Firm support against the anteroproximal surface of the leg at the time of push-off. Careful fitting against the wedgelike medial and lateral surfaces of the tibia can satisfy this requirement.</li><li>Similar support against the posterior surface of the leg at the time of heel contact. This requirement can be satisfied by pressure in the region of the gastrocnemius. Here the main interest is to prevent lost motion between socket and stump as the reaction point shifts from the posterior to the anterior surface of the leg.</li><li>Provision for shifting of the center of pressure against the distal end of the stump, as indicated by the force analysis. If a cuplike receptacle is provided for the stump end, it must extend around and up the sides of the bulbous stump far enough to prevent relative motion between stump and socket in the anteroposterior direction. It is particularly important to provide for the horizontal component of the force against the posterodistal region of the stump during push-off.</li><li>Adequate stabilization against the torques about the long axis of the leg. A three-point stabilization against the medial and lateral flares at the anteroproximal margin of the tibia and a flattening of the postero-proximal contour can be highly effective in providing the necessary torque resistance. If the needed stabilization is not provided, torques acting on the distal end of the stump will result in skin abrasion and other associated difficulties in more proximal areas.</li></ol> <p>Either the posterior cutout of the socket favored by the Canadian workers or the medial cutout proposed by the VA Prosthetics Center will result in a socket of adequate strength if a laminate of the correct type is used. When a posterior cutout is incorporated, the laminate must be capable of resisting high tension stresses. Fiberglass-epoxy laminates are therefore indicated. When a medial cutout is used, particularly in those cases where a large proportion of proximal weight-bearing is provided, the critical stresses are compressive. When compression stresses are involved, the thicker nylon-polyester laminate may have advantages.</p> <p><b>References:</b></p> <ol> <li>Bresler, B., and F. R. Berry, <i>Energy and power in the leg during normal level walking, </i>Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 15, May 1951.</li> <li>New York University, Prosthetic Devices Study, Research Division, College of Engineering, <i>Evaluation of the solid ankle cushion heel foot (SACH foot)</i>, May 1957</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, Research Division, College of Engineering, Evaluation of the solid ankle cushion heel foot (SACH foot), May 1957</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bresler, B., and F. R. Berry, Energy and power in the leg during normal level walking, Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 15, May 1951.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Mechanical Engineering, University of California, Berkeley.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1961_01_076/d001.jpg Figure 2 http://www.oandplibrary.org/al/images/1961_01_076/d002.jpg Figure 3 http://www.oandplibrary.org/al/images/1961_01_076/d003.jpg Figure 4 http://www.oandplibrary.org/al/images/1961_01_076/d004.jpg Figure 5 http://www.oandplibrary.org/al/images/1961_01_076/d005.jpg Figure 6 http://www.oandplibrary.org/al/images/1961_01_076/d006.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 Biomechanics of the Syme Prosthesis Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * https://staging.drfop.org/files/original/3bd373d7b71c5da2b6a9a46f7a8b1a61.pdf 0902badc0f53cd23ac3d290e99214489 https://staging.drfop.org/files/original/4a95db85b24a9753157d2091a3a2a5ec.jpg c7bc89ef10dd6110b7b5107695947e36 https://staging.drfop.org/files/original/873ca0c36463fdee471bc415f3db6a30.jpg fb11174d4492e099d8c5bf4ada23cb5a https://staging.drfop.org/files/original/cc5c394b9babc8c66452d969e0ec3360.jpg 6002758e2fce5cc2c9cb4a78a4673074 https://staging.drfop.org/files/original/f4d6246ae5163ec9fd33ac86c230a674.jpg 5efe317f898eb54a61e9af475e49b444 https://staging.drfop.org/files/original/80d686ca496322d9bab4e840a41d9ed5.jpg 90254103541c6ed9430f948a568504ee https://staging.drfop.org/files/original/7522225df64cd7f5a947c3ae9914c2eb.jpg f6a79e27bd830681dec524c398cdb24b https://staging.drfop.org/files/original/658e23dc8166ab586faa2bf8eace64e1.jpg b155747e7c2e83cd2fdd9ca2e2ed8fde DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1962_02_016.pdf Year 1962 Volume 6 Issue 2 Page Number(s) 16 - 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/1962_02_016.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1962_02_016.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 Biomechanics of Below-Knee Prostheses in Normal, Level, Bipedal Walking</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>Human locomotion involves the transformation of a series of controlled and coordinated angular motions occurring simultaneously at the various joints of the lower extremity into a smooth path of motion for the center of gravity of the body as a whole. Though largely taken for granted, it is an extremely complicated process, the complexity becoming evident when one considers that the path of motion is influenced by six major factors: knee-ankle interaction, knee flexion, hip flexion, pelvic rotation about a vertical axis, lateral tilting of the pelvis, and lateral displacement of the pelvis. A thorough study of walking in the orthograde attitude would therefore include not only the influence of each of these factors on the total displacement pattern but also a complete analysis of the action of major muscle groups of the lower extremity. The present discussion is limited to a consideration of the hip, knee, and ankle joints and of their interaction during level walking-first in the normal person and then in the case of the below-knee amputee wearing the patellar-tendon-bearing prosthesis with and without additional impedimenta in the form of thigh corset and sidebars.</p> <h4>Phases of the Walking Cycle</h4> <p>The upright, bipedal walking cycle may be divided into two phases-the stance (or weight-bearing) phase and the swing phase. The stance phase of any given leg begins at the instant the heel contacts the ground, ends at toe-off when ground contact is lost by the foot of the same leg. The swing phase begins at toe-off and ends at heel contact. The two feet are in simultaneous contact with the walking surface for approximately 25 percent of a complete two-step cycle, this part of the cycle being designated as the "double-support" phase.</p> <p><b>Fig. 1</b> gives a graphic account of the interaction between the knee and ankle joints and of the phasic action of major muscle groups during a typical walking cycle. The particular curves shown represent the average of actual measurements recorded during studies<a></a> of four male college students considered to be representative of a larger population sample. The sequence of events is arbitrarily started at heel contact and followed until the next heel contact of the same foot. The term "knee moment" refers to the action of the muscle groups about the knee which tends to change the knee angle, either in flexion or extension. Similarly, "ankle moment" refers to the muscular action about the ankle joint which may cause either plantar flexion or dorsiflexion. The mechanics of major muscle groups of the lower extremity is indicated in <b>Fig. 2</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Correlation between joint action and muscular activity in the lower extremity during normal, level walking. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Major muscle groups of the normal lower extremity (schematic), showing the major mechanics in the parasagittal plane. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Eevents Just Prior to Heel Contact</b></p> <p>In reference to <b>Fig. 1</b>, and particularly to the curves in the region corresponding to the end of the swing phase (about 95 percent of a complete cycle), it may be noted that the knee joint reaches its maximum extension just prior to heel contact and that a period of knee flexion then initiated continues on into the stance phase. As seen in the curves of muscle activity, this decrease in the rate of knee extension at the end of the swing phase, in preparation for the contact of the foot with the floor, is due primarily to the action of the hamstring muscle group, which is attached to the pelvis behind the hip joint and to the tibia and fibula below the knee joint. Tension in the hamstring group may cause either hip extension or knee flexion or the two simultaneously.</p> <p><b>Heel-Contact Phase</b></p> <p>As the heel makes contact, the hamstring action tends to bring it forcibly backward into contact with the floor, while the knee continues to flex rapidly. The activity in the hamstring group continues, but with decreasing magnitude, while the quadriceps action begins to build up quickly. The quadriceps group, acting anteriorly about the knee joint, and the pre-tibial group, acting about the ankle joint, serve to control the knee-ankle interaction and thus to effect a smooth motion of the forepart of the foot toward the floor. The major function of both knee and ankle during this phase is smooth absorption of the shock of heel contact and maintenance of a smooth path of the center of gravity of the whole body. Although the function of the knee as a shock absorber is often overlooked, energy studies<a></a> have shown that the knee and ankle contribute equally to shock absorption.</p> <p><b>Mid-Stance Phase</b></p> <p>The controlled knee flexion of the heel-contact phase continues into the mid-stance phase (between foot flat and heel-off), and the maximum angle of knee flexion, approximately 20 deg., occurs in the first part of the mid-stance phase. As the body rides over the stabilized knee, the upward thrust of the floor reaction moves forward on the sole of the foot, thus gradually increasing the dorsiflexion of the ankle and causing the knee to begin a period of extension. In this period, control of the leg is through ankle-knee interaction, there being only minimal muscular activity in the groups acting about the hip and knee. The knee reaches a position of maximum extension about the time the heel leaves the ground, the calf group providing the resistance to knee extension and ankle dorsiflexion. As the heel leaves the ground, the knee again begins a period of flexion, chiefly because of muscular action about the hip joint. This sequence of controlled flexion at heel contact, release to allow gradual extension in mid-stance, and controlled flexion preparatory to swing is important in accomplishing a smooth and energy-saving gait in normal persons.</p> <p><b>Push-off Phase</b></p> <p>During the push-off phase, a phase complex and often misunderstood, the knee is brought forward by action of the hip joint, and a sensitive balance is maintained by interaction of hip, knee, and ankle joints. The combined action has two purposes-to maintain the smooth forward progression of the body as a whole and to initiate the angular movements in the swing phase that follows. As the knee begins to flex (about the time the heel leaves the ground), the knee musculature must first resist the external effect of the force on the ball of the foot which passes through space on a line ahead of the knee joint. Then, as the knee is brought forward by hip-joint action, so as to pass through and then anterior to the line of the force acting upward on the foot, the knee must reverse its action to provide controlled resistance to flexion by increasing quadriceps activity. Some inconsistent hamstring activity is noted as an antagonist. The calf group continues to provide active plantar flexion during the entire push-off phase. At the time the toe leaves the floor, the knee has flexed 40 to 45 deg. of the maximum of 65 deg. it reaches during the swing phase. In normal persons, knee flexion in the swing phase is not due primarily to hamstring action, as might be supposed. Complete prosthetic restoration of normal function in the push-off phase is difficult, if not impossible. A proprioceptive sense of knee position by the amputee is necessary, as well as an active source of energy in the ankle. Because of lack of an active source of ankle energy, initiation of knee flexion in amputees wearing a prosthesis must come from active hip flexion.</p> <p><b>Swing Phase (Quadriceps Action)</b></p> <p>The over-all objective in the swing phase is to get the foot from one position to the next in a smooth manner while clearing the usual obstacles of terrain. At the start of the swing phase, the leg has just completed a period of rapid increase in kinetic energy caused by the active extension of the ankle and flexion of the hip during the push-off phase. The knee is flexing and continues to flex after toe-off. During rapid walking this would result in excessive knee flexion and heel rise were it not for the action of the quadriceps group in limiting the angle of knee flexion to approximately 65 deg. and then continuing to act to start knee extension. Knee extension continues as a result of a combination of pendulum effects owing both to muscle action and to the weight of the inclined shank and of the foot. Little quadriceps action is required, since other factors are of equal importance. For example, the iliopsoas muscle contributes by developing active hip flexion, which in turn accelerates the knee forward and upward.</p> <p><b>Mid-Swing</b></p> <p>During mid-swing there is a period of minimal muscular activity, and the leg accelerates downward and forward like a pendulum with forced motion of its pivot point.</p> <p><b>Terminal Deceleration (Hamstring Aaction)</b></p> <p>Near the end of the swing phase, the rate of knee extension must be reduced in order to decelerate the foot prior to heel contact. This "terminal deceleration" of the normal leg is due primarily to the extension resistance of the hamstring group.</p> <h4>Knee Action in Amputee Gait</h4> <p>In the past a common cause of difficulty in the use of the so-called "muley" below-knee prostheses<a></a> has been the "breakdown" of the stump, in particular of the knee joint on the amputated side. It has been due in part to overstraining of the ligamentous structures of the knee by excessive hyperextension under load. In order to protect these ligamentous structures on the amputated side, it is necessary to maintain within safe limits the forces and moments about the knee which tend to force it into hyperextension. In normal individuals a precise sense of knee position limits the hyperextension moment by maintaining the knee center close to the line of the force transmitted through the lower extremity. Since in many below-knee amputees the knee action is unaffected by amputation, it is reasonable to expect such an amputee to walk with a normal knee action. When this potential is anticipated and accounted for in the fitting and alignment procedure, a below-knee amputee of average-to-long slump length can make use of the controlled flexion-extension-flexion sequence of knee action required in absorbing shock and smoothing the path of motion of the center of gravity (<b>Fig. 1</b>). The socket must be fitted to accommodate the dynamic forces, and the amputee must contribute voluntary control of the knee by action of the musculature.</p> <h4>Analysis of Stump-Socket Forces</h4> <p>The contact pressures between the stump and socket of a below-knee amputee are influenced by a combination of factors. In the case of the patellar-tendon-bearing prosthesis (or of any other below-knee prosthesis without thigh corset and sidebars), the two major factors are the fit of the socket and the alignment of the prosthesis, <i>i.e., </i>the location of the foot with respect to the socket. When the thigh corset is used, there are certain modifying effects even when optimum alignment of sidebars and corset with respect to the socket is obtained. In discussing the relationship between fit and alignment, it is often helpful to discuss alignment factors first, since the method of fitting a socket to an amputee's stump is dictated largely by the manner in which he can be expected to perform while wearing his prosthesis. His performance, in turn, is influenced considerably by the structural relationship between the elements of his prosthesis, <i>i.e., </i>the alignment. The patellar-tendon-bearing cuff-suspension below-knee prosthesis, without side joints or corset, is here discussed first. Thereafter the modifying influences resulting from the addition of the side joints and corset are considered.</p> <p>The following analysis is based on the assumption that a below-knee amputee with a stump of at least average length can be expected to walk in a manner similar to that of a normal person. That is, if the prosthetic foot is properly designed to minimize the effects of the loss of normal ankle function, the amputee can compensate by hip and knee action so as to achieve a gait which closely approximates the normal. Accordingly, he should be expected to go through the following sequence of knee motions:</p> <ol> <li>Control of knee flexion from the time of heel contact until the foot reaches a stable position flat on the floor.</li><li>Control of knee flexion-extension during roll-over. The foot-shank serves as a firm base during this portion of the stance phase. The position of the knee relative to the force acting on the foot can be gauged accurately by properly trained amputees. The muscular moment about the knee required to maintain a particular knee position serves as an excellent source of proprioceptive sensation if the socket fit is intimate enough to reduce lost motion to a minimum.</li><li>Control of knee flexion during the push-off phase as an aid in accelerating the prosthesis forward in the swing phase.</li></ol> <p><b>Mediolateral Forces, Cuff-Suspension Below-Knee Prosthesis</b></p> <p><b>Fig. 3</b> is a front view of a below-knee amputee in a position corresponding to the mid-stance phase. Two force systems are shown. Figure <i>3A </i>shows the forces exerted on the amputee. These forces are of two types- the body weight due to the effect of the earth's gravitational pull and the forces applied through contact with the socket. <b>Fig. 3B</b>shows the forces acting on the prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Mediolateral force diagram for a below-knee amputee wearing the patellar-tendon-bearing prosthesis with supracondylar cuff only. <i>A, </i>Forces on the amputee; <i>B, </i>forces on the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If, as seen from the front, the prosthesis is considered as a means of supporting the body, it must be capable of providing both vertical support and mediolateral balance. It is apparent that vertical components of pressure are applied against the surfaces of many areas of the stump, but for purposes of simplified analysis the combined effect of all these forces is shown as the single support force <i>S.</i></p> <p>Considering the point of application of the support force <i>S</i> as a balance point, the lateral force <i>L </i>times the distance <i>b </i>equals the body weight <i>W </i>times the distance <i>a, </i>or, in equation form:</p> <p><i>Lb = Wa </i>and <i>L = Wa/b </i>  (1)</p> <p>Unfortunately, the effect of the horizontal acceleration of the center of gravity cannot be ignored in this case, and hence in neglecting the horizontal acceleration equation 1 is incorrect.</p> <p>As indicated in <b>Fig. 3</b>, the horizontal acceleration of the body in a medial direction, due to the medial inclination of the total floor reaction <i>R, </i>results in a lateral inertia force which tends to oppose the acceleration. This inertia force must be included when consideration is given to balancing moments about the point of support. The correct relationship is therefore <i>Lb </i>+ <i>Ic = Wa:</i></p> <p><i>L </i>= (<i>Wa</i> - <i>Ic</i>) / <i>b</i>   (2)</p> <p>Equation 2 shows that the magnitude of the required lateral stabilizing (balancing) force <i>L </i>can be reduced in one of two ways-by increasing the horizontal inertia force or by increasing the effective lever arm <i>b. </i>Increasing the horizontal inertia force requires that the horizontal acceleration be increased or, in other words, that the foot should be moved laterally so as to increase the medial inclination of the total floor reaction.</p> <p><b>Effect of Foot Iinset-Outset on Mediolateral Forces</b></p> <p>The effect of changing the inset or outset of the foot is shown in <b>Fig. 4</b>, where it is possible under special conditions, as shown in <b>Fig. 4B</b>, to eliminate the need for the lateral stabilization force <i>L, </i>since in this case the weight and inertia force are seen to be in balance:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Change in mediolateral force diagram owing to inset or outset of foot from optimum position, PTB prosthesis with cuff only, as in Figure 3. <i>A, </i>Inset; <i>B, </i>outset. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Wa </i>= <i>Ic </i>  (3)</p> <p>The force on the lateral aspect of the stump has shifted to the region of the head of the fibula.</p> <p>Complete elimination of the lateral stabilizing force <i>L </i>by outset of the foot is generally undesirable, for the resulting wide-based gait is abnormal and unnecessary. Actually, a narrow-based gait with a definite need for the lateral force <i>L </i>(and corresponding lack of pressure on the head of the fibula) is definitely indicated for stumps 4 in. or more in length, the wide-based alignment being then reserved for very short below-knee stumps. It must be remembered, however, that planning the fit and alignment of a below-knee prosthesis to accommodate a narrow-based gait requires that the need for a definite lateral stabilizing force be recognized and accounted for in the fitting of the socket.</p> <p><b>Effect of Thigh Corset and Sidebars on Mediolateral Forces</b></p> <p><b>Fig. 5</b> shows the modifying effect of the thigh corset and sidebars on the pressures between stump and socket. If the sidebars are stiff enough it is possible to develop against the medial thigh a force <i>T </i>which acts in cooperation with the lateral-distal socket contact force <i>L </i>in providing mediolateral stabilization. In fact, with judicious use of bending irons the lateral pressure can be greatly reduced. In the past, this has been done to compensate for uncomfortable lateral-distal stump pressure. With a good socket fit against the lateral aspect of average-length stumps, however, the need for lateral stabilization by the thigh corset is minimized. Use of a thigh corset is indicated only for amputees with very short stumps or those in whom other medical factors require reduction in stump-socket contact forces.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Effect of thigh corset and sidebars on medio-lateral stump-socket forces, PTB prosthesis. When the thigh corset applies a force against the medial side of the upper part of the thigh, the effect is similar to a force on the laterodistal side of the stump. Corset adjustment constitutes a possible means of modifying the magnitude and distribution of forces against the lateral side of the stump. This circumstance suggests that if the lateral sidebar is constructed with sufficient stiffness it may be of assistance in relieving excessive pressure on the laterodistal end of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Anterposterior Forces, Cuff-Suspension Below-Knee Prosthesis</b></p> <p><b>Fig. 6</b> shows a side view of a below-knee amputee and the cuff-suspension prosthesis under three conditions-at heel contact, during the shock-absorption portion of the mid-stance phase, and during push-off. At the instant of heel contact, and for a short time corresponding to about 5 percent of the walking cycle, knee stability is maintained primarily by active extension of the hip joint. The tendency of the external load on the prosthesis to extend the knee is resisted by hamstring action. During this phase, forces are acting as shown in <b>Fig. 6A</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anteroposterior force diagrams for a below-knee amputee wearing the patellar-tendon-bearing prothesis -with supracondylar cuff only. <i>A, </i>At heel contact; <i>B, </i>during shock absorption (foot flat in midstance); <i>C, </i>during push-off. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Analysis of the forces acting during the shock-absorption portion of the mid-stance phase shows that it is typical for the floor-reaction force <i>R </i>to be acting along a line which passes posterior to the knee center. Under such circumstances, a completely relaxed knee would buckle, but the amputee is able to resist this tendency by active knee extension. The resulting force pattern on the stump (disregarding end-bearing) is as shown in <b>Fig. 6B</b>,where the forces are concentrated in three areas-around the patellar tendon, on the anterodistal portion of the tibia, and in the popliteal area. The socket fit must be designed to accommodate the resulting functional pressures.</p> <p>During the push-off phase, the floor reaction continues to pass behind the knee, and the anteroposterior forces are concentrated in the same three areas, as shown in <b>Fig. 6C</b></p> <p><b>Effect of Thigh Corset and Sidebars on Anteroposterior Forces</b></p> <p>If a below-knee amputee is fitted with a thigh corset and back-check so that he relies on the mechanical action of the back-check to resist knee extension, the force pattern is altered considerably. <b>Fig. 7</b> shows the effect. The floor reaction <i>R </i>must now be assumed to pass anterior to the knee, since otherwise the knee would not be extended against the back-check. If the knee joint is considered as a moment center, the effect of the force <i>R </i>is resisted by the back-check moment <i>Mo </i>and the two forces <i>A </i>and <i>P </i>exerted by the stump within the socket. Under the proper conditions, it is possible for the mechanical back-check to provide the total resistance to the floor reaction, the stump being suspended freely in the socket. This would indicate that, by proper adjustment of thigh corset, sidebars, and back-check, it is possible to modify the pattern of anteroposterior stump-socket contact pressures.