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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_02_044.pdf Text Any textual data included in the document <h2>Clinical Analysis of Foot Problems</h2> <h5>Karen S. Seale, M.D.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Orthotists are vital members of the foot care team. Their expertise and special interests in materials and biomechanics add a unique dimension to the management of foot problems.</p> <p>It is hoped that the principles of clinical assessment of foot problems set forth in this article will foster even greater interest in and understanding of the pathophysiology of foot problems. The purposes of this article are threefold:</p> <ol> <li> <p>To familiarize the orthotist with the general concepts of clinical analysis of the foot.</p> </li> <li> <p>To assist the orthotist in designing the most appropriate orthosis based on clinical assessment of the problem.</p> </li> <li> <p>To give examples of clinical analysis of the following common foot problems for which an orthotic treatment may be prescribed:</p> <ol> <li> <p>Heel pain</p> </li> <li> <p>Pes planus</p> </li> <li> <p>Metatarsalgia</p> </li> <li> <p>Ankle instability</p> </li> </ol> </li> </ol> <h3>Discussion</h3> <p>Clinical analysis of the foot consists of obtaining a pertinent history and performing a physical examination of the lower extremity. The medical history is an opportunity to gather as much information as possible by asking the patient to describe the pain, problem, or deformity. Specific information is sought by asking about the type of pain, its duration, onset (whether insidious or abrupt), location of the pain, and activities that help or aggravate the pain (such as rest, walking, or wearing or removing certain shoes).</p> <p>Physical examination involves inspection, palpation, and manipulation. Observe the patient, first with and then without his typical footwear, both standing and walking, with arms hanging freely at the sides. The patient should be observed from the front and from the back. With the patient seated at a height comfortable for the examiner and the shoes removed, palpation and manipulation can be performed. Palpation is not intended to inflict pain, but rather to identify areas of discomfort. For example, applying direct pressure in the center of the heel pad may cause discomfort in a patient with "heel spur" syndrome.</p> <p>In addition to palpation, manipulation is used to assess range of motion of the various joints and to determine the biomechanical relationships of the component parts of the lower extremity. Although a description of a comprehensive foot examination is beyond the scope of this paper, clinical analysis of four common foot problems is included in the next section.</p> <h3>Heel Pain</h3> <p>A very common clinical problem for which shoe modifications may be prescribed is heel pain. Although many causes of heel pain exist, common etiologies include, (1) fat pad atrophy, (2) plantar fascitis or "heel spur" syndrome, and (3) neuritis of the medial calcaneal or lateral plantar nerves.</p> <p>Atrophy of the fat pad is particularly common among older individuals who will complain of localized pain about the heel brought on by walking, especially in hard soled shoes. Varying degrees of fat atrophy of the metatarsal area as well as the heel pad are observed on physical examination and the underlying tubercle of the calcaneous can be readily palpated. The key to successful shoe modification in treating this condition is to increase the padding beneath the heel.</p> <p>The onset of chronic heel pain due to plantar fascitis or "heel spur" syndrome may be either acute or insidious. It is often most severe upon arising in the morning, but improves after a period of "warming up." However, it may worsen if the patient remains on his feet during the day or with intermittent periods of rest and activity. The patient is usually tender to palpation at the origin of the plantar fascia on the plantar tubercle of the calcaneus and about one centimeter distally (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-1.jpg"><b>Fig. 1a</b></a>). The principles of shoe modification management are soft soles, relief in the center of the heel, and a soft arch support to better distribute the weight and relieve the painful heel area.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-1.jpg"><strong>Figure 1A. Point of tenderness in patient with plantar fascitis.</strong></a><br /> <p>Neurologic causes of heel pain include neuritis and/or compression of the medial calcaneal nerve, the lateral plantar nerve, or the nerve to the abductor digiti quinti, which is a branch of the lateral plantar nerve.<a></a> The pain is usually not well localized as with plantar fascitis, but tends to be diffuse. On physical examination tenderness may be found on the medial aspect of the heel over the origin of the abductor hallucis (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-2.jpg"><b>Fig. 1b</b></a>). Occasionally, the examiner can elicit pain or tingling along the medial aspect of the heel with light tapping or pressure in this area. For these patients, an orthosis which limits excessive pronation, and thereby decreases the pull of the abductor hallucis across the nerves, is useful.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-2.jpg"><strong>Figure 1B. Point of tenderness in patient with neuritis of medial calcaneal and/or lateral plantar nerve.<br /></strong></a><br /> <h3>Pes Planus</h3> <p>Pes planus, or flat foot, is a descriptive term indicating the loss of height of the medial arch, but is a more complex entity than the name implies. There are many causes of symptomatic flat feet, including posterior tibial tendon rupture, Charcot joint degeneration secondary to neuropathy, rheumatoid arthritis, and generalized ligamentous laxity.<a></a> The specific complaints vary depending on the etiology, but in general, pes planus leads to diffuse aching of the foot and early fatigue. Patients with inflammation or early rupture of the posterior tibial tendon will note pain on the medial aspect of the foot and ankle early on, but as significant deformity develops, pain occurs on the lateral aspect of the hindfoot due to impingement of the fibula against the valgus-tilted calcaneus.<a></a> The rheumatoid patient may have a great deal of diffuse pain, whereas the patient with Charcot joint degeneration secondary to neuropathy may have little or no pain in the presence of very severe deformity.</p> <p>Pes planus is best observed seen while the patient is standing. One notes the decrease in the medial arch height, the increase in forefoot abduction and external rotation as well as the presence of heel valgus (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-3.jpg"><b>Fig. 2a</b></a>). Observations, made from behind as the patient walks, are (1) the excessive external rotation of the foot relative to the line of progression, and (2) the lack of significant heel inversion motion from foot flat to heel lift.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-3.jpg"><strong>Figure 2A. Note loss of longitudinal arch, with the excessive forefoot abduction and external rotation.</strong></a><br /> <p>Further biomechanical evaluation is performed by sitting in front of the seated patient to observe the relationships of the hindfoot to the leg and of the forefoot to the hindfoot. The subtalar joint motion is assessed by grasping the heel and tilting it laterally (into valgus or eversion) and then medially (into varus or inversion). Not infrequently, the patient with pes planus will demonstrate excessive eversion, greater than the normal excursion of 10°.</p> <p>The foot is then placed in its "neutral position," which is the point at which the calcaneus is centered under the tibia and the talar head is adequately covered by the tarsal navicular. This is done by the examiner's holding the heel in alignment with the long axis of the tibia or in a few degrees of valgus and then adducting the forefoot approximately halfway between maximum forefoot abduction and maximum adduction. The position of the plantar aspect of the forefoot relative to the perpendicular axis of the tibia is noted. There is usually a component of forefoot varus which means the plantar aspect of the foot is facing medially (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg"><b>Fig. 2b</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg"><strong>Figure 2B. Forefoot varus-plantar aspect of foot facing medially.</strong></a><br /> <p>The principles of orthotic management of pes planus include correcting the valgus tilt of the calcaneous, providing a medial arch support, and posting of the first ray to control the hyper-pronation.</p> <h3>Metatarsalgia</h3> <p>Metatarsalgia is pain in the forefoot area for which a wide variety of etiologies have been identified. For the purposes of this article, which is aimed at the practicing orthotist dealing with foot problems, the discussion will be limited to the following:</p> <ul> <li> <p>Fat pad atrophy</p> </li> <li> <p>Sesamoiditis</p> </li> <li> <p>Disorders of the lesser metatarsophalangeal joints</p> </li> <li> <p>Interdigital neuroma</p> </li> <li> <p>Rheumatoid arthritis</p> </li> <li> <p>Pes cavus</p> </li> </ul> <p><i>Fat Pad Atrophy</i></p> <p>As in heel pad atrophy, the soft tissue padding under the metatarsal heads may become atrophied with age, causing diffuse pain under the metatarsal heads due to the lack of sufficient padding for shock attentuation. The patient may complain of pain especially when walking on a hard floor without shoes. The atrophy is apparent on general inspection; palpation reveals the prominence of the metatarsal heads plantarly. The patient may be tender to palpation directly under the metatarsal heads. Soft soled shoes and soft inner soles with metatarsal pads proximal to the metatarsal heads are beneficial modalities.</p> <p><i>Sesamoiditis</i></p> <p>Patients with inflammation of the sesamoids of the first metatarsophalangeal joint will complain of well localized pain on the medial aspect of the foot just proximal to the first metatarsal head upon weight bearing. There may be a history of repeated jumping or running on the balls of the feet or of a crush injury due to a heavy object falling on the foot. The patient may walk by rolling his foot into supination and inversion, thus bearing the majority of the weight on the lateral border of the foot. Palpation directly over the involved sesamoid will cause localized tenderness beneath either the tibial or the fibular sesamoid (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg"><b>Fig. 3a</b></a>). Look for associated edema and swelling under and around the first metatarsal head. Passive extension of the first metatarsophalangeal joint will aggravate the pain. Placing the patient in low heeled shoes with padding devices which relieve weight bearing under the first metatarsal head are indicated.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg"><strong>Figure 3A. Area of point tenderness of fibular sesamoiditis.</strong></a><br /> <p><i>Disorders of the Lesser Metatarsal Joints</i></p> <p>Disorders such as subluxation or dislocation, isolated synovitis, or Freiberg's disease can cause pain limited to a single metatarsophalangeal joint.<a></a> The onset of pain may be insidious and there may or may not be a history of trauma associated with the onset of pain. The patient is usually able to point to the involved area. Pain can be elicited upon palpation of the involved joint and with passive manipulation. Synovial thickening may be appreciated when comparing the thickness of the involved joint to the normal joint of the opposite foot.</p> <p><i>Interdigital Neuroma</i></p> <p>The well localized pain associated with an interdigital, or Morton's, neuroma is caused by a thickening of the soft tissues surrounding the common digital nerves on the plantar aspect of the foot and occurs most frequently between the third and fourth metatarsal heads. This entity occurs frequently in women and probably results from the repeated trauma to the metatarsal region caused by the wearing of high heeled shoes. The patient is usually able to point out the area of maximum pain on the plantar aspect of the foot, pain which occasionally radiates to the toes, and which is worse with weight bearing when wearing snug, thin soled shoes. Removing the shoes and massaging the foot usually affords some temporary relief.</p> <p>The physical examination will be normal to inspection, but upon palpation pain can be elicited by squeezing the soft tissues between the involved metatarsal heads. This is done by using the thumb and forefinger of one hand to simultaneously press from dorsal and plantar while compressing all the metatarsal heads medially and laterally with the opposite hand (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-5.jpg"><b>Fig. 3b</b></a>). Occasionally, the enlarged nerve tissue can actually be felt to roll between the finger and the thumb.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-5.jpg"><strong>Figure 3B. Technique for eliciting tenderness of interdigital neuroma between third and fourth metatarsal heads.</strong></a><br /> <p>Keeping the pressure off the involved area with a metatarsal support proximal to the metatarsal heads and eliminating snug, high heeled shoes can be helpful in decreasing the pain.</p> <p><i>Rheumatoid Arthritis</i></p> <p>The typical advanced deformities of rheumatoid arthritis causing metatarsalgia are hallux valgus with lateral deviation and dorsal dislocation of the lesser metatarsophalangeal joints. This results in the distal displacement of the plantar fat pad, thus leaving the metatarsal heads displaced plantarly with insufficient fat pad coverage (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-7.jpg"><b>Fig. 3c</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-8.jpg"><b>Fig. 3d</b></a>). Broad, soft soled shoes with an adequate height of the toe box to accommodate the deformities are necessary. Providing a soft, total contact insert with metatarsal padding proximal to the prominent metatarsal heads is helpful in decreasing the weight born by the metatarsal heads and more evenly distributing the weight across the sole of the foot.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-7.jpg"><strong>Figure 3C. Typical forefoot deformities of rheumatoid arthritis-hallux valgus and dorsal dislocation of metatarsalphalangeal joints (plantar view).</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-8.jpg"><strong>Figure 3D. Typical forefoot deformities of rheumatoid arthritis-hallux valgus and dorsal dislocation of metatarsalphalangeal joints (lateral view).</strong></a><br /> <p><i>Pes Cavus</i></p> <p>A common complaint of the person with pes cavus, or a high arch, foot deformity is metatarsalgia. The elevated arch results in greater weight being borne on the metatarsal heads. The cavus foot is more rigid and, thus, has less shock attentuation capability than the normal, more supple foot. Metatarsalgia can be worsened in the presence of clawing of the toes, which involves hyperextension of the metatarsophalangeal joints, thus making the metatarsal heads even more prominent plantarly.</p> <p>The deformity can best be appreciated on physical exam by watching the patient in a standing position. In addition to the elevated longitudinal arch, heel varus may be noted. Plantar flexion of the first ray may be present and can be seen by viewing the foot anteriorly with the patient seated. Stabilize the calcaneus in alignment with the tibia and note the level of the plantar aspect of the first metatarsal head relative to the others. The patient with metatarsalgia secondary to pes cavus may benefit from a soft arch support to increase the weight bearing surface of the foot and to improve shock attenuation.</p> <h3>Ankle Instability</h3> <p>Ankle instability may be the result of lateral ligamentous laxity, a varus heel, or a varus an-gulated tibia.<a></a> A patient with lateral ligamentous laxity of the ankle may give a history of having initially sustained an ankle sprain secondary to significant ankle trauma followed by recurrent sprains with minimal or no trauma. The wearing of high heeled shoes worsens the tendency of recurrent ankle sprains as this further throws the foot into supination.</p> <p>Ligamentous laxity causing ankle instability can usually be demonstrated by the "lateral talar tilt" test. The ankle is stress tested both in dorsiflexion, to test the calcaneofibular ligament, and in plantarflexion, to test the anterior talofibular ligament. The tibia is held stationary as the examiner applies pressure on the lateral aspect of the hindfoot in a medial direction (<a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-9.jpg"><b>Fig. 4</b></a>). The ankle, which lacks adequate ligamentous support, will tilt medially indicating instability.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-9.jpg"><strong>Figure 4. "Lateral talar tilt" test for ankle instability.</strong></a><br /> <p>The presence of heel varus can be appreciated by viewing the patient from behind as he stands with shoes removed. It will be noted that the calcaneous is medial to the longitudinal axis of the tibia. Upon manipulation of subtalar joint motion, there may be decreased eversion of the calcaneous relative to inversion.</p> <p>A person who had a varus angulated tibia, either from a congenital deformity or secondary to a tibia fracture which has united in varus, may also experience ankle instability. With such malalignment, the biomechanical forces pass lateral to the center of the calcaneous. Observing the standing patient from the front, the examiner will note that an imaginary plumb line dropped from the center of the patella will fall lateral to the center of the ankle on the affected side.</p> <p>A lateral heel and sole wedge tilts the hind-foot into slight valgus to help prevent recurrent ankle instability.</p> <h3>Summary</h3> <p>The principles of clinical assessment of four common clinical problems for which orthotic treatments are prescribed have been discussed. The information gained from the medical history and physical examination used in clinical assessment of foot problems can aid the ortho-tist in improving his or her effectiveness as a vital member of the foot care team.</p> <p><b>References:</b></p> <ol> <li>Baxter, Donald E., "The Evaluation and Treatment of Forefoot Problems in the Athlete" (Unpublished manuscript).</li> <li>Baxter, Donald E. and C. Mark Thigpen, "Heel Pain-Operative Results," Foot &amp; Ankle, 5:1, 1984, pp. 16-25.</li> <li>Johnson, Kenneth, "Tibialis Posterior Tendon Rupture," <i>Clinical Orthopaedics &amp; Related Research</i>, 166, 1983, pp. 143-150.</li> <li>Mann, Roger A., "Biomechanical Approach to the Treatment of Foot Problems," <i>Foot &amp; Ankle</i>, 2:4, 1982, pp. 205-212.</li> <li>Mann, Roger A., "Metatarsalgia," <i>Postgraduate Medicine</i>, 75:5, 1984, pp. 150-167.</li> <li>Mann, Roger A. <i>Surgery of the Foot</i>, The C.V. Mosby Co., 1986.</li> </ol> <p><em><b>*Karen S. Seale, M.D. </b> Karen S. Seale, M.D. is assistant professor in the Department of Orthopedics, University of Arkansas Medical School Center<br /><br /><br /></em></p> Page Number(s) 44 - 50 Year 1988 Volume 12 Issue 2 Figure 1 FIGURE 1A http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-1.jpg FIGURE 1B http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-2.jpg Figure 2 FIGURE 2A http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-3.jpg FIGURE 2B http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-4.jpg Figure 3 FIGURE 3A http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-5.jpg FIGURE 3B http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-6.jpg FIGURE 3C http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-7.jpg FIGURE 3D http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-8.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_02_044/1988_02_044-9.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 Clinical Analysis of Foot Problems Creator An entity primarily responsible for making the resource Karen S. Seale, M.D. * https://staging.drfop.org/files/original/8ecb54a3012ed38f7b171812350a731d.pdf 05c8e25798ef9b43b1cb55d9b9839e68 https://staging.drfop.org/files/original/6098481d015061b362e56ee04136384f.jpg 11d8c7e9bba2ec02aa1e933df086c33a https://staging.drfop.org/files/original/46a799d6d2420300645917eaf2723c59.jpg e63018f515b90c2eb69c4ec89a8898ca https://staging.drfop.org/files/original/624a1233ecee23ac46ae637b18ba146b.jpg a6de0ab1da660648e99d40c903b27f11 https://staging.drfop.org/files/original/ab290fff59eadd267873a2decbd4e440.jpg 5bbfa7208d171dc56b90017e06f551e2 https://staging.drfop.org/files/original/520e88e49706cc661d53c602c6e33230.jpg 24830d3188a99030c51f97e3e6dea71a https://staging.drfop.org/files/original/de6139b99b662a5dfe5610dfbab30787.jpg 8947cfdfdd64cad477ba692f14656a82 https://staging.drfop.org/files/original/c3b9f7080112397202c2fbd0564d6efe.jpg e1aed6122e85990b09b25c20ed48a2a8 https://staging.drfop.org/files/original/230a7ff66eb4ce78118fada1bc78690f.jpg d1ad6fe57d3b51df0d72ad4bb9ab701c https://staging.drfop.org/files/original/38421551a83fa4614592b3b366304871.jpg e537771eaa35ec2c0fec8c6fd155000b https://staging.drfop.org/files/original/8905983959c857a3fe44468e0648daa2.jpg c124186a879f11ce49da830054807aaf https://staging.drfop.org/files/original/9507fd0de770b04b5b6b8e66a960c096.jpg 7243d43f3f603331b9462b61af3bd63c https://staging.drfop.org/files/original/acdca25dbb06cf22df9a79b8cf50487c.jpg ed2380d140dd85f67e802126564821f4 https://staging.drfop.org/files/original/ba2951f2e3d1435d01cfab4a4e31b29a.jpg 07a034fc807db2900fe28dd8c647f4ce https://staging.drfop.org/files/original/eff10f36de6ee111d6f50738c3442319.jpg 1f3a3b4d0f9af8451b1947b0c7e73341 https://staging.drfop.org/files/original/38b0e67c23198fd71257d8e8feed8cc6.jpg b2cf1ba3890019f43e712145bfd7b3d3 https://staging.drfop.org/files/original/b952520c020ff58786ca31aa71420aef.jpg 2c49308b27810bfa3ae14cb5897584ae https://staging.drfop.org/files/original/921292d7f6c4054098369270f1c94ceb.jpg 104f419a0f65a4dd1c13dbf1c3905dd3 https://staging.drfop.org/files/original/88a9ff9aebe0c40faa2273099450814e.jpg 8abd9344644628bec1edebd0dc336e1a https://staging.drfop.org/files/original/37804103eaaa550d65be09f5159b801b.jpg 8f81c43924b242f36e3c7f23e9daf146 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_01_046.pdf Year 1971 Volume 15 Issue 1 Page Number(s) 46 - 67 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_01_046.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_01_046.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Clinical Applications of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace</h2> <h5>Hector W. Kay <a style="text-decoration:none;">*</a><br /></h5> <p>In certain pathological conditions of the lower extremity, the stress of weight-bearing cannot be tolerated because of pain or the possibility of actual tissue damage. Pathologies encountered in such situations fall into three broad categories: <a></a> those affecting bone-delayed unions or nonunions of fractures; <a></a> those involving the ankle or foot joints, such as traumatic arthritis or similar conditions; and <a></a> those involving the soft tissue, such as ulcers and traumatic loss of the heel pad or other soft tissues.</p> <p>In these circumstances, bracing is frequently used as an aid to management, the brace serving as a weight-bearing device to relieve the skin-muscle-bone complex of intolerable stresses.</p> <p>Historically, the application of a brace to unweight the lower extremity has involved provision for support of the body weight at the level of the pelvis, typically some form of ischial weight-bearing. A variable proportion of body weight is then transmitted to the ground through side bars and a locked knee. This type of brace is inherently disadvantageous because of its bulk and because the locked knee imposes a stiff-legged gait which increases energy costs. In situations where the pathology is located above the knee, avoidance of these disadvantages may be impossible. However, in selected below-knee lesions, a brace which bears weight about the knee (like the patellar-tendon-bearing prosthesis) appears not only desirable but possible. A brace of this type would not only allow unrestricted knee motion, and hence a more natural gait, but it would have the advantages of reduced bulk and the absence of equipment above the knee.</p> <p>In 1958, VAPC designed such a below-knee weight-bearing brace. <a></a> The VAPC design was based on the then current below-knee patellar-tendon-bearing (PTB) prosthetic techniques. The primary weight-bearing component is a partial socket of laminated plastic with a soft (Kemblo [TM]) liner similar to the proximal portion of a PTB prosthesis (<b>Fig. 1</b>). Stainless-steel uprights were used with a stainless-steel limited-motion stirrup (<b>Fig. 2</b>). The ankle joints were modified to permit 10 degrees of plantar flexion and to limit dorsiflexion at 90 degrees. The stirrup and uprights were fitted and aligned as in a conventional ankle brace. In wearing the brace, an open-end wool stump sock was used as with a below-knee prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Proximal weight-bearing portion of the PTB brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Completed brace of initial design. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As experience with the PTB-type brace accumulated at VAPC, a number of modifications were introduced (<b>Fig. 3</b>). A compressible heel, similar to that of the solid-ankle cushion-heel (SACH) prosthetic foot, and a rocker bar attached to the sole of the shoe became incorporated as standard components of the device. The SACH heel wedge and rocker bar were incorporated in the shoe to simulate plantar flexion and provide a more natural roll from heel to toe, thus minimizing gait deviations imposed by limited ankle motion. <a></a> The SACH heel wedge is also considered to function as a shock absorber, contributing to a smoother gait. Some patients with painful ankles were unable to tolerate motion in the ankle joint at the brace and were fitted with rigid joints.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Views of the modified brace showing application of SACH heel and rocker bar. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Veterans Administration Prosthetics Center submitted the PTB weight-bearing brace to the Committee on Prosthetics Research and Development for evaluation. Unfortunately, at that time procedures for the testing of orthotic devices were not available. However, in December 1963 an orthotic evaluation program was inaugurated by New York University, and the VAPC device was selected by CPRD as a suitable item for this program.</p> <p>The initial phase of the NYU evaluation involved the review and examination of patients fitted by VAPC. Of the 22 patients who had been fitted by VAPC between 1958 and November 1963, 8 accepted the invitation to appear for interview and examination. The findings of this review study indicated that the VAPC pa-tellar-tendon-bearing brace was an effective device from the medical, orthotic, functional, and wearer-reaction points of view. <a></a></p> <h3>Clinical Fittings</h3> <p>On September 1, 1966, the National Academy of Sciences-National Research Council entered into Contract SAV-1053-67 with the Vocational Rehabilitation Administration (now the Social and Rehabilitation Service) to establish a pilot program for the clinical evaluation of prosthetic and orthotic devices under the jurisdiction of the Committee on Prosthetics Research and Development. Two orthotic items were selected to initiate this program: the Baylor (Engen) hand orthosis and the University of California dual-ankle control system. The Engen study was undertaken <a></a> but, for various reasons, the UC study could not be undertaken, and evaluation of the VAPC PTB brace was substituted for the UC item.