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Effect of thigh corset, sidebars, and back-check on anteroposterior stump-socket forces, PTB prosthesis. Shear force, <i>Sh, </i>is absorbed by mechanical side joint. Moment reaction forces on the stump are reduced through absorption of moment by knee stop. Without a knee stop, the stump would have to resist moment due to floor reaction passing ahead of knee joint. The resulting high pressure on the patellar tendon can be eliminated if the knee is allowed to flex (Fig. 6) instead of being forced into full extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Summary</h4> <p>Thus it may be seen that, while normal skeletal and neuromuscular structure of the lower extremity is so organized as to accommodate the complex and precisely phased performance needed for erect, bipedal locomotion, the below-knee amputee, even though provided with a well-fitting prosthesis of the patellar-tendon-bearing cuff-suspension type, is unavoidably destined to experience in walking a continually changing set of stump-socket forces in both the anteroposterior and the medio-lateral directions. Successful fitting of the below-knee amputee means, therefore, the resolution of stump-socket forces in such a way as to provide both comfortable support and adequate stabilization throughout the walking cycle. Whenever addition of thigh corset and sidebars is required, there occurs a change in the pattern of motion, and hence a change in stump-socket forces to be anticipated, and accordingly suitable modifications are required. Allowance for such factors calls in every case for the sound judgment of the prosthetist if fully satisfactory results are to be obtained.</p> <p><b>References:</b></p> <ol> <li>Bresler, B., and F. R. Berry, <i>Energy and power in the leg during normal level walking, </i>Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 15, May 1951.</li> <li>Murphy, Eugene F., <i>The fitting of below-knee prostheses, </i>Chapter 22 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The fitting of below-knee prostheses, Chapter 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bresler, B., and F. R. Berry, Energy and power in the leg during normal level walking, Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 15, May 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Mechanical Engineering, University of California, Berkeley.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Biomechanics of Below-Knee Prostheses in Normal, Level, Bipedal Walking Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * https://staging.drfop.org/files/original/d9df07ada71e9d7d83fffc2b3882605b.pdf dd5973e756028d4e9b05572ed933a126 https://staging.drfop.org/files/original/0f45aa6fc046dad209c2ecd2246d719d.jpg ef9ee0e2d6b75fb5a0f601219455c33c https://staging.drfop.org/files/original/d95df4afa4a2f4646ae80ab0c81b2c59.jpg eaf808db85894142fab323e6a395c193 https://staging.drfop.org/files/original/b6abea62fdee85f63c01f9f92f63427f.jpg 0cb011992156bd6cb8e3d2d0c7084ef2 https://staging.drfop.org/files/original/f0010ef48d7220a546c6825555e192d9.jpg 7d7fdedf615e168cb6806068e1c6ec9f https://staging.drfop.org/files/original/3b4551aa2727f7de686c9653c2e5a0a2.jpg 362acdaa1b00733aa29554d23964db97 https://staging.drfop.org/files/original/9d2755df918b9d45aa9be1ca6f563d0c.jpg 005f7f0338d752126218dd2d68eafbad https://staging.drfop.org/files/original/6c2c983e3d245d5c78f0820ce9ee4915.jpg 1d90a72444738f10f27abd1bac5c0faa https://staging.drfop.org/files/original/624b108ea7d5ee0507c22228b6f0d6a3.jpg 26f4ff3a54c4bccd797ca390cdf7ca5b https://staging.drfop.org/files/original/254ddecf8418d838cb6a8af9873a58de.jpg b4f775c186a69f8d2e53b158ac858068 https://staging.drfop.org/files/original/377df229bb696a03072dfd1c676bd050.jpg c0c4072b156f521d98c4f1354bbc325b https://staging.drfop.org/files/original/fd3e3ccdd2420ab18d0d0fffcbc9ab3c.jpg 0e72757a1dc47a5de48d7308461d5f6d https://staging.drfop.org/files/original/b5a660e0a92fcfe1dc39c8ff7fb409bf.jpg 2d614435d8ff3fe18ea8d22c8f3e3eb6 https://staging.drfop.org/files/original/bca83eadc2d6bdd1414a4a6220815d9b.jpg af655a4773be177a6f4c493d206128dd https://staging.drfop.org/files/original/a3377673f8480eff6b780ea492790238.jpg 31b69497a6c30f74af9e798ed25997b9 https://staging.drfop.org/files/original/14d1a5ad883e575f6f4ef41150d9abf1.jpg 3715824627641a0a6f1d6ee0636f59c2 https://staging.drfop.org/files/original/976df78ead28d770ef285a09c9bc0af9.jpg 423273a8db9972de7c0193e94f0f8bdc https://staging.drfop.org/files/original/cd85393dfea9ad19f0b6b560e893c1a6.jpg e2175b21b49484d983de253617cf5baf https://staging.drfop.org/files/original/59c142d232f6be2114140f4624655085.jpg 8e077cebc372f08ef05dd8002caf70d3 https://staging.drfop.org/files/original/efdc01af5dc1a7b942d551d17167eeca.jpg c00df2061434f0cde77ab3c22578b6b7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_01_041.pdf Year 1957 Volume 4 Issue 1 Page Number(s) 41 - 75 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1957_01_041.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_01_041.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Experience with Prosthetic Problems of Above Knee Amputees</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br />Norman C. Johnson, M.D. <a style="text-decoration:none;">*</a><br />James Foort, M.A.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p>For almost a dozen years the University of California has been active in prosthetics research. On the recommendation of the then Committee on Prosthetic Devices (now the Prosthetics Research Board) of the National Research Council, there was established in 1945, with the cosponsorship of the School of Medicine in San Francisco and the College of Engineering in Berkeley, the Prosthetic Devices Research Project (now the Lower Extremity Amputee Research Project), a program designed primarily for the purpose of conducting studies in several areas of importance to leg amputees, especially fundamental studies of the processes of human locomotion. Supported on a continuing basis with funds supplied by the Veterans Administration, the work has from the beginning been under the supervision of Howard D. Eberhart, Professor of Civil Engineering, and Verne T. Inman, Professor of Orthopedic Surgery.</p> <p>In the course of fundamental research, the need for experimental devices required the activation of an engineering design group, and consequently a small staff of design engineers, draftsmen, and technicians has been active since 1948. This group, working with the fundamental study groups, research prosthe tists, and amputee subjects, has designed improved prosthetic devices, developed mechanical aids to fitting and alignment, and assisted in the application of well known principles of engineering mechanics to the problems of fitting and aligning lower extremity prostheses.</p> <p>As correlation of the results of the various fundamental study groups progressed, and as the engineering design group developed improved devices, it became increasingly apparent that, in order to make their results useful to the members of the medical profession and to prosthetists serving amputees, a program of amputee application was indicated. Accordingly, there was organized in the spring of 1953 a Clinical Study aimed at providing increased opportunity for application of research results to the solution of typical prosthetic problems of leg amputees. The work in fundamental research had studied the "man"; the Clinical Study was needed to consider the 'man machine combination." Its objectives were to evaluate current prosthetic practice and to develop improved procedures where needed, to establish basic principles of fit and alignment for all levels of lower extremity amputation, to evaluate medical and prosthetic factors in the rehabilitation of amputees, and to develop methods for evaluation of lower extremity amputees and their prostheses.</p> <p>An immediate outgrowth of the Clinical Study was an increasing awareness of the need for additional research directed toward the solution of the medical problems of the amputee. At the present time, the Medical Division of the Lower Extremity Amputee Research Project, located at the Medical Center in San Francisco, includes groups active in the fields of stump dermatology, amputation surgery, skeletal changes, energy, neuroanatomy, psychology, and the physiology of pain. The Clinical Study provides an opportunity for the solution of the prosthetic problems associated with the medical studies and also of the purely prosthetics research problems connected with better materials and improved techniques of fitting. To date, most of the experience has been had with above knee amputees, as here reported, although more than 100 patients, presenting all levels of lower extremity amputation, are currently under study.</p> <h3>Procedures</h3> <p>Each amputee processed through the Clinical Study has certain unique problems, and each must therefore be considered on an individual basis. Initially, it was thought that it would be possible to process amputees in certain rather loosely defined groupings such as ''short stump above knee," "long stump below knee," and so on. But this procedure has not been found practical since each amputee is referred to the study as his particular problem arises. Largely because of the attendant requirements of time, travel, and inconvenience, it is difficult to induce an amputee to become a research subject when he considers his prosthesis to be comfortable and well fitted. The cases reported here have almost without exception been referred to the Clinical Study as "problem cases" and have had chronic difficulties upon referral. The sample does not, therefore, necessarily indicate a typical cross section of the amputee population. The prosthetic problems of the group as a whole, however, constitute what we believe to be a rather common group of problems facing above knee amputees.</p> <p>Each amputee referred to the Clinical Study is given a preliminary examination for the purpose of obtaining information as to the nature of his problems, if any. The preliminary examination includes:</p> <ol> <li>An interview with an amputee specialist <i>(i.e., </i>a trainer). The amputee specialist obtains a brief prosthetic history, explains the research program to the amputee, and records personal data.</li><li>Medical examination by an orthopedic surgeon. The orthopedic surgeon obtains a brief medical history and endeavors to classify the major complaints of the amputee.</li><li>Prosthetic evaluation by staff prosthetists and other specialists. A group consisting of three or more people examines the amputee's stump, his prosthesis, and his performance in order to analyze the fit, alignment, and functional behavior of the amputee with his prosthesis.</li></ol> <p>The results of each of these examinations are recorded in the form of a written memorandum report. Upon completion of the reports, a group discussion is held for the purpose of making recommendations as to the further handling of the case. For example, it may appear on preliminary examination that a particular amputee has a severe skin infection of unknown origin. In such a case, the recommendation might be to refer the patient to the Skin Study Group at the Medical Center in San Francisco before considering any work directed toward improving fit and alignment.</p> <p>Certain cases considered to be of interest to the research staff as a whole are referred to the Amputee Conference held at the Medical Center, San Francisco, on a regularly scheduled weekly basis. Amputees may be referred to the Amputee Conference by medical study groups as well as by the Clinical Study Group. Attendance at the conference is limited to University of California staff members, and not more than three amputees are presented for discussion at any one session. The Amputee Conference provides an opportunity for presentation of the results of the preliminary examination and, thereafter, a general group discussion. At this time a general plan of treatment, including broad research objectives, is formulated.</p> <p>If an amputee is accepted by the Clinical Study as a case of research interest, a more complete medical examination is required. Cases referred to the Clinical Study from the medical study groups or the Amputee Conference have usually been examined at the Medical Center prior to referral. The complete medical examination includes routine clinical tests, plus x-rays of the stump and pelvis.</p> <p>Before any actual treatment is undertaken, a plan of approach is worked out by a team consisting of an orthopedic surgeon, a pros thetist, an engineer, and an amputee specialist. The team discusses research objectives in detail, writes a prescription for one or more phases of prosthetic treatment, and lays out an estimated schedule. A report is then written summarizing the discussion and recommendations, and the team meets periodically, as necessary, to review progress and to make further recommendations. Each phase of the treatment of the amputee is reported in a memorandum which becomes a written record of progress. Permanent records embrace medical records, including x rays; evaluation records, including evaluation forms and 16 mm. motion pictures (100 ft. per evaluation); black and white still photographs; 35 mm. color transparencies; and memorandum reports on plans and progress.</p> <h3>General Principles of Above Knee Prosthetics</h3> <p>As already noted, one of the major objectives of the Clinical Study was to provide the means for additional amputee trials of certain principles of fitting and alignment which had been evolved during several years of fundamental research, evaluation of current practices, and amputee trials but which had been developed with a limited number of amputee subjects. The technique of fitting the suction socket prosthesis to an above knee amputee has been reported by the University of California in a series of publications<a></a> which have been revised periodically as new knowledge and techniques became available. The latest article<a></a> stressed the interdependence of the shaping and fitting of the socket and the biomechanics of alignment of the prosthesis. A rational basis for planning and fitting the above knee prosthesis was presented. All of the patients reported upon in the present paper were fitted in accordance with these principles. It is therefore well to offer here a brief summary of the more important considerations.</p> <p>The prosthetist is undoubtedly <i>the </i>person on the prosthetics team with the heaviest responsibilities. His skill with his hands is largely responsible for the eventual rehabilitation of the amputee. But in carrying out his assignment of providing the amputee with a satisfactory prosthesis, he is faced with something of a dilemma in the establishment of an order of procedure. In order of importance, he must provide the amputee with, first, comfort; second, function; and third, appearance. It can be argued that he should approach the solution of these problems in reverse order if optimum results are to be achieved. Actually, there are two separate and distinct phases of equal importance in the fitting of a leg prosthesis the planning phase and the construction phase. It is during the planning phase that the objectives listed above should be considered in the reverse order. One of the principal reasons for failure to achieve optimum results in the fitting of a suction socket above knee leg is lack of appreciation of, and hence failure to formulate, a working plan before beginning the construction of the prosthesis.</p> <p>In order properly to plan the fitting and alignment of a prosthesis, the clinic team must have in mind a rational sequence which will eventually result in a satisfactory fitting for the amputee. The order of the sequence is necessarily dictated by the type of problem to be solved at a particular stage. Let us consider, for example, the case of a typical leg amputee. During the medical and prosthetic examination by members of the clinic team, a careful analysis is made of the patient's potential as a wearer of a prosthesis. This analysis includes classification as to stump type, stump length, activity level, habit patterns, and special medical factors. It dictates in general terms the type of alignment to be incorporated in the amputee's prosthesis (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 1. Variations in alignment to accommodate stumps of different functional lengths. With the short stump, the slow or hesitant walker, having limited use of the hip abductors and extensors, needs considerable alignment stability. The moderate walker, with stump of medium functional length, has average use of the hip abductors and extensors. Alignment for the long stump is for an active walker having good use of the hip abductors and extensors. These figures serve as a guide to typical features of alignment once the amputee has been classified After Radcliffe (6). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The alignment of the prosthesis will in large measure establish the gait pattern of the amputee, assuming of course that he has been trained to use his prosthesis in a manner consistent with its alignment. A leg amputee can walk efficiently with a symmetrical, narrow based gait only if his prosthesis has been planned and constructed to achieve such a gait pattern. The type of alignment also affects the manner of fitting the socket. An amputee walking with a narrow base may require a distribution of contact forces between stump and socket entirely different from that of an amputee walking with a wide base <i>(i.e., </i>abducted gait).</p> <p>The distribution of stump socket contact forces is determined by the functions the socket must perform, the major functions of a typical above knee suction socket being as follows:</p> <ol> <li>Suspension of the leg in the swing phase of walking. This requirement dictates that an airtight seal be maintained between stump and socket, especially in the proximal third of the stump.</li><li>Vertical support of body weight in the stance phase. The only efficient areas of an above knee stump for weight bearing are the ischial tuberosity and the gluteus maximus. Attempts to use for weight bearing in a suction socket the attachments of the adductor musculature in the perineal area have been unsuccessful Almost without exception this procedure leads either to painful pressure on the pubic ramus or to skin irritation where there exists a definite roll of adductor musculature over the medial brim of the socket.</li><li>Stabilization of the ischial tuberosity on the posterior brim (ischial seat) of the socket. Failure to provide stabilization of the tuberosity will allow the pelvis to slide forward and down into the socket, a circumstance which causes chafing and irritation of the skin under the ischial tuberosity and, in addition, is a major source of crotch discomfort.</li><li>Provision of effective stump reaction points for utilization of hip musculature on the side of the amputation. Any attempt to use the hip musculature either for control of the torso above the hip joints or for control of knee joint movements below the hip joint will require that the stump transmit a moment, or torque. For lateral stabilization of the torso, there is required a pair of mediolateral reaction forces equal in magnitude but opposite in direction one acting on the lateral side of the stump, concentrated in the lower third, and a second acting horizontally against the medial side of the stump in the upper third. During those times when the stump acts to maintain knee stability by active stump extension, the reaction points are against the posterodistal and the anteroproximal areas of the stump.</li></ol> <p>On the basis of these functional requirements, the quadrilateral shape of suction socket shown in (<b>Fig. 2</b>) has been developed. It not only conforms to the anatomical skeleton and musculature but also provides the four functions already listed suspension, support, ischial stabilization, and torque reaction points.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Quadrilateral shape of suction socket, as developed at the University of California, showing anatomical features of an above knee stump in weight bearing. Cross section 1/2in. below ischial level. After Radcliffe (6). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Thus far the objectives of appearance and function have been accounted for. It has been stated that appearance is determined by proper alignment and use of the prosthesis and that function is dictated by proper alignment accompanied by a rational design of socket to provide the necessary accommodation of stump socket forces. These concepts can be restated in the following two principles:</p> <ol> <li>Gait and alignment establish a definite pattern of stump socket forces.</li><li>The force pattern, in combination with anatomical proportions, dictates a rational design of socket of a generally quadrilateral shape.</li></ol> <p>The third objective is to provide a completely comfortable socket which will be consistent with the functional requirements and yet allow the amputee to use his prosthesis for long periods. Comfort is achieved by application of three additional principles:</p> <ol> <li>Relative motion or rubbing between stump and socket should be held to a minimum.</li><li>Stump socket contact forces can never be eliminated. Contact forces can be tolerated most comfortably if distributed over a large skin area.</li><li>Where a contact force must be transmitted in an area of the stump involving both soft and firm tissues, a uniform distribution of the contact pressure is accomplished by a proportionately greater distortion of the softer tissues.</li></ol> <p>Application of the three principles relating to comfort have resulted in four features of socket shape at the brim that are of particular importance:</p> <ol> <li>The anteroposterior dimension of the socket must be determined with considerable accuracy from skeletal measurements. Any error in this dimension will be reflected in improper placement of the ischial tuberosity on the posterior brim of the socket.</li><li>To ensure distribution of vertical support over the entire posterior brim <i>(i.e., </i>to achieve ischial gluteal weight bearing), a rather flat posterior contour with a flare in the gluteal area is required.</li><li>An anterior wall extending into the inguinal area (the high front), when used with the proper anatomical dimension, is extremely efficient in stabilization of the ischium on the ischial seat.</li><li>A definite protuberance into Scarpa's triangle (the adductor area extending downward into the socket), accompanied by a channel to fit the belly of the rectus femoris, is necessary to ensure a uniform pressure distribution and an airtight seal across the anterior brim of the socket.</li></ol> <p>The following cases have been selected as illustrative of typical problem cases and as being informative to others engaged in the rehabilitation of above knee amputees. Treatment was not completed in all cases because considerable improvement over the previous condition sometimes caused the individual to believe the optimum had been reached and to be reluctant to devote additional time. The cases are in general indicative of the kind of results that can be obtained under the team approach to the problem of amputee rehabilitation.</p> <h3>Some Above Knee Cases</h3> <h4>Case 1, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 1, a male, was 32 years of age, measured 5 ft. 8 1/2 in., and weighed 190 lb. His left leg had been amputated above the knee in October 1944 as the result of a wound. He was employed as a civil engineer. For two years after the amputation, he received intermittent physical therapy and exercise before being fitted with a conventional prosthesis with pelvic belt. The patient's second and third prostheses were similar. His fourth prosthesis, also a pelvic belt leg, was worn with fair results for 18 months. It was then converted to suction suspension in an unsuccessful attempt to increase comfort. The fifth prosthesis, also suspended by suction, was worn for a year with continuous stump trouble before the amputee was finally hospitalized.</p> <p>The patient was referred to the clinical study program in November 1953 following hospitalization for severe edema precipitated by his suction socket prosthesis. Treatment consisted of remaining off the prosthesis during and immediately following hospitalization.</p> <h5><i>Examination and Evaluation</i></h5> <p>The stump was 12 in. long, with limited tolerance to weight bearing on the end. Subcutaneous tissue was light and musculature soft, with some bunching of the hamstrings and slight atrophy at the distal end. X ray showed a healed but laterally displaced fracture of the distal 5 1/2 in. of the femur. The end of the femur was slightly rounded, was closed with new bone growth, and had a small medial spur. Approximately half an inch of muscle padding lay over the end of the femur. The ischial tuberosity was well padded, and the general health of the amputee was excellent.</p> <p>When the patient was admitted to the hospital, the end of his stump was severely edematous, open, and weeping. At the time of entrance to the study program, there was still some weeping and edema, and the end of the stump was discolored (<b>Fig. 3</b>). Follicular lesions were apparent in the area of the inguinal crease and of the crotch, and a small, healing abscess existed on the anteromedial portion of the stump 5 in. below the groin. Some rawness and irritation were still apparent in the crotch area. The distal area of the posterior aspect of the stump was tender, and there was a moderate adductor roll. Examination of the socket fit showed constriction of the stump, especially in the upper third. Weight was carried on a flesh roll at the brim of the socket (<b>Fig. 4</b> and <b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Case 1. Condition of the distal end of the stump on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Case 1. Prosthesis worn prior to referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Case 1. Shape of socket of prosthesis worn prior to referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>Interest in the case centered around the edema, roll formation, and skin problems, including discomfort in the crotch. Ischial gluteal weight bearing, with increased area of support at the anterior wall, particularly in the upper third, was expected to eliminate crotch discomfort, skin lesions and irritation, roll formation, and constriction of the proximal portion of the stump. A snug fit of the socket in the upper third was required to reduce the adductor roll, and a close fit of the distal two thirds of the stump was required to reduce remaining edema and to maintain fit as the edema subsided.</p> <p>The amputee was provided with a suction socket prosthesis using a Navy above knee set up,<a></a> including the variable cadence knee, the functional ankle, and the sponge rubber toe. The socket was made of willow wood reinforced with rawhide and finished inside with cellulose acetate lacquer, and an automatic expulsion valve with standard spring was used. A flat, leather covered, sponge rubber pressure pad was placed in the bottom of the socket to provide back pressure on the edematous tissue at the end of the stump.</p> <p>No special provision was made for relief of the adductor roll. The anterior wall provided no protuberance over the femoral triangle, and there was no special relief for the displaced section of the femur. The perimeter of the socket was 2 1/4 in. less than that of the stump at the proximal end, 3/4 in. less at the mid stump level, and equal to that of the stump at the end. The distance from the channel for the tendon of the adductor longus to the ischial seat was 4 1/2 in., the corresponding anatomical dimension being 3 3/4 in. This difference between medial socket width and anatomical measurement was subsequently found to be a major source of difficulty. Current practice is to have the medial width of the socket compare very closely with the anatomical measurement.</p> <p>Prosthetic evaluation showed some instability of the knee in ramp descent owing to reduced range of plantar flexion. Although there was drop off at the end of the stance phase because of the soft dorsiflexion stop and the soft, sponge-rubber toe, the amputee's performance was excellent.</p> <p>During the final fitting, the end of the stump turned red, but a sponge rubber pad placed in the bottom of the socket improved stump color markedly within two hours. One week after delivery of the prosthesis, the edema was reduced; three weeks after, there was no edema; nine months after fitting, some edema was evident at the distal end of the stump.</p> <p>Evaluation indicated that the ischial tuberosity was sliding anteriorly off the ischial seat so that the stump was settling deeper into the socket, with increased constriction at the proximal end. Several factors were involved. The stump had shrunk, and the anteroposterior dimension of the socket, especially in the medial third, which had been too great initially, had been increased in an unsuccessful attempt to relieve discomfort in the inguinal crease and in the weight bearing area of the stump. The edema was confined to the areas of the stump which extruded into the valve recess and into the gap between the pad and the socket walls. The valve recess was lowered, the pad was refitted so that more weight was carried on the end of the stump, and the space between the pad and socket walls was eliminated. The edema cleared up.</p> <p>Roll formation over the anterior brim of the socket was eliminated through extension of the anterior wall of the socket above the level of the ischial seat. The adductor roll was completely contained within the socket. Tightness of fit in the upper third was a source of minor discomfort immediately, but this problem decreased with reduction of the roll, which was complete within six months (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Case 1. Present prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Follicular lesions in the area of the crotch and the inguinal crease quickly cleared up with reduced forces from the socket brim and elimination of roll formation over the brim. One year after treatment began, the discoloration at the end of the stump was markedly decreased. Irritation of the skin over the posterior brim was a persistent problem directly related to decreased effectiveness of ischial gluteal weight bearing and wedging of the posterior aspect of the stump against the inside edge of the posterior brim of the socket. Attempts to increase weight bearing on the distal end of the stump showed that the amputee preferred ischial gluteal weight bearing because of discomfort experienced on the stump end with prolonged support of body weight.</p> <p>Reduced support on the ischial tuberosity followed stump and socket changes and caused discomfort on the ramus. The medial brim of the socket was lowered to provide relief. This expedient was partially successful, but the stump sank deeper into the socket after wear, and ramus discomfort has recurred.</p> <h5><i>Summary</i></h5> <p>The problems of edema, roll formation, skin lesions, and discomfort in the crotch were studied. Edema was originally caused by a tight fit of the stump with constriction of the proximal end. Definite ischial gluteal weight bearing, with increased area of anterior support, was the primary factor in clearing up the edema. A pressure pad under the end of the stump helped to reduce the edema. Stump and socket changes which allowed the ischial tuberosity to slide into the socket, with wedging of the stump proximally, caused edema to recur. Improved fit of the pressure pad, with increased end bearing, cleared up the edema. The adductor roll was brought about by weight bearing in the crotch on the tight socket. Ischial gluteal support, adduction of the femur in the socket with relaxation of the adductors, and extension of the medial brim to the level of the ischial seat, without provision of a relief pocket, eliminated the adductor roll. Discomfort due to tightness of fit for adductor roll reduction decreased as the roll reduced. The high anterior wall eliminated roll formation over the anterior brim of the socket. Skin lesions and irritation were caused by high force concentrations on the stump. Ischial Gluteal weight bearing, with increased area of anterior support, eliminated irritation and follicular lesions in the area of the crotch and the inguinal crease. Ramus discomfort following stump and socket changes was a sign of reduced effectiveness of ischial gluteal weight bearing, which allowed the stump to sink deeper into the socket. Discomfort in the weight bearing area posteriorly was caused by wedging of the stump against the posterior brim of the socket as the tuberosity slid inside the socket.</p> <h4>Case 2, Mid Thigh</h4> <h5><i>History</i></h5> <p>Case 2, another male, was 57 years of age, measured 6 ft., and weighed 187 lb. He was employed as a district manager for an insurance company. Amputation was through the right femur following a railway accident at the age of 17. He was referred to the clinical study in November 1953 by a local limbshop because of a history of problems. These included skin infections and irritations, fatigue, and low back pains which had persisted since amputation. At the time, the amputee considered his prosthesis satisfactory. The first prosthesis, with shoulder harness suspension, was fitted in 1913 and worn until 1928. Prostheses with shoulder harness suspension were worn until 1943, when a change was made to pelvic belt suspension. The pelvic belt was uncomfortable and aggravated the back pains, and prior to referral the prosthesis was converted to suction suspension.</p> <h4><i>Examination and Evaluation</i></h4> <p>General health and physical condition were good. The stump was 10 in. long and cylindrical, with light subcutaneous tissue and average musculature except for moderately prominent hamstrings. There was a lateral distal bone spur, a mass of redundant tissue at the lateral posterior end of the stump, and sensitive scar tissue which was adherent to the femur. Perspiration level was high. Skin irritations were present in the area of the crotch and the inguinal crease, and hard skin nodules existed in the ischial gluteal area (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Case 2. Lateral view of patient standing. Note scar on distal portion of stump over lateral and posterior aspects. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The prosthesis did not provide ischial gluteal weight bearing, and the tuberosity of the ischium was sliding inside the socket during weight bearing. This set of circumstances resulted in painful pressure on the ramus and wedging of the proximal portion of the stump against the anterior and posterior brims of the socket, with a high concentration of forces at the brim level. The medial brim had been lowered a half inch below the level of the ischial seat in an unsuccessful attempt to relieve the discomfort at the ramus. Walking with a narrow base increased the ramus discomfort because the femur was not adducted in the socket for stabilization of the pelvis. There was roll formation over the low anterior brim. Knee stability at the end of the stance phase was excessive owing to a long forefoot and posterior placement of the knee joint, which further increased the force concentrations at the socket brim. Insufficient security at heel contact was due to stiff plantar flexion action. A pelvic hike on the side of the amputation in the swing phase was noticeable, probably because of experience with shoulder harness and pelvic belt suspension.</p> <h5><i>Treatment</i></h5> <p>Problems of interest included skin lesions, horny nodules, ramus discomfort, fatigue, and backaches. It was decided that relatively standard procedures, including ischial gluteal weight bearing with increased support from the anterior wall, would be effective in eliminating roll formation and in reducing pressure concentrations on the stump, especially in the crotch, in the inguinal crease, and in the ischial gluteal area. Further reduction of vertical forces in the region of the crotch could be achieved by adduction of the femur in the socket, thus eliminating pelvic drop in the stance phase.</p> <p>The amputee was provided with a suction socket prosthesis which included a single axis constant friction knee, a plantar dorsiflexion ankle, and a foot with single toe break. Segments of the prosthesis were willow wood reinforced with rawhide. The socket interior was finished with cellulose acetate lacquer, and use was made of an automatic expulsion valve with standard spring.</p> <p>Since the ischial tuberosity was not adapted to weight bearing, the gluteal channel was held shallow to increase gluteal support. In addition, this arrangement offered increased sitting comfort by allowing a thinner posterior wall. Definite hamstring relief was provided by channeling the posteromedial apex of the socket (<b>Fig. 8</b>). The medial brim was approximately 1/4 in. lower than the posterior brim to provide clearance for the ramus. The medial socket width was 4 3/4 in. as compared to an anatomical measurement of 3 3/4 in., a difference subsequently found to be a major source of difficulty. As already mentioned, current practice is to have the medial width of the socket compare very closely with the anatomical measurement. The anterior wall was extended 2 in. above the level of the ischial seat and was relieved slightly over the femoral triangle. But this idea, which was tried for fear that pressure in the femoral triangle would interfere with circulation, has since been abandoned in favor of a definite protuberance into this area. Such a shape gives considerable distributed anterior support.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Case 2. Socket shape of prosthesis worn at present. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket was placed well forward on the knee block to allow initial flexion of the femur in the socket for increased voluntary control, reduced energy requirements, and decreased lordosis of the lumbar portion of the spine. Prosthetic evaluation indicated that there was excessive stability at the end of the stance phase owing to a long forefoot and the posterior location of the knee axis, the long forefoot having been dictated by the large foot size. In the swing phase, there was some whip, which was not removed during alignment trials on the adjustable leg,<a></a> but the gait was markedly improved on the new prosthesis. There was no ramus discomfort, no irritation, and no roll formation in the crotch or inguinal crease. The ischial tuberosity was close to the inside edge of the socket, so that the medial wall had to be lowered to prevent ramus discomfort.</p> <p>After stump shrinkage, ramus discomfort recurred. The medial brim was lowered, but this measure provided only temporary relief as the stump settled deeper into the socket. Skin irritations from the anterior brim were reduced but persisted, since wedging occurred owing to inefficient ischial weight bearing. Force concentration at the anterior brim was reduced somewhat by extension of the brim 2 in. above the level of the ischial seat. Undercut of the anterior wall over the femoral triangle reduced the effective area of anterior support.</p> <p>Skin lesions in the crotch cleared up initially but recurred with failure of ischial weight bearing. Formation of horny nodules in the weight bearing areas was unchanged because poor ischial support allowed the tuberosity to move in and out of the socket over the inside edge of the posterior wall, thus creating abrasive and wedging action. Excessive perspiration was considered a factor both in the formation of horny nodules and in stump irritation because of the deteriorating effect it had on the inside finish of the socket.</p> <p>Although the anterior and posterior brims were rolled and adjusted periodically to reduce discomfort from skin irritations in the inguinal crease and from nodules in the weight bearing areas, this expedient provided only temporary relief, since the forces involved were either unchanged or increased. Reduced alignment stability, with increased flexion of the stump in the socket, did not relieve the backache. Activity level was not noticeably changed, and fatigue also remained unchanged.</p> <p>In the course of treatment, redundant tissue at the lateral distal portion of the stump was a problem in fitting because of the sensitivity of the adherent scar tissue. A large pocket was provided to give relief. Doing so reduced the effective length of the femur available for stabilization of the pelvis.</p> <h5><i>Summary</i></h5> <p>Failure of ischial gluteal weight bearing resulted in ramus discomfort and skin lesions. Lowering the medial brim provided only temporary relief, since the stump settled further into the socket. With recurrence of vertical pressure in the crotch, skin lesions were again a problem. The need for effective anterior stabilization to maintain the ischial tuberosity on the ischial seal was definitely indicated.</p> <p>The high anterior wall eliminated roll formation and reduced skin infections in the inguinal crease. Undercut of the anterior wall over the femoral triangle reduced the anterior support area and increased the force concentration al the brim. Modifications of the anterior wall and of the posterior brim reduced discomfort temporarily only, since the force pattern was unchanged.</p> <p>Placement of the prosthetic toe break at the shoe crease provided excessive knee stability at the end of the stance phase. This result suggested that the conventional location of the toe break was too far forward.</p> <h4>Case 3, Mid Thigh</h4> <h5><i>History</i></h5> <p>Case 3 was another male, age 51, height 6 ft., weight 180 lb. He lost his left leg above the knee at the age of 17 after an injury sustained in a baseball game. Since his original surgery, he had had no further revision. For the first five years after amputation, he used crutches without a prosthesis. He had since worn three prostheses during his 34 years as an amputee. The first leg had a shoulder harness suspension. The leg worn upon his acceptance as a research patient had been converted in 1952 from an aluminum socket, pelvic belt leg to a wooden suction socket prosthesis a year and nine months previously. He was employed as an expediter in a shipyard, and the nature of his employment was such as to involve considerable standing and moving about over short distances. His chief complaint was concerned with persistent edema of the stump since conversion to suction suspension, and this was the reason for his referral to the clinical study program by a local limbshop in November 1952. The patient complained of occasional phantom pain but had no persistent local pain.</p> <h5><i>Examination and Evaluation</i></h5> <p>The patient was in good general health, with normal reflexes and above average musculature. The stump was cylindrical, with 6 1/2 in. of femur below the perineum and 2 1/2 in. of soft tissue over the end of the femur (<b>Fig. 9</b>). Stump musculature was not abnormally prominent, and subcutaneous tissue was light. On contraction of the muscles, the redundant tissue pulled upward without bunching. A large scar, adherent to the distal end of the femur, extended 6 in. up the lateral side of the stump (<b>Fig. 10</b>). There was severe, nonpitting edema in the redundant tissue. The skin in the edematous area was without hair, distended, discolored, and scaly, with an orange peel texture. Small cysts and horny nodules were evident in this region as well as in the inguinal area and in the crotch. The patient said that these cysts frequently enlarged and broke down, producing a pinkish yellow discharge.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9 Case 3. X ray of stump, mediolateral view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Case 3. Lateral view of stump. Note large, adherent scar. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>X ray revealed the usual finding that there was lessened bone density on the amputated side and that the femur tapered and curved medially toward the distal end, which appeared to be closed. Comparison of socket and stump perimeters showed the socket smaller than the stump by 1 1/4 to 2 in. at corresponding levels. The distance from the tendon of the adductor longus to the ischial tuberosity was 3 1/2<i> </i>in., as compared to the corresponding socket measurement of 5 in.</p> <p>The suction socket the patient was wearing, although of the ischial bearing type, did not achieve ischial bearing. The anteroposterior dimension was too large, the mediolateral dimension too small (<b>Fig. 11</b>). The socket was too tight, especially in the distal half, and the proximal end of the stump was constricted because of a wedging action precipitated by failure to establish ischial gluteal bearing. Weight was borne on the medial brim of the socket, which was 3/8<i> </i>in. below the level of the ischial seat and generously flared. There was a small adductor roll, and the anterior brim of the socket was level with the posterior brim, with some roll formation in the area of the inguinal crease. The anterior wall was undercut, a feature that caused localized high pressure on the stump at the anterior brim. The patient was well adapted to the use of the prosthesis, although a number of undesirable characteristics of gait were apparent, including a 7 in. walking base, considerable sidesway, and exaggerated arm swing on the side of the amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11, Case 3. Socket shape of prosthesis worn on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>This patient's chief problem was the severe edema. It was felt that this disorder, as well as the skin lesions, could probably be controlled adequately by proper fit and alignment. The question of prime interest to the study group was whether or not suction suspension was the cause of the edema in this case.</p> <p>The amputee was provided with a suction socket prosthesis with conventional components, including a single axis constant friction knee, a plantar dorsiflexion ankle, and a foot with a single toe break. Segments were made of wood and reinforced with rawhide. An automatic expulsion valve with a strong spring was used to increase positive pressure in the socket during the stance phase.</p> <p>The socket perimeters were 1 1/2<i> in.</i> less than corresponding stump dimensions in the top third and equal to stump dimensions below that.</p> <p>The distance from the tendon of the adductor longus to the ischial tuberosity was 3 1/2 in., and the corresponding socket dimension was 4 in. The anterior wall was relieved to avoid pressure in the area contacting the femoral triangle (<b>Fig. 12</b>), and a flat sponge rubber pad covered with soft leather was placed in the bottom of the socket to provide back pressure on the edematous tissue.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Case 3 Socket shape, present prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the patient had worn the prosthesis for six weeks, the edema in the redundant tissue had decreased markedly. The improvement was maintained over a nine month period, although at no time was the condition completely eliminated. About the ninth month, there was a sudden increase in the amount of edema. Three factors seemed to be involved. There was increased activity. A weaker valve spring had been installed to reduce loss of suction. And there had been stump shrinkage, as indicated by the experience of ramus discomfort. The thickness of the control pad was increased, but doing so did not alter the condition. Next, a stronger valve spring was provided to increase the positive pressure in the stance phase, and there was then a marked and immediate improvement in the edematous condition of the stump. To provide increased ischial weight bearing by reducing the anteroposterior dimensions of the socket, liners were added in the area of the socket contacting the femoral triangle. Although ischial weight bearing was improved, as evidenced by the elimination of ramus discomfort, there was no change in the edema.</p> <p>The decision was then made to provide the amputee with a socket that would make total contact with the stump end, thus exerting greater back pressure on the edematous tissue. After a four day trial period, the patient found that accumulated perspiration irritated the stump acutely, and the socket had to be discarded. At present the amputee continues to wear the first prosthesis provided and still has moderate edema.</p> <p>Skin infections initially present in the crotch area were cleared with provision of ischial gluteal weight bearing, but with stump shrinkage the condition recurred because of decreased effectiveness of such weight bearing. Provision of liners over the area of the socket contacting the femoral triangle increased the effectiveness of ischial gluteal weight bearing and reduced the skin problems. Throughout treatment, there was irritation on the weight bearing area of the stump, especially around the ischial tuberosity. Provision of a section of nylon stocking, fastened to the outside of the socket and draped interiorly over the weight bearing area, improved comfort considerably by reducing shear between the skin and the socket. The skin irritations were due primarily to excessive anteroposterior socket dimensions, especially along the medial wall. This situation allowed the tuberosity to slip into the socket and the entire stump to settle deeper, with consequent wedging of the stump against the posterior brim and the anterior wall, thus creating a high force concentration on the ischial tuberosity. A pressure pad was found very helpful in controlling edema when other elements of the fit were satisfactory.</p> <p>Minor skin irritations resulted from deterioration of the inside finish of the socket, but refinishing the socket cleared them.</p> <h4><i>Summary</i></h4> <p>Although treatment was never completely successful in eliminating this patient's edema, function and comfort were markedly improved, and the course of his prosthetic treatment served to demonstrate several principles. Provision of ischial gluteal weight bearing eliminated ramus discomfort, reduced edema, and cleared skin infections anteriorly and medially where the stump contacted the socket brim. The posterior brim caused irritation of the stump when ischial bearing was indefinite, with the tuberosity near the inside edge of the socket, or when the radius of curvature over the inside edge was too small, or when the ischial area was not conditioned for weight bearing. Use of liners to decrease the anteroposterior dimension increased comfort. When there was stump shrinkage and decreased ischial support, edema increased, and a pressure pad alone was not successful in controlling it. Use of a stronger valve spring, to increase the positive pressure, decreased edema. In spite of the failure to control the edema completely, the patient was able to perform at a high level of activity.</p> <h4>Case 6, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 6, male, was 56 years old, stood 6 ft. <i>2 </i>in. tall, and weighed 142 lb. He lost his right leg above the knee as a result of a motor coach accident when he was 47. The patient's first prosthesis, fitted six months after amputation, used shoulder harness suspension. It was worn for two years. The next prosthesis provided pelvic belt suspension. It was being worn when he entered the Clinical Study in November 1953 (<b>Fig. 13</b>). Complaints included tightness of the socket, discomfort due to abrasion of the hip by the belt on the side of the amputation, and irritation in the distal lateral area of the stump. The prosthesis was in a state of general disrepair.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Case 6 Original prosthesis. Weight carried on adductor roll. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>General health was good, and activity level was high both at home and at work. The stump was conical, with light subcutaneous tissue and very light musculature, muscular atrophy having been brought about by stump inactivity in the walking cycle. Tissue over the end of the stump was very thin. The lateral distal portion of the stump was scarred, and the ischial tuberosity was small, sharp, and lightly padded. Scars in the crotch area indicated periodic folliculitis and boil formation, and there was local pain posterodistally.