</p> <p>Since the earlier favorable NYU review, an instructional manual has been prepared by the developer. <a></a> Accordingly, five treatment centers were recruited as participants in a clinical application study of the VAPC PTB brace: the University of Alabama Medical Center, Birmingham, Ala.; Goldwater Memorial Hospital, New York, N.Y.; Jackson Memorial Hospital, Miami, Fla.; Rancho Los Amigos Hospital, Downey, Calif.; and the Rehabilitation Institute of Chicago, Chicago, Ill.</p> <p>A course of instruction in the fabrication and application of the VAPC PTB brace was conducted at the Veterans Administration Prosthetics Center, New York, by the developers. Orthotists from the participating clinics undertook training for five days (May 8-12, 1967), while physicians had a one-day orientation (May 12, 1967).</p> <p>A protocol for the study, together with appropriate data-recording forms, was prepared by the CPRD staff.</p> <p>Following the instructional course, several fittings were accomplished at each of the participating centers. Subsequently, a number of factors arose to militate against the completion of the planned course of study. Two of the clinics suffered the loss of the physician member of the participating team, and two other centers became engaged in studies of cast braces for fractures of the lower extremity. These fracture-cast braces had some of the same characteristics and performed similar functions as the test item. The physician member of the fifth participating team suffered a prolonged illness, which disrupted the progress of the study at his center.</p> <p>The clinical study of the VAPC PTB brace was reactivated early in 1970 when the physician who had been ailing recovered his health and it was discovered that the orthotics clinical group at the Duke University Hospital had been fitting the test item since 1962 and had accumulated a sizable series of patients. Arrangements were made, therefore, to review patients fitted in Birmingham and Durham. The data obtained in these reviews form the basis for this report. The experience of these two centers is presented in the following sections of this report.</p> <h4>Birmingham, Alabama</h4> <p>Following the return of the physician—orthotist team from the instructional course at VAPC, seven patients were fitted in the study. Two of these patients were civilians (one woman and one boy) and five were veterans. The injuries of three of the veterans were non-service-connected.</p> <p>Review of the data available on these seven patients fitted in Birmingham indicates that in four instances the experimental brace was used satisfactorily and successfully. In two cases, the results were inconclusive in that the follow-up data are not available. The seventh patient must be considered a probable failure, although again follow-up data are not available. Condensed case histories on these patients follow.</p> <h4>Successful Outcomes</h4> <p><i>Case No. 1</i></p> <p><i>P.S. </i>was born on February 28, 1953. He suffered from congenital pseudarthrosis of the right tibia and fibula, essentially constituting a defect similar to an ununited fracture. Prior to referral to the Crippled Children's Service Clinic in Birmingham, he had undergone surgery at an early age. This surgery, involving the use of metallic screws and sutures, was unsuccessful. Further surgical procedures were attempted subsequently, an onlay bone graft being done on July 20, 1965. This surgery was followed by infection and was unsuccessful. A sliding bone graft was attempted on June 6, 1967, but this also was unsuccessful.</p> <p>The VAPC PTB brace was fitted in April 1968. The condition of the right tibial and fibular defects at that time is shown in <b>Fig. 4</b>. The brace prescription included a SACH heel and a rocker bar incorporated into the shoe build-up (the right leg being shorter than the left). Initially, no motion was provided at the ankle joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. X-ray of P.S.'s leg at time of fitting the VAPC PTB brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Following application of the brace, the leg shrank rapidly, and a new socket was required in approximately one month. Because of this loss of fit, the amount of weight borne on the defective limb was increased. This boy was a very active user; he played basketball and reported that he went hunting almost every day. As a result of this active use, numerous breakages occurred at the junction of the brace upright and shoe plate. The upright was eventually strutted for extra strength, and after about a year and a half of wear a few degrees of motion were introduced at the ankle joint. This limited motion resulted in reduction of the breakage problems.</p> <p>Although the patient was well pleased with the brace and wore it satisfactorily, the tibial and fibular defects failed to unite (<b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. P.S.'s leg after wearing the experimental brace approximately 14 months. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The physician, orthotist, and patient all considered this brace to be superior to any previously worn.</p> <p><i>Case No. 2</i></p> <p><i>C.S. </i>was born on April 17, 1915. He was injured on March 2, 1967, when he slipped on the ice and fell, sustaining fractures of the left tibia and fibula. He was treated with plaster casts, but union of the tibial fracture was delayed.</p> <p>He was fitted with the VAPC PTB brace in September 1968. The prescription was standard, and included a SACH heel, a rocker bar, and a rigid ankle. A full leather cuff was applied over the fracture site.</p> <p>This patient's treatment program proceeded uneventfully, and by June 1969 a good bone union was evident clinically and confirmed by X-ray (<b>Fig. 6</b>). This patient was discharged from the doctor's care.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. C.S.'s X-rays after wearing the experimental brace for 9 months Good bone union is evident at the fracture site. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 3</i></p> <p><i>H.E. </i>was born on October 25, 1933. He was hit by a car on October 12, 1966, sustaining a fracture of the right tibia, which failed to unite. Draining osteomyelitis also was present.</p> <p>He was fitted with the experimental brace on October 25, 1968. The prescription included a SACH heel, a rocker bar, a fixed ankle, a short leather cuff, and a high shoe. He initially walked with crutches or canes but later discontinued these aids.</p> <p>This patient is a large, heavy man and very active. Many repairs were required at the shoe-plate junction, and eventually a strut had to be added for additional strength.</p> <p>This patient's treatment program proceeded relatively uneventfully. In August 1969, the brace was reported as working well, and no drainage had been experienced since October 1968. Although the fracture had not healed, X-rays revealed some indications of healing (<b>Fig. 7</b>). In March 1970, apparent ankylosis of the ankle joint was noted, and progressive ossification within the fracture area was evident. The patient continues to wear the brace and tolerates it well. He still wears an elastic below-knee stocking, but this is apparently more for insurance than because of actual need.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. H.E.'s X-rays show indications of healing of fracture after the brace was worn for 10 months. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 4</i></p> <p><i>J.C. </i>was born on October 27, 1948. He was injured by shrapnel on May 14, 1967, sustaining a fracture of the neck of the talus on the right leg and loss of soft tissue on the right heel. <b>Fig. 8</b> shows the condition of his right ankle approximately five months after the injury.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. X-ray of J.C.'s right ankle 5 months after injury. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The experimental brace was prescribed for this patient on November 21, 1967, and it was delivered on December 13. The prescription incorporated a SACH heel, a rocker bar, a reinforced foot plate, and no ankle motion. This patient experienced no particular problems other than the need for shoe changes. He found the brace useful and comfortable. X-rays taken on April 9, 1968, showed marked improvement (<b>Fig. 9</b>). His injuries proceeded to complete healing, and he is no longer wearing the VAPC brace.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Marked improvement is evident in J.C.'s ankle after wearing the experimental brace approximately 5 months. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 5</i></p> <p><i>S.D. </i>was born on May 18, 1927. She was injured on August 30, 1967, sustaining a comminuted fracture of the right tibia and fibula. The tibial fracture failed to unite.</p> <p>She was treated with long and short leg casts and fitted with the PTB brace on May 29, 1968. The prescription was standard, and included a SACH heel, a rocker bar, and no ankle motion. The patient tolerated the brace well, and X-rays taken on July 1, 1968, indicated satisfactory progress (<b>Fig. 10</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. S.D. shows satisfactory progress one month after fitting with a PTB brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Few maintenance requirements were found, except that the shoes had to be changed and one upright and one foot plate broke.</p> <p>The patient was seen in August 1969, at which time she was using the brace with crutches. She has not been seen since, so the end result is unknown.</p> <p><i>Case No. 6</i></p> <p><i>D.E. </i>was run over by a truck in May 1966, and he sustained fractures of both legs and the left foot. The left tibia failed to unite, as indicated in X-ray films taken six months after the injury (<b>Fig. 11</b>). He was fitted for the VAPC PTB brace in December 1968, but left the hospital before the brace was delivered. The brace was delivered at home just before Christmas 1968, and he apparently has not been seen since except for a casual encounter with the or-thotist on the street, when it was reported that the fracture had healed and that the patient no longer needed the brace. Again, because of the loss of this patient to active follow-up, the full story is not known.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Condition of D.E.'s leg prior to fitting with a PTB brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Assumed Unsuccessful Outcome</h4> <p><i>Case No. 7</i></p> <p><i>R. McK. </i>was born on May 21, 1908. His injury occurred as a result of a land-mine explosion on February 27, 1942. He sustained the loss of the os calcis and the heel pad bilaterally.</p> <p>He was fitted with the VAPC PTB brace on the right side only, the device having a fixed ankle, SACH heel, and rocker bar.</p> <p>This patient was apparently dubious about the brace from the outset, and expressed lack of confidence in the doctors and the course of treatment. He wore the experimental brace for a very limited period (approximately five days) and claimed that it limited his freedom, particularly when driving. This patient subsequently became lost to follow-up, and all indications were that the application of the brace in this case was unsuccessful as well as perhaps ill-advised.</p> <h4>Discussion And Conclusions</h4> <p>The evidence in the Birmingham fittings of the VAPC PTB brace was strongly positive with respect to its value as a means of patient management. In some instances, this value was in providing partial un-weighting so that the damaged part could heal. In other instances, the unweighting provided by the brace permitted the patients to engage in vigorous programs of activity despite a lack of union in the tibia.</p> <p>In addition to these general findings, some specific findings of interest emerged.</p> <ol> <li>Following application of the VAPC PTB brace, shrinkage of the limb enclosed by the plastic cuff was encountered. Close control of the fitting during this period is essential in order to avoid the development of loose fit and a reduction in the amount of weight borne by the brace.</li><li>As in all prosthetic-orthotic applications, judicious selection of patients is essential. In the Birmingham group, one fitting was apparently doomed to failure from the outset because of the patient's attitude, while another patient was a chronic alcoholic, so that the possibility of securing follow-up data was negated from the outset.</li></ol> <p>It should be emphasized that the Birmingham fittings closely followed the technique practiced and taught by the Veterans Administration Prosthetics Center. Review by one of the co-developers of the device on a number of the cases fitted early in the study indicated good workmanship and generally excellent fit and alignment.</p> <p>Some observations by the orthotist member of the fitting team were:</p> <ol> <li>Fabrication of the VAPC PTB brace requires experience in both prosthetics and orthotics, since elements of both specialties are involved.</li><li>A course of instruction in the technique during which the braces are actually fabricated under competent instructors is a most desirable means of transmitting fitting knowledge and skill.</li><li>The selection of patients for the device is most important and should include not only considerations of psychological factors such as those described above but also of physical factors which may increase the difficulty of fitting. (The presence of loose tissue around the knee which could become a flesh roll above the brace cuff was cited as an example of this type of difficulty.)</li><li>All patients fitted in the Birmingham group were initially provided with braces with no provision for motion at the ankle joint. In active and/or heavy patients, this resulted in numerous brace-upright and shoe-plate breakages. Later, some patients were provided with a small amount of ankle motion, and this had the effect of reducing incidence of breakage. Criteria for the prescription of fixed or limited motion in ankle joints should therefore be defined more carefully.</li></ol> <h4>Durham, North Carolina</h4> <p>Mr. Bert Titus, director of the Department of Prosthetics and Orthotics, Duke University, began fitting the VAPC-PTB-type brace in 1962. The initial braces were fabricated in accordance with the VAPC manual of January 3, 1961. <a></a> Over the years, however, the original VAPC procedures were modified at Duke in a number of ways. Although the original concept of patellar-tendon weight-bearing for reduction in the amount of weight borne by the affected part of the limb was maintained, the changes are significant enough to be worthy of note.</p> <ol> <li>The socket, which in the VAPC version was hinged on the medial side, was first changed to a bivalve construction involving anteroposterior sections joined by adhesive tape (<b>Fig. 12</b>). The type of socket now fitted in Durham involves a plastic laminate without liner which is flexible on the posterior aspect and the posteromedial corner (<b>Fig. 13</b>). The socket is split along the posterolateral corner and closure is effected by two or more Velcro (TM) straps (<b>Fig. 14</b> and <b>Fig. 15</b>). The fabrication of this socket is described in a report being prepared by Titus. An abbreviated description of the Duke procedures appears as a supplement to this article.</li><li>The sidebars in the Durham version of the weight-bearing brace are of either stainless steel or aluminum, and most recently have been attached to the outside of the socket with rivets. This procedure is in contradistinction to the VAPC method, which involves insertion of the proximal ends of the sidebars into prepared channels. Distally, the bars are detachable from the shoe.</li><li>All the VAPC-type braces fitted at Durham incorporated some degree of ankle motion. Typically, this was 20 degrees to 25 degrees of dorsiflexion with a 90 degrees stop. However, some of the ankle joints were completely free. This feature again contrasts with the VA practice in which the brace ankles are frequently of the rigid type. It was reported that none of the braces fitted at Durham had completely rigid ankles.</li><li>Typically, the Durham version of the weight-bearing brace does not include either a SACH heel or a rocker bar. Doubtless, the need for such aids to roll-over is reduced or eliminated by the provision of ankle motion.</li></ol> <p>Between the initial fittings in 1962 and June 15, 1970, the Duke Limb and Brace Shop fitted approximately 27 PTB-type braces. Of these patients, 20 were civilians seen through the Orthopaedic Department of Duke University Hospital and 7 were veterans who were treated through the Veterans Administration Hospital at Durham. Three additional braces were being fabricated at the time of this review.</p> <p>On June 22-23, 1970, the author, accompanied by William McIlmurray from the VAPC, reviewed 8 patients who had been fitted through the Duke University Department of Prosthetics and Orthotics. The group of patients reviewed included 5 civilians and 3 veterans. The case-history files of 12 additional patients were also reviewed. The data obtained in these reviews are presented below in three sections-one indicating the types of disabilities for which the brace was used, the second containing illustrative case histories of patients treated, and the third containing comments on fit and alignment. In general, the outcomes of the fittings appeared to be very positive.</p> <h4>Types Of Disabilities</h4> <ul> <li>Chronic osteomyelitis with secondary deformity of distal tibia and fibula and partial ankle fusion.</li> <li>Slow-healing spiral fracture of the tibia and fibula.</li> <li>Compound fracture of the tibia and fibula and fracture of the left foot followed by infection and numerous operative procedures culminating in ankle fusion.</li> <li>Fracture of the tibia and fibula.</li> <li>Nonunion of the tibia and fibula with compression-plate fixation.</li> <li>Nonunion of a tibial fracture with draining osteomyelitis.</li> <li>Comminuted fractures of the distal right tibia and proximal right fibula and fracture dislocation of the right ankle. A painful ankle led to the performance of a triple arthrodesis.</li> <li>Comminuted fractures of the ankle mortice bilaterally (right medial malleolus and tibia, left spiral fracture of tibia and fibula; both ankles stabilized with pins). Six pins were subsequently removed.</li> <li>Traumatic arthrosis of the right ankle following fracture of the distal right tibia and fibula.</li> <li>Compound trimalleolar fractures of the left ankle with dislocation.</li> <li>Nonunion of a left tibial fracture with osteoporosis.</li> <li>Calcaneal valgus deformity of the right foot treated with a triple arthrodesis of the right foot and ankle; delayed healing of subtalar, talonavicular, and calcaneocuboid joints with severe osteoporosis.</li> <li>Pain on plantar aspect of heel following fracture of the os calcis.</li> <li>Foot pain following football injury; triple arthrodesis performed.</li> <li>Degenerative changes in left knee secondary to old fracture of the tibial plateau.</li> <li>Nonunion of medial malleolus following trimalleolar fracture sequelae of traumatic arthrosis and arthrodesis.</li> <li>Comminuted fracture of os calcis leading to a crushed heel pad, osteoporosis, and triple arthrodesis subsequently.</li> <li>Right heel pain, characteristic of traumatic or degenerative arthritis.</li> <li>Fracture of the right os calcis with painful right foot and ankle.</li> </ul> <h4>Case Histories</h4> <p><i>Case No. 1</i></p> <p><i>W.J. </i>was born on April 3, 1927. From early childhood, he had suffered from a defect in his left leg which had been attributed to an aftermath of diphtheria. His condition was reported as being chronic osteomyelitis with a secondary deformity of the distal tibia and fibula combined with partial ankle union.</p> <p>The patient was fitted with a PTB brace in August 1962, and thus had worn the device for almost eight years. The brace worn had an ankle with a positive 90 deg. stop and approximately 30 deg. of dorsiflexion motion. He wore a low shoe with a 2 1/2-in. build-up. Otherwise, the brace was of the Durham type as described previously. He reported that he wore the brace for more than nine hours daily, and that it was generally quite comfortable and satisfactory. His condition was reported to have stabilized, although his ankle and shin sometimes ached after prolonged standing or walking. He stated that he felt that he was bearing more than 50% of his weight on the brace. From his remarks, it would appear that the brace was a definite aid to his mobility.</p> <p><i>Case No. 2</i></p> <p>J.G. is a 30-year-old male garbage collector who was jammed between the garbage truck and a brick wall, sustaining a fracture of his left tibia and fibula on March 22, 1967. A nonunion of the fractures with a draining osteomyelitis ensued (<b>Fig. 16</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. J.G., with nonunion of fractures and draining osteomyelitis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient was fitted with a PTB brace in September 1969. He reported that he was feeling fine, the osteomyelitis had stopped draining, and he had returned to work driving a garbage truck.</p> <p>The brace worn was the Durham bivalve device with the ankle completely free (<b>Fig. 17</b>). He wore the brace all day every day and reported absolutely no problems with it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. J.G,, with Durham bivalve-type brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>From the patient's remarks, his return to work, and his comments concerning the brace, it would appear that this fitting was quite successful.</p> <p><i>Case No. 3</i></p> <p><i>T.L., </i>a physician, sustained a spiral fracture of the tibia and fibula on February 5, 1969. He wore a long leg cast for six months following the injury, and on August 8, 1969, he was fitted with the PTB brace. The condition of his fractures just prior to fitting is shown in <b>Fig. 18</b>. With the device, he was able to return to his medical practice. The fracture was pronounced healed in November 1969, and the PTB brace was discarded. His brace was of the standard Durham type with a completely free ankle joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Views of T.L.'s fractures before fitting with PTB brace. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When interviewed, the patient's comments concerning the brace were very positive. So much so, in fact, that when the interviewer remarked that he seemed like a happy customer, he retorted that he was more than happy—he was delighted—and in fact had sent two patients with fractures to be fitted with the same type of brace.</p> <p><i>Case No. 4</i></p> <p><i>F.E., </i>a 43-year-old male, was buried under eight to ten tons of chemical in March 1966, sustaining compound fractures of the left tibia and fibula, a fracture of the left foot, and fractures of the pelvis and of the right upper femur. Following open reduction and internal fixation, the injury became infected and the fixation was removed. The patient had a number of operative procedures on his right hip, and on October 3, 1967, underwent multiple fusions of the ankle bones.</p> <p>He was fitted with a PTB brace on March 27, 1968, and thus had worn it for slightly more than two years. The device is of a standard Durham type with a 90 degrees ankle stop and with approximately 5 degrees of dorsiflexion. The sidebars were of aluminum with an anterior aluminum calf band. A low shoe was worn with a build-up on the opposite side because of a shortening of the right leg related to the pelvic and femoral fractures. The brace was of the bivalve type. <b>Fig. 19</b> and <b>Fig. 20</b> show the condition of the foot and distal tibia and fibula over the period from January to October 1969. The patient reported that without the brace he experienced discomfort at the fracture sites, but that with the device he was reasonably comfortable and could wear the brace all day. He claimed that he took about 30<i>% </i>of his weight on the brace. Again, it appeared that this brace is a highly acceptable aid to the mobility of the patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. X-rays of F.E.'s distal leg, ankle, and foot. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Condition of F.E.'s limb 9 months later. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 5</i></p> <p><i>H.H., </i>40 years of age, sustained multiple fractures of the lower extremities on August 4, 1969. His injuries included fractures of the left femur, tibia, and fibula, and right tibia and fibula. He was fitted with a PTB-type brace in February 1970. His condition two months after fitting (eight months after injury) is shown in <b>Fig. 21</b>. His device was of the single-lamination type and incorporated a free ankle and a high shoe. The fit of the socket was somewhat loose, and the patient expressed the opinion that no weight was being taken on the socket. He used Canadian-type crutches bilaterally. The clinical notes on his condition indicated good alignment of the bony fragments and no pain. He was wearing the brace all day and had no problems with it.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Condition of H.H.'s fractures 8 months after injury (2 months' wear of PTB brace). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 6</i></p> <p><i>J.H., </i>born in 1927, suffered his injury in December 1966. Nonunion of the left tibia and fibula ensued, with compression-plate fixation.</p> <p>The patient had been fitted initially with the bivalve-type socket (separate anterior and posterior sections), but was currently wearing the one-piece laminated socket with a flexible posterior section. The brace incorporated a free ankle, and a low shoe was worn.</p> <p>Recent clinical notes on this case indicated that on March 25, 1970, there was good alignment of the bony fragments, and early bridging of bone had begun in the tibia and fibula. On May 27, 1970, the patient was reported to be feeling well, but there was still nonunion of the fibula (<b>Fig. 22</b>). The patient reported no problems with the brace.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Persisting nonunion of fibula approximately 4 1/2 years after injury. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Case No. 7</i></p> <p><i>R.C.M., </i>39 years old, sustained a comminuted fracture of the left tibia and fibula when a tree fell on his leg in March 1967. Nonunion of the left tibial fracture ensued, with chronic osteomyelitis and drainage (<b>Fig. 23</b>). A bone graft to the tibia was attempted in March 1968.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Nonunion of tibial fracture 10 months after accident. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient wore a long leg cast, followed by an initial weight-bearing brace. He was fitted with the PTB device in December 1969. His clinical record indicated that there was intermittent drainage in December and January but no drainage in February or March 1970 (<b>Fig. 24</b>). On April 1, 1970, it was reported that no active osteomyelitis was evident. However, at the time of the review (June 24, 1970), the patient reported that drainage had restarted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Nonunion persisting 3 years after accident. PTB brace worn 3 months. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>His brace included a 90 degrees posterior stop with about 10 degrees of dorsiflexion motion evident. The patient wore a built-up low shoe to accommodate a 2 1/2-in. shortness of the affected limb. His socket was of the two-part (bivalve) type. He used a cane as an aid in ambulation.</p> <p>The patient reported that the brace felt comfortable most of the time, although he had occasional swelling of the leg after long use and some discomfort at the site of the fracture after prolonged sitting.</p> <p><i>Case No. 8</i></p> <p><i>R.McC, </i>69 years old, was injured in an automobile accident on November 15, 1969. He sustained fractures of the head of the tibia, the head of the fibula, and the proximal third of the fibula (<b>Fig. 25</b>). He was fitted with the PTB brace on April 6, 1970 (<b>Fig. 26</b>). Thus, at the time of the review, he had been wearing the device for approximately two and one-half months. He reported that the brace was generally comfortable, but that he had had some problems with swelling and stiffness in the ankle. He estimated that the brace was taking approximately 25% of his body weight. His brace was a standard Durham type with a 90 degrees posterior stop and dorsiflexion motion of approximately 30 degrees. When first fitted with the PTB brace, he had used two crutches, but now was only using one.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. <i>Left, </i>R.McC.'s initial injury, Nov. 15, 1969. <i>Right, </i>after open reduction and internal fixation, Jan. 2. 1970. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. <i>Left, </i>R.McC.'s fractures at time of fitting the PTB brace, 4 1/2<i> </i>months after injury, April 1970. <i>Right, </i>after 1 month's wear of PTB brace, May 1970. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although in this instance the period of brace wear was too short for definite conclusions to be drawn, the brace was being tolerated well by the patient and was of assistance to him in ambulation.</p> <p><i>Case No. 9</i></p> <p><i>J.B., </i>67 years old, was admitted to Duke University Hospital on March 12, 1969, with a closed comminuted fracture of the left distal tibia, fibula, and ankle joint, and an open trimalleolar fracture of the right ankle. Operative procedures were carried out the same night, and the patient was discharged from the hospital on April 11, 1969, with the wounds healed and the feet in apparently satisfactory condition, with the right foot in a better state than the left.</p> <p>X-rays taken on January 12, 1970, showed an old fracture of the right ankle with fixation by metallic pins and screws and good external bony bridging and normal alignment (<b>Fig. 27</b>). On the left side, internal-external bridging of the fibula with marked angulation, as well as poor healing of the tibial fragments, was evident.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. <i>Left, </i>J.B.'s left ankle 10 months after reduction, Jan. 1970. <i>Right, </i>views of ankle 12 months after reduction (1 month after fitting with PTB brace) March 1970. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>He was fitted with the PTB brace in February 1970. Four weeks later, the clinic notes reported that the fibula had healed, and that the tibia was nontender.</p> <p>No significant further changes were noted at examination on May 26, 1970. However, that patient reported that since wearing the PTB brace he had experienced practically no pain in the ankle or foot. He was to continue wearing the brace.</p> <h3>Critique Of Fabrication And Alignment</h3> <p>William McIlmurray of the Veterans Administration Prosthetics Center, one of the co-developers of the PTB brace, participated in the review of patients at the Durham facilities. Mr. Mcllmurray described the fitting and alignment of the braces seen as generally good. He noted some of the characteristics of the Durham devices previously mentioned: the one-piece socket lamination, the ankle motion provided in all prostheses in contrast to the need that VA found to fit some braces with rigid ankles, the external attachment of the sidebars, the use of detachable stirrups, and the absence of SACH heels and rocker bars on the shoes of the patients. The absence of a liner in the sockets fitted and the fact that some patients did not wear stump socks was also noted.</p> <p>Mr. Mcllmurray subsequently discussed these features of the Duke fittings with Werner Greenbaum, the other co-developer of the VAPC technique. Their joint comments follow.</p> <blockquote><p>No objection is raised to the use of hard, unlined sockets which have a flexible medioposterior corner. However, it should be emphasized that, if this portion of the socket is too flexible, it will not offer support and the weight-bearing effectiveness of the brace will be reduced.</p> <p>In courses of instruction on the PTB brace, it would be desirable to teach fabrication methods for both lined and unlined sockets. Clinics would then have the choice of using either method, thus creating a situation similar to current practice in the prescription of PTB prostheses.</p> <p>VAPC also employs a one-piece socket fabrication procedure, and the use of this method is endorsed by the Duke experimentation.</p> <p>The channels which are prepared in the socket for insertion of the sidebars result in a product which is cosmetically more acceptable than one with bars externally attached. Moreover, these channels are very necessary for alignment adjustability during the fitting procedures. They permit us to make minute height adjustments and to tilt the socket either medially or laterally. This adjustability is a most important feature, and we would not agree to its elimination.</p> <p>We think that, in general, detachable stirrups are contraindicated, although they might possibly be used on lightweight, inactive patients.</p> <p>Usually we do allow some ankle motion if warranted by the pathology. However, the weight-bearing characteristics of the brace are better maintained if only plantar flexion is allowed. When mechanical ankle-joint motion is not provided, SACH-heel and rocker-bar principles are applied.</p> </blockquote> <h4>Discussion And Conclusions</h4> <p>The clinical records of 27 patients fitted with the patellar-tendon-bearing brace through the Department of Prosthetics and Orthotics at Duke University were reviewed. A number of the patients in this series were interviewed and examined. From the data gathered, it appears incontrovertible that this type of brace has useful applications for a variety of below-knee problems.</p> <p>Two broad areas of application were noted:</p> <ol> <li>In instances where fractures or operative procedures were slow to heal, the brace was used as a means of mobilizing the patients more rapidly than might otherwise have been the case.</li><li>In cases of chronic pain in the leg, ankle, or foot arising from fractures, traumatic arthritis, and the like, the weight-bearing relief provided by the brace permitted patients to be ambulatory with considerably less pain and discomfort than was the case without the brace.</li></ol> <p>The review data indicated that the outcomes of the application of the brace were viewed very positively by the orthopedists, the orthotists, and the patients.</p> <p>The variations in fabrication and fitting procedures used at Durham as compared with those originally promulgated by VAPC are noteworthy:</p> <ol> <li>One-piece fabrication of the PTB-type socket or cuff without a liner appears to be a possible improvement over the original VA procedure.</li><li>The external attachment of sidebars appears somewhat less cosmetic than the original technique, but is probably somewhat simpler and faster to do.</li><li>Detachable stirrup-type upright applications showed some loosening tendencies.</li></ol> <p>In some cases, the provision of ankle motion in the brace undoubtedly eliminated the need for a SACH heel and a rocker bar, and resulted in less breakage of sidebars at the shoe attachment. However, the question as to whether some of these patients should have had rigid ankles with a SACH heel and/or rocker bar is unclear. The rule of thumb used at Duke appeared to be that, the closer the disability was to the ankle joint, the less motion had to be provided. However, as reported, all patients were given some degree of ankle motion.</p> <p>In conclusion, it would appear that the Duke application of the PTB brace was in general highly successful. Some of the changes made in the original VAPC procedures appeared to have definite merit.</p> <h3>Recommendations</h3> <p>Since the results of this study indicate that the VAPC PTB brace can be successfully and beneficially applied by unaffiliated treatment centers, thus corroborating the developer, it is recommended that: (1) the results of the study be broadly disseminated by publication in <i>Artificial Limbs </i>and by other means, (2) the prosthetics-orthotics schools be encouraged to include instruction in the PTB brace as part of the lower-extremity orthotics curriculum, and (3) the fabrication modifications introduced by the Duke University Department of Prosthetics and Orthotics be tried at VAPC, and that following these trials the two institutions collaborate on the production of a fabrication manual for the PTB brace which will incorporate the best procedures currently known.</p> <h3>Summary</h3> <p>In the late 1950s, a brace to unweight the leg was designed at the Veterans Administration Prosthetics Center (VAPC), New York, N.Y. This brace incorporated a lined plastic cuff essentially similar to the proximal portion of the patellar-tendon-bearing (PTB) prosthesis. By varying the tightness of this cuff and the lengths of the uprights connecting it to the shoe, the amount of body weight borne on the proximal shank could also be varied. By these mechanisms, the distal portions of the limb could be unweighted to the desired degree.</p> <p>The VAPC PTB brace was reported by the developer as having beneficial applications in cases of delayed or ununited fractures (tibia and fibula), painful ankles, and soft-tissue damage to the heel and the plantar aspect of the foot. It appeared potentially useful in any leg condition which produced pain on weight-bearing. Patients fitted by VAPC were reviewed by an independent agency (New York University) in 1963, and the developer's claims for the device were essentially substantiated.</p> <p>The present report presents the results of VAPC PTB brace fittings performed by two groups other than the developer. The clinical records of 36 patients were reviewed, and approximately one-third of the patients were examined and interviewed.</p> <p>The studies generally corroborated the positive findings previously reported by the developer. Wide dissemination of information concerning the VAPC item and its incorporation in orthotics instructional courses is recommended.</p> <h3>Acknowledgments</h3> <p>To all who participated in the various phases of the VAPC PTB brace evaluation study, we express our sincerest appreciation. To Chestley L. Yelton, M.D., Moody L. Smitherman, Jr., of Birmingham, Ala., and Bert R. Titus of Durham, N.C., we extend our special thanks for their extraordinary efforts in scheduling and reviewing patients and in providing the X-rays and pictures for this report.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Front, rear, and side views of PTB brace with earlier Durham bivalve socket lined with horsehide, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Front, rear, and side views of current Durham socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Medial, lateral, rear, and oblique views of socket with sidebars and shoe attached. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Current version of Durham modification fitted to patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Kay, Hector W., and Heidi Vorchheimer, A Survey of Eight Wearers of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace, Prosthetic and Orthotic Studies, New York University, July 1965.</li> <li>Kay, Hector W., and A. Bennett Wilson, Jr., Clinical Evaluation of Prosthetic and Orthotic Devices and Techniques, Report E-l, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 1969.</li> <li>McIlmurray, William, and Werner Greenbaum, A below-knee weight bearing brace, Orth. Pros. Appl. J., 12:2:81-82, June 1958.</li> <li>McIlmurray, William, and Werner Greenbaum, The application of SACH foot principles to orthotics, Orth. Pros. Appl. J., 13:4:37-40, December 1959.</li> <li>Veterans Administration Prosthetics Center, A Manual for Fabrication and Fitting of the Below-Knee Weight-Bearing Brace, April 1967.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, A Manual for Fabrication and Fitting of the Below-Knee Weight-Bearing Brace, April 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Veterans Administration Prosthetics Center, A Manual for Fabrication and Fitting of the Below-Knee Weight-Bearing Brace, April 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical Evaluation of Prosthetic and Orthotic Devices and Techniques, Report E-l, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Kay, Hector W., and Heidi Vorchheimer, A Survey of Eight Wearers of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace, Prosthetic and Orthotic Studies, New York University, July 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">McIlmurray, William, and Werner Greenbaum, The application of SACH foot principles to orthotics, Orth. Pros. Appl. J., 13:4:37-40, December 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">McIlmurray, William, and Werner Greenbaum, A below-knee weight bearing brace, Orth. Pros. Appl. J., 12:2:81-82, June 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>3.</b> </td><td class="clsTextSmall">McIlmurray, William, and Werner Greenbaum, A below-knee weight bearing brace, Orth. Pros. Appl. J., 12:2:81-82, June 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>2.</b> </td><td class="clsTextSmall">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical Evaluation of Prosthetic and Orthotic Devices and Techniques, Report E-l, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Kay, Hector W., and Heidi Vorchheimer, A Survey of Eight Wearers of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace, Prosthetic and Orthotic Studies, New York University, July 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Research Council-National Academy of Sciences.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-16.jpg Figure 13 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-17.jpg Figure 14 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-18.jpg Figure 15 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-19.jpg Figure 16 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-20.jpg Figure 17 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-21.jpg Figure 18 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-22.jpg Figure 19 http://www.oandplibrary.org/al/images/1971_01_046/1971_01_046-23.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Applications of the Veterans Administration Prosthetics Center Patellar-Tendon-Bearing Brace Creator An entity primarily responsible for making the resource Hector W. Kay * https://staging.drfop.org/files/original/211972ac2450f7c379e75a6afbeee2dc.pdf ae8db5d5134f237d958bbd2b68be6d08 https://staging.drfop.org/files/original/520946adfb02dd1afbd9b4c67af73f08.jpg 61cd9ff898171a3445f27886c90a2493 https://staging.drfop.org/files/original/9170dd45d7ca4e14488f584a811dd23e.jpg fe5833e8ce6bc7bdf61f5f73baf816e3 https://staging.drfop.org/files/original/3b0777a43f09e4e4ee2114768fb56d30.jpg d22944087f7c13edf9ac4ccc260893d8 https://staging.drfop.org/files/original/fe459c0ecfb645ab7220642b51f9c593.jpg f2423f9a630bfe7e433bda250a03a58c https://staging.drfop.org/files/original/7cfdf4864b7be4044c17cc555926b0e2.jpg 05467aefe472260562820f5c91fb6f4c https://staging.drfop.org/files/original/54b46adc00046b649185688bcfa06ed8.jpg d9288be7f7a62533a8e62cb9e56ac3e8 https://staging.drfop.org/files/original/e21b7388fdb6d845283dd747b9618c11.jpg dfe82d1c37e1a9669c31bcfda7e97869 https://staging.drfop.org/files/original/c228c40b5262dd433fd295410cdae1e4.jpg 6f2c4233f38372d631252e490f83e18f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_013.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 13 - 26 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_01_013.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_013.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Clinical Evaluation of the Engen Plastic Hand Orthosis</h2> <h5>Hector W. Kay, M Ed. <a style="text-decoration:none;">*</a><br /></h5> <p>A primary function of the hand is prehension, the ability to grasp an object. While the hand can perform numerous types of grasp, of major importance is the type involving flexion of the index and middle fingers towards or against the opposing thumb to provide what is sometimes referred to as "three-jaw-chuck" prehension.</p> <p>Temporary or permanent paralysis can impair or completely inhibit the function of hand, wrist, or entire upper extremity, and the ability to oppose the thumb to the flexing fingers may be lost. In these instances, various types of orthotic systems have been designed to achieve the goals of prevention or correction of deformities, or restoration of function, or both. A key feature of these systems is the stabilization of the thumb in opposition to the fingers.</p> <p>Pioneering efforts in the area of hand-splinting were undertaken at the Georgia Warm Springs Foundation where many types of assistive devices were developed to meet the needs of a large patient population having residuals of poliomyelitis. Although the number of polio patients has decreased in recent years, rehabilitative medicine has expanded to include patients with many other types of neuromuscular and skeletal disorders. A systematic method of hand splinting to meet the needs of these patients has continued to be of paramount importance. On-going efforts in this regard have been maintained not only at GWSF but also at Rancho Los Amigos Hospital and other institutions. <a></a></p> <p>As part of Research Project VRA RD-1564, Thorkild J. Engen, Project Director, Baylor University College of Medicine, Houston, Texas, in 1959 initiated the development of a plastic hand orthosis having the basic configuration shown in <b>Fig. 1</b>. <a></a> Based on the premise that preservation of hand posture is best maintained by support, rather than suspension, the device is designed to hold the thumb in the opposed position and simultaneously support the metacarpal arch. The aim has been to develop a standardized item shaped to conform to the natural contours of the hand which could then be adapted to meet individual needs. The Engen orthosis is made in four sizes: large, medium-large, medium, and small; and for both right and left hands. Because the orthosis is fabricated of polyester resins, it can be remolded upon application of heat.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Basic Engen plastic hand orthosis being prepared for individual application. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the early stages of redevelopment, the Engen orthoses were fabricated of epoxy resins with and without fiberglass reinforcement. Ultimately these models were discarded because of breakage problems. The plastic shells originally submitted to New York University for a laboratory evaluation program were made of fiberglass and polyester resins. <a></a> The current shell is a polyester resin and nylon laminate prepared by means of a vacuum-molding technique. With the new materials, the fitting technique is essentially unchanged; the orthosis is molded and modified by the orthotist as necessary to provide a custom fit.</p> <p>In the course of development, attachments were devised or adapted to provide wrist support and to provide prehension.</p> <p>Three versions or adaptations of the Engen plastic hand orthosis were selected as the subject of the field evaluation: the short opponens orthosis, the long oppo-nens orthosis, and the reciprocal wrist-extension, finger-flexion unit. Additional modifications of the basic concept involving the use of external power were specifically not included in the study.</p> <h3>Short Opponens Orthosis</h3> <p>The so-called short opponens orthosis is the simplest application or adaptation of the Engen equipment. <a></a> It consists essentially of the basic hand shell with a retaining strap (<b>Fig. 2</b>). The prime purpose of this device is to maintain the thumb in apposition to the index and long fingers and to support the metacarpal arch. The functional goal is the achievement of "three-jaw-chuck" prehension as distinct from "lateral" grasp. Patients said to benefit from this orthosis are those with neuromuscular disorders resulting in various degrees of muscle imbalance of the intrinsic and opponens muscle groups. Such patients would typically have spinal cord injuries at the C-7, C-8, and T-l levels, peripheral neuropathy (ulnar and median nerves), or hemiplegia.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Two views of the short opponens orthosis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Long Opponens Orthosis</h3> <p>This adaptation <a></a> consists essentially of the basic plastic hand shell with an attached extension arm which is stabilized on the forearm by appropriate straps (<b>Fig. 3</b>). Like the short opponens orthosis, this device is designed to prevent deformity and achieve "three-jaw-chuck" prehension if the necessary residual muscle movements are present and can be controlled. Patients with spinal lesions at the C-5, C-6 levels, peripheral neuropathy involving the median or ulnar nerves, or both, and the radial nerve, or hemiplegia, are said to be suitable candidates for this device.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Two views of the long opponens orthosis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Reciprocal Wrist-Extension Finger-Flexion Orthosis</h3> <p>This adaptation, which is the most complex of those studied, is designed to provide prehension when voluntary wrist-extension power is available (<b>Fig. 4</b>). Quadriplegic patients who retained innervation to the wrist-extensor muscles are said to be appropriate subjects for this type of functional orthosis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Two views of the reciprocal orthosis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Procedures</h3> <h4>Participating Clinics and Personnel</h4> <p>As an initial step in the activation of the proposed field study, the Committee on Prosthetics Research and Development, through its staff and Subcommittee on Evaluation, selected five treatment centers known to be active and interested in the application of hand splints. These clinics were approached and each agreed to participate in the study. The institutions and personnel involved were:</p> <ol> <li>Duke University Medical Center, Durham, N. C. (Frank W. Clippinger, Jr., M.D.; Bert R. Titus; Felton Elliott).</li><li>Georgia Warm Springs Foundation, Warm Springs, Ga. (Edward Haak, M.D.; H. G. Bowden).</li><li>Highland View Hospital, <a style="text-decoration:none;">*</a> Cleveland, Ohio (Al-vin A. Freehafer, M.D.; Arthur Guilford, Jr., G. A. Guilford and Sons).</li><li>Ohio State University, Columbus, Ohio (Marvin H. Spiegel, M.D.; Lawrence Czap; Charles W. Rosenquist, Columbus Orthopaedic Appliance Co.).</li><li>Veterans Administration Hospital, Hines, Ill. (James F. Kurtz, M.D.; Vladimir T. Liberson, M.D.; Walter J. Piotrowicz, CO.).</li></ol> <h4>Instruction In Fabrication Procedures</h4> <p>The study of the Engen devices was initiated by an instructional course in the three applications to be evaluated. This course was conducted by the developer and his staff at the Texas Institute for Rehabilitation and Research, Houston, Tex., from Dec. 5 to 8, 1966 (orthotists, four days; physicians, one day). Instructional material and fitting check lists were prepared by the developer, <a></a> and used as the basis for the course. A special training session for Mr. Sigars was conducted December 4-6, 1967, after he joined the Rancho Los Amigos Hospital team.</p> <h4>The Study Plan</h4> <p>Concurrent with the recruitment and training of participating clinic personnel, the CPRD staff, in collaboration with the developer, and under the guidance of its Subcommittee on Evaluation, prepared the schedule and data-recording forms for the study. <a></a></p> <p>Essentially, each clinic was requested to seek patients appropriate for applications of the Engen devices. Data related to the fittings would be recorded on the forms developed by the Committee on Prosthetics Research and Development. Each patient fitted was to be followed for a period of 12 months unless treatment was terminated prior to that time. The CPRD staff was to provide liaison with the field clinics as necessary during the course of the study.</p> <h3>Results</h3> <h4>Technique Transferability</h4> <p>With a new fabrication or fitting technique which is said to yield excellent results in the hands of the developer, an important consideration is whether or not the skill and "know-how" involved in the applications can be successfully transferred to others.</p> <p>In the present study the means of achieving this transfer were: (1) Written instructional material prepared by the developer; (2) A course of instruction which included practice in the fabrication of devices; and (3) Follow-up visits made by the developer to each participating facility. Problems encountered locally were analyzed and supplementary instruction given.</p> <p>It was the consensus of the evaluation team as well as that of the participants that the fabrication techniques for the three EPHO adaptations under study were successfully transmitted by these procedures. Moreover, while the orthotists participating in the evaluation were selected and highly skilled, indications were that less skilled technicians could be satisfactorily taught by the same methods.</p> <h4>Patient Fittings</h4> <p><i>The Sample</i></p> <p>During the period of the evaluation program, 22 patients were fitted with the Engen Plastic Hand Orthosis. Distribution in terms of the three adaptations under study were: short opponens orthosis, 7; long opponens orthosis, 3; and reciprocal units, 12.</p> <p>Moreover, data was available on an additional 48 patients distributed as follows: short opponens orthosis, 11; long opponens orthosis, 7; and wrist-driven reciprocal units, 30. These patients were fitted at Hines VA Hospital following the closure of the official phase of the study. Some findings of interest from these additional fittings are included.</p> <p>In the total of 70 fittings reported, 18 were with short opponens, 10 with long opponens, and 42 with reciprocal units, roughly a 2:1:4 ratio. Whether this ratio could be extrapolated to the general population is not known.</p> <p>Typical conditions for which the three versions of the EPHO<a style="text-decoration:none;">*</a> were applied were: (1) short opponens orthosis: rheumatoid arthritis of the hands (<b>Fig. 5</b>); quadriplegia (to prevent deformities and support the hand in a position of function pending fitting of reciprocal units); contraction deformity of the wrist; (2) long opponens orthosis: quadriplegia (as a stabilizing device pending reduction of contractures and fitting with a reciprocal unit) (<b>Fig. 6</b>); or as a base for the addition of self-help devices (<b>Fig. 7</b>); reciprocal units: quadriplegia (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Left, palmar and dorsal views of patient's arthritic hands. Above, left hand fitted Engen short opponens orthosis and Thomas outrigger splint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Patient fitted with Engen long opponens orthosis as stabilizing device. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Patient fitted with Engen long opponens orthosis with attachment for self-help devices. Note atrophy of thenar cleft. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Patient fitted with reciprocal unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Outcomes</i></p> <p>Results of the fittings in the five participating clinics were variable, success or failure being related primarily to three factors:</p> <ol> <li>Proper selection of patients. In several of the clinics patients were selected under somewhat experimental circumstances, that is, either the motivation of the patients was less than optimal or the anticipated benefit to be derived from the Engen device was marginal. In these instances, the fittings typically proved to be failures.</li><li>Objectivity in the evaluation of outcomes. Two of the clinics participating in the study had devices of their own design which were "competitive" with the Engen items. Personnel of these clinics were of the opinion that the Engen devices provided no features superior to their own devices other than perhaps the telescoping rod on the reciprocal unit application.</li><li>Meticulous care in application and follow-up. Although the Engen Plastic Hand Orthosis is essentially a prefabricated shelf item, it must be carefully tailored to the needs of the individual patient. This tailoring may involve: (a) some reshaping of the plastic shell to accommodate atrophy or size discrepancy in the patient's hand; (b) the addition of accessory finger pieces and other equipment to the basic Engen shell.</li></ol> <p>Moreover, since the condition of the patient's hand changes with time and with the use of the Engen splint, follow-up to maintain fit of the device is essential. This follow-up is obviously best accomplished when the patient is being treated on an in-patient basis, in-house orthotic facilities are available, and there is close cooperation between the disciplines involved in the care of the patient.</p> <p>Where the foregoing conditions were satisfactorily met, excellent success was achieved in the fittings of the Engen devices. Selected cases which illustrate the applications and outcomes of the three EPHO modifications under study are presented below.</p> <h3>Case Presentations</h3> <h4>Short Opponens Orthosis</h4> <p><i>Case No. 1</i></p> <p>A. M. was a 40-year-old male with a diagnosis of quadriplegia resulting from a physiologically incomplete lesion of the spinal cord at the C-5 level. A short op-ponens orthosis was prescribed for his right, dominant hand with a view to aiding in the restoration of function, and the prevention and correction of deformities. It was hoped that eventually Mr. M. would be a candidate for a right reciprocal unit. The patient was described as having a motivational level of fair and a tolerance to pain that was average.</p> <p>Mr. M. was fitted with a medium-sized orthosis. The suitability of the preformed size and shape was rated as good and the ease of customizing and the clarity and completeness of the instructions for doing so were also rated as good. No special modifications of the shell were necessary for this patient.</p> <p>A. M. was reevaluated at 1, 3, 6, 9, and 12 months following the initial fitting. The efficacy of the splint in achieving the objectives of the fitting was rated as good in all respects. The patient's performance in such activities as turning pages in a book and writing was rated as fair. The performance in feeding and using a toothbrush was cited as being poor. The patient's reactions to the orthosis were good with respect to fit, comfort, and cosmesis, and fair as regards function. During the course of his treatment the patient was given physical and occupational therapy and special instruction in the use of the Engen device. He was also given medication for spasticity which did not involve the hands.</p> <p>The evaluation of the device with regard to this patient remained remarkably consistent throughout the entire 12 months of the test period except that the patient's own reactions to the functional assistance provided by the device declined from fair to poor from the third month on.</p> <p>The outcome in this instance was considered to be excellent, but two other patients, D. R. and J. A., whose initial conditions were remarkably similar, withdrew from the study one and four months, respectively, after the initial fitting. In these two instances the restoration of function achieved with the orthosis was minimal and this factor, combined with low levels of motivation, resulted in the withdrawals.</p> <p><i>Case No. 2</i></p> <p>Patient N. E. was a 60-year-old male with a diagnosis of rheumatoid arthritis of some eight years' duration. He was prescribed an EPHO short opponens orthosis for his right, dominant hand, the objectives being assistance in the restoration of function and the prevention and correction of deformities. His tolerance to pain was described as average, and his skin condition as thin, and his motivational level was said to be good.</p> <p>N. E. was fitted with the large-sized EPHO shell. With regard to the fitting, the suitability of the preform size and shape was rated as good, as were the ease of customizing and the clarity and completeness of instructions. No special modification was necessary initially, but some five weeks later a Thomas outrigger suspension was applied to prevent further subluxation of the metacarpophalangeal (MCP) joints (<b>Fig. 5</b>). Mr. E. was reevaluated at 1, 3, 6, 9, and 12 months following fitting and then left the clinic area taking the provided splint with him.</p> <p>Initially the achievement of objectives involving the prevention and correction of deformities was rated as good, but the restoration of function as poor. Mr. E.'s performance in typical activities of daily living were all rated as poor. The patient's reactions to the device were good with respect to fit, comfort, and cosmesis, but poor as regards function.</p> <p>As Mr. E. continued to wear the experimental device his ratings in all performance activities were raised to fair, and finally to good in such activities as page-turning, writing, and feeding. The patient's rating of the functionality of the device gradually improved until finally it was reported as good.</p> <p>In this fitting the outcomes appeared to be positive from the beginning with respect to the prevention and correction of deformities with gradually increasing benefit in the area of function.</p> <h4>Long Opponens Orthosis</h4> <p><i>Case No. 3</i></p> <p>Patient J. K. was a 21-year-old male. His primary diagnosis was quadriplegia with a spinal-cord injury at the C-5, C-6 levels which was incurred some nine months prior to his inclusion in the evaluation program. He was fitted with an EPHO long opponens orthosis, medium-size, to the right hand which was less impaired than the left. His hands were atrophied, especially in the thenar-cleft area, and he had a slight lateral palmar drift on the (right) hand fitted. The patient's motivational level was said to be good and his pain tolerance average. The objectives of the fitting were restoration of function, and prevention and correction of deformities in the hope that he might eventually be fitted with a reciprocal orthosis.</p> <p>The application of the device proceeded without difficulty except that the device was somewhat too large for the patient's atrophied thenar-cleft area. The splint tended to displace itself into this area. Three weeks after the initial fitting a reduction in the cock-up angulation was recommended by the developer, together with the addition of a T-bar to abduct the thumb and a dorsal strap for better retention.</p> <p>The patient preferred the EPHO splint to his previously worn Royalite device and requested that the EPHO be modified to include the self-aid attachments worn on the earlier splint. The device was subsequently reinforced with a Monel metal piece and has held up well since that time. The patient's flexed lateral palmar drift was held in proper position by the orthosis.</p> <p>At the one-month follow-up of this patient the ratings of outcomes were generally poor to fair with only the patient's reaction to the cosmesis of the device being designated as good. However, steady improvement occurred throughout the follow-up period, and by 9 months after initial fitting the device was rated as good in all characteristics specified in the evaluation program. Thus, in this instance, the outcomes of fitting the Engen plastic hand orthosis must be considered as excellent.</p> <p><i>Case No. 4</i></p> <p>On another patient, F. G., with a somewhat similar disability, the results of the fitting were considerably less positive. This patient was a 40-year-old male with complete transverse severance of the spinal cord at the C-6, C-7 levels. The injury to this patient had occurred some six and a half years prior to the present study and he had had a surgical transfer of the brachioradialis tendon to the wrist extensors on his left hand several years previously. The hand tended to go into marked radial deviation on voluntary extension of the wrist. He could raise his elbows and shoulders bilaterally. He had muscle spasms.</p> <p>F. G. was fitted with a medium-sized long opponens orthosis and it was immediately noticeable that the splint would not hold the patient's marked radial deviation. At the developer's suggestion the cock-up angle of the splint was reduced to prevent creeping and a plastic clip added on the proximal medial side. A lateral Velcro strap was added to pull the ulnar side of the wrist toward the radial side, and an elastic sling was added to correct the flexion of the interphalan-geal (IP) joint of the thumb. The patient was to be considered for a reciprocal orthosis if his contractures could be reduced. The patient's motivational level was rated as poor with respect to any type of splinting.</p> <p>The outcomes of this fitting initially were also mixed and failed to show appreciable improvement, particularly with regard to function, over a 6-month follow-up period. The patient was then taken off the program at his own request.</p> <h4>Reciprocal Wrist-Extension Finger-Flexion Orthosis</h4> <p><i>Case No. 5</i></p> <p>Patient V. C. was a 42-year-old male who had sustained a spinal-cord injury at age 26. His primary diagnosis was "dislocation and compression of the spinal cord at the C-5, C-6 levels with complete paralysis." With no prior experience with orthotic devices, he was fitted with a reciprocal unit on his right, dominant hand. His motivational level was rated as good, but his pain tolerance was given as low. The objectives of the fitting were restoration of function and prevention and correction of deformities.</p> <p>The fitting utilized a large reciprocal orthosis and finger pieces but a medium-sized forearm piece. The component sizes were considered to be good for this patient. However, the shape of the plastic shell did not provide good support for the arch of the hand or conform well to the thenar-cleft area. A thumb sling and a middle-finger IP stabilizer were added. A later review of this case indicated that the MCP and the wrist joints were incorrectly placed. With these conditions the patient had no desire to try and use the splint and did not wish to keep it. Replacement of the malpositioned joints effected a marked improvement in the function of the device and the patient's acceptance of it. This high level of performance and acceptance was maintained throughout the remainder of the patient's 12-month participation in the study. In this case, obviously the difference between success and failure hinged on the proper joint positioning, emphasizing the importance of this aspect of the fitting. This type of experience was repeated with a number of other patients in the evaluation.</p> <p><i>Case No. 6</i></p> <p>Patient W. M. was a 47-year-old male who sustained a spinal-cord injury approximately one year prior to being fitted with the Engen orthosis. His diagnosis was given as "compression of cord, level C-5, C-6 incomplete, C-7 complete." Mr. M.'s motivational level was said to be good, but his pain tolerance was given as low. He was fitted with a reciprocal orthosis on his right, dominant hand, the objectives being restoration of function, and prevention and correction of deformities.</p> <p>The initial application of the device seemed to proceed satisfactorily, the component parts being a large plastic shell, a larger finger unit, and a large forearm piece. The sizes and shapes of the various components seemed to be appropriate. Three days later a "knuckle bender" was added because of tightness of the MCP joints and a modified Oppenheimer splint was fitted to increase the limited range of wrist extension and thumb abduction.</p> <p>A later review of this case indicated that the joint hinges had been incorrectly positioned and this deficiency was corrected. Again a dramatic improvement in the achievement of fitting objectives, functional level and patient acceptance, was evident, although this subject's function was not as good as that of the previous patient. This case again illustrates the importance of joint positioning and indicates the use of the Engen basic equipment as a module to which other accessories might be added.</p> <h3>Summary and Recommendations</h3> <p>In the present study it would appear evident that orthotists with prior experience and skill in the fabrication of hand splints can be taught to apply the EPHO variations successfully. In this connection the instructional manual and fitting checkout sheets developed in conjunction with the field study provided an excellent basis for the transfer of techniques from developer to field orthotists. However, this written material is not regarded as an adequate substitute for direct person-to-person instruction. Moreover, a follow-up visit to each of the clinics following initial fittings helps to insure that the techniques taught are being properly applied and assists in the solution of specific local problems.</p> <p>The outcomes of the field fittings of the Engen equipment were mixed, positive results being related primarily to three factors: (1) proper selection of patients, including consideration of motivational factors; (2) meticulous care in application and follow-up of the devices; and (3) objectivity in evaluating outcomes. Where these considerations were observed, the successful outcomes achieved support the developer's claims for the device.</p> <p>Fitting results for each subject in the study showed no significant changes after 6 months' wear of the Engen device. Hence, consideration might be given to reducing the follow-up period in similar future studies from 12 to 6 months.</p> <h4>The Devices</h4> <p><i>Prescription Criteria</i></p> <p>The criteria for prescription of the Engen adaptations as set forth above were re-affirmed by the results of the field study. The following additional comments also emerged:</p> <ol> <li>Short Opponens Orthosis <ul><li>a. has been found useful as a stabilizing splint in several instances of postsurgical management;</li> <li>b. has been used in providing patients with various self-help devices as attachments to the basic shell;</li> <li>c. with special modifications has been used in rheumatoid arthritic cases to help prevent ulnar and radial finger drift and align the fingers in proper position for finger prehension;</li> <li>d. has been used as the stabilizing splint pending evaluation for application of a reciprocal unit.</li></ul></li><li>Long Opponens Splint with Extension Arm Support <ul><li>a. has also been utilized for the same applications as the short opponens orthosis above.</li></ul></li></ol> <h4>Specific Findings</h4> <p>Specific findings relating to the design and applications of the EPHO devices were:</p> <ol> <li>Although the Engen Plastic Hand Orthosis is ostensibly a prefabricated shelf item, it must be carefully tailored to the needs of the individual patient. This tailoring may involve: <ul> <li>a. some reshaping of the plastic hand shell to accommodate atrophy or size discrepancy in the patient's hand;</li> <li>b. the addition of accessory finger pieces and other equipment to the basic Engen shell.</li></ul></li><li>In the installation of the EPHO reciprocal orthosis, great care must be exercised in the location of the joint axes.</li><li>Since the condition of the patient's hand changes with use of the Engen splint, follow-up to maintain fit of the device is essential. This follow-up is best accomplished when the patient is being treated on an in-patient basis, in-house orthotic facilities are available, and there is close cooperation between the disciplines involved in patient care.</li><li>The telescopic rod feature of the reciprocal unit was frequently cited as a most significant new characteristic of this type of orthosis.</li><li>Although definitely related to the level of experience gained in the application of the EPHO devices, saving of the orthotist's time was a significant feature of the system.</li><li>Some deficiencies in the design and materials of the EPHO were noted: <ul> <li>a. The range of three sizes provided initially were considered inadequate but the addition of the fourth (medium-large) size virtually eliminated this problem.</li> <li>b. A very common problem was that of fitting the hand shell to atrophied thenar-cleft musculature. The likelihood that this problem would be encountered and measures for adapting the shell to meet it should be emphasized in the instructional material.</li> <li>c. Some problems were encountered with stripping and bending of the telescopic rods.</li> <li>d. Some tendency for the shells to revert to their original shape after heating and modification was reported. However, in general, the physical properties of the splints were considered adequate to last an indefinite period with proper care and maintenance.</li></ul></li></ol> <p>In conclusion, the field evaluation of the EPHO adaptations clearly revealed that the devices are useful additions to the armamentarium of orthotic items available for the treatment of patients with disabilities of the hand. It is recommended that the outcomes of this study be forwarded to the prosthetics-orthotics schools with a view to the possible inclusion of instruction in this system as part of the orthotics curriculum.</p> <p><b>References:</b></p> <ol> <li>Anderson, Miles H, <i>Upper extremities orthotics</i>, Charles C Thomas, Springfield, Ill., 1965.</li> <li>Bisgrove, J. G., <i>A new functional dynamic wrist extension-finger flexion hand splint, a preliminary report</i>, J. Assoc. Phys. Ment. Rehab., 8:5:162-163, September-October 1954.</li> <li>Engen, Thorkild J., <i>A plastic hand orthosis</i>, Orthop. Pros. Appl. J., 13:2, September 1959.</li> <li>Engen, Thorkild J., <i>A "modification" of a reciprocal wrist extension-finger flexion orthosis</i>, Or-thop. Pros. Appl. J., 14:1, March 1960.</li> <li>Engen, Thorkild J., <i>Instructional manual for a reciprocal wrist extension-finger flexion orthosis</i>, Baylor University, Houston, Tex., 1: April 1968.</li> <li>Engen, Thorkild J., <i>Fabrication instructions, long opponens orthosis,</i> unpublished.</li> <li>Engen, Thorkild J., <i>Fabrication instructions, short opponens orthosis</i>, unpublished.</li> <li>Kay, Hector W., and A. Bennett Wilson, Jr., <i>Clinical evaluation of prosthetic and orthotic devices and techniques</i>, Committee on Prosthetics Research and Development, National Academy of Sciences, Washington, D.C., 1969.</li> <li>Vorchheimer, Heidi, <i> Summary of fittings - Engen hand orthoses</i>, Prosthetic and Orthotic Studies, New York University, June 1966.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall"> Utilizing the basic Engen items as modules to which accessory equipment was added if indicated by the needs of the patient.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical evaluation of prosthetic and orthotic devices and techniques, Committee on Prosthetics Research and Development, National Academy of Sciences, Washington, D.C., 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Engen, Thorkild J., Instructional manual for a reciprocal wrist extension-finger flexion orthosis, Baylor University, Houston, Tex., 1: April 1968.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Engen, Thorkild J., Fabrication instructions, long opponens orthosis, unpublished.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Engen, Thorkild J., Fabrication instructions, short opponens orthosis, unpublished.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Kay, Hector W., and A. Bennett Wilson, Jr., Clinical evaluation of prosthetic and orthotic devices and techniques, Committee on Prosthetics Research and Development, National Academy of Sciences, Washington, D.C., 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Unfortunately, the Highland View Hospital team had to withdraw prior to the commencement of the study. It was replaced by a team from Rancho Los Amigos Hospital consisting of E. Shannon Stauffer, M.D., and Dale Fries, orthotist. In the course of the study, Mr. Fries transferred to another position and was replaced by Mr. Charles Sigars.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Engen, Thorkild J., A plastic hand orthosis, Orthop. Pros. Appl. J., 13:2, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Engen, Thorkild J., A plastic hand orthosis, Orthop. Pros. Appl. J., 13:2, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Vorchheimer, Heidi, Summary of fittings - Engen hand orthoses, Prosthetic and Orthotic Studies, New York University, June 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Engen, Thorkild J., A plastic hand orthosis, Orthop. Pros. Appl. J., 13:2, September 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Anderson, Miles H, Upper extremities orthotics, Charles C Thomas, Springfield, Ill., 1965.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bisgrove, J. G., A new functional dynamic wrist extension-finger flexion hand splint, a preliminary report, J. Assoc. Phys. Ment. Rehab., 8:5:162-163, September-October 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Research Council, 2101 Constitution Ave., N.W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_013/spring69-13.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_013/spring69-14.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_013/spring69-15.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_013/spring69-16.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_013/spring69_17.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_013/spring69_18.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_013/spring69-19.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_013/spring69-20.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Evaluation of the Engen Plastic Hand Orthosis Creator An entity primarily responsible for making the resource Hector W. Kay, M Ed. * https://staging.drfop.org/files/original/b5321419e7289e34cedd7b3e0cbe4493.pdf 1cb64ea6151a427da372f111e67022a4 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_041.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 41 - 42 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_02_041.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_02_041.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Clinical Study of the Application of the PTB Air-Cushion Socket</h2> <h5>Eric Lyquist <a style="text-decoration:none;">*</a><br /></h5> <p>From January 1966 to September 1968, the Orthopaedic Hospital in Copenhagen conducted a clinical evaluation study of the patellar-tendon-bearing (PTB) air-cushion socket (see p. 1).</p> <p>The Prosthetic/Orthotic Research Department at the hospital fabricated the sockets, using the casting procedure described by Wilson and Lyquist <a></a> and the fabrication procedures described by Lyquist and his associates<a></a>. These procedures and the results of fitting 45 amputees were published in September 1968.<a style="text-decoration:none;">*</a></p> <p>Forty-five amputees were selected for the test series and fitted with air-cushion sockets. Four patients were eventually dropped from the study, three because of their inability to return for re-examination, and one because of her confinement to a wheelchair as a result of progressive vascular disease.</p> <p>The group of 41 amputees consisted of 30 males and 11 females, with ages ranging from 7 to 74 years (average age: 44).</p> <h3>Clinical Evaluation</h3> <p>Seventeen of the amputees had been satisfied wearers of a PTB prosthesis for at least 12 months. After being fitted with air-cushion sockets, 13 noted improved comfort and function, 3 found no change in comfort and function, and 1 was dissatisfied because of nocturnal stump pain.</p> <p>Seven patients had previously been fitted with the standard type of PTB prosthesis, but satisfactory fittings had never been achieved. With fitting of the air-cushion socket, 4 amputees obtained satisfactory comfort and function. One patient was able to wear a modified air-cushion socket with a soft insert. The remaining 2 had to abandon the socket; both had short stumps (2-1/2 in.) with distal hypersensitivity.</p> <p>Seven amputees had previously worn prostheses, but with complications such as ulcerations and secondary distal edema. Six obtained satisfactory comfort and function with the air-cushion socket, but one who had a short stump (2 in.) and extensive skin transplants was fitted after four weeks with a standard PTB prosthesis.</p> <p>Four amputees had successfully worn conventional BK prostheses for periods of 40, 30, 13, and 6 years. Nonetheless, when fitted with an air-cushion socket, each preferred it to the conventional prosthesis.</p> <p>Of the remaining 6 amputees, 5 had never worn a prosthesis. Two of those had distal edema and ulceration, which healed when an air-cushion socket was applied. Another had stump problems not attributable to the prosthesis, but he managed well with the air-cushion socket. A fourth patient had no stump problems, and successfully wore the socket. One amputee had to be fitted with a different type of prosthesis because his stump was hypersensitive distally and the volume was constantly changing.</p> <h3>Summary</h3> <p>Of the 41 amputees fitted with the air-cushion socket, 36 had previously worn prostheses. In that group, 27 noted increased comfort and function, 4 were considered unchanged, 3 returned to wearing a standard PTB prosthesis, and 1 required fitting with a conventional prosthesis. One amputee had previously been fitted with an air-cushion socket by a private pros-thetist, and got along very well. Of the 5 amputees who had not previously worn a prosthesis, 1 was not successfully fitted, but 4 were able to manage well with the air-cushion socket.</p> <p>At the time of this report, 36 of the 41 amputees evaluated in this study were wearing the air-cushion socket. Although extensive final medical examinations of the entire group have not been completed, it is unlikely that the information resulting from those examinations will differ greatly from the results presented in this report.</p> <p><b>References:</b></p> <ol> <li>Lyquist, E., L. A. Wilson, and C. W. Radcliffe, <i>Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, principles and fabrication procedures</i>, Technical Memorandum, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 1965.</li> <li>Wilson, L. A., and E. Lyquist, <i>Plaster bandage wrap cast</i>, Pros. Int., 3:4-5:3-7, 1968.