</p> <p>A number of points were of interest in this case. They included a heavy adductor roll due to abducted gait and the plug fit; inexperience with suction suspension and ischial gluteal weight bearing; gait faults, including the abducted gait and pelvic hike on the side of the amputation; and the history of boils and folliculitis in the crotch due to weight bearing in that area (<b>Fig. 14</b>, <b>Fig. 15</b>, and <b>Fig. 16</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 14. Case 6, Relaxed position of stump prior to treatment </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15, Case 6. Adductor roll prior to treatment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Case 6. Triangular shape of original socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The amputee was provided with a suction socket prosthesis which included a single axis knee with constant friction swing phase control, a plantar dorsiflexion ankle, and a foot with a single toe break. Segments were willow wood reinforced with rawhide (<b>Fig. 17</b> and <b>Fig. 18</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Case 6. New prosthesis, with ischial gluteal weight bearing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Case 6. Shape of socket of new prosthesis </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the gluteus maximus was atrophied, the extensor channel and gluteal flare were fitted closely. No relief was provided for the heavy adductor roll, which was drawn completely into the socket as a part of the process of reduction. The socket perimeters at the brim of the socket were 3 in. less than stump dimensions. Two inches below the level of the ischial seat, socket perimeters were approximately half an inch less than stump dimensions. At the lower levels, socket and stump perimeters were identical. The distance from the ischial seat to the channel for the tendon of the adductor longus was 3 3/4 in., the corresponding anatomical measurement being 3 in.</p> <p>Adduction of the femur in the socket relaxed the adductors and permitted inclusion of the roll in the socket with less difficulty (<b>Fig. 19</b>). Initially a safety belt was provided to increase the amputee's sense of security, since he had a fear of losing the leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 19. Case 6. Condition of subject one year after application of new prosthesis. Note reduced adductor roll. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For the first three months of treatment the prosthesis was worn three hours a day. During the next six months use of the prosthesis was increased to all day, the extended period of adaptation to use of the prosthesis being due to discomfort at the ischial tuberosity. After nine months there was marked increase in comfort, a circumstance which induced the amputee to discard the cane he had theretofore used regularly. A soft pad over the ischial seat reduced discomfort but was discontinued after two weeks in the expectation that adaptation would be accelerated.</p> <p>Tight fit of the proximal third of the stump for reduction of the adductor roll resulted in edema in the distal portion of the stump. But when the socket perimeters in the upper third were increased to reduce constriction, the edema cleared up. Two weeks later the adductor roll had shrunk, and there was loss of suction. A new socket was made and modified with liners at intervals for a period of a month as shrinkage continued. By this time, the perimeter of the stump at the perineum had been reduced 2 1/2 in., so that a new socket was required. The dimension of this socket from the ischial seat to the channel for the tendon of the adductor longus was reduced by half an inch, and a protuberance was provided over the area contacting the femoral triangle.</p> <p>Edema recurred after six months, and examination of fit showed considerable development of the hamstring muscles. Accordingly, the socket was opened at the posterior wall starting 2 in. below the ischial seat level; the edema cleared up.</p> <p>Further development of stump musculature resulted in edema at the end of the stump during the ninth month of treatment. Increased hamstring relief was provided, a stronger valve spring was installed, and a sponge rubber pad was placed in the bottom of the socket to increase back pressure on the end of the stump. Again the edema cleared up.</p> <p>Training was provided for a period of one hour a day for six weeks. Gait was excellent under observation, although there was some reversion to old habits when the amputee was not under supervision. Pelvic hike was particularly persistent. Those habits which were dependent on fit and alignment, including abducted gait, were gradually eliminated.</p> <h5><i>Summary</i></h5> <p>Problems studied included stump changes, particularly at the large adductor roll, adaptation to suction suspension, adaptation to ischial weight bearing, and gait faults. Boils and folliculitis did not recur during the process of treatment.</p> <p>Reduction of the large adductor roll formed in five years of weight bearing in the crotch with abducted gait required six months of treatment. During this period there was some edema owing to constriction of the proximal third of the stump. Edema was reduced by increasing the perimeters of the socket in this region. Edema resulted again owing to constriction following hamstring hypertrophy.</p> <p>Relief for this development, the use of a stiffer valve spring for increased positive pressure in the stance phase, and a sponge rubber pad in the bottom of the socket cleared up the edema.</p> <p>There was periodic loss of suction following stump shrinkage. The light subcutaneous tissue could be distorted very little. As a result, slight stump changes led to loss of suction.</p> <p>Initially some lateral instability and reduced control of the prosthesis, probably resulting from weakness of the gluteus medius, was experienced. With adaptation to suction suspension, there was increased stability and control as the gluteus medius became stronger. Adaptation was completed within the nine months required to stabilize the stump. The ischial tuberosity took more than nine months to condition for weight bearing, chiefly because of the lack of previous experience, the light padding over the tuberosity, and the especially sharp configuration of the bone.</p> <h4>Case 8, Mid Thigh</h4> <h5><i>History</i></h5> <p>Case 8, another male, was 42 years old, measured 6 ft., and weighed 175 lb. His right leg was amputated above the knee in December 1949 after a shotgun wound received in a hunting accident approximately a year previously. He had had only one prosthesis since amputation and was wearing it at the time he was accepted by the Clinical Study in January 1954. Although the prosthesis provided suction suspension, the components were conventional. The patient was dissatisfied with the prosthesis primarily on the basis of poor fit, but he felt that the alignment could be improved and that such improvement might give him more comfort and better function. He also complained of needlelike phantom pains in the ball or sole of the "foot," with persistent tingling.</p> <h5><i>Examination and Evaluation</i></h5> <p>General physical examination was normal. The stump was conical (<b>Fig. 20</b>), approximately 9 in. of femur remained below the perineum, and about an inch of tissue covered the end of the femur. Musculature of the stump was firm, but there was retracted muscle on the lateral side about 2 1/2<i> </i>in. from the tip of the femur. There was little subcutaneous fat. On the posterior aspect of the stump at the distal end was an inverted T shaped scar, and the distal end of the femur was sensitive to pressure. X ray showed a medioposterior spur arising from the end of the femur, curving upward, and tapering. There was edema and brown discoloration at the end of the stump (<b>Fig. 21</b>), and small follicular lesions were evident in the areas contacting the anterior and medial brims of the socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 20. Case 8 Stump molded by tight fit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Case 8. Socket shape of original prosthesis. Note edema and brown discoloration at the end of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The prosthesis had a wooden socket reinforced with rawhide, a single axis knee with constant friction for swing phase control, an ankle providing plantar dorsiflexion action, and a foot with a single toe break 5 in. anterior to the ankle axis. Weigh t was carried through a roll of flesh at the brim of thesocket (<b>Fig. 22</b>), and the amputee walked with a wide based gait owing to crotch discomfort and out set of the foot. Knee stability was excessive because of the long forefoot and the posterior position of the knee axis, which fell approximately 1 in. posterior to the tro chanter ankle reference line. The prosthesis was short, but this detail was not too apparent since the ischial tuberosity was 1 1/2 in. above the posterior brim of the socket. Because of insufficient knee friction and excessive kicker action, there was heavy impact at the end of the swing phase, and there was whip during the swing phase, probably owing to muscle activity within the socket and to the vigorous stump action required to break the prosthetic knee at the end of the stance phase. Rotation at heel contact was due to excessive stiffness of the plantar flexion bumper.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Case 8. Original prosthesis. Plug fit, with roll formation over the socket brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Problems of interest to the Clinical Study included the edema encountered with use of suction suspension, skin infections, the adductor roll, the time and circumstances involved in conditioning the amputee to ischial gluteal weight bearing, and gait training.</p> <h5><i>Treatment</i></h5> <p>Reduction of the edema required reduced constriction of the proximal third of the stump through provision of ischial gluteal weight bearing, extension of the anterior wall above the level of the ischial seat, and close fit of the distal two thirds of the stump. Reduction of pressure on the proximal end of the stump from the superior brim of the socket was required to clear up skin infections. At the same time, snug fit, with adduction of the femur in the socket to relax the adductors, was required for reduction of the adductor roll. Improved fit and alignment, with training, were planned to correct gait faults.</p> <p>The amputee was provided with a suction socket prosthesis which included a single axis knee with constant friction swing phase control, a plantar dorsiflexion ankle, and a foot with a single toe break. Segments were of wood, reinforced with plastic laminate. The extensor channel was held shallow and flared minimally at the brim to increase gluteal weight bearing, since the amputee was not accustomed to ischial weight bearing. Xo relief was provided for the adductor roll. The anterior wall of the socket was slightly relieved over the area contacting the femoral triangle (<b>Fig. 23</b>). The toe break was cut 5 in. anterior to the ankle axis so as to coincide with the normal break of the shoe. To increase knee stability in the initial phase of the fitting, the knee axis was placed 3/4 in. behind the trochanter ankle reference line. Socket perimeters were 1 1/4 in.<i> </i>under stump perimeters at the proximal end and equal to stump perimeters at the level of the distal two thirds. The distance between the ischial tuberosity and the adductor longus tendon was 3 3/4 in., the corresponding socket dimension being 4 1/2 in.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Case 8 Socket shape, new prosthesis </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Evaluation following delivery of the prosthesis indicated that knee stability was excessive owing to the long forefoot and the posterior position of the knee axis. Training was required to improve balance and cadence symmetry and to overcome the vaulting as well as to reduce the width of the walking base. The ischial tuberosity was on the seat, and there was no ramus contact with the medial brim of the socket. The adductor roll was contained in the socket. Roll formation over the anterior brim of the socket was eliminated (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24 Case 8. New prosthesis. Note elimination of roll formation over the brim of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Initially there was some edema at the distal end of the stump owing to constriction proximally. As the flesh roll reduced, constriction and edema decreased, and finally the edema cleared up. After an illness which caused the patient to lose considerable weight, the stump settled deeper into the socket as the ischial tuberosity slipped inside. This circumstance allowed the ramus to contact the medial brim and caused the anterior and posterior brims to constrict the stump. But because the somewhat conical shape of both stump and socket maintained the snug fit over the entire stump as the latter settled down into the socket, and because, consequently, the pressure differential between the proximal and distal portions of the stump was not increased sufficiently, edema did not recur. Nevertheless, ramus discomfort decreased activity on the prosthesis. The problem was eliminated with provision of a new socket.</p> <p>Follicular lesions cleared up with effective ischial gluteal weight bearing but recurred when ischial support was decreased following loss of weight. Provision of a new socket with ischial gluteal weight bearing again cleared up the skin condition. With the first socket, poor stabilization of the ischial tuberosity on the seat contributed to skin irritation and to the formation of horny nodules in the weight bearing area. Comfort was greatly improved by reduced anteroposterior dimensions, with improved anterior support by provision of a protuberance on the anterior wall over the area contacting the femoral triangle.</p> <p>Gait training improved walking habits but focused attention on deficiencies of fit by forcing the amputee to walk according to a preconceived pattern rather than one that provided maximum comfort. Sixteen months after training was complete, evaluation indicated that, because of discomfort from loss of fit, gait was somewhat worse than before training. Since in any case the amputee adapted his gait pattern to provide maximum comfort, training was of doubtful value as compared with good prosthetic treatment. With the first prosthesis, excessive knee stability detracted from naturalness of gait, and this condition also was a factor in causing the discomfort in the ischial gluteal area and at the end of the femur anteriorly, where the stump showed the results of the force required to break the knee. Subsequent fit and alignment corrected these problems and greatly improved comfort. The length of the forefoot was reduced to approximately 3 1/2 in. to decrease knee stability, and the knee axis was placed on the ankle trochanter reference line.</p> <h5><i>Summary</i></h5> <p>The patient's edema on the prosthesis worn at the time of referral was apparently caused by constriction of the stump in the socket, especially in the proximal third. A contributing factor was weight bearing on the adductor roll over the medial brim. Provision of ischial gluteal weight bearing, with wide distribution of the pressure on the anterior aspect of the stump, had a number of consequences. The edema disappeared with the reduction of the adductor and anterior rolls and recurred only when fit and ischial support were lost with loss of weight from illness. Skin irritations in the crotch, along the gluteal fold, and around the ischial tuberosity were cleared up by reduction of shearing forces when positive support was provided. Reduction of alignment stability by shortening the toe break length and by moving the knee axis forward cleared up the skin irritation on the anterodistal aspect of the stump by reducing the force required to break the knee at toe off. Training appeared to have far less effect on symmetry of gait than did fit and alignment. When the patient was able to walk symmetrically with comfort, he did so. When last seen, the amputee reported a general increase in comfort and a corresponding increase in his level of activity.</p> <h4>Case 9, Bilateral Above Knee, Upper Third of Thighs</h4> <h5><i>History</i></h5> <p>Case 9, male, 27 years of age, weight 100 lb., underwent amputation at the age of eight as a result of crushing injuries to both legs sustained in a truck accident. He had had six pairs of legs since his amputation, the first pair having been fitted four months after surgery, without preliminary conditioning iherapy or exercise. That pair, employing shoulder harness suspension, was worn for four years. Between that time and 1948, he had had three sets of legs, all employing pelvic belt suspension and using conventional components. In 1948 he was fitted at the University of California with suction suspension. The prostheses were worn for two years and then discarded because of disrepair. New suction sockets, provided in 1950, were worn for two years. These were uncomfortable owing to tightness of fit. In 1953 a local limbshop fitted the patient with the suction socket prostheses he was wearing when referred to the Clinical Study in September 1953. The complaints included skin irritation with folliculitis, boils, and abrasion on areas of the stump contacting the socket brim; crotch discomfort; and edema in the ends of the stumps. Although working at essentially a sedentary occupation, he did a great deal of walking around his office.</p> <h5><i>Examination and Evaluation</i></h5> <p>There were no significant physical findings except as pertaining to the amputations. This young man was well nourished, healthy, and of average intelligence. The stumps were almost identical. They were approximately 6 in. long, measured from the perineum, and cylindrical, with approximately 2 in. of tissue over the distal ends of the femurs (<b>Fig. 25</b>). Hygiene of the stumps and prostheses was poor, perspira ation level high. There were boils, folliculitis, and abrasions on the stumps and the crotch areas, with boils and folliculitis in the inguinal creases. Both stumps had heavy, nonpitting edema and petechiae at the distal ends. The stumps were held in 28 deg. of abduction, but ranges of motion and muscle power were normal and equal. X ray showed medial curvatures of both femurs distally. The medullary cavities appeared to be closed, and there were no sensitive areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Case 9. Stumps relaxed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The prostheses (<b>Fig. 26</b>, <b>Fig. 27</b>, and <b>Fig. 28</b>) had rectangular suction sockets on single axis knees with constant friction swing phase control, plantar dorsiflexion ankles, and wooden feet with single toe breaks. Segments of the prostheses were made of willow reinforced with rawhide. No auxiliary suspension or control straps were used. Although the sockets were intended to provide ischial gluteal weight bearing, the ischial tuberosities were down inside the sockets so that weight was carried on the medial brims, which had been lowered in an unsuccessful attempt to provide relief, with severe wedging of the stumps against the anterior and posterior brims. This situation was a cause of irritation and infection of the stumps in the areas contacting the medial and posterior brims of the sockets and promoted edema by restriction of circulation. Excessive alignment stability due to posterior placement of the knee axes increased forces on the posterior aspects of the stumps as the amputee attempted to break the knees to initiate swing phase.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Case 9. Socket shape of prostheses worn at time of referral, medial walls nearest patient's hands. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Case 9. Prostheses worn at time of referral, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 28. Case 9. Pros theses worn at time of referral. posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient walked with a wide based gait, at least partially because of the abducted position of his stumps. He customarily used a cane but was able to walk without it. Because the amount of friction in the swing phase control units was adjusted to provide minimum resistance to rotation, there was impact at the end of the swing phase. Rotation at heel contact was due to excessive stiffness of the heel bumper of the left prosthesis. Torso and pelvic list were due to shortness of the right prosthesis.</p> <h5><i>Treatment</i></h5> <p>The objectives of treatment in this instance were:</p> <ol> <li>Elimination of crotch discomfort and skin problems by providing definite ischial gluteal weight bearing ;</li><li>Elimination of irritation and follicular lesions in the inguinal areas by reducing force concentrations in these areas through use of high anterior walls and definite ischial gluteal weight bearing;</li><li>Reduced wedging of the stumps proximally through provision of definite ischial gluteal weight bearing and high anterior walls for increased area of support;</li><li>Close fit oi the slumps along their entire lengths, with decreased wedging of the stumps proximally, for reduction of the edema;</li><li>Reduction in energy consumption by providing increased voluntary control with flexion of the stumps in the sockets and reduced alignment stability; and</li><li>Study of the effect of narrow and wide base alignment on lateral stability, within the limits imposed by the abducted positions of the stumps.</li></ol> <p>In March 1954, the patient was provided with two suction socket prostheses (<b>Fig. 29</b>). A light webbing belt was furnished to aid suspension. Single axis constant friction knees, plantar dorsiflexion ankles, and wooden feet with rocker toe breaks and foam crepe shoe sole material in the toes were used. The prostheses were reinforced with rawhide, the inside surfaces of the sockets were finished with cellulose acetate lacquer, and automatic expulsion valves with standard springs were used. For knee stability, the reference line joining the ankle axis to the point of contact of the greater trochanter passed 1 in. ahead of the knee axis on both prostheses. The ankles were provided with stiff plantar flexion bumpers to increase anteroposterior stability.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Case 9. Present prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Within approximately a month from the time of fitting the initial prostheses, there was substantial improvement in comfort and skin problems in the crotch areas. The medial brims were not appreciably lower than the posterior brims. Skin problems in the inguinal creases were relieved by ischial gluteal weight bearing, by high anterior walls, and by provision of a protuberance over the region of the femoral triangle (<b>Fig. 30</b> and <b>Fig. 31</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Case 9. Socket shape, present prostheses. Ischial seats are at bottom center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Case 9. Present prostheses, medial view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Provision of ischial gluteal weight bearing and increased anterior support resulted in reduced wedging of the stumps proximally, and a close fit of the stumps over their entire length produced a prompt and marked reduction in edema. Irritation in the weight bearing area was a persistent problem in the early stages of fitting. At one point, the amputee had the sockets modified in a commercial limbshop in an attempt to relieve this discomfort. But these changes increased the anteroposterior adjusted to dimensions of the sockets medially in the upper third. The tuberosities slipped into the sockets, and edema recurred. New sockets were fitted to re establish ischial support. Irritation and discomfort in the area of the tuberosities disappeared after approximately two months of conditioning. Ischial gluteal weight bearing raised the stumps in the sockets and decreased voluntary control, but after four months the patient became this change. It was found that he could walk with adequate control and stability when using stiff plantar flexion bumpers, with the ischial seats well behind the projected lines through the ankle and knee axes, and with initial flexion of the stumps for voluntary control (<b>Fig. 31</b>). Because of long established habits of abduction, it was necessary to provide wide base a lignment of the second pair of prostheses. At the time of the final evaluation, the stumps were in excellent condition.</p> <h5><i>Summary</i></h5> <p>The patient's problems of edema and skin irritation in the areas of the crotch, the inguinal creases, and the gluteal folds responded well to the standard principles of fitting. Irritation in the weight bearing area was a temporary problem which cleared up with tissue conditioning. A wide walking base was required in this case for lateral stability. The stiff plantar flexion bumpers provided anteroposterior stability both standing and walking. Placement of the sockets well forward on the knees provided adequate security.</p> <h4>Case 10, Very Short Above Knee</h4> <h5><i>History</i></h5> <p>Case 10, male, was 51 years of age, weighed 150 lb., and was 5 ft. 7 in. tall. Amputation was through the left femur in the upper third. The original amputation had been carried out in December 1952 as a result of arteriosclerosis, and the stump had been revised in August 1953.</p> <p>This patient was referred by a local limb shop that was in the process of fitting him with a pelvic belt prosthesis converted from a suction socket because of failure to maintain suction. He was pessimistic about the use of suction suspension and was unwilling to attempt it except for the benefit of the research group. Because of pressure in the groin, insecurity at the knee, toe scuffing in the swing phase, and stump withdrawal when sitting, he was dissatisfied with the leg being fitted by the local shop.