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Prosthetic/Orthotic Research Department technical report (Danish).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Lyquist, E., L. A. Wilson, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, principles and fabrication procedures, Technical Memorandum, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Wilson, L. A., and E. Lyquist, Plaster bandage wrap cast, Pros. Int., 3:4-5:3-7, 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eric Lyquist </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetic/Orthotic Research Department, Orthopaedic Hospital, Copenhagen, Denmark.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Study of the Application of the PTB Air-Cushion Socket Creator An entity primarily responsible for making the resource Eric Lyquist * https://staging.drfop.org/files/original/673830cf47fc4145408e60fb59c2e58e.pdf daa60cba2d873060d065a59d7d151976 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_02_001.pdf Year 1964 Volume 8 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Collaboration for Rehabilitation</h2> <h5>Mary E. Switzer <a style="text-decoration:none;">*</a><br /></h5> <p>I welcome the opportunity to express my appreciation for the wonderful cooperation and assistance that the Vocational Rehabilitation Administration has enjoyed in our many close relationships with the National Academy of Sciences-National Research Council. Our associations with the Committee on Prosthetics Research and Development and the Committee on Prosthetic-Orthotic Education have been long and fruitful, and the contributions of these committees have been substantial in the development and coordination of the research and informational programs for the fields of prosthetics and orthotics. VRA is glad to be associated with the National Institutes of Health-which is another agency of the Department of Health, Education, and Welfare-and with the Veterans Administration in supporting the CPRD program; and, naturally, we look with special pride on the CPOE program since we are its primary support.</p> <p>In our search for the judgment of the most knowledgeable people in each field which we support, the members of our National Advisory Council on Vocational Rehabilitation and the consultants on our Medical Advisory Committee have come to respect the professional competencies of the engineers, physicians, therapists, prosthetists, and orthotists who serve on CPRD. The professional advice and recommendations available to the Academy-Research Council on this basis assure impartial excellence in judgment and accessibility to professional skills that are not readily available from any other source in this country.</p> <p>I have been particularly impressed with the extensive informational program that CPOE has developed, especially the brochures, films, and slides for use in schools of medicine, physical therapy, and occupational therapy and for the work that has been initiated in the development of new amputee clinics in several of our State programs.</p> <p>There are special reasons why the functions of the Committees continue to hold special significance to our total rehabilitation program: State-Federal, research and demonstrations, and training activities.</p> <p>A recent study was made of the 120,000 persons who were rehabilitated in the State-Federal program during 1964, and it was found that the classifications of amputations, absence of extremities or other orthopedic deformities, accounted for a total of 42,352 persons rehabilitated. Approximately 35% of the total group, therefore, were orthopedic rehabilitants. Thus, it is obvious that, even with the changing emphases in disability groups needing service, the thread of orthopedic disabilities runs through the entire program of rehabilitation, and orthopedic cases are almost four times as large as the next largest category of disability.</p> <p>The VRA program of research and demonstrations, which began with a trickle ten years ago, has broadened into a flow of new ideas, methods, and patterns of service to facilitate and improve the restoration of the disabled to worthwhile lives. There have been approximately 850 VRA research projects approved during the period 1955-1964, and about seven per cent of these projects have been for studies primarily concerned with problems caused by or related to orthopedic disability. Thirty-one universities, hospitals, or rehabilitation centers have sponsored 55 research projects relevant to this field of work. During fiscal year 1964, VRA awarded research grants to 13 new projects relating to the orthotic-prosthetic field and an additional 14 ongoing projects received continuation grants.</p> <p>Some of the most imaginative and creative work in our total program is going on in this field of research, and we are constantly aware of the dramatic advancements that are taking place. The collaboration of medical rehabilitation and engineering with some of the discoveries in the space program should bring a whole new dimension to the war on disability. So naturally we are pleased that CPRD has followed our recommendation to hold a conference on the Control of External Power in Upper-Extremity Rehabilitation so that leading engineers, physicians, and scientists can come together to formulate and coordinate their programs and assist us in developing future plans for support of their efforts.</p> <p>Our training program, which continues to pour a steady stream of new professional rehabilitation workers into the ranks, has expanded so that professional training in all of the fields that contribute to rehabilitation has been influenced by VRA training grants: medicine, nursing, physical therapy, occupational therapy, rehabilitation counseling, social work, speech pathology and audiology, rehabilitation of the blind and deaf, the mentally ill and the mentally retarded, and recreation for the ill and disabled.</p> <p>Since 1953, over 600 short-term courses in prosthetics and orthotics with a total enrollment of about 9,500 trainees have been attended by physicians, surgeons, therapists, counselors, prosthetists, orthotists, and related rehabilitation personnel. Last year alone, over 1,500 persons were enrolled in 90 courses which were a part of the extensive offerings in upper- and lower-extremity prosthetics and orthotics, management of the juvenile amputee, and general orientation courses for these fields. The work of the University Council on Orthotic-Prosthetic Education has done much to achieve a more uniform approach in curriculum offerings, teaching materials and methods, and evaluation procedures for the courses.</p> <p>The semester courses at UCLA and Northwestern, the Associate in Arts courses proposed at Cerritos College and Chicago City Junior College, and the undergraduate curriculum at New York University-all these attest to the professionalism that is developing in prosthetics and orthotics.</p> <p>CPRD's and CPOE's paramount asset to us is a technical proficiency while ours is a resource of public funds and a wealth of experience which we try to combine through the State-Federal partnership and our research and training projects into a comprehensive program for helping the disabled to reach their physical, economic, social, and personal goals. Our task, as public servants, is to administer these Federal funds as wisely as we can, always bearing in mind the true function of the law and purpose of our program: to convert dependency into competence and independence. As we work together along the paths of rehabilitation, exchanging our knowledge and our resources, perhaps we can all share in the conviction expressed on the seal of the Department of Health, Education, and Welfare which reminds us constantly that Hope is the Anchor of Life.</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>Mary E. Switzer </b></td></tr><tr><td class="clsTextSmall">Commissioner, Vocational Rehabilitation Administration, Department of Health, Education, and Welfare, Washington, D. C. 20201.</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 Collaboration for Rehabilitation Creator An entity primarily responsible for making the resource Mary E. Switzer * https://staging.drfop.org/files/original/8bb8e9e8755bb707d94843a7f67c3c83.pdf 2d1e1c9eb5739153c629b229aba1573c https://staging.drfop.org/files/original/0aa3c65a77880b3f215c6a379f41ebdf.jpeg 4e53ce2cb0da74c0306d918dbcbf3600 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/1979_03_003.pdf Text Any textual data included in the document <h2>Comment</h2> <h5>Lawrence W. Friedman, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><b></b><strong><a href="/files/original/0aa3c65a77880b3f215c6a379f41ebdf.jpeg">Photo</a>: Lawrence W. Friedmann, M.D.</strong></p> <p>Dear Sir:</p> <p>I have just been reading <a href="https://staging.drfop.org/items/show/179433">Volume II, Number 4, 1978</a> of the NEWSLETTER. While I have a lot to say on immediate postsurgical fittings, whose major problem I fear is the inaccurate name since very few people really fit a prosthesis immediately post-surgically, I think that the part of the NEWSLETTER that deserves the most comment is the reprint of the article "<a href="https://staging.drfop.org/items/show/179433">Prostheses, Pain and Sequelae of Amputation as Seen by the Amputee</a>" from Prosthetics and Orthotics International.</p> <p>There appears to me to be little doubt that the complaints of the amputees are accurate. There is not only poor fitting and poor fabrication, but a tremendous absence of knowledge on what is correct on the part of the medical profession, the amputees, and, unfortunately, sometimes even the prosthetists. We must recognize the fact that many doctors "prescribe" an artificial limb with instructions to the prosthetist to "give the patient a prosthesis" or, if they want to be very accurate, "give the patient an above-knee prosthesis". This leaves the entire prescription, fabrication and sometimes training of the amputee on the prosthesis to the prosthetist, who does the best he can, but is not adequately trained to take over the entire responsibility for the care of the patient. It is the exact equivalent of a doctor "prescribing" a medication for a patient and saying "give heart medicine".</p> <p>Most of the doctors doing amputation have little or no interest in the aftercare of the amputee once the wound is healed. For that reason, the amputee is required to be responsible for his own care and must seek out amputee clinics in which adequate prescription, checkout and training can be given to assure that adequate prosthetic fabrication has been achieved. The average general or vascular surgeon cannot be assumed to have been able to keep up with the latest in prosthetic components, fitting and training. While research is important, we are not, at the present, delivering the standard of care which we could have delivered twenty-five years ago had every amputee the access to an amputee clinic team.</p> <p>It is obvious that the amputees questioned are suggesting checkout procedures, such as x-rays, to measure the accuracy of prosthetic fit which have been available to us and have been used for decades. Unfortunately, it is the "consumer" who determines what is produced in the market place. In my view, the amputees must band together and insist on getting adequate service. When they do so, the competitive market place will give them what they need.</p> <p>In some areas, there is a problem because there are very few prosthetists and the amputee is, to some extent, at the mercy at that individual. With modern transportation however, any dissatisfied amputee should be able to get to a knowledgeable amputee team for adequate care. I know that there are many problems. In a neighboring state I know that the orthopedic surgeons have inhibited any competitor from coming into the state to challenge what everyone admits is an inadequate prosthetist-orthotist because they like that individual as a person, even though they know that the devices produced are grossly inadequate. While this is beneficial to the individual prosthetist-orthotist, it is to the detriment of his patients.</p> <p>Part of the problem is that each amputee is concerned with his own welfare, and when his needs are satisfied to a tolerable level, he tends not to band together with his fellows for their common good. This decreases their effectiveness in demanding optimal care. Rehabilitation is a process in which a patient is made responsible for his own well-being. In this regard, we may have made amputees feel so independent that they have lost sight of the power of communal action.</p> <p>Perhaps the NEWSLETTER format should be duplicated for the amputees as well as for those of us serving the amputees, so that the amputee himself could know what is going on and what devices and techniques are available to him should he need them. Certainly a list of the formal clinics and services would be of help.</p> <p>While there is much discussion of the advantages and disadvantages of different socket designs and other prosthetic components, it appears to me that these are, to some extent, academic discussions, since even the plug fit socket can be made comfortable for the majority of above-knee amputees, provided it is properly fabricated for the individual. What is needed is to improve the state of prosthetic delivery, even more than the state of the prosthetic art. The situation in prosthetics is the same as the situaiton in general medicine, in which in many places in this country what has been known in the medical literature is not getting to the individual patient.</p> <p>As far as upper extremity amputees go, the professor is much more satisfied with the appearance of the cosmetic hand cover than are the amputees themselves. I believe that I have the opportunity in this region to see." some of the most cosmetic hand covers available. They are, despite all our efforts, still inadequate and rejected by the great majority of amputees. As far as myo-electric hands are concerned, all of my patients want them. Most of them use them for a period of a few months and then discard them, except for rare use as a cosmetic hand, since they are so poorly functional as well as delicate. I believe it is important to prescribe one, if the patient demands a myo-electric hand, because he will never be satisfied of its mediocre function, until he has the opportunity to try it. I think the professor needs to be aware of many of its limitations. We, perhaps, get carried away too often by our favoritism for our own development.</p> <p>I believe further discussion on this point would be of help to the amputee community and also to the medical community in its broader sense, to give us a proper perspective of where our problems are.</p> <p>Best wishes for a happy and productive year.</p> <p style="margin-left: 50%;"><i>Lawrence W. Friedmann, M.D.</i></p> <br /> <div style="width: 400px;"></div> <em><b>Lawrence W. Friedman, M.D.<br /></b>Chairman of the Department of Rehabilitation Medicine at the Nassau County , Medical Center in East Meadow, New York.<br /></em><b><br /></b> Page Number(s) 3 - 4 Year 1979 Volume 3 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete. Figure 1 http://www.oandplibrary.org/cpo/images/1979_03_003/1979_03_003-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Comment Creator An entity primarily responsible for making the resource Lawrence W. Friedman, M.D. * https://staging.drfop.org/files/original/3ec7888cee2f851b5ad939cfc35e9698.pdf fa3c522ca3dfd7e1953c8cf88f054613 https://staging.drfop.org/files/original/2616f512f3d92ac4e805d79a4a8c64e8.jpg 6cd68ef1007dbe4d5d6544411ccf6f4f https://staging.drfop.org/files/original/d371115128acfc7dc1bd1659a5ceb2f1.jpg 8deb734fb9677fc2cf23fb2b9da7508a https://staging.drfop.org/files/original/e917b8732cef50461c1b681f0c7ecf1b.jpg e7deb03a7c60d3420be551312817837d https://staging.drfop.org/files/original/e1cf8112df2a1bb2aaf97e8332e6283c.jpg 00d0af6d0e569c08eb99f6c8a0b9bfb9 https://staging.drfop.org/files/original/c47154226c8b4249202c0177d968f9e4.jpg 788be41c8c242497efb0357b9909d3bd https://staging.drfop.org/files/original/d2df4f38ae19ba6c1560527a9c637a97.jpg 789ef1b71b6b7f3880aa1cc1b897b13b https://staging.drfop.org/files/original/425550a68b616b6cce5a9eeb50c3fc1b.jpg 11e3639315fd4c06d8fd6f7599c446ed https://staging.drfop.org/files/original/c00b05fc2d9be2f9a1cbf792263fab16.jpg 468d623d117056703073eb6525cb72bd https://staging.drfop.org/files/original/f7ef05f73d6d3e5119b1b1a3ea3df648.jpg 0f90542403702a924a2c605a62d317aa https://staging.drfop.org/files/original/62f30434ecf0464e8a03a8e7566f1fee.jpg e87645ad72adee68b98015e48c906e9d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_04_159.pdf Text Any textual data included in the document <h2>Commercial Options for Positioning the Client with Muscular Dystrophy</h2> <h5>Michael Silverman, CO.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Before the advent of modern medicine, progressive weakening of the musculature was thought to be due to disorders of the nervous system. Early researchers thought the problem was with the nerves somehow being unable to activate the muscles, which in turn caused the muscles to atrophy. It wasn't until the late nineteenth century that researchers began to understand that these problems were due to the muscles only, without involvement of the nerves.</p> <p>In 1861, Guillaume-Benjamin-Amant Duchenne, a Bolognese sea captain's son, published the first description of the severe childhood form of muscular dystrophy now known by his name. Specifically, Duchenne noted that the disease ran in certain families, and he clearly defined pseudohypertrophy (false overdevelopment) of the calf muscles as one of the disease's symptoms. It was thirty years later that Wilhelm Erb described the underlying clinical features of the various forms of progressive muscular dystrophy and outlined four subvarieties. "Some of the observed features included symmetrical muscle wasting, progression, abnormal gait, a development of charcter-istic body deformities. Erb was the first to see that these symptoms were disorders of muscle tissue, not of nerves, and he hazarded to guess that they were due to a complex nutritional disturbance."<a></a></p> <p>Over the last few decades, many categories of muscular dystrophies have been designated. Some, such as Myasthenia Gravis, are controllable with simple medication and do not require special devices other than lightweight orthoses. Others, such as Duchenne muscular dystrophy, are progressive and require increasing amounts of specialized equipment to make the disability as manageable as possible. In this paper, the development of specialized seating for clients with muscular dystrophy, as well as new systems on the market today, which can help to make these clients remain as functional as possible for as long as possible, will be reviewed. Below are listed some of the major types of muscular dystrophy whose treatment will often require specialized seating.</p> <blockquote> <p><b>Duchenne</b><br />(<i>Pseudohypertrophic</i>)</p> <p>Rapid, ultimately involving all the voluntary muscles. Death usually occurs within 10-15 years of clinical onset.</p> <p><b>Werding-Hoffmann</b><br />(<i>Infantile Spinal muscular atrophy</i>)</p> <p>The earlier the onset, the more rapid the course. Respiratory failure and/or infection usually cause death.</p> <p><b>Kugelberg-Welander</b><br />(<i>Juvenile spinal muscular atrophy</i>)</p> <p>Variable, but usually very slow. Most patients live to old age.</p> <p><b>Amyotrophis Lateral Sclerosis</b><br />Rapid, leading to death usually within three to five years.<a></a></p> </blockquote> <p>There are no easy rules for seating the client with muscular dystrophy. The pattern and severity of weakness varies from client to client and is usually changing so that each client has to be looked at for his individual needs. With the early onset of Werdnig-Hoffmann, specialized seating can be used to help with the prevention of deformities. These children tend to be very floppy. The positioning system will make them easier to handle and put them in a position where they can use their arms and hands to explore the world around them.</p> <p>The pre-adolescent onset of Duchenne muscular dystrophy will often times lead to extreme curvatures of the spine unless the client is properly managed in a positioning system or orthosis. The advantage of using a positioning system in place of an orthosis is usually that of comfort. The positioning system should provide greater comfort to its user than the use of a wheelchair with a sling seat and back. The orthosis can be a source of discomfort to the user and, for this reason, is likely to be left in the closet. "This tendency for the brace to be uncomfortable is understandable because of deformity is a collapsing type of scoliosis and the patient lacks the muscle power to pull away from a painful pressure area."<a></a> With degenerative forms of muscular disease, <b>the most important thing a positioning system can do for the client is to aid in increasing his function, allowing him to continue with normal activities of daily life for as long as possible.</b></p> <p>The client with Amyotrophis Lateral Sclerosis (ALS) presents a whole new set of problems for the clinician. Because of the age of onset and rapid progression of the disease, the clinician does not usually have to worry about the prevention of deformity. But these same problems make it nearly impossible to design a positioning system that will provide these clients with comfort and function for any reasonable length of time. Clients with ALS tend to prefer less contoured systems, and require adjustable reclining mechanisms for comfort.</p> <p>Once the decision has been made that a positioning device may be beneficial, certain questions must be considered and information about the clients' family and home environment must be obtained. Then methods of transportation must be looked into. What is the prognosis of the clients condition? Is the client out with the family occasionally or most of the time? Are the outside conditions rural or urban? What are the client's favorite activities? What are the families needs? Does the family have, or will they be getting, a van which would allow the client to be transported in his or her positioning system? How close is the roofline to the clients head while seated in their standard wheelchair? Is powered mobility needed now or in the future?</p> <p>An overall clinical evaluation should be made and the results of these tests should be available before any positioning decisions are made. A complete physical and functional evaluation of the client is necessary to determine the extent of the weakness and whether there are any contractures present. Orthopedic considerations add another dimension and may require the input of a surgeon to determine if releases are possible to aid in good long-term positioning. (A consideration with Duchenne muscular dystrophy is the question of a possible spinal fusion.) Any deformities which are present must be noted, as their severity will help further narrow the options for positioning the client. Slight flexion contractures of the hips or knees should not pose a problem for a successful positioning system. However, extension contractures of the hips or ankles could be more of a problem. Remember that a positioning system can serve a preventative role in reducing the formation of contractures and deformities, but the positioning system cannot be used to correct these situations. If correction is needed, it is best done on the operating table before the seating system is provided.</p> <p>The seating system should allow the client enhanced abilities when using the system. The extremities also need to be looked at in relation to function. Arms must be free if independent mobility is possible. Strength must be tested to determine if ultralight bases would be of benefit. The wheelchair is as much a part of the seating system as a headrest or foot support. There are many types of wheelchairs on the market today and the initial evaluation is critical in determining what type wheelchair would best serve the client. For the purposes of this paper, we will concentrate on positioning solutions only.</p> <p>When deciding on the best position in which to seat a client with muscular dystrophy, it is necessary to start with the pelvis and achieve a neutral position to provide a stable base of support. Standard sling seats provide an unstable surface for sitting, as the pelvis will not sit level and forces a lateral compensatory curve up the spine (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-01.jpg"><b>Fig. 1</b></a>). The pelvis should be in midline and should not be allowed to slide laterally by blocks built into the positioning system. A 90 degree position of hip flexion is desired, and in some cases, a back-to-seat angle of less than 90 degrees may be beneficial, especially when introducing increased lordosis into the spinal section. An anteriorly wedged seat will help to achieve a proper hip angle, while assisting to maintain the client in the seating system. The object is not to immobilize, but to stabilize the pelvis.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-01.jpg">Figure 1.</a> A person with abnormal tone becomes more a asymmetrical when seated on a hammock type surface. (A. Bergen and C. Colangelo, "Positioning the Client with CNS Deficits," 1985, p. 7).</strong><br /> <p>To complete the base of support for the upper body, the clinician must properly position the lower extremities. An abductor (wedge) will help to position the legs slightly apart giving a wider base of support (be careful not to bring the legs any wider apart than the diameter of the hips.) When using an abductor, keep it away from the groin and make sure it is of the flip-down or removable variety if a urinal is being used. Sometimes the clinician may wish to use an abductor as a reminder of the proper placement of the client in the positioning system, especially when there may be multiple care givers. The knees and ankles should be at 90 degrees unless contractures are present. In many cases, the knees may have to be extended slightly in order to clear the front casters of the wheelchair. The feet should always be supported so as to complete the stable positioning of the pelvis. As you can see, a great improvement in seating can be made just by replacing the sling seat upholstery with simple plywood and foam componentry (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-02.jpg"><b>Fig. 2</b></a>).</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-02.jpg">Figure 2.</a> A firm sitting surface provides a base for symmetrical sitting. (A. Berger and C. Colangelo, "Positioning the Client with CNS Deficits," 1985, p. 7)</strong><br /> <p>Now, the clinician is ready to work his way up the spine. The trunk must be held in midline, as close to natural shape as possible to allow better head control. In older clients, the natural shape of the spine includes forward curves at the neck and lumbar region of the spine. For the floppy client, as well as those with a scoliotic deformity, lateral trunk supports are usually required. Usually with scoliosis, the pads are placed under the apex of the curve on the convex side and under the axilla on the other side. The third point of the pressure system is the pelvis held in with good lateral positioners (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-03.jpg"><b>Fig. 3</b></a>).<a></a></p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-03.jpg">Figure 3.</a> Transverse loading in seating the patient with scoliosis (rear view).