</p> <h5><i>Examination and Evaluation</i></h5> <p>Physiologically, the patient appeared older than his age, but he was alert and cooperative. The abdomen was severely scarred from surgical incisions for appendectomy and double sympathectomy, and scars also extended from the distal end of the stump up the antero medial aspect to mid groin. The medial scars were deeply adhered to underlying tissue. Subcutaneous fat was moderate and musculature firm, with prominent adductors and gluteus maximus. There were no sensitive areas. Skin was normal. The femur extended 1 1/2 in. below the perineum and 7 in. below the great trochanter (<b>Fig. 32</b> and <b>Fig. 33</b>). A spur extended upward on the medial side, and the stump showed some abduction contracture.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Case 10. Lateral view of the stump in the hanging position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Case 10. Stump in 90 deg. of flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This patient was of interest primarily because of the very short stump. Also of interest was the patient's inexperience, which offered an opportunity to study problems of adaptation and stump changes. Experience in prosthetic treatment of cases with circulatory impairment was also desired.</p> <h5><i>Treatment</i></h5> <p>The patient was provided with a suction socket prosthesis. At first a single axis knee with constant friction swing phase control, a plantar dorsiflexion ankle, and a foot with single toe break were used. Segments were of wood, reinforced with plastic laminate. Later the knee was changed to a friction stabilized type. The final socket was made of plastic laminate, and a SACH foot (solid ankle, cushioned heel) was used instead of the conventional foot.</p> <p>Two sockets were fitted within the first two months. With the second socket, all requirements for the successful application of suction suspension had been met, but, because of obscuring factors related to the amputee's attitude, this condition was not altogether understood at the time. A remolding process had brought about elongation of the stump, a feature which made suction easier to maintain.</p> <p>Successful application of suction suspension depended upon undercutting the posterior, medial, and anterior walls of the socket below the ischial seat level, maintaining the lateral wall above the level of the ischial seat, and holding the fit close in the proximal part of the stump. Because of the undercut medial wall, bunching of the adductors did not break the suction. Suspension aids, valuable in providing increased sense of security in the initial phase of treatment, were unnecessary once the amputee was adapted to the use o'f his prosthesis. Because of the limited amount of femur available, and also because of the abducted position of the stump, no attempt was made to adduct the femur in the socket. Flexion of the stump in the socket was designed to meet the natural requirements of the stump and spine rather than to provide voluntary control of the knee, since stump power was limited and undercutting of the anterior and posterior walls of the socket reduced the effectiveness of the stump in controlling the knee (<b>Fig. 34</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Case 10. Rectangular socket provided for patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Initially the patient was provided with a conventional single axis knee with adequate knee stability. Fear of falling and buckling of the prosthetic knee due to weakness of the normal leg, inexperience, and other factors, however, led to use of a friction stabilized knee. But aligning the friction stabilized knee in accordance with the rules for the single axis conventional knee resulted in excess stability at the end of the stance phase. Accordingly, the knee was later aligned to provide decreased alignment stability with greater reliance on the friction mechanism.</p> <p>Although narrow based gait was not anticipated in the alignment of the limb, the amputee was able to walk with a 4 to 6 in. base. The prosthesis was made about 1 1/2 in. shorter than the normal limb (<b>Fig. 35</b>) because the amputee found that the shorter prosthesis permitted better control. Before prosthetic treatment started, the patient had back pains, and it was anticipated that the shorter leg might lead to recurrence. As a matter of fact, he had some recurrence of the back pains early in the fitting when a webbing belt was tried as a supplement to suction suspension. But this problem disappeared when use of the belt was discontinued.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Case 10. New prosthesis, posterior view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Stump changes during the study were minimal. In the first two and a half months, stump shrinkage occurred, but the stump remained stable throughout the following two years of observation. After the patient had worn the first suction socket prosthesis a short time, the tissue of the stump started to extend, so that by the time the stump had stabilized there was an increase from 1 1/2 in. to 3 in. of tissue available below the perineum for effecting a suction seal. At no time was there more than a reddening of the stump in the weight bearing area, and, as the tissue became conditioned, the skin became dark and tough. There was no edema.</p> <h5><i>Summary</i></h5> <p>The problem in this case was to attempt application of suction suspension to a very short, heavy, above knee stump. Suction proved to be a practical means of suspension. All walls were concave, and relief was provided for bunching adductors to prevent the stump from being forced away from the socket in the medial apexes with consequent failure of the suction seal. For increased control and reduced effort, the amputee preferred the prosthesis approximately 1 1/2 in. shorter than the normal leg. There were no back pains. The stump shrank slightly during the first two months, and there was elongation of the stump, particularly on the medial side. Because of insufficient knowledge for adequate prosthetic treatment of the patient, and because of the poor adjustment of the patient to his amputation and physical condition, rehabilitation was a lengthy process. Once the patient was successfully treated, no changes in fit and alignment were required over a two year period.</p> <h4>Case 24, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 24, female, was 41 years of age, stood 5 ft. 2 in. tall, and weighed 126 lb. She had undergone amputation at the level of the lower third of the left femur. There had been a congenital lymphangioma involving the tissues of the left leg from the knee down. Infection developed in the soft tissues over the anterior portion of the tibia, and subsequently there was an osteomyelitis of the tibia. Later a mass, which was diagnosed as carcinoma, appeared in the ankle. Amputation was performed in May 1954.</p> <p>The amputee had had only one prosthesis since amputation. It consisted of conventional components and a molded leather socket laced anteriorly (<b>Fig. 36</b>). When she entered the study program in January 1955, complaints included skin irritation and infection, with discomfort in the crotch, discomfort and restriction from the corset used to suspend the prosthesis, right sided backache, and excessive wear of hosiery.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Case 24. Prosthesis worn on referral. Note lateral displacement of the socket on the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>Normally a very active person, the patient had a rather low activity level owing to limitations imposed by her prosthesis. General physical condition was good, except for very flabby abdominal musculature, but the patient experienced phantom sensations as though the "leg" were "falling asleep." Phantom pains in the form of cramps in the ''calf" and shooting pains on the medial side of the "ankle" also were present. They lasted only a few seconds and were less frequent since she had been fitted with a prosthesis.</p> <p>The stump was cylindrical and 9 in. long measured from the perineum, including approximately 2 in. of redundant tissue over the end of the femur. Subcutaneous tissue was heavy but firm. Musculature was of average strength, with no group particularly prominent. There was no significant edema or skin problem in the distal end of the stump, but follicular lesions existed in the crotch, and areas of irritation were present on the torso from pinching and bruising by the corset stays.</p> <p>The prosthesis provided weight bearing on a flesh roll around the brim of the socket, in the crotch, and against the side walls of the socket (<b>Fig. 37</b> and <b>Fig. 38</b>). A pressure pad in the bottom of the socket did not provide appreciable support, and the patient walked with a wide base and with torso and pelvic list owing to excessive length of the prosthesis, wide base alignment, and discomfort in the crotch. Stride length, cadence, and arm attitude were unsymmetrical because of excessive stability of the prosthetic knee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Case 24. Socket shape at the brim, prosthesis worn on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Case 24. Lateral view of the stump in the hanging position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This amputee presented several problems of interest to the study group. They included skin infections, the relationship between redundant tissue at the end of the stump and edema with suction suspension, factors involved in changeover from corset to suction suspension, factors involved in changeover to ischial gluteal weight bearing, stump changes, the cosmetic problems of a female amputee, and use of the SACH foot with high heeled shoes.</p> <h5><i>Treatment</i></h5> <p>In September 1955, the patient was provided with a suction socket prosthesis consisting of a single axis constant friction knee, a SACH foot made for a high heeled shoe, and wooden segments reinforced with plastic laminate. An automatic expulsion valve with standard spring was used, and the inside surface of the socket was finished with phenolic resin varnish. A polyvinyl chloride acetate cosmetic cover was provided for the shank. Since the amputee was unaccustomed to ischial weight bearing, and also in order to increase sitting comfort, the gluteal flare and the extensor channel were fitted closely to provide increased gluteal support. The lateral wall was closed in over the stump above the ischial seat level, and the anterolateral apex was closed to reduce conspicuousness of the brim of the socket under the clothing.</p> <p>This socket was worn on the adjustable leg<a></a> for approximately a month and was then installed in a finished prosthesis. After a week, the redundant tissue at the end of the stump was moderately edematous. The only known difference between the prosthesis with the adjustable leg and the finished prosthesis was that the latter had five coats of "Platon" varnish on the inside of the socket. There were three possibilities related to the finish of the socket interior. The stump worked down into the socket through weight bearing, with increased effect of muscle activity on negative pressure and reduced positive pressure in the stance phase owing to reduced excursion of the stump in the socket. There was adherence of the stump to the walls of the socket and, hence, reduced massaging action at the distal end. Vacuum seal was improved so that negative pressure was maintained, especially during sitting.</p> <p>The edema cleared up after provision of a pressure pad in the bottom of the socket and after atrophy of the stump, which reduced constriction proximally. In addition there was, as a result of aging and lubrication of the surface finish by body oils, decreased adherence of the stump to the socket. Addition of liners to compensate for shrinkage did not cause edema with this socket.</p> <p>A second prosthesis was supplied in December 1955, the socket of this limb being fitted snugly in anticipation of further shrinkage of the stump. Six weeks after delivery of the prosthesis, examination showed edema at the end of the stump. A pressure pad was provided, but there was no reduction in the edema during the next two months. Pad thickness was then increased. When the amputee was examined next, six weeks later, the pad had been discarded owing to ineffectiveness in controlling the edema. Edema was reduced, and the stump had atrophied further. This development had reduced constriction of the proximal portion of the stump without reducing the effectiveness of ischial support, thus indicating that edema was caused by constriction of the proximal area and that the pressure pad was ineffective in reducing it so long as constriction persisted proximally. Six weeks later there was no edema, and the socket was looser. Liners were installed over the anterior and posterior walls to decrease perimeters of the socket in the upper third by one inch. Edema did not recur. Socket perimeters proximally were reduced another inch two months later as a result of stump atrophy. There was no edema before or after addition of the liners, and at no time was there failure of ischial support.</p> <p>The patient adapted very well to the changeover from corset to suction suspension and appreciated the comfort and freedom that resulted. Control of the prosthesis was excellent. Adaptation to ischial gluteal weight bearing was immediate, and skin lesions and discomfort in the crotch cleared up quickly. The shallow gluteal flare and extensor channel, with relief for hamstring attachments at the ischial tuberosity, provided sitting comfort. As the stump atrophied, proper weight bearing was maintained effectively by the addition of liners to the anterior and posterior walls of the socket as necessary (<b>Fig. 39</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Case 24. Socket shape, new prosthesis. Note liners added for shrinkage adjustment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Stump atrophy due to heavy subcutaneous tissue was a problem, and the stump had not stabilized at the end of a year. It was found that initial fitting of the socket snugly, in anticipation of shrinkage, was satisfactory practice and did not produce a serious amount of edema. Such edema as was produced subsided as stump atrophy proceeded. As further shrinkage occurred, liners were added without complications.</p> <p>Closing the lateral wall over the stump above the ischial seat level and curving the anterolateral apex improved appearance of the prosthesis under clothing. The SACH foot provided a good cosmetic junction between the shank and the foot and permitted use of high heeled shoes. The polyvinyl acetate cosmetic covers used were sufficiently durable (<b>Fig. 40</b>) and were acceptable in appearance until they become discolored. Staining was objectionable within about six months.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 40. Case 24. Anterior view of new prosthesis with cosmetic covering. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the cosmetic effect of the SACH foot was appreciated by the amputee, there was objection to the decreased plantar flexion action and to the damage this caused to spike heeled shoes. As a result, the patient requested a foot with an articulated ankle. It was found that the decreased plantar flexion action was a problem down ramps only.</p> <h5><i>Summary</i></h5> <p>In spite of the excessive amount of redundant tissue at the distal end of the stump, it was possible to use successfully suction suspension embodying the principles and techniques previously outlined. Problems of edema, skin changes, and loss of suction that occurred during fitting and wearing of the prosthesis were successfully treated by controlling the fit and alignment. Proper fit and alignment were instrumental in promoting stump reduction to a more firm and functional state and in eliminating skin lesions and discomfort in the crotch due to the heavy subcutaneous tissue and steady stump reduction. With a properly fitted suction socket prosthesis, the patient was able to assume a more satisfactory level of activity without discomfort, and it was possible without difficulty to adapt this type of prosthesis to the requirements of cosmetic appearance. Foot and ankle function were suitable for use with high heeled shoes, but frequent examinations and modifications to socket fit were required to maintain comfort.</p> <h4>Case 28, Lower Third of Thigh</h4> <h5><i>History</i></h5> <p>Case 28, male, age 62, height 5 ft. 11 in., weight 121 lb., underwent amputation in the lower third of the left femur in June 1955 following circulatory failure. When he entered the Clinical Study in August 1955, he was wearing a plaster socket on a peg leg with shoulder harness suspension. He disliked the peg leg because of its appearance and because of discomfort in the crotch. Activity level postoperatively was very much less than prior to amputation and was a matter of great concern to the amputee, who had just retired to a small farm.</p> <h5><i>Examination and Evaluation</i></h5> <p>The amputee's physiological age was in advance of his chronological age. The stump was 11 in. long and cylindrical, with light subcutaneous tissue, average musculature considering the age of the patient, and full range of motion at the hip (<b>Fig. 41</b>). The end of the femur was adequately covered and tolerated considerable pressure. At the end of the stump there was persistent, mild pain not related to use of the temporary prosthesis, and there were diminishing shooting phantom pains. X ray showed a spur on the lateral distal end of the femur. Postoperative edema was slight. The plaster socket on the pylon leg had been furnished to aid in reducing the stump. As shrinkage proceeded, the number of stump socks used had been increased to adjust for it. Considerable stump shrinkage had occurred, a circumstance which, despite the added stump socks, allowed the stump to drop into the socket. Severe crotch discomfort was present, since ischial weight bearing was not used. The amputee walked with a circumducting gait, stride length on the prosthesis was shorter than that on the normal side, there was rotation around the pylon in stance phase, gait was abducted, and one cane was used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Case 28. Stump in abduction, slack tissue on medial side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of interest to the research group were the effects of the temporary plaster socket and the peg leg, stump changes, the rate of rehabilitation of the amputee, and evaluation of suction suspension on an elderly amputee with circulatory deficiency.</p> <h5><i>Treatment</i></h5> <p>The patient was provided with a suction socket prosthesis which included a willow socket, a variable cadence friction controlled knee, a willow shank, and a SACH foot (<b>Fig. 42</b> and <b>Fig. 43</b>). Wooden segments were reinforced with plastic laminate, and the socket was finished inside with a phenolic varnish. The extensor channel was shallow, and there was minimal gluteal flare to ensure as much gluteal support as possible (<b>Fig. 44</b>). The anterior wall protruded over the area contacting the femoral triangle starting at the anterior brim and extending downward to a point one third the distance down into the socket. Evaluation of the finished prosthesis indicated that the forefoot was too long and that there was insufficient initial flexion of the stump in the socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Case 28. Lateral view of new prosthesis. Note amount of initial flexion of the stump, as indicated by the angle between the shank and thigh sections Note also extension of the gluteus maxi mus over the brim of the socket, indicating weight bearing on the tendinous hamstring attachments. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 43. Case 28. Posterior view of new prosthesis providing ischial gluteal weight bearing and narrow based alignment. Knee is friction stabilized. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Case 28. View of the crotch area of the stump and of the socket brim of the new prosthesis. Note the distance between the level of the ischial tuberosity and the very prominent tendon of the adductor longus. Note also the corresponding socket dimension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At first the amputee found it difficult to don the prosthesis, partly because of his age and partly because of the snugness of fit, which was intended to aid in stump reduction. The difficulty decreased as the patient became more accustomed to the limb and as snugness was reduced with stump shrinkage. Because of the patient's age and physical condition, it was necessary to maintain a comparatively low activity level during fitting and training, a matter which resulted in minimum discomfort or abrasion of the skin from impact between the stump and socket. The single axis knee offered sufficient stability under normal circumstances, but the amputee felt insecure at such activities as gardening. As a result, he was provided with a friction stabilized knee, and alignment stability was reduced. Initial indications were that the friction stabilized knee was an advantage, especially at heel contact. More supervision during fitting and training was required than is usually the case with younger amputees. Suction suspension offered good control, but had the patient been weaker this method of suspension might not have been practical because of the difficulty of putting the leg on.</p> <p>Gait evaluation showed two faults. One, circumduction of the prosthesis, was probably carried over from the peg leg. The other, which consisted of stepping from the prosthesis to the normal leg as soon as the resistance of the prosthetic forefoot was felt, may also have been related to the use of the pylon. Training reduced but did not eliminate these characteristics of nonsymmetrical gait.</p> <p>There was consistent stump shrinkage over the first six months of treatment. The initially snug fit of the socket was of limited significance since shrinkage was extensive. Addition of liners as the stump shrank was a successful means of maintaining fit, although it eventually affected alignment. Most extensive shrinkage occurred in the proximal third of the stump. Postoperative edema was not a significant factor, nor was stump hypertrophy. To avoid excessive enlargement of the socket during adjustments, it was necessary to apply a shrinker bandage before prosthetic treatment was started.</p> <p>There were no fitting problems related to the limited time lapse between amputation and prosthetic treatment. Adaptation was rapid, and the cane used with the plaster pylon was discarded before delivery of the permanent prosthesis. Use of the prosthesis as part of the reduction treatment introduced the difficulty of frequent examinations and adjustments but was less troublesome and more effective than applying the shrinker, especially at the proximal end of the stump, which the amputee found difficult to wrap properly.</p> <p>At no time were there skin or circulatory problems with suction suspension, but initially there was moderate discoloration at the distal end of the stump owing to the snugness of fit at the proximal end. Loss of suction, a matter related to the lightness of the subcutaneous tissue, was a frequent problem. Only a small amount of stump shrinkage produced loss of suction, since the amount of tissue distortion possible prior to shrinkage was limited, which is to say that stump fit had to be maintained close to optimal at all times.</p> <p>Some end bearing was provided on a pad of foam crepe shoe sole material in the bottom of the socket. When end bearing was increased periodically as the stump dropped deeper into the socket with stump shrinkage, the stump end became sensitive and even painful.</p> <h5><i>Summary</i></h5> <p>Problems studied with this amputee included those involving his age, his experience on the peg leg, stump changes, rate of rehabilitation, use of suction suspension where there had been circulatory impairment, and training. Prosthetics treatment was more time consuming, but stump discomfort was not a problem since activity level was low. At first the patient found the leg hard to put on, but this problem was overcome with practice. Fitting and training schedules were less strenuous than would be followed with a younger amputee. Use of the friction stabilized knee increased the amputee's confidence, and voluntary control was thus improved because it was possible to provide more flexion of the stump in the socket. Use of the temporary prosthesis with plaster socket and peg leg attachment introduced gait problems which could not be eliminated entirely, but the plaster socket was effective as a means of reducing postoperative edema. There was, for example, almost no postoperative edema when treatment was started. It was therefore not a problem. Suction suspension caused no circulatory difficulties.</p> <h3>Case 37, Very Short Above Knee</h3> <h5><i>History</i></h5> <p>Case 37, male, age 39, height 5 ft. 11 in., weight 180 lb., underwent amputation through the right femur, 1 1/2<i> in.</i> below the perineum, as a result of an injury sustained in World War II. At various times, but without success, attempts had been made to fit him with above knee prostheses, including suction (<b>Fig. 45</b>) and belt suspension. These circumstances led to a proposal by the referring agency to have the patient fitted as a hip disarticulation case using the Canadian type of prosthesis.<a></a> A plaster cast check socket had been fitted as a preliminary, with apparent success.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Case 37. Unsuccessful suction socket worn on referral. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Examination and Evaluation</i></h5> <p>The stump, though short, was powerful, and the end of the femur was covered by approximately 1 in. of muscle padding. Subcutaneous tissue was fairly heavy. The ischial tuberosity was broad and well padded, but there was pressure sensitive scar tissue on the lateral side of the stump and in the crotch (<b>Fig. 46</b>, <b>Fig. 47</b>, and <b>Fig. 48</b>). The distal end of the stump tolerated considerable pressure but, because of a trigger point on the anterodistal aspect, it was unsatisfactory for end bearing. Abduction and flexion contracture of the hip was typical of an above knee amputee with a short stump. Because of the habit of extending the knee when crutch walking, a practice which had reduced extensor control at the knee, the normal knee buckled occasionally under load in the flexed position. A triple arthrodesis of the normal ankle was an additional complication.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Case 37. Posterior view of stump. Note scar on posterolateral apex. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 47. Case 37. Anterior view of stump. Note scars in crotch and on lateral side of anterior aspect. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Case 37. Lateral view of stump in maximum flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Treatment</i></h5> <p>The problem presented was how to fit an amputee who was on the borderline between the above knee case and the hip disarticulation. Were the patient fitted as a hip disarticulation, there would be loss of stump function, and, since the amputee lived in a hot summer climate, the socket would present a particularly acute heat problem. Joint placement with the hip disarticulation prosthesis would also be a problem, since, when the stump was flexed, it extended 2 in. ahead of the usual anterior contour for a hip disarticulation amputee.</p> <p>An above knee type of prosthesis offered the advantage of preserving stump function, particularly where suction suspension could be used effectively, since with the use of suction there is reduced excursion and piston action of the stump in the socket. At the same time, the shortness of the stump, with the reduced area for effecting a suction seal, and the large volume change in the stump between the relaxed and the tensed states, accompanied by prominent bunching of the adductors, could cause difficulty in achieving a reliable suction seal. Moreover, the possibility existed that the close fit required could cause discomfort to the sensitive scar tissue in the crotch.</p> <p>It was decided to treat this patient simultaneously as an above knee and as a hip disarticulation amputee, first to check the possibilities of using suction suspension on such a short stump and, second, to check the Canadian hip disarticulation prosthesis as a method of treating very short above knee stumps. The amputee was successfully fitted with a plaster hip disarticulation check socket and walked for two hours with a peg leg attached. The socket constructed from this check socket would have provided sufficient clearance for installation of the hip joint, but the hip disarticulation fitting was discontinued at this stage because of success achieved with suction suspension.</p> <p>Within five days of the beginning of treatment the subject walked successfully on the adjustable leg using suction suspension. The first socket failed from loss of suction through the posterolateral apex because the socket had been enlarged in this area in an attempt to compensate for the action of the gluteus maxi mus, which tended to force the stump away from the socket. The second socket, modified in view of lessons learned from the first, held suction and was comfortable (<b>Fig. 49</b>). It was provided in a finished prosthesis. A short above knee pelvic harness, as designed at the University of California (<b>Fig. 50</b>), was added to assist in swing phase control and to maintain the prosthesis on the stump in the sitting position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Case 37 Successful suction socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Auxiliary suspension for short stump above knee amputee (modified Silesian belt), as designed at the University of California. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Components incorporated into the finished prosthesis included a SACH foot, a wooden shank reinforced with plastic laminate, a friction stabilized knee, and a wooden socket providing definite ischial gluteal weight bearing. The tuberosity was located on the posterior edge of the seat, so that considerable weight was carried on the tendinous hamstring attachments, and the gluteal flare was fitted close to provide some gluteal support and to ensure a suction seal. The medial brim was held level with the posterior brim, while the anterior brim extended 2 1/2 in. above the ischial seat level. The socket protuberance into the area of the femoral triangle did not extend below the level of the ischial seat, and the lateral brim was held at the same level as the anterior brim. To aid in effecting a suction seal, the perimeter of the socket was enlarged below the brim level. The concavity of the anterior wall started 1 in. above the level of the ischial seat and extended downward, while the concavity of the lateral wall was above the ischial seat level. Concavity of the medial wall below the brim provided room for the prominent adductors, so that suction was not lost when the stump was tensed. At the brim, the socket perimeter was approximately 3 in. less than the stump perimeter. Alignment stability was reduced, inasmuch as a friction stabilized knee was provided.</p> <p>The short stump harness was successful in preventing loss of suction during sitting, the leg adhered firmly with tensing of stump musculature when the amputee walked, and there was no ramus discomfort. The scar in the crotch proved to be no problem in fitting and was not a source of discomfort. Except for a mild discomfort in sitting, which resulted in stretching of the skin, especially while sitting in soft seats, there was no discomfort from the posterior brim of the socket. Gait was satisfactory using one cane.</p> <p>Examination one month after treatment. was begun showed little change in the stump since the initial examination; it had simply elongated about 1/2 in. on the medial side. The ischial tuberosity tolerated weight bearing without difficulty, and the skin over that area was somewhat toughened. No edema, skin abrasion, or skin infection was evident. Six weeks after treatment started the amputee used the leg all day with one cane, but at a low activity level. Buckling of the normal knee was reduced as a problem when use of the knee increased with improved physical condition.</p> <p>Five months after treatment started the amputee wore the prosthesis from rising to retiring, and the stump was in excellent condition. Activity level was average, considering the level of amputation. One cane was used, although the patient was able to walk without it. There was some brownish discoloration in the weight bearing area. Stump shrinkage was not noticeable, and there was no further elongation of the stump. The tuberosity was firmly supported on the ischial seat, and there was no crotch discomfort, although there was slight skin irritation in the crotch due to roughness of the socket finish. The amputee considered the socket comfortable but wanted the leg lengthened. The rough area on the medial brim was covered with "Teflon" tape in an attempt to reduce friction. Elongation of the prosthesis by 5/8<i> </i>in. resulted in an improved gait appearance.</p> <h5><i>Summary</i></h5> <p>The problem in this case was to define prosthetic requirements correctly. Suction suspension with the above knee type of prosthesis, in conjunction with the short stump pelvic harness, was successful and, since it preserved usable function of the stump, seemed to offer for this amputee a method of treatment to be preferred over the hip disarticulation prosthesis. Difficulties encountered were minimal owing to the previous experience gained with Case 10 (page 64).</p> <p>Gait, more natural with the use of one cane, improved markedly over the five months of study. Weight bearing on the gluteus maxi mus, ischial tuberosity, and tendinous attachments of the hamstring musculature was satisfactory. Use of the high anterior wall, without a protuberance of the socket wall over the area in contact with the femoral triangle, except above the ischial seat level, was satisfactory. For retention of suction, it was necessary to make all walls of the socket concave, especially below the medial brim because of bunching of the adductors.</p> <h3>Conclusion</h3> <p>From working with a group of amputees such as has been reported here, or from work with any similar group, many lessons are to be learned. One of the most obvious is that considerable "tincture of time" is required to solve chronic problems. The hope is that, as a result of the considerable amount of time devoted by a relatively small group of research subjects at the University of California, prosthetics clinic teams will gain some insight into possible methods of solving the problems of many other amputees.</p> <p>The most common prosthetic problems of above knee amputees as a group are edema, formation of an adductor roll, discomfort in the perineum (ramus pressure), and skin lesions. It has been found possible to control edema by maintaining a relatively uniform contact pressure between stump and socket. The proximal third of the socket need be fitted only slightly tighter than the more distal areas while still maintaining an airtight seal. In the case of an edematous stump, it is important to recognize the necessity for skillful application of socket liners to maintain a functional socket fit as the edema is reduced. Such liners are usually applied along the anterior and lateral walls only.</p> <p>The adductor roll which typically occurs with plug fit requires considerable time before the change can be made to an efficient, well fitting suction socket. Almost without exception, such a condition requires a second socket to complete the fitting.</p> <p>Ramus pressure is a thing of the past. Use of the higher anterior brim and the proper anteroposterior dimension from Scarpa's triangle to the posterior brim will eliminate completely this most troublesome complaint of above knee amputees. No longer need the above knee amputee suffer in silence because he just naturally expects his leg to be uncomfortable in this area.</p> <p>Provision of an efficient supporting surface along the posterior brim of the socket and of a proper fitting of the lateral wall of the socket to provide femur stabilization will relieve common areas of skin irritation, such as at the anterior brim, at the ischial seat, at the medial brim, and at the lateral distal end of the stump. The most common sources of skin difficulties are poor stump hygiene or rubbing and abrasion. Abrasion can be minimized by a functional fitting of the socket.</p> <h3>Acknowledgments</h3> <p>The group that worked on the patients presented in this article comprises in fact the whole staff of the Lower Extremity Amputee Research Project. Even more than amputee treatment must be, this study has been the product of many minds and many labors. Particular mention should be made of the staff members who were especially concerned in the study of the patients here reported. Dr. Henry E. Loon, Coordinator of the Medical Division, served as medical consultant to the group through much of the work. Jack C. Bates, Prosthetic Specialist, served in the vital function of trainer, in addition to making all arrangements with patients. And Jim C. McKennon and William H. Hoskinson served as prosthetists and faced the task of interpreting the plans of the research group as fully as possible to the patients in the fitting room.</p> <p><b>References:</b></p> <ol> <li>Eberhart, Howard D., and Jim C. McKennon, <i>Suction socket suspension of the above knee prosthesis</i>, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</li> <li>Foort, J., and C. W. Radcliffe, <i>The Canadian types hip disarticulation prosthesis</i>, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Prosthetics Research Board, National Research Council, March 1956.</li> <li>Radcliffe, C. W., <i>Use of the adjustable knee and alignment jig for the alignment of above knee prostheses</i>, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</li> <li>Radcliffe, Charles W., <i>Mechanical aids for alignment of lower extremity prostheses</i>, Artificial Limbs, May 1954.</li> <li>Radcliffe, Charles W., <i>Alignment of the above knee artificial leg</i>, Chapter 21 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Radcliffe, Charles W., <i>Functional considerations in the fitting of above knee prostheses</i>, Artificial Limbs, January 1955.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, <i>The suction socket above knee artificial leg</i>, revised edition, April 1948.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>The suction socket above knee artificial leg</i>, 3rd edition, April 1949.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, <i>Functional considerations in fitting and alignment of the suction socket prosthesis</i>, March 1952.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Functional considerations in the fitting and alignment of the suction socket above knee prosthesis</i>, 2nd edition, August 1953.</li> <li>Wagner, Edmond M., <i>Contributions of the lower extremity prosthetics program</i>, Artificial Limbs, May 1954.</li> <li>Wagner, Edmond M., and John G. Catranis, <i>New developments in lower extremity prostheses</i>, Chapter 17 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954. See especially pp. 497 and 547.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Foort, J., and C. W. Radcliffe, The Canadian types hip disarticulation prosthesis, University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Prosthetics Research Board, National Research Council, March 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower extremity prostheses, Artificial Limbs, May 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower extremity prostheses, Artificial Limbs, May 1954.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower extremity prosthetics program, Artificial Limbs, May 1954.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis, New developments in lower extremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954. See especially pp. 497 and 547.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Functional considerations in the fitting of above knee prostheses, Artificial Limbs, January 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon, Suction socket suspension of the above knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower extremity prostheses, Artificial Limbs, May 1954.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above knee artificial leg, revised edition, April 1948.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above knee artificial leg, 3rd edition, April 1949.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in the fitting and alignment of the suction socket above knee prosthesis, 2nd edition, August 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>James Foort, M.A.Sc. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Engineer, Lower Extremity Amputee Research Project, University of California, Berkeley; formerly with Prosthetic Services Centre, Canadian Department of Veterans Affairs, Sunnybrook Hospital, Toronto.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Norman C. Johnson, M.D. </b></td></tr><tr><td class="clsTextSmall">Orthopedic Consultant, Lower Extremity Amputee Research Project, University of California, Berkeley.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Engineering Design, University of California, Berkeley; member, Committee on Prosthetics Research and Development, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-39.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-42.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-43.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-44.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-45.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-46.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-47.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-48.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-49.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-50.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-51.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-52.jpg Figure 13 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-53.jpg Figure 14 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-54.jpg Figure 15 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-54b.jpg Figure 16 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-55.jpg Figure 17 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-56.jpg Figure 18 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-57.jpg Figure 19 http://www.oandplibrary.org/al/images/1957_01_041/1957-Spring-58.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Some Experience with Prosthetic Problems of Above Knee Amputees Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * Norman C. Johnson, M.D. * James Foort, M.A.Sc. * https://staging.drfop.org/files/original/627090118e7550aef32b928f5cfc5097.pdf c7c3671e2f62151182aae56f91f5d70f https://staging.drfop.org/files/original/c7e92f6d5fe85c8d6ef8544614a97aa3.jpg e468493086048ce57199f393dee24774 https://staging.drfop.org/files/original/04ce23f2e2248f3d1d49330516618203.jpg 5ad71da0cd2407e65b1be1093f9dad0d https://staging.drfop.org/files/original/37a6c5bccac772225e463355b7ce5b99.jpg 5fdd10eb7e82869440f88ddc8281c621 https://staging.drfop.org/files/original/1df47c562dff18af23aea5737e89ad4f.jpg d057a4335966a37fed05ecf311b6fa49 https://staging.drfop.org/files/original/66602a6f594faa462098d6e7eae66228.jpg b1e3ac1eed82d64494c9acf1af76bd6f https://staging.drfop.org/files/original/beceed2ac3ba9eecfcc08cf2abe51169.jpg 9ae2a1c0df624061372096332c5fce03 https://staging.drfop.org/files/original/d308ea30b792e6fb6e57c9d43f2f66f5.jpg 8be6fb5bd0b864a1f0104a3e23affdd6 https://staging.drfop.org/files/original/5e8c8f8672d073a25e049c5a392e5ef1.jpg 5774196adae9a8c9364a6e9134b7bde9 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_029.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 29 - 39 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_029.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_029.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>Status of the Above-Knee Suction Socket in the United States</h2> <h5>Chester C. Haddan <a style="text-decoration:none;">*</a><br />Atha Thomas, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The above-knee suction socket constitutes a means of attaching an artificial leg to the stump of an amputee without necessity for the conventional pelvic band, a metal hip joint, or other types of suspension harness (<b>Fig. 1</b>). The leg is held on by the slight vacuum created in the socket each time the leg is lifted from the ground, the pressure usually being controlled by a valve installed in the lower portion of the socket. Accurate functional fit of the socket, as distinguished from the conventional "plug" fit, permits the creation of negative pressure, gives a wider range of muscular control of the leg, and provides comfort while walking or sitting. Because the conventional belt and hinge joint are eliminated, the suction socket gives the above-knee amputee more freedom and less interference with clothing. The leg feels more like an integral part of the body, a feature which tends to decrease the sensation of dead weight and to improve sense of position. Reduced piston action of the stump in the socket results in greater toe clearance during walking. No stump sock is necessary. Any adductor roll is corrected. And finally, active use of the stump muscles causes them to develop instead of becoming atrophied. For a complete discussion of the prescription, fabrication, fitting, alignment, and use of the above-knee suction-socket prosthesis, reference may be had to Bechtol,<a></a> to Eberhart and McKennon<a></a>, and to the so-called "suction-socket brochure" of the University of California.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical above-knee suction-socket leg before application of the usual rawhide finish. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Early History</h3> <p>The earliest known reference to the suction socket is in the form of a patent issued by the United States, February 10, 1863, to Dubois D. Parmelee<a></a> of New York City. Subsequent patents have been issued to George Beacock and Terence Sparham<a></a> of Brock-ville, Ontario, Canada, in 1885; to Justin K. Toles<a></a> of Stockton, California, in 1911; and to Ernest Walter Underwood<a></a> of Birmingham, England, in 1926. The fundamental principles of the Beacock and Spar-ham suction socket differed but little from those of the Parmelee method. Toles' description was basically the same but with the addition of a rubber lube and bag lining which could be inflated by air to assist in holding the socket on. The socket described by Under- wood had smooth helical grooves, which he claimed ventilated the stump as well as assisted in holding the socket in place.</p> <p>A search of the literature on above-knee suction sockets has revealed only a few articles prior to the last few years. In 1925 Muirhead Little<a></a> of England reported favorably on 11 amputees fitted with the suction socket after the design of Blatchford,<a></a> made of metal, and containing a smooth helical groove of a little more than one turn around the circumference of the socket. Some 30 cases were reported as fitted at Roehampton, England, following World War I using a metal socket with a helical groove as described by Blatchford.<a></a> It is not known whether these 30 cases included the 11 reported by Muir-head Little, but it is considered doubtful since during this period several different groups were using the suction socket in England. Use of the suction socket has been practically dormant in England since that time, although it has been revived in recent years.</p> <p>Pfau<a></a> of Berlin says the suction socket has been known in Germany for 30 years but that it was not popularized until Oesterle, in Ulm, started his work in the early '30s. Felix,<a></a> a surgeon of Diisseldorf, reported on above-knee sockets in 1941. He stated that the suction socket had been used in Germany to some extent since World War I but that it was not popularized until a satisfactory suction-socket valve had been developed in 1932. After this accomplishment, numerous selected cases were successfully fitted in Germany.</p> <p>As a result of the apparent reported success with artificial limbs in Germany, early in 1946 the Surgeon General of the United States Army sent to Europe a "Commission on Amputations and Prostheses" to observe foreign practice. One principal item of interest was the successful use in Germany of suction sockets for above-knee prostheses. Because of the favorable report<a></a> issued by the commission, the Advisory Committee on Artificial Limbs instituted, as one activity of its general plan of providing information on the best possible prostheses, a program to determine the possibilities and limitations of the suction-socket type of suspension for the above-knee leg.</p> <h3>Clinical Research in the United States</h3> <p>After extensive trials and studies in their own laboratory, workers at the University of California, Berkeley, prepared instructional material and started a nation-wide program to determine the feasibility of use of the above-knee suction-socket technique under field conditions in the United States. By September 1947, 52 subjects had been fitted in 10 widely separated localities by local prosthetists in their own shops with materials and devices normally employed but making use of supplementary information and supervision by University personnel.</p> <p>The success of this program led the Advisory Committee on Artificial Limbs, in October 1947, to recommend to the Veterans Administration the use of the suction-socket technique for above-knee amputees, its use being limited for the time being to further field tests within the VA under the direction of qualified surgeons. The recommendation was accepted and, from December 1947 through January 1949, 20 schools, each of one week duration, were held throughout the country to provide 250 orthopedic surgeons and 200 prosthetists with sufficient knowledge of the fabrication and application of the suction socket to introduce it on an experimental basis.</p> <p>By October 1949 comprehensive records had been made of over 500 cases, and ACAL felt that sufficient experience had been gained in the use of the suction socket to warrant its general application. Accordingly, a recommendation was made to the Veterans Administration, and the above-knee suction socket has since been in use routinely. The Orthopedic Appliance and Limb Manufacturers Association and the Veterans Administration, in a cooperative effort, have sponsored suction-socket schools from time to time to permit surgeons and limbfitters to gain sufficient knowledge in this field to qualify them to prescribe and fit the suction socket.</p> <h3>Surveys Of Amputee Acceptance</h3> <p>The enthusiasm with which the suction-socket above-knee leg has been accepted in the United States is indicated by the results of a number of surveys. Among them are the surveys of selected groups made by Thorndike and Eberhart <i>, </i><a></a> by Mazet, McMaster, and Hutter <i>, </i><a></a> and by Canty and Asbelle.<a></a> Results of three surveys, two by the Orthopedic Appliance and Limb Manufacturers Association, are shown in <b>Table 1</b>. The earliest data are from a University of California report<a></a> of April 1948. The 52 cases reported at that time had been carefully screened, selected, and fitted under the supervision of representatives of the Advisory Committee on Artificial Limbs. The results were carefully recorded. At the termination of this initial experimental program on April 15, 1948, of the 52 subjects fitted, 40 had been wearing their suction-socket legs routinely for 4 to 20 months. All were satisfied and had no intention of returning to the type of prosthesis worn previously. Six of the subjects, owing to improper fittings, nervous disorders, or lack of cooperation, were still alternating between the suction-socket leg and their previous legs. Six had been dropped from the program and were considered as failures.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In February 1949, the Orthopedic Appliance and Limb Manufacturers Association, in an effort to determine the extent of acceptance of the suction-socket leg in the United States, mailed questionnaires to approximately 200 limbshops. Of these, 159 shops reported. Eighty of those reporting had made no suction sockets at all; 79 shops had at that time fitted 1262 men, women, and children, with an amazingly small number of complete failures. A comparatively small group of 46 were converted to pelvic-belt-controlled legs, but many of these continued to use the suction-socket shape and some the suction valve, thus retaining many of the advantages of the suction-socket leg. The 1954 survey, also conducted by OALMA, with 72 firms reporting on 5882 cases, indicates similar conclusions. The 1954 OALMA questionnaire includes those firms reporting as few as three cases fitted and those reporting as many as 500 cases or more.</p> <p>Many of the limbshops reporting in both the 1949 and the 1954 OALMA questionnaires indicate that they have adopted the suction-socket method of fitting (that is, ischial bearing) as standard practice even though the amputee cannot actually wear the suction socket as such. Auxiliary supports, such as the Silesian bandage (<b>Fig. 2</b>), are used almost routinely by some limbshops. One of the most widely known and reputable shops in the United States reports the use of auxiliary supports on 300 out of 322 cases fitted. Another reports auxiliary supports applied in 300 out of 373 cases fitted. Another highly successful shop, in fitting 181 cases (of which 91 were children), used auxiliary supports on 90 cases. It is interesting to note that the firms reporting the largest number of cases also report the largest percentage of cases fitted with auxiliary supports.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Two forms of the Silesian bandage commonly used as an auxiliary support for the suction-socket leg, both in the United States and in Europe, particularly in Germany, where, according to Pfau, Hepp, and others <i>(13), </i>it is used almost routinely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The surveys indicate that over 96 percent of all suction sockets fitted since the introduction of the program were fitted to stumps over 3 in. long. In the one shop that reported 90 children fitted, not a single one was fitted with a stump shorter than 3 in. It is to be noted that most of those fitted with the stump shorter than 3 in. were women; and some reported that, although they did not believe the fitting of a stump shorter than 3 in. to be practical, they were almost forced at least to attempt it because of pregnancy, a condition which precludes wearing the conventional pelvic belt.</p> <p>It may therefore be assumed that, except in very rare instances, generally it is impractical to prescribe the suction socket for stumps less than 3 in. long. A further observation is that of the large number of apparently quite successful cases of Gritti-Stokes amputations fitted, no failures whatever being reported in the case of amputation at this level.</p> <p>Another interesting feature brought out is that, while in 13 percent of the cases reported edema was present in the early stages of fitting, in only two cases did the edema persist and become a contributing cause of failure of the suction-socket leg. It is obvious from these data that, while edema may be common, it need not be considered a serious problem.</p> <p>An effort was made to determine the number of bilateral above-knee amputees fitted successfully with suction sockets, but reliable data were not obtained on this question. From the information received in the survey, however, it is believed that the number will probably be about 100, the percentage of failures being approximately the same as in the case of unilaterals.</p> <p>The overwhelming reason given for failure in the use of the suction socket comes under personality factors. An effort has been made in the surveys to obtain reliable data as to the definite reasons for failure. Personality factors are found to be predominant, with physical factors next in line, the condition of the stump third, and social and economic considerations fourth in importance. Thus tabulated, the causes of failure look about like this:</p> <blockquote><p> <i>1. Personality Factors</i><br />Unfavorable temperament<br />Poor cooperation<br />Inability to adjust<br />Discouragement<br />Lack of interest<br />Low order of intelligence<br />Insecurity<br /><i>2. General Physical Factors</i><br />Skin trouble<br />Age<br />Change in weight<br />Circulatory difficulties<br />Inability to bear weight on ischium<br />Buerger's disease<br />Overweight<br />Perspiration<br />Allergy<br />General weakness<br />Loose abduction<br />Unsocial noises<br /><i>3. Slump Characteristics</i><br />Inadequate length<br />Bone spurs<br />Interfering scars<br />Undue length<br /><i>4. Social and Economic Considerations</i><br />Insufficient time for proper fitting<br />Excessive distance from shop<br />Undue sales influence<br />Employer disapproval<br />Occupational requirement </p> </blockquote> <p>Another question asked the reporting firms was: "What percentage of above-knee amputees could, in your opinion, be fitted with a suction socket?". While the answers to this question range from a low of 30 percent of all amputees to as high as 100 percent, the average is 73 percent, a figure thought, in the opinion of the authors, to represent a realistic approach.</p> <p>Another question, asked because of the unusual amount of interest in children and the older age group on the part of the Committee on Artificial Limbs, was: "Is the socket suitable for amputees under five and over seventy?". Almost without exception the suction socket was said not to be suitable for the very young or the very old.</p> <p>Again, the question was asked: "When is the suction socket a practical approach to prosthetic fitting?". The following list of conditions, in the order of frequency with which they were mentioned, indicates the thinking prevalent among the reporting firms on this particular question:</p> <blockquote><p>Right personality factors and willingness to cooperate<br />Healthy, unscarred stump over 3 in. long<br />Under 65 years of age<br />New amputees not conditioned to suspenders or pelvic control<br />Easy access to facility<br />Good muscular reaction<br />Patient's enthusiasm<br />Good circulation<br />Good balance and coordination<br />Available training and therapy<br />Reasonable occupational demands</p> </blockquote> <h3>Factors in Suction-Socket Technique</h3> <p>Accumulated experience with fitting the suction-socket above-knee prosthesis over a period of seven years has clearly demonstrated its many advantages and its desirability over the conventional belt- or shoulder-suspended leg. On the other hand, the experience of the authors during the same period has convinced them that the suction socket is not suited for all above-knee amputees. This belief has been confirmed further by reports of survey studies previously conducted by others and by the results of the surveys reported here. In our opinion, there is considerable question as to the validity of the statement made by some to the effect that the suction socket can be used profitably by any thigh amputee who can wear the conventional type of prosthesis successfully. Experience has shown that there are certain amputees who cannot wear a suction-socket prosthesis successfully. If failures are to be avoided, all cases should be studied and screened carefully before a suction socket is prescribed.</p> <p>The factors to be considered are divided roughly into two groups, each often affecting the other-those relating to characteristics of the prosthesis itself, and those relating to the characteristics of the amputee. Chief among the mechanical considerations of the leg are alignment and socket shape. Factors relating to the amputee are the general physical and mental condition, the condition of the stump, and the condition of the opposite extremity.</p> <h4>Factors Relating To The Artificial Leg</h4> <p><i>Alignment</i></p> <p>With the suction-socket leg, which is controlled entirely by the stump muscles, alignment becomes much more critical than in the case of the pelvic-band suspension and therefore must be correct for proper control and comfort. If alignment is incorrect, there is a definite whip or rotation of the prosthesis during the swing phase. The problem of alignment has not yet been solved completely, and opinions differ a little as to what constitutes the ideal alignment of the prosthesis. Theoretically, it is desirable to incorporate as much adduction of the stump within the socket as is possible mechanically, since to do so tends to suppress body sway and to place the iliotibial band (or that portion of it which may remain intact) under tension.</p> <p>In the normal, the centers of hip, knee, and ankle joints coincide in the frontal plane with the mechanical axis of the lower extremity as a whole (<b>Fig. 3</b>). After amputation through the femur and fitting with a prosthesis, however, the body weight is no longer borne through the center of the hip joint but on the ischial tuberosity, which lies medial to the center of the hip joint. This would indicate, then, that the mechanical axis of the well-aligned above-knee prosthesis would more nearly coincide with a vertical line extending from the ischial tuberosity through the centers of the knee and ankle joints (<b>Fig. 4</b> and <b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Normal alignment in the frontal plane, showing how centers of hip, knee, and ankle joints coincide with the mechanical axis of the lower extremity as a whole. From Thomas and Haddan (14). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Forces acting on the stump and pelvis of an above-knee amputee during the stance phase. In the well-aligned prosthesis, the heel of the foot and the center of the knee should fall approximately on a vertical line (A-A') through the point of contact of the ischium (a). The tendency of the pelvis to rotate downward on the normal side owing to the body weight can be reduced by keeping the dimension (b) as small as possible. This is accomplished by an upward force through the ischium (a). Lateral rotation of the pelvis and side-sway in the shoulders and torso can both be minimized if the force in the abductor muscles (c) is sufficient to balance the body weight by lever action about the ischial seat <i>(a). </i>The stump must be anchored firmly and comfortably by pressure along the entire lateral side <i>(d). </i>Failure to do this results in discomfort at the crotch (e). From Haddan (8). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Posterior view of the above-knee prosthesis showing position of the socket in relation to the rest of the leg. The medial line (a) should be approximately vertical. The lateral line (b) is sloped downward and inward. From Had-dan <i>(8).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the sagittal plane, the weight line in the normal person is a vertical line drawn through the centers of the shoulder, hip, knee, and ankle joints (<b>Fig. 6</b>, left). After amputation and fitting of a prosthesis, however, this vertical weight line must be shifted forward in order to obtain alignment stability (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Normal posture and two postural deviations which must be compensated for in fitting and aligning the prosthesis. Left, normal; center, slight deviation from normal presenting few difficulties in prosthetic fitting; right, extreme postural abnormality which, unless corrected by postural exercises, would present almost insurmountable alignment problems. From Gocht (7). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Alignment in the sagittal plane. The stump should be oriented in the socket with several degrees of initial flexion <i>(a) </i>to allow the stump to control knee stability over the widest range of hip motion possible. The ankle may be positioned either in front of or behind the knee. The dimension (i) will depend upon the individual amputee, his age, range of motion in the stump, stump musculature, and prevailing terrain. From Haddan (8). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the amputee is young and agile, with no stump deformities and with strong and well-developed muscles in the back of the stump, the dimension <i>b </i>in <b>Fig. 7</b> may be reduced to zero. On the other hand, in the presence of flexion contracture in the stump, or weak musculature, this dimension may have to be increased to give sufficient stability. But to do so may result in the sacrifice of a normal gait and cause a tiring and awkward one. Similarly, postural abnormalities (<b>Fig. 6</b>, center and right) can make proper alignment very difficult to achieve.</p> <p>Such deviations in the weight line have upon postural stability and body alignment a biomechanical effect that is obvious. To complicate matters further, the amputee is deprived of a number of those sensory cues upon which every normal human being depends for the autonomous control of posture and motion. These include touch and pressure sensations from the soles of the feet and the never-ending bombardment of proprioceptive impulses that emanate from sensory receptors in the muscles, tendons, and joints of the weight-bearing limbs and sweep upward to the cerebellum. In the aggregate, these physiological and biomechanical deviations from normal appear formidible. Yet with proper fitting and alignment of his prosthesis, and with adequate training in the proper gait and posture, the average amputee can compensate for them to an amazing degree.</p> <p><i>Socket Shape</i></p> <p>Exactly what constitutes the most successful socket shape has not yet been fully determined owing to the many variables involved in the use of this technique. Several successful designs have been fully described in the literature <i><a></a><a></a><a></a><a></a>. </i>In these designs, weight-bearing occurs chiefly about the top posterior portion of the socket, particularly in the region of the ischial tuberosity, with a lesser amount on the gluteal muscle. The addition of a well-defined . . ischial seat reduces pis- ton action of the stump in the socket to a minimum and allows for a looser fit at the top of the socket. Incorrect shape, size, or location of the ischial seat leads to definite discomfort and frequent loss of suction, particularly when the wearer is sitting. In some very muscular stumps, the ischial seat may be reduced in size and in some cases removed entirely. Such amputees bear weight on their well-developed muscles, with the load distributed around the top portion of the socket. The socket is shaped the same except for the reduction or removal of the ischial seat.</p> <h4>Factors Relating To The Amputee</h4> <p><i>General Physical and Mental Factors</i></p> <p>A complete history and physical examination is the first step in determining the desirability of fitting the suction socket. Age is an important consideration, and as a rule elderly amputees are poor candidates for the for this reason it requires considerably more effort and muscular skill to learn to use it. If, therefore, the elderly amputee is, as is so often the case, debilitated and feeble, with muscles weak and flabby and with poor coordination and balance, he is a poor candidate for the suction socket. On the other hand, if he is strong, alert, and agile (that is, if he "appears younger than he is"), and if the stump is in proper condition and of adequate length, there is no reason why the elderly amputee cannot use a suction socket successfully.</p> <p>Experience has indicated that children as young as seven years can be fitted successfully.<a></a> The problem of lengthening and replacement as growth proceeds is no different from that with the conventional prosthesis.</p> <p>Before a suction socket is prescribed, every effort should be made to determine the psychological make-up of the amputee. All reports indicate that most failures have been due to suction socket. But old age <i>per se </i>is not a contraindication. Amputees over 70 years of age have been fitted successfully. As already noted, the suction-socket prosthesis is activated almost entirely by the muscles of the stump, and for this reason it requires considerably more effort and musulcar skill to learn to use it. if, therefore, the elderly amputee is, as is so often the case, debilitated and feeble, with muscles weak and flabby and with poor coordination and balance, he is a poor candidate for the suction socket. On the other hand, if he is strong, alert, and agile (that is, if he "appears younger than he is"), and if the stump is in proper condition and of adequate length, there is no reason why the elderly amputee cannot use a suction socket successfully.</p> <p>Experience has Indicated that children as young as seven years can be fitted successfully<a></a>. The problem of lengthening and replacement as growth proceeds is no different from that with the conventional prosthesis.</p> <p>Before a suction socket is prescribed, every effort should be made to determine the psychological make-up of the amputee. All reports indicate that most failures have been due to psychological or emotional difficulties. Learning to wear and use a suction-socket prosthesis requires cooperation, effort, patience, and perseverance. If the amputee is impatient, resentful, undependable, easily discouraged, unreasonable, or otherwise emotionally unstable, he most likely will be uncooperative and is apt to be a poor subject for the suction socket. Many failures can be attributed to the fact that the amputee is either unwilling or unable to devote the necessary time and effort to obtain a satisfactory fitting. As experience has been gained by the prosthetists, and with the additional aid of the recently developed alignment devices (page 23), the time required for construction and fitting has been considerably lessened in recent years. The interesting observation has been made that, when an amputee has to purchase his limb himself, he is likely to be much more cooperative than if he is given one by some agency.</p> <p><i>Slump Considerations</i></p> <p><i>Length. </i>Stump length is not so important a consideration as might be thought. Contour, muscle tone, and mobility are important determining factors in deciding whether or not a short stump can be fitted. Naturally, the longer the stump the better is the muscular control and the easier is the fitting and training problem. But stumps as short as 3 in. (measured from the crotch) have been fitted successfully. Usually the shorter stumps require the addition of an auxiliary suspension belt (such as the Silesian belts shown in <b>Fig. 2</b>) in order to stabilize the socket on the stump.</p> <p>End-bearing supracondylar and Gritti-Stokes amputation stumps can be fitted successfully with the suction socket, although in such cases the mechanical knee joint usually has to be placed at a level slightly below that of the opposite knee.</p> <p><i>Stump Contour. </i>With the conventional socket, a conical-shaped stump has always been considered desirable. Such is not the case with the suction socket. A stump of more cylindrical shape, with only slightly tapering sides and a fairly broad end, seems to maintain better suction and friction than does the conical or pointed stump. Most undesirable is a long, redundant, flabby mass of skin and fat extending beyond the bone end. Such a mass of tissue not only offers fitting problems but is prone to become edematous and swollen, thus making it difficult to don the leg or to remove the stump from the socket. In such cases, surgical revision is advisable before a suction socket is prescribed.</p> <p>Excessive subcutaneous fat or extreme flabbiness of stump muscles frequently results in marked changes in the contour of the stump after the suction socket has been worn for a while. Repeated modification of the socket thus becomes necessary. With excessive subcutaneous fat, the stump may shrink considerably after wearing the socket, necessitating the insertion of leather liners or even the making of a new socket. Muscles that are atrophied and flabby and of poor tone will develop and increase in size with the use of the suction socket, necessitating enlargement of the socket.</p> <p><i>Muscle Control and Strength. </i>Good muscular control and mobility of the stump are essential for successful use of the suction socket. Fixed deformities due to muscle contracture are very common in amputations above the knee, particularly in the older age group, and they not only present very serious fitting and alignment problems but also handicap the amputee in walking. Flexion and abduction deformities are the usual ones, and the shorter the stump, with resulting greater muscle imbalance, the more likely are they to occur. Once they do occur they are very difficult to correct. It is imperative, therefore, that every effort be made postoperatively to prevent such deformities. Studies in alignment conducted at the University of California<a></a> indicate that the most efficient gait with the suction-socket prosthesis is obtained by fitting the socket with the stump in adduction and slight flexion (<b>Fig. 7</b>). Severe flexion-abduction deformity of the stump makes such alignment very difficult, if not impossible, without producing marked tilting of the pelvis and excessive pressure on the stump.</p> <p>The adductor and hamstring muscles are important not only in controlling the limb but also in preventing flexion-abduction deformity by overcoming muscle imbalance. The shorter the stump, the less power remains in these muscles and the greater the tendency to deformity. It is well known that, in order for muscles to function at maximum efficiency, they must have a fixed insertion. In amputations through the thigh, the major muscles are sectioned well above their insertions, and all too often these muscles are allowed to retract upward, no attempt being made to fix their cut ends to fascia or over the end of the bone. Failure thus to fix the free ends seriously impairs muscle function in controlling the stump. In considering an amputee for a suction socket, the stump should be carefully examined to determine how well the thigh muscles are functioning and whether there are any fixed deformities. If any are present, active and passive exercises should be carried out to correct them as much as possible before the socket is fitted.</p> <p><i>Scars. </i>Deep linear scars near the socket brim may interfere with maintenance of suction. Tender, adherent scars in the weight-bearing area beneath the ischial tuberosity and over the buttocks may cause pain sufficient to prevent the wearing of a suction socket. Deep, folded, adherent, or puckered scars over the end of the stump, which so often cause difficulty with the conventional socket, rarely offer any problem with the suction socket. In fact, it has been observed repeatedly how often these scars smooth out and become more pliable after a suction socket has been worn for some time.</p> <p><i>Ulceration and Infection. </i>Open ulcers, draining sinuses, and active deep infection of the soft tissues of the stump, as well as active osteomyelitis, are definite contraindications to the use of the suction socket. With adequate surgery and use of antimicrobial drugs, these conditions can usually be eradicated readily.</p> <p><i>Bony Spurs. </i>Although in many thigh stumps bony spurs develop at the end of the femur, they rarely offer any difficulty in the fitting or wearing of a suction-socket prosthesis. Occasionally, however, a large spur will develop on the lateral side of the bone in a stump with a fixed abduction, thus producing painful pressure against the side of the socket. Relieving the socket at point of pressure, realigning the socket, or surgical removal of the spur usually solves such a problem.</p> <p><i>Skin Disturbances. </i>Skin sensitivity, irrita- tion, and infections are not uncommon in amputation stumps, and there appears to be considerable variation in the skin's resistance to pressure, friction, and irritation among individual amputees. Some are constantly troubled, while others have no difficulty. Der-matological complications are cited as a fairly common cause of failure in the use of the suction socket. Usually they can be prevented by proper hygienic care of the stump and good fitting, or else they can be relieved by derma-tologic treatment. Skin allergy and contact dermatitis, of rare occurrence with the suction socket, usually can be controlled readily. The troublesome adductor roll, with recurring "pressure boils" (suppurative hydroadenitis and folliculitis), so commonly encountered with the use of the conventional socket, rarely if ever occurs with the well-fitted suction socket. In fact, when such a condition exists with a conventional socket, and the socket is converted to a suction one, usually the roll and cysts rapidly disappear. This is one of the great advantages of the suction socket.</p> <p><i>Perspiration. </i>One troublesome problem occurs in individuals who perspire excessively and who also have a high bacterial count in their perspiration. Irritation or skin friction in such a situation leads to suppurative hydro-adenitis and furunculosis. Excessive perspiration is not uncommon when the suction socket is first worn, but it usually subsides after varying lengths of time. In alleviating these superficial skin infections, x-ray treatment is often of value. Autogenous vaccines have also been used with some success. Before any suction socket is discarded as a failure, every possible effort should be exerted to treat and eradicate such troublesome skin conditions. Some of them can be anticipated from previous history and careful examination and can be eliminated by proper treatment before the socket is fitted.