</strong><br /> <p>With clients who have flexible spines, many different approaches to positioning are used. For the small child with spinal muscular atrophy, allowing the spine to shape into a gentle C-curve may promote the best head position. Increasing the lordosis with these clients may help to push them out of the chair and cause their heads to fall backward. In the case of adolescent clients with Duchenne muscular dystrophy, increasing their lumbar spinal extension may actually help with the prevention of lateral curvature, as well as promote good head positioning. To understand this idea, one must first understand the mechanism of the spinal collapse in the client with Duchenne muscular dystrophy.</p> <p>The first sign of spinal instability as demonstrated by roentgenograms (x-rays) is the appearance of a long thoracolumbar curve of less than 10 degrees sent in patients who are ambulating with the aid of long leg braces. During the early wheelchair bound stage, the curves lose their flexibility. They also involve fewer vertebral segments, primarily in the lumbar spine, without axial rotation in curves of less than 20 degrees of lateral curvature as measured by Cobb's method. Rotation in the upper segment of the curve, which generally extends over the bodies of T10 to L3, is followed with maximal rotation at L2 of an estimated 5 degrees. Vertebral rotation then increases at a faster rate than the lateral displacement. Once rotation reaches 15 degrees and the lateral curve 30 degrees, both parameters increase rapidly.</p> <p>Mr. Jan Koreska and his group at the Hospital for Sick Children in Toronto, Ontario have done many studies of the spine which suggest that if lateral displacement of the lumbar spine is not prevented, axial rotation follows, and by this time conservative bracing is unlikely to succeed since structural failure has already occurred.<a></a> They also found that the posterior facets and ligaments of the lumbar spine appear to be responsible for the linear alignment of the lumbar spine. The influence of the posterior facets on the upper lumbar spine appears to be less significant because their resistance to axial rotation is reduced.</p> <p>"Some 80 percent of the children develop a collapsing type of scoliosis." The observation of 62 spines of boys by the Hospital for Sick Children yielded consistent results. "A few patients' spines gradually became very stiff and somewhat hyperextended over a period of years. When this happens, the patient will be a good sitter for a long time. The more usual pathway involves moving gradually from a straight spine to a rapidly steady progression into a severe kyphoscoliotic."<a></a></p> <p>The first seating system developed specifically for prophylactic use by clients with Duchenne muscular dystrophy was developed in the mid 1970's. This specially designed seat was effective in limiting the progression of spinal curves to less than one degree per month in 13 out of 16 patients. The thought was, if spinal deformity could be maintained until skeletal maturity was achieved, good spinal alignment could be maintained. Clients whose curves progressed to greater than 35 degrees would usually ultimately require surgery.</p> <p>The Toronto Spinal Support System (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-04.jpg"><b>Fig. 4</b></a>) is made of a fiberglass shell, lined with custom carved ethafoam, upholstered with a modified urethane foam and a tricot double knit covering. Headrests, arm rests and leg supports are attached to the fiberglass shell. The unit is meant to be inclined backward a minimum of 15 degrees. The pelvis is snugly fitted and the thoracolumbar junction extended, while the back has lateral guides to promote midline sitting. "The snug fit gives the spinal column a stable base (the pelvis), and the extension of the thoracolumbar region reduces the mobility seen when the interarticular facet joints at this level are opened up in flexion. The 15 degree backward tilt reduces the load on the spine every time the patient leans back, while the foam lining makes it comfortable and acceptable to the patient."<a></a></p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-04.jpg">Figure 4.</a> The Toronto Spinal Support System.</strong><br /> <p>Conclusions from the group in Toronto over the last few years show that, although spinal deformity is not absolutely prevented, development is slowed, prolonging the period of trouble free sitting. This slowing down of the development of the spinal deformity takes place at a time when spinal growth is rapid, making the introduction of the system at a young age before puberty of utmost importance. A 10 year follow-up to the development of the Spinal Support System (SSS) sponsored by the Muscular Dystrophy Association of Canada was completed in late 1983. Following are some of the more significant findings.</p> <ol> <li> <p>The Spinal Support System has made a significant contribution to the management of individuals with Duchenne muscular dystrophy across Canada. Improvement of user comfort is the attribute most consistently stated. The SSS development has been particularly well received by parents.</p> </li> <li> <p>The SSS in its originally conceived design does not arrest the progression of spinal deformity. However, reduction in the rate of progression of deformity (1/3 to 1/2) was reported by the participating clinics.</p> </li> <li> <p>From the clinical data available, it was not evident that any one single feature of the SSS is the key to the improvement of spinal management; but rather suggests that there is a combination of multiple interrelated factors involved.</p> </li> <li> <p>There is no clear evidence supporting the hypothesis that extension of the lumbar spine is the key contributor to the lateral stabilization of the spine.</p> </li> <li> <p>Lack of easy adjustment for growth or change of spinal alignment creates serious delays or the postponement of the necessary revisions.</p> </li> <li> <p>Although biomechanically advantageous, the 15 degree recline of the backrest necessitates that the child lean anteriorly and away from the posterior supporting surfaces when participating in functional activities or seeking head stability. Only rarely were children observed or reported as using the back and head rest as intended by the designers.</p> </li> <li> <p>The use of prefabricated modular components which results in relatively easy assembly is viewed as a very positive feature of the design concept.</p> </li> </ol> <p>The overall experience with the Spinal Support System was pretty well summed up in a follow-up study completed by a review committee in 1983. "Most of the principles obtained from the SSS study in Toronto have included the importance of the incorporation of a lumbar lordotic pad to maintain the lumbar and thoracic spine in a lordotic position. The concept is, if the spine is going to become fused or rigid spontaneously, it will adopt a stiff extended alignment rather than collapsing kyphoscoliosis. However, this is the exception rather than the rule. There is no orthotic or seating system in use today, including the Spinal Support System, that will prevent the majority of these children (approximately 90 percent) from developing a collapsing kyphoscoliosis. Even in the few cases (perhaps 10 percent) in which the result is a stiff extended spine, the contribution of the seating system towards that outcome is probably only minimal. Surgery is serious; it must be offered to the patients and parents with full knowledge of potential complications. The patient's pulmonary reserve must be sufficient to withstand the surgery and the disease. The rationale for surgical intervention may be difficult to accept by the parents when the effects of non-surgical intervention are not yet readily evident. If successful, the surgical intervention will stabilize the spine, making the seating problems easier for the management team. However, even when surgical stabilization is undertaken, appropriate seating systems are required since the patient still requires pelvic support, upper and lower limb alignment and support, head support and mobility. Generally, the Spinal Support System has addressed the problem of development of scoliosis in muscular dystrophy patients. It has decreased the rate of progression, as shown in several studies. However, this may be detrimental to the patients general health because of the progression of the decreased pulmonary reserves. That is, the management team may be lulled into a "wait and see mode," only to find out later that the reduced vital capacities have shifted the balance of risk towards non-surgical management, whereas early surgical intervention would have been the treatment of preference. The use of the modified Spinal Support System in conjunction with early surgical stabilization of the spine may be useful.<a></a></p> <p>The Spinal Support System was a pioneering development at a time when there were virtually no commercially available seating systems or components. Today, the interest in specialized seating is booming, and commitment by manufacturers has led to a variety of systems and components. In this next section, some of the newer systems on the market and how they are used as tools for positioning different types of clients will be reviewed. Also, current methods of seating and their ability to correct a corresponding level of orthopedic deformity will be considered.</p> <p>In a case where there is no, or very little, orthopedic deformity, that does not present positioning problems; the standard wheelchair should still be modified with a rigid seat insert or off the shelf wheelchair cushion over a rigid base. The normal folding wheelchair with a sling seat and back does not provide a stable base of support for the pelvis. It is alright when used temporarily, but if it is to be used for any length of time, a firm seat insert is mandatory. Sitting on a sling seat causes the hips to internally rotate, which contributes to abduction and usually an oblique pelvis. This causes a compensatory spinal curve. The client with muscular dystrophy will have differential muscle weakening in the spinal musculature and will almost always assume this position in due time. Therefore, for anyone sitting in a wheelchair for more than just quick trips, the addition of a rigid seat is mandatory.</p> <p>Most wheelchairs can be ordered from the factory with a rigid seat of either the drop-hook variety or attached with a special folding mechanism. A firm seat can also be made as a separate piece meant to be placed on an existing wheelchair seat. Those wheelchairs with attached non-removable rigid seats tend to make the folded chair unruly and increase the weight. The separate variety is preferred, but because it is removable, it is often left behind. This problem is usually alievated with the drop-hook seat. After removing the seat upholstery, these cushions have special hooks which clip on to the seat rails with clamps. (The wheelchair then can not be used if the seat is left behind.)</p> <p>The base of the seat cushion is usually plywood, at least 3/8". On top of the wood, different foams can be used. Preferably, a high density urethane which will not bottom out over time. In Chicago, we make three or four-inch cushions of two different types of T-foam or Sun-Mate foam, which have special weight distribution properties. On the first layer, we use one to two inches of firm Sun-Mate for the base and two inches of medium-to-soft foam on top of that. The cushions are then upholstered with a thin flexible vinyl surface. The vinyl takes away some of the properties of the Sun-Mate foam but protects the open cell structure against water damage.</p> <p>Where problems with either boney prominences or an already oblique pelvis are envisioned, the Jay Cushion will provide a stable surface while accommodating these deformities. The Roho cushion provides excellent pressure relief but may not provide enough stability and encourage leaning. The Roho is best used where pressure relief is the main concern and stability is not a problem, as with paraplegics. This is why an overall clinical evaluation is important as well as an understanding of available products. There are many other commercially available seating cushions on the market, and they must be in stock and tried on the client to determine if one will better fit the clients needs than another. A good place to see all of what is commercially available in this field is at the National Home Health Care Expo in Atlanta.<a></a> The show is always in late fall or early winter and is free.</p> <p>For the moderately involved clients with muscular dystrophy, there are also many choices available. More likely, they are the type of clients seen. When not in bed, these clients spend almost all of their time in a wheelchair and are in the early to moderate stages of deformity or contracture. Moderate levels of deformity or contractures are measurable but not enough to create seating or functional problems.</p> <p>The most widely used method of manufacture for seating devices today is using plywood and foam technology. Here, there is a seat and back section, with body supports, pelvic supports, and leg supports bolted on. Many clinicians combine the linear plywood technology with custom carving of blocks of foam (usually ethafoam) to give a custom contoured look. The advantage of the contoured system is that they provide a larger area of contact between the seating system and the client. The Toronto Spinal Support System mentioned earlier is just an advanced version of this method, utilizing component parts such as a preshaped fiberglass shell instead of plywood. It was also one of the first systems to have head rests, arm rests and leg supports specially designed as part of the seating system.</p> <p>Today, it really makes little sense to make an entire seating system from scratch with so many commercially available components on the market. Many companies will actually make the entire seating system based on measurements of the individual client. For componentry and/or complete systems of the non-molded variety, some of the leading systems include those manufactured by Scott Therapeutics, Freedom Designs, Miller's, CRD, Gunnell, and CP seat by Pin Dot Products. Of the contoured modular systems, there is the Winnipeg system, the Otto Bock MOSS System (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-05.jpg"><b>Fig. 5</b></a>) and the Pin Dot Modular Seating System (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-06.jpg"><b>Fig. 6</b></a>).</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-05.jpg">Figure 5.</a> The M.O.S.S. system from Otto Bock.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-06.jpg">Figure 6.</a> Pin Dot Modular seating system.</strong><br /> <p>These systems are all designed for "moderately involved" clients who have minimal deformities only, with no rotational deformities. Rotational deformities become more and more evident as lateral deformities increase, and the linear systems (or those contoured with preformed cushions) becomes less and less effective.</p> <p>The next group with rotational as well as lateral deformities are designated the high moderates or low severe. Two new systems developed recently by the University of Tennessee Rehabilitation Engineering Program work well for this category. The Foam-in-Place seating system (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-07.jpg"><b>Fig. 7</b></a>) uses a plastic module with an elastic bladder which fits into the chair, and liquid polyurethane foam is measured, mixed and injected into the empty bladder while the client is properly positioned on a pre-ischial strap. The foam rises and within minutes sets up and forms a customized seat or back cushion. Because the foam takes on the exact contours of the individual, it is possible to accommodate difficult rotational deformities. The difficulties with this system are that the client is forced to sit on a 2 inch wide strap, and be perfectly positioned in a chair while the foam is mixed, injected and set up (about 5 minutes). Even though the foam can shape to the most severely involved, only the high moderates can support themselves or be supported in the proper position under these conditions. Foam-in-Place may be better used for seat cushions only, as they are easier to form and more consistent in their results.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-07.jpg">Figure 7.</a> Foam-In-Place seating system.</strong><br /> <p>It is important to remember that all of the systems described here should not be thought of as complete systems only, but also as various components. The best way to produce an individualized seating system is to use some of the various components of each system in the best way possible to give the desired result for the individual client. Adrienne Bergen, O.T.R., a pioneer in this field, has used the word "eclectic" to describe those devices made from a variety of components from various companies, and it allows her to best fill her clients needs in the most economical manner.</p> <p>The Bead Seat is another new development from Douglas Hobson's group at The University of Tennessee Rehabilitation Engineering Program, which uses essentially the same componentry of the Foam-in-Place seating system. The difference between the two systems is the filling or "stuffing" in the cushions. In the Foam-in-Place system, there is a liquid foam which sets up and forms while the person is suspended over the empty shell. The Bead Seat's "stuffing" is a mixture of a fast setting epoxy and polystyrene pellets (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-08.jpg"><b>Fig. 8</b></a>). The epoxy will set up two hours after the introduction of the catalyst, locking the lightweight pellets into the form desired. The form is made while the whole system is under vacuum using the dilation method.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-08.jpg">Figure 8.</a> Side view of Bead Seat Technology.</strong><br /> <p>Dilation is a molding technique used for more than three decades and consists of an airtight bag filled with pellets and attached to a vacuum pump. When the vacuum is introduced into the system, the bag compresses against the pellets and holds whatever shape it has prior to the introduction of the vacuum. To change the shape, air is introduced into the bag, loosening the pellets' structure and allowing a change in shape.</p> <p>The Bead Seat system depends on the vacuum to hold the shape until the epoxy sets up, creating a mechanical bond between the styrene pellets. Once the epoxy has set, the vacuum can be removed and the positioning system completed. The advantage of the Bead Seat over Foam-in-Place is that there is more time available to mold and remold the system, while simulating the finished system, to attain the desired shape. The extra time available for shaping with the Bead Seat allows it to be used with more severely involved clients than Foam-in-Place. This advantage of extra time is also a disadvantage when compared to the Foam-in-Place system, since it takes longer to produce the finished product. Also, when finished, the Bead Seat has a harder surface compared to the flexible surface of the Foam-in-Place cushion. This harder surface may be an advantage with positioning, but a disadvantage when pressure relief is the objective. Bead Seat, as well as Foam-in-Place, will accommodate rotational deformities but may not be durable enough for the long-term needs of the larger clients because of the plastic framework. For lighter clients (under 100 pounds), the Bead Seat will easily accommodate the severely involved. Another limiting factor of both the Foam-in-Place and Bead Seat systems is that only a headrest system and a simple 90 degree legrest are available as options for customizing the systems, as they are designed to be used with the accessories in the existing wheelchair and this may not be enough for the most severely involved clients.</p> <p>When dealing with the severely involved, the traditional orthotic approach is the vacuum-formed plastic or Gillette style seating system. Using this system, a mold is taken of the individual by placing the client prone on a table with the hips flexed to 90 degrees. The mold is taken using either the dilation method or with plaster bandages. This method of taking an impression is a problem. The mold (or measurements) should always be taken while the client is simulating the final seating position. The effect of gravity on the client cannot be felt when the client is molded in a prone position, and the client's shape may be completely different when upright. It is easy to straighten a client's spine when prone on a table; the problem is that the client may not be able to tolerate this corrected position for long periods of time when upright. This applies especially to the client with muscular dystrophy, who may not have the muscle strength to pull away from a sore area. When one is dealing with a client in the severely involved category, the idea is to correct as much flexible deformity as possible, while making the positioning system as comfortable as possible so the client will be able to use the system for long periods of time during the day.</p> <p>Other difficulties with the traditional orthotic approach include the time needed to fabricate the finished system and the inability to adjust the system once it is finished. These problems are the same as those encountered when making a sophisticated seating system out of plywood and foam. With the traditional orthotic approach, the finished mold is filled, smoothed and corrected. Over the finished mold, a layer of foam is vacuum formed, then a layer of polypropylene is added. The plastic shell is then trimmed out, set in a box to form a base so it sits in the wheelchair at the desired angle, and upholstered. Time is valuable, and today most private facilities cannot profitably produce seating systems in this manner.</p> <p>Today, because of the large amount of commercially available componentry, systems do not have to be made this way. Is anybody still hand forging knee joints? Today seating is where orthotics was in the late 50's or early 60's, at the advent of commercially available componentry.</p> <p>Two newly developed systems work especially well for the severely involved clients: the Contour-U seating system (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-09.jpg"><b>Fig. 9</b></a>) and the Matrix seating system. Contour-U utilizes the same dilation technology as the Bead Seat, but molds are taken on a specially designed molding frame with rubber seat and back bags filled with polyethylene pellets. Once a mold is taken of the individual in the proper position, plaster splints are worked into the mold to give a positive impression of the client. The molds are then turned into flexible upholstered cushions on a central fabrication basis, designed to eliminate the shop time needed for fabrication. The finished seat and back cushions snap into aluminum hardware, which also has the ability to be angularly positioned (both back-to-seat angle and recline orientation) and adjusted for length. This system accepts a wide variety of accessories designed to accommodate even the most severely involved client properly. The system is not labor intensive but can be expensive, especially when used with the many accessories available.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-09.jpg">Figure 9.</a> Contour-U seating system.</strong><br /> <p>As clinicians, knowledge of patient priorities should be uppermost. Don't use Contour-U when a Bead Seat will do. Don't use a Bead Seat where a Jay cushion will do the job. Think eclectically for the patient. Contour-U cushions with plywood and simple componentry can be used to create an inexpensive, custom molded seating system. For another client, a Bead Seat molded back and a Foam-in-Place seat may be the best solution.</p> <p>Another advancement in seating developed in Vancouver and now manufactured in England is the Matrix system (<a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-10.jpg"><b>Fig. 10</b></a>). The Matrix takes an altogether different approach by providing a flat sheet of locking ball joints which can be contoured to almost any shape and locked into that position by individually tightening the ball joints.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-10.jpg">Figure 10.</a> Matrix seating system.</strong><br /> <p>Essentially, a sheet of material into which tucks can be taken and contours formed, Matrix can be fabricated to position somebody in any position desired. A nice feature of the Matrix is that it can be loosened and reshaped when necessary. Also, where growth is expected, the matrix can be extended by just adding a row or two of modules. The disadvantage of this system is in the time required to produce the finished product. Anywhere from 15 to 25 hours is necessary, which puts it into the same category as traditional orthotic seating systems. Fortunately, Matrix fabrication is also available on a central fabrication basis.</p> <p>Some may consider the Matrix unattractive, but its high tech design also makes it airy, lightweight, and waterproof. The Matrix fits in well with the eclectic approach, as pieces of the material may be used for a custom head rest or arm trough when needed, making a whole system out of material unnecessary, unless preferred for the client.</p> <p>These are brief descriptions of some of the newer systems on the market today. Information is available from the manufacturers to learn the benefits and weaknesses of all these systems (see suppliers list). The idea is to best provide the client with a product which, individually, does what is required for the most economical price. Having a variety of systems at our disposal, as well as the ability to custom fabricate components when necessary, will allow us to provide the best service to our clients and establish our facilities as specialists in this expanding field.</p> <p>In Chicago, we have done just this by establishing the Chicago Seating Institute. At the facility, we specialize in proper positioning of clients, while providing various styles of seating systems, wheelchairs, and environmental controls. In the future, we hope to expand our field of expertise to include communication devices as well. Over the last few years, the development of the specialized seating side of our business has increased our volume from 12-15 clients a year in 1981 to 150-200 clients a year today. In no other area of our business could we have expected to see a ten fold increase in the number of clients seen, even with the same commitment made as we've done for specialized seating. The field of specialized seating is up and coming, not only for the orthotist, but the prosthetist and other allied health professionals as well.</p> <p>Unfortunately, traditional education for specialized seating is not available. However, there are some programs and seminars offered, with increasing frequency in the past few years. Watch the upcoming issues of the American Orthotic and Prosthetic Association Almanac, or contact The Association for the Advancement of Rehabilitation Technology (RESNA) at Suite 700, 1101 Connecticut Avenue, Washington, D.C. 20036; (302)857-1199. Historically, as with orthotics and prosthetics, the best and only real way to learn is to learn by doing. See your clients, and learn from making systems for them. This hands-on method is the best teacher for seating because you can watch the clients expression to know if they are comfortable. The "cookbook" approach with easy rules just doesn't work here since people do not demonstrate this reflex or that reflex, this deformity or that deformity, but a hodgepodge of various reflexes, deformities and contractures. Add to this differing age groups, backgrounds, living conditions, and mental abilities, and the cookbook method becomes impossible. Have a variety of solutions at your disposal. Think of the client as an individual. This education will help you understand your clients discomforts and needs. With the help of a therapist, decide on realistic attainable goals. With this in mind, there are many ways to achieve the desired results of functional (where possible) and comfortable (always possible) seating for clients.