</p> <p><i>Condition of the Opposite Extremity</i></p> <p>During the experimental program, and in the early suction-socket schools, abnormalities and disabilities in the opposite extremity were considered as constituting an important factor—and even as a probable contraindication—in determining the suitability of the amputee for a suction socket. Subsequent experience has shown that abnormalities in the opposite extremity, while still to be considered, are not necessarily contraindicative. Amputees with disabilities so great as to require permanent bracing of the opposite limb have been fitted successfully with suction sockets; many persons with below-knee amputations on one side are wearing above-knee suction-socket prostheses with ease and comfort on the other. In fact, in such cases the suction-socket leg appears to have several advantages over the conventional above-knee leg. Survey studies also reveal that some bilateral above-knee amputees have been successfully fitted with suction-socket prostheses. But of course it is apparent that all such cases must be selected only after a very thorough analysis of individual problems.</p> <p>Peripheral vascular disease which has necessitated amputation is in itself no contraindication to use of a suction socket, provided the opposite limb is not too seriously affected by the disease.</p> <h3>Conclusions</h3> <p>On the basis of the surveys reported upon, it appears quite definite that the suction-socket prosthesis has many advantages over the conventional belt- or shoulder-suspended leg. Approximately 75 percent of all above-knee amputees can be fitted successfully with the suction socket. Chief causes of failure, listed in decreasing order of importance, are psychological difficulties, general physical factors, stump abnormalities, and social and economic factors. Teamwork between physician, prosthe-tist, therapist, and amputee is an essential requirement in the successful fitting and wearing of the suction-socket prosthesis. Meticulous attention to fitting and alignment techniques is important, as is also adequate training.</p> <p>Research studies in gait and principles of alignment, and the development of new alignment devices and duplicating jigs, have been of great value in reducing the time involved in construction and fitting by eliminating, to a great extent, trial-and-error methods. Although many limb manufacturers in this country still do not appreciate the advantages of the suction-socket above-knee limb and make no attempt to fit it, the wide acceptance of the above-knee suction-socket prosthesis in the United States today indicates that it can no longer be considered an experimental device, its use limited to a few selected amputees. Use of the above-knee suction socket is now so prevalent that it can be safely stated—and fairly stated-that the majority of above-knee amputees can successfully be fitted with the suction-socket prosthesis.</p> <p><b>References:</b></p> <ol> <li>Aitken, G. T., and C. H. Frantz, <i>The juvenile ampu-tee, </i>J. Bone and Joint Surg., 35A:659 (1953).</li> <li>Beacock, George, and Terence Sparham, U. S. Pat-nt 329,880, November 10, 1885.</li> <li>Bechtol, C. 0., <i>The suction socket, </i>J.A.M.A., <b>146:625 (1951).</b></li> <li>Canty, T. J., and C. C. Asbelle, <i>Above knee suctionsocket prosthesis. </i>Final Technical Report No. 4, Amputation Center, U.S. Naval Hospital, Oakland, Calif., 1952.</li> <li>Eberhart, Howard D., and Jim C. McKennon, <i>Suc-tion-socket suspension of the above-knee prosthesis, </i>Chapter 20 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954,</li> <li>Felix, W., <i>Praktische Erfahrungen mil der Saugpro-these, </i>Ztschr. f. orthop., 72:352 (1941).</li> <li>Gocht, H., <i>Kunstliche Glieder, </i>Berlin, 1920.</li> <li>Haddan, C. C, <i>Alignment principles, </i>paper readefore a meeting of AAAS, Sec. M., Philadelphia, 1951.</li> <li>Little, E. M., <i>A new method of fitting artificial legsockets, </i>Brit. Med. J., 2:896 (Nov. 14, 1925).</li> <li>Mazet, R., P. E. McMaster, and C. G. Hutter<i>Analysis of one hundred and twenty four suction socket wearers followed from six to fifty five months, </i>J. Bone and Joint Surg., 33A:618 (1951).</li> <li>OALMA Journal, 3(3) :36 (Spring 1949).</li> <li>Parmelee, Dubois D., U. S. Patent 37,637, Febru-ry 10, 1863.</li> <li>Pfau, Heintz, personal communication.</li> <li>Thomas, A., and C. C. Haddan, <i>Amputation pros-thesis, </i>Lippincott, Philadelphia, 1945.</li> <li>Thorndike, A., and H. D. Eberhart, <i>Suction socketprosthesis for above knee amputations, </i>Am. J. Surg., 80:727 (1950).</li> <li>Toles, Justin K., U. S. Patent 980,457, January 3,1911.</li> <li>Underwood, Ernest Walter, U. S. Patent 1,586,015,ay 25, 1926. Also, British Patent 253,729, June 24, 1926.</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, <i>The suction socket above-knee artificial leg, </i>revised edition, April 1948.</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>The suction socket above-knee artificial leg, </i>3rd edition, April 1949.</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Functional considerations in fitting and alignment of the suction socket prosthesis, </i>March 1952.</li> <li>War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, <i>Report on European observations, </i>Washington, 1946.</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>20.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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, G. T., and C. H. Frantz, The juvenile ampu-tee, J. Bone and Joint Surg., 35A:659 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, G. T., and C. H. Frantz, The juvenile ampu-tee, J. Bone and Joint Surg., 35A:659 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Eberhart, Howard D., and Jim C. McKennon, Suc-tion-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954,</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bechtol, C. 0., The suction socket, J.A.M.A., 146:625 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, revised edition, April 1948.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Canty, T. J., and C. C. Asbelle, Above knee suctionsocket prosthesis. Final Technical Report No. 4, Amputation Center, U.S. Naval Hospital, Oakland, Calif., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Mazet, R., P. E. McMaster, and C. G. HutterAnalysis of one hundred and twenty four suction socket wearers followed from six to fifty five months, J. Bone and Joint Surg., 33A:618 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Thorndike, A., and H. D. Eberhart, Suction socketprosthesis for above knee amputations, Am. J. Surg., 80:727 (1950).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Felix, W., Praktische Erfahrungen mil der Saugpro-these, Ztschr. f. orthop., 72:352 (1941).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Pfau, Heintz, personal communication.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Little, E. M., A new method of fitting artificial legsockets, Brit. Med. J., 2:896 (Nov. 14, 1925).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Little, E. M., A new method of fitting artificial legsockets, Brit. Med. J., 2:896 (Nov. 14, 1925).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Little, E. M., A new method of fitting artificial legsockets, Brit. Med. J., 2:896 (Nov. 14, 1925).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Underwood, Ernest Walter, U. S. Patent 1,586,015,ay 25, 1926. Also, British Patent 253,729, June 24, 1926.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Toles, Justin K., U. S. Patent 980,457, January 3,1911.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Beacock, George, and Terence Sparham, U. S. Pat-nt 329,880, November 10, 1885.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U. S. Patent 37,637, Febru-ry 10, 1863.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Eberhart, Howard D., and Jim C. McKennon, Suc-tion-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954,</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bechtol, C. 0., The suction socket, J.A.M.A., 146:625 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Atha Thomas, M.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Orthopedic Surgery, University of Colorado School of Medicine, Denver; member, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Chester C. Haddan </b></td></tr><tr><td class="clsTextSmall">President, Gaines Orthopedic Appliances, Inc., Denver, Colorado; Past-President, Orthopedic Appliance and Limb Manufacturers Association; member, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-25.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-26.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-27.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-28.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-29.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-30.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-31.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_02_029/May-1954OCRBatch1-32.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Status of the Above-Knee Suction Socket in the United States Creator An entity primarily responsible for making the resource Chester C. Haddan * Atha Thomas, M.D. * https://staging.drfop.org/files/original/acdfaaea21f1bfb4bdf97517f56845da.pdf 8af470c4b6b701d48e3966ab0ccc3937 https://staging.drfop.org/files/original/da4a595957bc641bc12ab26505f5bc08.jpg 23df8755ba0d58ec9874f7994d9987b6 https://staging.drfop.org/files/original/3e1236ea8c0c6360fc9d94a682044776.jpg f6f4a8994e2b10e235ee989b410d0094 https://staging.drfop.org/files/original/f25284165068c830330ede2c991e2476.jpg d4825a44e2c821c04b64c148b394c7e3 https://staging.drfop.org/files/original/5d0bc90db35789e97ef273601770ac77.jpg ccef6e0b55533d001c84558310b107be https://staging.drfop.org/files/original/3ed8dd3d9835175e80b43108f1e0ea71.jpg 0aa14032fb6af7d768b416963fbcd6fb https://staging.drfop.org/files/original/c3873a676dcabeca9b3d3fe41c175283.jpg d8935b1a857dc9988df89329d750a061 https://staging.drfop.org/files/original/2a8d7cea53b9c3f88d25c8d7ad9afca6.jpg 3e5e6cdd2e67572178aba7a53ebb8bf8 https://staging.drfop.org/files/original/c9b975f98002c412af3fafaa613f23c2.jpg 36bcdc363071c806bbb269950ca61d95 https://staging.drfop.org/files/original/c1b80cf0553630bc898178fc4a134a50.jpg 479573d0757401271d9c5e2d2db19e0b Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_024.pdf Text Any textual data included in the document <h2>Imler Partial Foot Prosthesis I.P.F.P.: "Chicago Boot"</h2> <h5>Clarence D. Imler, CP.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Surgeons are now performing a greater number of distal amputations, including those of the distal forefoot. Among these are the Lis-France, Chopart, Boyd, and other difficult to fit deformities.</p> <p>The Imler Partial Foot Prosthesis fulfills the need for a light weight, structurally strong prosthesis, that provides ankle support, has an anterior lever arm, acts as a shoe filler, and is cosmetically acceptable.</p> <p>The essential element of the prosthesis is the interface, consisting of a vacuum formed copolymer1 U.C.B, type insert with a toe filler of soft foam. This interface is inserted into a laminated, flexible rubber-epoxy-resin (Lyna-dure) cosmetic sleeve that encompasses the foot and interface. This sleeve extends proximally to above the malleolus and has an anterior opening. The interface is removable, and enables the prosthetist to make adjustments (i.e., alignment and/or relief). Closure is obtained by eyelets and lacer for greater suspension, or Velcro® for cosmesis.</p> <h3>Casting Procedure</h3> <p>A negative impression may be obtained using any conventional method. A midfoot amputation should be placed on a casting board or covered with a plastic bag and inserted into a patient's shoe to simulate heel height. Very little weight should be applied to avoid spreading of the foot. With a Chopart amputation, where the calcaneous is plantar flexed or rotated posteriorly, a casting board is not used. The casting in all cases is similar to the procedure used when casting for a U.C.B, shoe insert.</p> <h3>Modification of the Positive Model</h3> <p>Modification includes a standard 3mm anterior relief. A 1mm relief for the malleoli is added, along with relief for any bony prominence or scar tissue as needed. Remove 2mm of plaster both medially and laterally, proximal to the calcaneous to enhance the support effect of the U.C.B, type heel cup. There is no relief needed for the anterior tibia, and in some cases plaster is removed for a tighter fit (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-1.jpg"><b>Fig. 1</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-1.jpg"><strong>Figure 1. A modified positive model.</strong></a><br /> <h3>Interface with Toe Filler</h3> <p>Over the modified positive model, thermo-mold a section of 5mm Pelite™, for an anterior end pad. Trim and bevel the edges to achieve a smooth transition (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-2.jpg"><b>Fig. 2</b></a>). A sheet of 3/16" Colyene is vacuum formed over the cast and end pad, with an anterior seam (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-3.jpg"><b>Fig. 3</b></a>). The interface may also be laminated with either acrylic or polyester resin. The posterior trim line is proximal to the calcaneous. The medial and lateral trimlines are both distal to the malleoli, and the anterior trimline is at mid-height level. Care should be taken not to cut into the Pelite™ pad as it extends above the trimline (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-4.jpg"><b>Fig. 4</b></a>). The anterior toe section can be constructed by various means. Pelite™ of 5mm firm density should be added until a flat surface distally is attained (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-5.jpg"><b>Fig. 5</b></a>). The anterior toe section is constructed of 12mm firm density Pelite™, bonded together lengthwise. This toe section is bonded to the heel cup and shaped to size. Other materials or foams may be used but they must be firm enough to hold their shape during lamination (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-6.jpg"><b>Fig. 6</b></a>). The finished heel cup interface with toe filler is replaced on the cast and inserted into the patient's shoe. At this point, a final determination is made of the alignment, and whether additional material must be added or removed to fit the shoe to leave room for the outer lamination (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-6.jpg"><b>Fig. 6</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-2.jpg"><strong>Figure 2. The positive model with distal cap in place.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-3.jpg"><strong>Figure 3. A vacuum-formed heel cup.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-4.jpg"><strong>Figure 4. A heel cup with distal end cap.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-5.jpg"><strong>Figure 5. A heel cup with distal end built up and flattened.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-6.jpg"><strong>Figure 6. Toe extension.</strong></a><br /> <p>Adjustments are made at this juncture. The heel cup and toe filler can be divided and the heel cup rotated, relative to the toe filler, to produce eversion, inversion, plantar/dorsi-flexion, toe-in, or toe-out. Due to the flexibility of the outer sleeve, these changes may be accommodated without the need for a new lamination.</p> <p>A 1.5mm thick strip of polyethylene is thermo-formed over the anterior surface. This will act as a separating agent, forming the tongue and overlap. This is cut to a width of approximately 2.6cm The length extends from the proximal edge of the cast, to 5mm past the proximal edge of the Pelite™ toe filler. The edges are beveled for a smooth transition.</p> <p>The layup for the outer sleeve lamination consists of a nylon hose covered by a PVA bag, which is capped off and put under full vacuum. Two layers of Comfort® stretch nylon stockinette and one layer of IPOS stretch nylon are applied. The strip of polyethylene wrapped in two layers of Dynalon3 is sandwiched between this and two additional layers of Comfort® stretch nylon and two layers of IPOS stretch nylon. A second PVA bag is applied with vacuum, and the rubber epoxy resin (Lynadure) is introduced (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-7.jpg"><b>Fig. 7</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-7.jpg"><strong>Figure 7. Lynadure lamination.</strong></a><br /> <p>Before final trimming, determine if closure is to be achieved by eyelets and lace or Velcro®. If eyelets are used, make a center cut through to the polyethylene strip, with inverted "T" slits to the edges of the strip. Remove the polyethylene strip and cut the inner tongue along the medial and distal edges only. To obtain a Velcro® closure, first cut along the medial and distal edge of the polyethylene strip, remove the strip, and cut the inner tongue along the lateral and distal border. Before cutting the laminate, be sure the material has fully cured; if the material has not completely cured, it may pull apart.</p> <p>The I.P.F.P. weighs approximately 250 grams, depending on the shoe size. It is extremely lightweight, but very durable.</p> <p>A leg length discrepancy may be accommodated for in the prosthesis by adding a Pelite™ pad of the proper height, either before or after the interface is vacuum formed.</p> <p>The prosthesis is thinly constructed to be used by the patient with regular shoes. There is no need for split-sized, or extra depth inlay shoes, in most cases. <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-8.jpg"><b>Fig. 8</b></a> shows the finished prosthesis in a patient's shoe.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-8.jpg"><strong>Figure 8. The prosthesis in the patient's shoe.</strong></a><br /> <p>Fabrication has changed very little since initial development. The Lynadure lamination layup has been strengthened with additional layers of stockinette and Dynalon. A few pros-thetists have requested that the co-polymer heel cup be extended anteriorly to the toes as an A.F.O. for greater push off.</p> <p>Another adaptation is the anterior section of a SACH foot with toes laminated into the Lynadure sleeve with the toes exposed, for cos-mesis when wearing open toe shoes or sandals (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-9.jpg"><b>Fig. 9</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-9.jpg"><strong>Figure 9. The finished prosthesis.</strong></a><br /> <p>This may not be the answer to every partial foot amputation, but is an alternative to be considered when fitting a patient with a particularly difficult situation.</p> <h3>Resources and Materials</h3> <p>Co-Polymer, Colyene: Orthotic Prosthetic Enterprises, 1316 Sherman Avenue, Evanston, Illinois 60202.</p> <p>Lynadure: Medical Center Prosthetics, 6955 Almeda Road, Houston, Texas 77021.</p> <p>Dynalon: Hosmer Dorrance Corporation, 561 Division Street, Campbell, California 95008.</p> <p><em><b>*Clarence D. Imler, CP. </b> Clarence D. Imler, CP., is with Oakbrook Orthopedic Services, Ltd., 1 South 132 Summit Avenue, Suite 102, Oakbrook Terrace, Illinois 60181.<br /><br /><br /></em></p> <div style="width: 400px;"></div> Page Number(s) 24 - 28 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-5.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_01_024/1988_01_024-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-7.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-8.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-9.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Imler Partial Foot Prosthesis I.P.F.P.: "Chicago Boot" Creator An entity primarily responsible for making the resource Clarence D. Imler, CP. * https://staging.drfop.org/files/original/80bd7e168ac76f3973055be7e00862b9.pdf e97318035d3d30c66366bd3b043f7eed DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_073.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 73 - 74 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_01_073.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_073.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Evaluation of Polysar Below-Elbow Fitting </h2> <h5>Clyde M. E. Dolan <br /></h5> <p>The technique of forming sockets directly on below-elbow stumps using Polysar<a style="text-decoration:none;">*</a>, presented in a January 1968 manual by Gennaro Labate and Thomas Pirrello of the Veterans Administration Prosthetics Center, was used to prepare complete prostheses for three amputees, following a demonstration of the technique by VA personnel. The subjects were male, unilateral below-elbow amputees, with stump lengths in the range of 40-60% of the sound-side measurement. Each amputee had previously worn a conventional prosthesis; one had been using a Munster-type fitting immediately prior to wearing the experimental prosthesis.</p> <p>The instructions in the manual were considered by our staff prosthetists to be clear and comprehensive; however, the demonstration of the procedure was particularly helpful. No difficulties were encountered in interpretation or application of the fabrication technique. Each prosthesis was fabricated, from measurement to delivery, in approximately one-half day.</p> <p>At the time of delivery, each synthetic-rubber prosthesis was weighed for comparison with the previously worn conventional product. A staff therapist checked out each prosthesis, and the subject was instructed to wear the arm exclusively during the evaluation period. No special precautionary measures were advised. Initial reactions of the subjects were recorded, with specific reference to weight, cosmesis, the soft foam covering, and comfort.</p> <p>The experimental arms were considerably heavier than the respective conventional arms worn by the subjects. The weights of the complete prostheses (including harness, cable, and APRL hand and glove) were:</p> <table> <tbody> <tr> <td> <p><strong>Subject    </strong></p> </td> <td> <p><strong>Conventional    </strong></p> </td> <td> <p><strong>Experimental    </strong></p> </td> <td> <p><strong>Difference    </strong></p> </td> <td> <p><strong>% Increase    </strong></p> </td></tr> <tr> <td> <p>A</p> </td> <td> <p>788.5 g</p> </td> <td> <p>967.5 g</p> </td> <td> <p>179.0 g</p> </td> <td> <p>22.7</p> </td></tr> <tr> <td> <p>B</p> </td> <td> <p>842.0 g</p> </td> <td> <p>1133.5 g</p> </td> <td> <p>291.5 g</p> </td> <td> <p>34.5</p> </td></tr> <tr> <td> <p>C</p> </td> <td> <p>777.0 g</p> </td> <td> <p>921.5g</p> </td> <td> <p>144.5 g</p> </td> <td> <p>18.7</p> </td></tr></tbody></table> <p>Despite these substantial differences, none of the subjects commented adversely about the weight of the synthetic-rubber prosthesis.</p> <p>Two of the subjects experienced problems related to cosmesis during the initial fitting. The cosmetic cover of Subject B's prosthesis was not sufficiently opaque, and irregularities in the foam underlayer presented an unsatisfactory appearance. This defect was remedied by covering the foam with a layer of Helenca stockinet to improve the color uniformity. Subsequent shifting of this layer caused a wrinkle to develop in the vinyl cover, but this did not disturb the patient.</p> <p>On initial fitting of Subject C's prosthesis, it was apparent that the foam (a 50-50 combination of Silastic 385 and 386) had collapsed in the area proximal to the wrist unit, producing an unsightly configuration. This difficulty was remedied by the use of a somewhat denser foam mixture, one which retained sufficient flexibility to simulate normal flesh turgor but which was nonetheless strong enough to maintain cosmetic shape when the cover was applied.</p> <p>Once those initial problems were solved, all reactions to the soft foam, with a vinyl cover, were highly positive. Initial reactions to the comfort of the experimental sockets were also positive.</p> <p>The three subjects wore the experimental prostheses for periods ranging from two to four months. Only one (Subject A) subsequently experienced problems, and these required that the prosthesis be replaced. It is worth noting that this patient was the one who had previously worn a Miinster-type prosthesis. After wearing the experimental socket for five weeks, he expressed a preference for his previously worn prosthesis in terms of comfort. His socket produced from Polysar had developed embossed ridges caused by the stockinet, which resulted in considerable discomfort and skin irritation. In addition, the socket had deformed, becoming elliptical in the direction of cable pull, which may have contributed to a dermatitis which occurred after that fitting.</p> <p>The other two subjects reported at the close of the period of wear that they preferred the synthetic-rubber fitting to their conventional prosthesis. Subject B reported increased comfort and cosmesis, and also reported greater range of motion, which may be due to slightly lower proximal trim lines and some socket flexibility. Subject C felt that he could wear the prosthesis continuously without discomfort; he found no problem with the weight of the prosthesis and felt "more secure" with the experimental prosthesis than with the previously worn arm.</p> <p>To summarize, the fabrication procedure using Polysar, as demonstrated and as presented in the draft manual, seems to offer advantages in terms of: <i>(a)</i> saving of shop time (the technique requires approximately one-half day, while standard techniques require nearly a full day, not considering curing time), <i>(b)</i>elimination of some opportunities for error through the reduction of the number of steps in the fabrication process, and <i>(c)</i> fabrication of a prosthesis with a soft external surface which simulates normal flesh turgor. Difficulties encountered were: (<i>a</i>) collapse of the foam cover (tending to dent when the sleeve was applied), which may be ameliorated by the use of a denser foam; <i>(b)</i>low opacity of the sleeves, which may be improved by using a dilaminar or a thicker material; (<i>c</i>) weight, which seemed excessive although not noted by the subjects; and (<i>d</i>) possible deformation or embossing of the socket, as noted in the case of Subject A.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Registered trademark of the Polymer Corporation Limited.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evaluation of Polysar Below-Elbow Fitting Creator An entity primarily responsible for making the resource Clyde M. E. Dolan