</p> <h3>Suppliers</h3> <p>BEAD SEAT<br />Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618. (Developed by The University of Tennessee Rehabilitation Engineering Program.)</p> <p>CP SEAT<br />Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618. (Second generation of the MPI seating system developed by The University of Tennessee Rehabilitation Engineering Program.)</p> <p>CONTOUR-U SEATING SYSTEM<br />Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618.</p> <p>CRE<br />Creative Rehabilitation Equipment, 513 NE Schuyler, Portland Oregon, 97212.</p> <p>FOAM-IN-PLACE SEATING SYSTEM<br />Carapace, Inc., P.O. Box 45040, Tulsa, Oklahoma 74147.</p> <p>FREEDOM DESIGNS<br />Freedom Designs, Inc. 18165 Napa #8, Northridge, California 91324.</p> <p>GILLETTE SEATING SYSTEM<br />Gillette Childrens Hospital, Orthotic Department, Minneapolis, Minnesota.</p> <p>GUNNELL<br />Gunnell Manufacturing, 221 North Water Street, Vassar, Michigan 48768.</p> <p>JAY CUSHION<br />Jay Medical Ltd., 805 Walnut, Boulder, Colorado 80302.</p> <p>MATRIX SEATING SYSTEM<br />Pin Dot Products, 2215, West Belmont, Chicago, Illinois 60618. (Developed by Clinical Engineering Designs, Kingston upon Thames, England.)</p> <p>MILLER'S<br />Miller's Rentals and Sales, 284 East Market Street, Akron, Ohio 44308.</p> <p>MOSS (Modular Orthotic Seating System)<br />Otto Bock Industries, 4130 Highway 55, Minneapolis, Minnesota 35422.</p> <p>PIN DOT MODULAR SEATING SYSTEM<br />Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618.</p> <p>ROHO CUSHION<br />Roho, Inc. P.O. Box 658, Belleville, Illinois 62222.</p> <p>SCOTTIE SEATING SYSTEM<br />Scott Therapeutic Designs, 430 Robertson Lane, San Jose, California 95112.</p> <p>TORONTO SPINAL SUPPORT SYSTEM<br />The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario.</p> <p><b>References:</b></p> <ol> <li>Ogg, Elizabeth, "Milestones in Muscle Disease Research," Published by the Muscular Dystrophy Associations of America, Inc., 1971.</li> <li>Muscular Dystrophy Associations of America, Inc., "Chart of Differential Diagnostic Characteristics of the Primary Diseases Affecting the Neuromuscular Unit."</li> <li>Gisbon, D.A. and Koreska, J., "The Management of Spinal Deformity in Duchenne's Muscular Dystrophy," <i>Orthopedic Clinics of North America</i>, Vol. 9, No. 2, April, 1978, pp. 437-450.</li> <li>Letts, M. and Rang, M., "Seating the Disabled," <i>Atlas of Orthotics</i>, American Association of Orthopedic Surgeons, p. 468.</li> <li>Koreska, J. and Robertson, D., "Biomechanics of the Lumbar Spine and its Clinical Significance," <i>Orthopedic Clinics of North America</i>, Vol. 8, No. 1, January, 1977, pp. 121-133.</li> <li>Gibson, D.A. and Koreska, J., "The Management of Spinal Deformity in Duchenne's Muscular Dystrophy," <i>Orthopedic Clinics of North America</i>, Vol. 9, No. 2, April, 1978, p. 439.</li> <li>Gibson, D.A. and Koreska, J., "The Management of Spinal Deformity in Duchenne's Muscular Dystrophy," <i>Orthopedic Clinics of North America</i>, Vol. 9, No. 2, April, 1978, p. 440.</li> <li>Hobson, D., Desrosier, F., Beauchamp, R., and Martel, G., "The Spinal Support System and Other Approaches to Specialized Seating for Duchenne Muscular Dystrophy Patients-A Review Report," The Muscular Dystrophy Association of Canada, November, 1983.</li> <li>National Home Health Care Expo, Atlanta, Georgia. Call (305)773-2222 for details.</li> </ol> <p style="width: 400px;"><em><b>*Michael Silverman, CO. </b> Michael Silverman, CO., is with Pin Dot Products, 2215 West Belmont, Chicago, Illinois 60618.</em></p> <div style="width: 400px;"></div> Page Number(s) 159 - 170 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-05.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-07.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1986_04_159/1986_04_159-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Commercial Options for Positioning the Client with Muscular Dystrophy Creator An entity primarily responsible for making the resource Michael Silverman, CO. * https://staging.drfop.org/files/original/f97cfd5235b0aee89a8a246f3bb36a96.pdf 0611831203afbaea806f867bafac8a09 https://staging.drfop.org/files/original/c4503bd0ade204d8bd8febe76bbb6f56.jpg 19fcf5623ec96a54d6f85f8b60b2d008 https://staging.drfop.org/files/original/fb7cc1d43658e6003753aaa44c247f01.jpg 4ff3ceb12158adbee0cf9b90e7a640f2 https://staging.drfop.org/files/original/3fa04d3962c39877277abfdfa7e54654.jpg c5e9b43e7d407777ca340bd7247b7a56 https://staging.drfop.org/files/original/48dff4cea5f12c24f5a7ec7718c459fe.jpg 78b79fa22696174683179cfcb09a400f https://staging.drfop.org/files/original/01326057960c319c4b1259bcd805ddd3.jpg d07268216e98fea759014f362be88ab8 https://staging.drfop.org/files/original/d9b33408099151592c9792c42710a205.jpg 18fbe3ca5c7150b3dfecd879beced63b https://staging.drfop.org/files/original/62b4779e67198aad3af7f94c6224cfa5.jpg 97a440c22672ac2d9f3359115cf894d0 https://staging.drfop.org/files/original/14d93f4c4979723e691b143fa14c65ef.jpg 910dfa8cf554c1cb90120318e8acf61b Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_03_099.pdf Text Any textual data included in the document <h2>Component Selection Criteria: Lower Limb Disarticulations</h2> <h5>John Michael, M.Ed., C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Because disarticulations comprise only a small percentage of the lower limb amputations performed each year,<a></a> questions sometimes arise regarding the most appropriate components to select. This paper will present a brief overview in an effort to clarify the criteria involved.</p> <h3>Hip Disarticulation/Hemipelvectomy Components</h3> <p>For the hip disarticulation or hemipelvectomy case, component selection is generally analogous to the more familiar above-knee patient. Endoskeletal components are preferred for the high level amputee because they offer light-weight and enhanced cosmetic appearance. A clear trend away from steel components to the much lighter titanium or carbon fiber versions is apparent. Most systems (particularly the Otto Bock "Modular") also permit subtle realignment, even in the definitive prosthesis. This can be an advantage due to the complex interplay between the mechanical hip, knee, and foot mechanisms.</p> <h3>Hip Joint Mechanisms</h3> <p>In general, a free motion hip joint is preferred, as originally proposed by McLaurin in 1954.<a></a> Careful attention to alignment details results in a very stable configuration by virtue of the weight line and reaction line forces. This permits very safe weight-bearing, yet allows easy hip flexion during swing phase.</p> <p>Stride length is generally controlled by a spring or elastic flexion limiting apparatus, sometimes called an "extension bias." In modern practice, the joint is placed near the anterodistal quadrant of the socket, which sometimes requires a slightly shorter thigh segment for the best appearance when sitting.</p> <p>Manual locking hip joints are also available but should be reserved as the component of last resort, even for bilateral amputees. In addition to disrupting swing phase, locked joints require the use of one hand on the unlocking mechanism during sitting. This often makes a difficult task more complicated, particularly for the double amputee.</p> <p>More importantly, a locked hip joint may place the patient in a more dangerous position during a fall backwards. If the joint prevents flexion at the hips, the head rather than the buttocks may strike the ground first. In our last 50 consecutive fittings at Duke, both unilateral and bilateral hip/hemi patients have never required a locked joint to ambulate securely.</p> <p>Two variations in hip joint design warrant mention. Peter Tuil of the Netherlands advocates the use of a reversed polycentric knee disarticulation joint (Otto Bock 3R21) as a hip joint.<a></a> Benefits claimed are parallel to those expected from a polycentric knee unit: increased ground clearance during swing phase due to the inherent "shortening" of the linkage in flexion and enhanced stability at heel strike (<b>Fig. 1</b>).</p> <strong><a href="/files/original/c4503bd0ade204d8bd8febe76bbb6f56.jpg">Figure 1</a>. Prosthesis utilizing reversed polycentric knee disarticulation mechanism at the hip, as proposed by Peter Tuil of the Netherlands. (Courtesy of Orthotics &amp; Prosthetics, 38/1, p. 33.)</strong><br /> <p>This view has been corroborated in a number of fittings over the past few years at the Royal Ottawa Regional Rehabilitation Centre in Canada.<a></a> Such a technique has also worked well in our hands at Duke, although we are not certain the benefits fully justify the special effort involved.</p> <p>An even more intriguing concept is the "Hip Flexion Bias" modification promulgated by Haslem, et al. of Houston, Texas.<a></a> In this system, hip extension from heel strike to mid-stance compresses a specially selected spring, which encircles the endoskeletal pylon. At toe-off, this kinetic energy is released and the thigh segment is propelled briskly forward (<b>Fig. 2</b>).</p> <strong><a href="/files/original/fb7cc1d43658e6003753aaa44c247f01.jpg">Figure 2</a>. Hip Flexion Bias system designed by Haslam et al. of Houston, Texas. Note compression spring encircling thigh tube, which propels the limb forward during swing phase. (Redrawn from reference 5)</strong><br /> <p>Not only does this result in a much more cosmetically "normal" gait, it also significantly improves ground clearance in swing phase. One of the inherent limitations of the Canadian hip disarticulation alignment system is the prosthesis must be significantly short (1cm+) to avoid forcing the amputee to vault for toe clearance.</p> <p><b>Fig. 3</b> and <b>Fig. 4</b> illustrate the biomechanics of the Canadian design. At toe-off, the heel rises up during knee flexion and pulls the hip joint firmly against its posterior (extension) stop. The thigh segment remains vertical until the knee has reversed its direction of motion and contacted the knee stop. Only then does the thigh segment rotate anteriorly, causing the hip joint to flex. In essence, the prosthesis is at its full length during midswing. Since the patient has no voluntary control over any of the passive mechanical joints, the prosthetist is forced to shorten the limb for ground clearance.</p> <strong><a href="/files/original/3fa04d3962c39877277abfdfa7e54654.jpg">Figure 3</a>. Canadian prosthesis in early swing phase. Hip joint remains neutral as shank swings forward. (Redrawn from reference 13)</strong><br /><br /><strong><a href="/files/original/48dff4cea5f12c24f5a7ec7718c459fe.jpg">Figure 4</a>. Canadian prosthesis just after mid-swing. Hip joint does not flex until shank motion is arrested by terminal extension stop. Prosthesis is fully extended at the instant of mid-swing. (Redrawn from reference 13)</strong><br /> <p>The hip flexion bias system neatly avoids this dilemma. As a result, the prosthesis can be lengthened to a nearly level configuration in most cases. However, two potential problems have been noted with this approach. One is the development of annoying squeaks in the spring mechanism after a few months of use, which sometimes tend to recur inexorably.</p> <p>A more significant concern is that as the spring compresses between heel strike and midstance, it creates a strong knee flexion moment. Unless this is resisted by a stance control knee with friction brake or a polycentric knee with inherent stability, the patient may fall. Since the friction brake mechanisms lose their effectiveness as the surface wears, the polycentric knee is the preferred component with this hip mechanism.<a></a></p> <h3>Knee Joint Mechanisms</h3> <p>Other than the exception discussed above, knee mechanisms are selected by the same criteria as for above-knee amputees. The single axis/constant friction design remains the most widely utilized due to its light weight, low cost, and excellent durability. The friction resistance is often removed to ensure the knee reaches full extension as quickly as possible. A strong knee extension bias enhances this goal, offering the patient the most stable biomechanics possible with this mechanism.</p> <p>Although this was proposed as the knee of choice for the Canadian hip disarticulation design, more sophisticated mechanisms have proven their value and are gradually becoming more common. The friction brake stance control knee (Otto Bock 3R15 or equivalent) is probably the second most frequently utilized component.</p> <p>Because there is very little increase in cost or weight and reliability has been good, many clinicians feel the enhanced knee stability justifies this approach—particularly for the novice amputee. Mis-steps causing up to 15° knee flexion will not result in knee buckle, making gait training less difficult for the patient or therapist.</p> <p>The major drawback to this knee is that the limb must be non-weight-bearing for knee flexion to occur. Although this generally presents no problem during swing phase, some patients have difficulty mastering the weight shift necessary for sitting. It should be noted that use of such knee mechanisms bilaterally must be avoided. Since it is impossible for the amputee to simultaneously unload both artificial limbs, sitting with two stance control knees also becomes nearly impossible.</p> <p>A third class of knee mechanisms which has proven advantageous for this level of amputation is the polycentric group (Otto Bock 3R20 or equivalent). Although slightly heavier than the previous two types, this component offers maximum stance phase stability. Because the stability is inherent in the multi-linkage design, it does not erode as the knee mechanism wears during use.</p> <p>In addition, all polycentric mechanisms tend to "shorten" during swing phase, adding slightly to the toe clearance at that time. Many of the endoskeletal designs feature a readily adjustable knee extension stop. This permits significant changes to the biomechanical stability of the prosthesis, even in the definitive limb.</p> <p>Because of the powerful stability, good durability, and realignment capabilities of the endoskeletal polycentric mechanisms, they are particularly well suited for the bilateral amputee.<a></a> All levels of amputation, up to and including bilateral hemipelvectomy (hemicorporectomy), have successfully ambulated with these components.</p> <p>At first glance, a manual locking knee seems a logical choice. However, experience has shown this is rarely required, and should be reserved as a prescription of last resort. Only multiple medical disabilities (e.g. concomitant blindness) will require this mechanism. The complications in unlocking a joint for sitting by the unilateral have been discussed previously; expecting a bilateral amputee to cope with dual locking knees and dual locking hips can be an overwhelming task.</p> <p>For many years, the use of fluid controlled knee mechanisms for high level amputees was considered unwarranted, since these individuals obviously walked at only one (slow) cadence. The development of the hip flexion bias mechanism and more propulsive foot designs have challenged this assumption. Furthermore, a more sophisticated understanding of the details of prosthetic locomotion has revealed an additional advantage for the hip/hemi amputee.</p> <p>It is well accepted that any fluid control mechanism (hydraulic or pneumatic) results in a smoother gait.<a></a> Motion studies conducted at Northwestern University revealed that a more normal gait for the hip/hemi patient is also a by-product.<a></a></p> <p>The preferred mechanism has separate knee flexion and extension resistance adjustments. A relatively powerful flexion resistance limits heel rise and initiates forward motion of the shank more quickly. In essence, the limb steps forward more rapidly.</p> <p>As the shank moves into extension, the fluid resistance at the knee transmits the momentum up the thigh segment, pushing the hip joint forward into flexion. In essence, the fluid controlled knee results in a hip flexion bias effect (<b>Fig. 5</b>).</p> <strong><a href="/files/original/01326057960c319c4b1259bcd805ddd3.jpg">Figure 5</a>. Canadian prosthesis with fluid controlled knee mechanism at mid-swing. Hydraulic extension resistance allows shank momentum to flex hip joint. Increased ground clearance may result. (Adapted from reference 13)</strong><br /> <p>Sophisticated gait analyses have demonstrated that this results in significantly more normal range of motion at the hip joint during the walking cycle.<a></a> Clinical observations suggest that a more varied cadence is possible, and the prosthesis can usually be fabricated to nearly full length without swing phase difficulties.</p> <p>Richard Lehneis, et al. have reported on a coordinated hip-knee hydraulic linkage using a modified hydrapneumatic unit.<a></a> This was designed to create a hip extension bias, and resulted in a smooth gait. We have no experience with this particular component at Duke.</p> <p>Finally, a number of new components have been developed recently which combine the characteristics of some of the above classes of knee mechanisms. For example, Teh Lin manufactures a "Graphlite" knee consisting of a polycentric set-up with pneumatic swing phase control in a carbon fiber receptacle.</p> <h3>Foot Mechanisms</h3> <p>Traditionally, the Solid Ankle Cushion Heel (SACH) has been considered the foot of choice for the Canadian hip disarticulation design due to its light weight, low cost, and excellent durability.<a></a> Provided the heel durometer is very soft, knee stability with this foot has generally been quite acceptable.</p> <p>In those cases where slightly more knee stability was desired, a single axis foot with a very soft plantar flexion bumper was preferred.<a></a> Added weight, maintenance, and cost, plus reduced cosmesis are the liabilities of this component.</p> <p>Multi-axis designs (such as the Greissinger) have similar liabilities to the single axis versions, but add extra degrees of freedom via hindfoot inversion/eversion and transverse rotation. In addition to accommodating uneven ground, absorbing some of the torque of walking, and protecting the patient's skin from shear stresses, multi-motion feet seem to decrease the wear and tear on the prosthetic mechanisms as well.<a></a></p> <p>In the last five years, more sophisticated foot mechanisms have reached the market, and all have been demonstrated to function successfully for the high level amputee. The Solid Ankle Flexible Endoskeleton (SAFE) foot inaugurated a class that could be termed "Flexible Keel" designs.<a></a> Other members of this class include the STEN foot and the Otto Bock 1D10 Dynamic foot. All are characterized by a softer, more flexible forefoot, resulting in a smoother rollover for the patient. The SAFE version offers some transverse rotation as well.<a></a></p> <p>In general, a softer forefoot requires special care during dynamic alignment to ensure that knee buckle does not occur inadvertently. However, when used in concert with a polycentric knee, the reverse occurs: the prosthesis actually becomes safer during late stance phase.</p> <p>The polycentric knee mechanism strongly resists a bending moment, which leads to its powerful stability at heel strike. It flexes during swing phase only if the forefoot remains firmly planted on the floor as the body "rides" the prosthesis over it.<a></a> This creates a shearing force which disrupts the linkage and permits easy flexion of the knee. Because the softer flexible keel delays this shearing moment, the polycentric knee is actually more stable in late stance than with a more rigid foot.</p> <p>Dynamic Response feet, which provide a subjective sense of active push-off, can also be used to advantage for the hip/hemi amputee.<a></a> Carbon Copy II, Seattle foot, and Flex-Foot(tm) have all been successfully utilized for this type of patient. They seem to provide a more rapid cadence, as evidenced by one long-term hip disarticulation wearer, who stated after receiving a Seattle foot, "For the first time in my life, I can pass someone in a crowd."<a></a></p> <p>Once again, the interaction between the foot and knee must be carefully monitored. In general, the more responsive the foot mechanism, the more important the knee unit resistances become. Many practitioners prefer a fluid controlled knee, or at least one with powerful friction cells.<a></a> Otherwise, much of the forward momentum of the shank can be wasted as abrupt terminal impact of the knee. Presumed reductions in energy consumption have not yet been documented by scientific studies.</p> <p>In addition to the foot mechanisms, several ankle components have recently reached the American market. These can be paired with most of the feet mentioned above, adding additional degrees of motion as desired. Examples include the SwePro ankle from Sweden, the Blatchford (Endolite) Multifiex ankle from England, and the recently announced Seattle ankle.</p> <p>Torque absorbing units are often added to hip/hemi prostheses to reduce the shear forces transmitted to the patient and components.<a></a> Ideally, they are located just beneath the knee mechanism. This increases durability by placing the mechanism away from the sagittal stresses of the ankle, yet avoids the risk of introducing iatrogenic swing phase whips.</p> <p>The major justification for such a component is that the high level amputee has lost three biological joints and, hence, has no way to compensate for the normal rotation of ambulation. Torque absorbers can be combined with virtually any foot available, if desired.</p> <p>Finally, transverse rotation units originally developed for the Oriental world have become available. Installed above the knee mechanism, these devices permit the amputee to press a button and passively rotate the shank 90° or more for sitting comfort. They not only facilitate sitting cross-legged upon the floor, but also permit much easier entry into automobiles and other confined areas.</p> <h3>Knee Disarticulation Components</h3> <p>Although it is generally agreed that knee disarticulation offers the possibility of increased function over an above-knee amputation,<a></a> it clearly restricts patients' options in knee mechanisms and results in cosmetic compromises as well. For these reasons, its advisability remains hotly contested among knowledgeable surgeons and prosthetists.</p> <h3>Knee Mechanisms</h3> <p>The traditional knee mechanism for disarticulation has been the single pivot external hinges. Inherent disadvantages have been the lack of swing phase control (no friction adjustments) and rapid wear due to the small bearing surface compared to the typical 4" long axle of the above-knee set-up. Even with the addition of a posterior "back check" to limit extension, rapid wear of the extension stops is common.</p> <p>The major virtues of this design are its simplicity and low cost. It probably functions best for small children. Although the knee ball does not protrude when sitting, external hinges result in a slightly wider mediolateral configuration which some patients find objectionable. Heavy duty wearers can quickly destroy these relatively slender joints.</p> <p>One manufacturer provides a yoke attachment permitting the use of a fluid-controlled cylinder with these hinges (<b>Fig. 6</b>). This improves swing phase significantly, but long-term durability remains problematic.</p> <strong><a href="/files/original/d9b33408099151592c9792c42710a205.jpg">Figure 6</a>. Cut-away drawing of special hydraulic mechanism with yoke, permitting swing phase control for knee disarticulations with single pivot external hinges. (Redrawn with permission of Hosmer-Dorrance Corporation)</strong><br /> <p>The only other type of knee possible is a special polycentric design. By using longer linkage arms, the shank appears to fold back under the thigh when sitting, thus minimizing the apparent protrusion of the knee (<b>Fig. 7</b>). Since no mechanism is alongside the knee, the me-diolateral silhouette is more acceptable as well.</p> <strong><a href="/files/original/62b4779e67198aad3af7f94c6224cfa5.jpg">Figure 7</a>. Polycentric knee disarticulation mechanism flexed to 90°. Note how linkage "folds up" beneath the thigh segment, effectively shortening the shank and minimizing anterior protrusion when sitting.</strong><br /> <p>Several manufacturers offer the option of fluid controlled units along with the polycentric mechanism, and almost all have friction control options as well. For this reason, swing phase functioning is much better than the simple external hinge design (<b>Fig. 8</b>).</p> <strong><a href="/files/original/14d93f4c4979723e691b143fa14c65ef.jpg">Figure 8</a>. Example of polycentric mechanism permitting interchange of mechanical and fluid control swing phase units. (Designed by Orthopedic Hospital of Copenhagen; redrawn with permission of United States Manufacturing Company)</strong><br /> <p>All polycentrics offer powerful inherent stance phase control, and this group is no exception. However, because distal weight-bearing dramatically simplifies the biomechanics of knee control, this feature is seldom of great value to the patient. One manufacturer offers a manual locking module as well, but this should be used only as a last resort.</p> <p>One subtle problem with knee disarticulation polycentrics is that the relative "shortening" of the shank in sitting may lift the foot completely off the floor, particularly for husky individuals who are less than 5' 6" tall. The resulting sense of insecurity can be very disconcerting to the amputee and may result in rejection of the prosthesis.</p> <p>Durability can sometimes be a problem, although it is generally better than for external hinges. Most knee disarticulation polycentrics work quite well for geriatric patients but can become increasingly problematic for extremely vigorous individuals.</p> <p>In some cases, the only effective solution to chronic breakage problems is to switch to a conventional above-knee set-up. This results in protrusion of the knee ball by at least 2", making sitting in tight spaces (such as bus seats) nearly impossible. Although the function and durability are excellent, the cosmetic liability of such malalignment is obvious to the casual observer as well.</p> <h3>Foot Mechanisms</h3> <p>Knee disarticulates can utilize all the feet and ankle options of the higher level amputee, as previously discussed. Knee stability is rarely a concern, but reducing stress on the relatively fragile knee mechanism is a concern. For that reason, the author favors flexible keel designs, with or without a torque absorbing unit, since these components reduce the forces transmitted to the limb.</p> <h3>Ankle Disarticulation (Symes)</h3> <p>Like his knee disarticulate brethren, the Symes amputee has a very limited range of choices in prosthetic componentry. In addition, a significantly poorer cosmetic result is inevitable. These disadvantages must be weighed against the functional advantages of distal weightbearing and the documented reduction in energy consumption over the below-knee amputee.<a></a></p> <h3>Foot Mechanisms</h3> <p>The Symes amputation generally precludes the use of any articulated ankle mechanism, due to space limitations. The heavy metal frame of yesteryear is virtually extinct.</p> <p>Most of today's Symes amputees are fitted with a SACH foot. The specially designed Symes version suffers from reduced durability due to the greater stresses the end-bearing residual limb can exert on the prosthesis. However, it can often be replaced economically if broken.</p> <p>The external keel SACH design limits inversion and eversion almost completely but can be more durable and more cosmetically pleasing than the standard SACH. Since its use precludes any alteration of alignment after transfer and finishing, great care must be exercised during the fitting.</p> <p>The Stationary Ankle Flexible Endoskeleton (SAFE) foot, discussed earlier, has a Symes version. This offers a flexible keel and much smoother roll-over. This reduces the forces transmitted to the prosthetic socket, increasing both patient comfort and socket durability. Reliability is adequate, and replacement is possible. The author prefers this design for Symes amputees for the reasons cited.</p> <p>The Carbon Copy II has recently developed a dynamic response design suitable for many adult male Symes. Patient response has been favorable, as they sense the dynamic push-off it offers. External appearance is excellent, as is the weight reduction. Our experience at Duke is too short to comment at this time on durability of this component or its effect on socket stresses.</p> <h3>Summary</h3> <p>Although disarticulations represent less than five percent of the lower limb amputees fitted annually,<a></a> appropriate components can be selected based on logical criteria. Both Symes and knee disarticulates, however, have limited component options, often with decreased reliability plus cosmetic limitations compared to more conventional amputation levels.</p> <p>Hip disarticulates and hemipelvectomies have as broad an array of choices as the above-knee, prescribed for generally analogous reasons. As our understanding of biomechanics has improved, more sophisticated mechanisms have been successfully provided to this group of patients. Current state-of-the-art requires careful consideration of the subtle interactions between the foot, ankle, hip, and ancillary mechanisms to ensure the optimum result for each patient.</p> <p><b>References:</b></p> <ol> <li><a href="al/1963_01_005.asp">Glattly, Harold W., "A Preliminary Report on the Amputee Census," <i>Artificial Limbs</i>, 7(1), 1963, pp. 5-10.</a></li> <li>McLaurin, C.A., "Hip Disarticulation Prosthesis," Report No. 15, Prosthetic Services Centre, Department of Veterans Affairs, Toronto, Canada, 1954.</li> <li>Webster, B. and P. Tuil, "Heupexarticulates Onder De Loep," <i>Infortho</i>, August, 1982.</li> <li>Van der Waarde, Tony, "Ottawa Experience with Hip Disarticulation Prostheses," <i>Orthotics and Prosthetics</i>, 38(1), 1984, pp. 29-33.</li> <li>Haslam, T. and M. Wilson, "Hip Flexion Bias," <i>Concept</i> 80, Medical Center Prosthetics, Houston, Texas, 1980.</li> <li>Ibid.</li> <li>McLaurin, op. cit.</li> <li>Greene, Michael, "Four Bar Knee Linkage Analysis," <i>Orthotics and Prosthetics</i>, 37(1), 1983, pp. 15-24.</li> <li>Mooney, Vert, in <i>Atlas of Limb Prosthetics</i>, C.V. Mosby Company, St. Louis, 1981, pp. 391-395.</li> <li>Van Vorhis, Robert, "Clinical Analysis of Hip Disarticulation Prostheses," 31st Scientific Meeting, Midwest Chapter, AAOP, Lincolnshire, Illinois, 1981.</li> <li>Ibid.</li> <li>Lehneis, H.R. et al., <i>Prosthetics Management for High Level Lower Limb Amputees</i>, Institute of Rehabilitation Medicine, New York, New York, 1980.</li> <li>Hampton, F., <i>A Hemipelvectomy Prosthesis</i>, Northwestern University Prosthetic Research Center, Chicago, Illinois, 1964, p. 32.</li> <li>Gehl, Gunter, "Proper Selection of Prosthetic Components," Northwestern University Prosthetic Orthotic Center, Certificate course, Chicago, Illinois, 1976.</li> <li>Ibid.</li> <li>Michael, John, "Analysis of Energy Storing Feet," AAOP Annual Meeting and Scientific Symposium, Newport Beach, California, 1988.</li> <li>Campbell, J. and C. Childs, "The S.A.F.E. Foot," <i>Orthotics and Prosthetics</i>, 34(3), 1980, pp. 3-17.</li> <li>Nader, Max et al., "Polycentric, Four Bar Linkage Knee Joint," <i>Technical Information Bulletin</i> No. 45, Otto Bock Industries, Duderstadt, West Germany, 1988, p. 3.</li> <li>Michael, op. cit.</li> <li>Michael, J., "Energy Storing Feet: A Clinical Comparison," <i>Clinical Prosthetics and Orthotics</i>, 11(3), 1987, pp. 154-168.</li> <li>Leal, J., personal communication, 1987.</li> <li>Nader, Max et al., "Torsion Adapter With Tube," <i>Technical Information Bulletin No. 2.6.1</i>, Otto Bock Industries, Duderstadt, West Germany, 1986, p. 3.</li> <li><a href="poi/1983_02_119.asp">Jensen, J.S. and T. Mandrup-Poulsen, "Success Rate of Prosthetic Fitting After Major Amputations of The Lower Limb," <i>Prosthetics and Orthotics International</i>, 7(2), 1983, pp. 119-122.</a></li> <li>Waters, R.L. et al., "Energy Costs of Walking of Amputees: The Influence of Level of Amputation," <i>Journal of Bone and Joint Surgery</i>, 58A, 1976, p. 46.</li> <li>Glattly, op. cit.</li> </ol> <em><b>*John Michael, M.Ed., C.P.O. </b> John W. Michael, M.Ed., C.P.O., is Director and Assistant Clinical Professor at Duke University Department of Prosthetics and Orthotics, Duke University Medical Center, P.O. Box 3885, M04 Davison, Durham, North Carolina 27710; (919) 684-2474.<br /><br /><br /></em> Page Number(s) 99 - 108 Year 1988 Volume 12 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-5.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/1988_03_099/1988_03_099-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-7.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_03_099/1988_03_099-8.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. 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Title A name given to the resource Component Selection Criteria: Lower Limb Disarticulations Creator An entity primarily responsible for making the resource John Michael, M.Ed., 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/854528621eb80bd8a9b4f7349f5d48a6.pdf e7ecf8eb166fd1de014a65d9a4e19c54 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_01_020.pdf Year 1966 Volume 2 Issue 1 Page Number(s) 20 - 23 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_01_020.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_01_020.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Conclusions of a Conference on Linkage Feeders</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br /></h5> <p>Following the preparation of the <i>Preliminary Design Analysis of Linkage Feeders </i>by Prosthetic and Orthotic Studies of New York University,<a></a> it seemed desirable to explore the significance of the design similarities and differences identified in the NYU report.</p> <p>Accordingly, a Workshop on Linkage Feeders was organized and conducted under the auspices of the Subcommittee on Evaluation of the Committee on Prosthetics Research and Development. Participants in the workshop conference, which was held at the University of Michigan, Ann Arbor, Mich., July 26-27, 1965, included representatives from the five centers whose feeder designs were discussed in the NYU analysis, plus unattached engineering and other consultants.<a style="text-decoration:none;">*</a></p> <p>At the conference, the design and applications of linkage feeders were discussed in considerable detail, both with respect to the major components (chair-attachment assemblies, proximal and distal links, rocker-arm assemblies, and troughs) and the device as a whole. In the following presentation of major points emerging from the discussions, it will be noted that while there were areas of disagreement, a community of agreement on many considerations was evident.</p> <h4>Adjustment</h4> <h4><i>Availability to the Patient</i></h4> <p>A characteristic of the University of Michigan and the Rancho Los Amigos Hospital systems is that provisions for adjustment are retained throughout the life of the orthoses. At the other centers, apparently, a temporary feeder is used initially, with adjustments made during the course of training by physician, therapist, or orthotist. Before the patient leaves the center, the optimal adjustments are frozen, so to speak, in a permanent unit.</p> <p>A basic difference in philosophy is evident here. The belief at the University of Michigan is that the patient's family can be taught to adjust the feeder and should have the privilege of doing so; for example, to accommodate changes in the status of the patient's muscular torques with time. The belief at the other centers is that the optimal feeder geometry established during training may be lost with patient-family manipulation.</p> <p>Since proponents of both approaches are apparently satisfied with the results achieved, no categorical rule would appear to apply. To the impartial observer, retention of adjustability would seem desirable with, perhaps, provision for locking the adjustment features, if this restriction were found necessary.</p> <h4><i>Precision</i></h4> <p>Theoretically-and perhaps actually-the threaded-screw adjustments of the University of <!--Page 21--> Michigan model provide the means for securing more precise adjustments than any of the other units.</p> <p>There appears to be no question that the provision of an efficient system of balances and biases is critical to the patient's performance and increases in importance with the extent of disability.</p> <p>There is, however, considerable question concerning the degree of precision achieved or required in these units. Since motion of the forearm in the trough shifts the center of gravity of the forearm in relation to its axis of rotation, as do objects of different weights held in the hand, optimal adjustment would seem to be dynamic rather than static. Moreover, desired adjustments are in relation to a particular configuration of trough and rocker-arm assembly, for example, and this configuration itself may not represent the optimal design. It is noteworthy, though, that all the systems reviewed appeared to be very useful devices, despite these lacks.</p> <h4>Extent of Use</h4> <p>Texas Rehabilitation Center apparently applies linkage feeders primarily or solely for use with lapboards. Most of the other institutions plan more extensive use, particularly that involving activities at tables or desks, with a strong bias toward vocational rehabilitation or an approximation of normalcy. This difference in approach obviously influences feeder design and application, particularly with respect to the "reach" provided and provisions for securing adequate trough height to avoid disturbing objects on the table or desk. Total linkage length, the use of drop rather than straight swivel arms, and curved rather than straight distal links, may all be affected by these considerations.</p> <p>On this question of limited <i>vs. </i>extended feeder usage, the latter approach (maximum function and use) seems preferable unless the goals are unrealizable.</p> <h4>Link Lengths and Ratios</h4> <p>In mechanical terms, the maximum feeder reach is the sum of the lengths of the proximal and distal links, while the minimum reach is the difference between the two lengths. Kinematically, the two links should be of equal length.</p> <p>A considerable variety of link lengths and ratios was evident in the five feeders reviewed, each apparently representing a compromise between kinematic and practical considerations, that is, the need to reduce the length of the proximal links to permit passage through doorways without interference by the projecting joint between the proximal and distal link. All compromises apparently worked satisfactorily. However, the maximum length for the proximal link commensurate with noninterference would appear desirable to reduce the stress on bearings.</p> <h4>Bearings and Friction</h4> <p>Four of the feeders reviewed incorporated ball bearings to reduce joint friction while only one (Texas Institute for Rehabilitation and Research) used needle bearings. However, since these latter were said to be strong and durable and result in smaller joints, they may well be the bearings of choice.</p> <p>There was some difference of opinion concerning the need for antifriction bearings at the rocker-arm assembly (for trough function). Some conferees deemed a small amount of friction (for dampening) desirable here (for some patients); others disagreed. An obvious solution to meet both contingencies would be the incorporation of antifriction bearings, with nylon washers available for insertion if friction were desired.</p> <h4>Distal Links</h4> <p>Straight, angled, and curved distal links were represented in the feeders reviewed. Functionally (reduced interference between distal link and trough) and aesthetically, the curved links appeared to be superior.</p> <h4>Trough Pivots and Forearm Position</h4> <p>Despite the variety of rocker-arm assembly designs and trough-pivot positions (offset, below the trough, and forked to each side of the trough), the function of all designs appeared to be reasonably satisfactory. Independent engineering opinion tended to favor a forked pivot supporting the trough halfway through the thickness of the forearm rather than below it.</p> <!--Page 22--> <p>Forearm motion (sliding) within the trough was considered. The value of the typical elbow disk (dial) in stabilizing the forearm was questioned by the engineering consultants at the workshop. A strap that pivots on an axis passing through the anatomical axis of the elbow (as in the University of Michigan design) was considered to be more satisfactory. Velcro was suggested as a possible means for retaining the forearm in the trough.</p> <h4>Cosmesis</h4> <p>Feeders are rather conspicuous, mechanical, utilitarian devices. Hence the stress placed on cosmetic considerations by the conferees was all the more noteworthy. Two factors are apparently involved: <i>first, </i>the appearance of the feeder itself, that is, graceful lines, lack of obtrusiveness, etc.; <i>second, </i>the simulation of normalcy in use, for example, sitting at the table to eat a meal rather than using a lap-board.</p> <h4>An Appropriate Name</h4> <p>So-called linkage or ball-bearing feeders are obviously more than this name connotes. A less awkward term that would more appropriately define the characteristics and function of the device would be very desirable. Numerous suggestions were made by the conferees, including the term "balanced forearm orthesis" developed by Dr. Robert L. Bennett at the Georgia Warm Springs Foundation. However, none of the suggestions aroused any enthusiasm.</p> <h4>Potential Users</h4> <p>An attempt was made by the workshop participants to estimate the number of persons who would derive benefit from the use of a feeder.</p> <p>It was mentioned that a large but unspecified number of postpoliomyelitis patients would require such devices for the remainder of their lives.</p> <p>As far as new cases were concerned, the five centers represented at the workshop fitted a total of approximately 150 cases per year. It was estimated that an equal number of patients who might benefit from feeders were not being fitted because of lack of publicity concerning their value or lack of knowledge concerning applications. The conferees were also of the opinion that although new poliomyelitis patients are rare, survivors of automobile, diving, trampoline, and other accidents resulting in high spinal-cord injuries are increasing. In general, these patients require more sophisticated feeders than those developed originally for victims of poliomyelitis.</p> <h4>Need for Further Research</h4> <p>All the feeders reviewed appeared to be of fairly adequate design, and all appeared to be fairly useful devices. Presumably, each device could be improved by incorporating features in other designs, or by taking cognizance of suggestions advanced during the workshop. However, further research to develop a new design-a "super feeder"-does not seem indicated at the present time.</p> <h4>Need for Education</h4> <p>If, as postulated at the workshop, numerous patients with high spinal-cord injuries (who could benefit from the use of a feeder) are not being provided with the device, an obvious educational need exists. To meet this need, two elements are involved: <i>first, </i>information concerning the existence and usefulness of linkage feeders should be brought to the attention of physicians and institutions treating appropriate patients; <i>second, </i>hospital and rehabilitation personnel should be trained in the application and adjustment of the device.</p> <p>To these ends, it was considered that:</p> <ol> <li>Publicity might profitably be given to the NYU review and to the deliberations of the workshop conference.</li><li>Announcement should be made that commercially made feeders closely resembling the Rancho Los Amigos Hospital model described in the NYU report are available.<a style="text-decoration:none;">*</a> </li><li>Announcement should be made that instructional material dealing with the application and adjustment of feeders has been prepared by the Georgia Warm Springs Foundation<a></a> and Rancho Los Amigos Hospital<a></a>, and that reports on design principles have been published by the University of Michigan.<a></a></li><li>Based on available experience, information concerning feeder design principles and applications might well be included in one or more courses offered by the Prosthetics and Orthotics Education Program.</li></ol> <p><b>References:</b></p> <ol> <li>Georgia Warm Springs Foundation, <i>Instructions forbalanced forearm orthesis and research kit.</i></li> <li>Georgia Warm Springs Foundation, <i>Instructions foruse of balanced forearm orthesis kit.</i></li> <li>New York University, Prosthetic and Orthotictudies, Research Division, School of Engineering and Science, <i>Preliminary design analysis of linkage feeders, </i>May 1965.</li> <li>Rancho Los Amigo Hospital, <i>How to fit and adjust aball bearing feeder.</i></li> <li>Rancho Los Amigos Hospital, <i>How to fit and adjust asuspension feeder.</i></li> <li>Rancho Los Amigos Hospital, <i>Uses and limitationsof mobile arm supports.</i></li> <li>Smith, Edwin M., and Robert C. Juvinall, <i>Theory of"feeder" mechanics, </i>Am. J. Phys. Med., <b>42:3, June </b>1963, pp. <b>113-139.</b></li> <li>Smith, Edwin M., and Robert C. Juvinall, <i>Designrefinement of the linkage feeder, </i>Arch. Phys. Med., 44, November 1963, pp. 609-615.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Smith, Edwin M., and Robert C. Juvinall, Theory of'feeder' mechanics, Am. J. Phys. Med., 42:3, June 1963, pp. 113-139.</td></tr><tr><td class="clsTextSmall"><b> 8.</b> </td><td class="clsTextSmall">Smith, Edwin M., and Robert C. Juvinall, Designrefinement of the linkage feeder, Arch. Phys. Med., 44, November 1963, pp. 609-615.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Rancho Los Amigo Hospital, How to fit and adjust aball bearing feeder.</td></tr><tr><td class="clsTextSmall"><b> 5.</b> </td><td class="clsTextSmall">Rancho Los Amigos Hospital, How to fit and adjust asuspension feeder.</td></tr><tr><td class="clsTextSmall"><b> 6.</b> </td><td class="clsTextSmall">Rancho Los Amigos Hospital, Uses and limitationsof mobile arm supports.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Georgia Warm Springs Foundation, Instructions forbalanced forearm orthesis and research kit.</td></tr><tr><td class="clsTextSmall"><b> 2.</b> </td><td class="clsTextSmall">Georgia Warm Springs Foundation, Instructions foruse of balanced forearm orthesis kit.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Jaeco Orthopedic Specialties, Box 616 M-R5, Hot Springs, Ark. 71919; J. A. Preston Corp., 71 5th Ave., New York, N.Y.; Orthopaedic Supplies Co., Inc., 9126 East Firestone Blvd., Bldg. R, Downey, Calif.; Rehabilitation Equipment, Inc., 175 E. 83rd St., New York, N. Y. 10028.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Persons attending the workshop were: Herbert Elftman, Sidney Fishman, as co-chairmen; Edward Haak, James Poulson, of the Georgia Warm Springs Foundation; Robert C. Juvinall, James W. Rae, Jr., Edwin M. Smith, of the University of Michigan; G. Hartmann, Nancy Verdon (Appoldt), of New York University; Alice Garrett, Patrick Marer, Betty Yerxa, of Rancho Los Amigos Hospital; Thorkild Engen, of Texas Institute of Rehabilitation and Research; Linda Parker, Randolph Witt, of Texas Rehabilitation Center; Hans A. Mauch, Colin A. McLaurin, Eugene F. Murphy, as engineering consultants; Hector W. Kay, James R. Kingham, A. Bennett Wilson, Jr., of the staff of the Committee on Prosthetics Research and Development. (Mr. Wilson also served as an engineering consultant.)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">New York University, Prosthetic and Orthotictudies, Research Division, School of Engineering and Science, Preliminary design analysis of linkage feeders, May 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Hector W. Kay, M.Ed. </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington, D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> 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 Conclusions of a Conference on Linkage Feeders Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * https://staging.drfop.org/files/original/897efa93c8f0f30a250eccc724813589.pdf e53c2e6eef7da7fdb79521021433f7d8 https://staging.drfop.org/files/original/c6c0a9c17de4d27109310814707b7ea9.jpg a92870c95ef82139b0b52a743706a5d4 https://staging.drfop.org/files/original/29c0d4894d9c12cab8e7e6de799c2eed.jpg 5aae8022f80eabcc317cdfc744911e6b https://staging.drfop.org/files/original/6ef64458260bc2d1bde1e86f529b05fd.jpg 059fabe5ce19ca7120b4dca37de6a827 https://staging.drfop.org/files/original/3ffdcbb4b21055eba4533c885af8d30e.jpg bf323b08ef78be03b4cdd81505b1117f https://staging.drfop.org/files/original/570c0db690f8d4929a4e24a544499f04.jpg a75a3433b11e417be3aaf5931af55647 https://staging.drfop.org/files/original/25ba53d34e86878d89a422613a423219.jpg 49d279d5f622a33f7bab7e9a13941475 https://staging.drfop.org/files/original/86c9a5fc2e2c6424943c5d82967bca6b.jpg df44bcb9079a48fad702bd6ce8cbd7c2 https://staging.drfop.org/files/original/7f22825f726c7c3cd036fdc490fc0311.jpg 49b270cdb8ab4bf273e44b7ff0d6adcd https://staging.drfop.org/files/original/d7e9a11114bd8cf398078615dc266ef0.jpg effa0ef8f6e071995f4db91e16956da6 https://staging.drfop.org/files/original/c791f2953272b15882d258981a1009c6.jpg 63e16f08b2372dab80ba402c7ec179da https://staging.drfop.org/files/original/b4e99d6ae2d85be6de0ebef5d20927f6.jpg 2764e06e43929f9813a2330db858522a https://staging.drfop.org/files/original/c90405176cc45ad9822c08f2c83403fc.jpg fb0324acf3b3efcca91cc33616b2ac93 https://staging.drfop.org/files/original/78a8fc8bb5859084900fc76a87459fec.jpg 39d5fd4f9942eeadc11787a402d0ee30 https://staging.drfop.org/files/original/3b8caa354bfe35ea776768597c689ace.jpg 3f44ac3f0d0fede052be1900dd619aa4 https://staging.drfop.org/files/original/234a59503cb92f7f867861e34588d1de.jpg be8cf73cabbf52ac504564063d5273ab https://staging.drfop.org/files/original/2c09290f6e88d7d02270ca5e0c495f52.jpg 0e05933eba5072a94777c38b2af8a9ba https://staging.drfop.org/files/original/9ebc06a2cd39befeb223452a2fce202d.jpg b4d10db15d99610189bd994126d8059a https://staging.drfop.org/files/original/e68efc6c51e5847738a124ba8c0650bd.jpg 3ca5390d466efbb2cefeaa72e57341c0 https://staging.drfop.org/files/original/72a98fe700fcf3286ffce2026dbfe490.jpg 926e883f350b7cc4cc2ca3e4da92e8d4 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_02_039.pdf Year 1957 Volume 4 Issue 2 Page Number(s) 39 - 51 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_039.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_02_039.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Construction and Fitting of the Canadian-Type Hip-Disarticulation Prosthesis</h2> <h5>James Foort, MASc. <a style="text-decoration:none;">*</a><br /></h5> <p>True hip disarticulation connotes removal of the femur at the acetabulum. But loosely within the hip-disarticulation category a residual length of femur, too short to control a prosthesis effectively, may be left. A much more drastic operation, the hemipelvectomy, removes all of the ischium, all of the pubis, and most or all of the ilium on the side of the amputation. In this discussion, a classical and idealized hip-disarticulation amputee is considered in outlining a method for making the Canadian-type hip-disarticulation prosthesis. Certain adaptations have been found suitable for the short-stump above-knee amputee and for the hemipelvectomy.</p> <p>Consider the remaining functions of the hip-disarticulation amputee. The gluteal muscles have been pulled anterior and fastened at the suture line to form a rugged pad which supports the body's weight. Support forces are transmitted through this gluteal musculature and the ischial tuberosity to the stable pelvic base. Movement of the pelvis relative to the normal leg permits the amputee to position the artificial foot at the beginning of the stance phase of walking and aids in flexing the knee at the end of the stance phase and in sitting down. Pelvic movement relative to the rest of the body enables him to secure balance on and to control the prosthesis. The tuberosity on the side of the amputation, the iliac crests, and the sacrum provide excellent keying points for securing the body in the socket. To minimize movement between the body and the socket for the most efficient transmission of forces, the socket must snugly enclose those areas providing support, suspension, and stabilization and must give relief for any sensitive areas or bony prominences.</p> <p>The socketmaking technique, as worked out by the Prosthetics Research Group at the University of California, Berkeley, is described in detail in the report by Foort and Radcliffe<a></a>. The socket is made by taking a female impression of the pelvis with plaster bandage, forming it into a check socket and making the necessary modifications, making a male model from the check socket, and using the model as a mold for the plastic-laminate socket to which the rest of the prosthesis is attached.</p> <h4>Taking the Cast</h4> <p>To provide relief pockets for the anterior-superior spines, the posterior-superior spines, the spinous processes of the vertebral column, and any other sensitive areas, patches of 1/4-in. skived felt are attached to the body with adhesive tape (<b>Fig. 1</b>). To protect the body from plaster, a covering of cotton stockinet is pulled up over the lower part of the torso and extended well beyond the area where the socket is to be shaped (<b>Fig. 2</b>). In order to define accurately the areas which may require modification, the iliac crests and those areas which have been covered with felt are marked on the stockinet covering with indelible pencil. A mark around the waist, marks on the front and back mid-lines, and a mark extending from mid-line to mid-line around the normal leg at the level of the inguinal crease will define the approximate trim lines of the plaster cast (<b>Fig. 3</b>). Metal strips may be placed over the mid-line marks to facilitate subsequent cutting of the wrap cast.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Application of skived felt patches over pressure-sensitive areas of the stump and torso. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Stockinet pulled over lower part of the torso well above the waist, tied at waist and around proximal end of sound thigh. Waist, mid-line, and bony prominences marked with indelible pencil. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Waist, mid-line, and bony prominences marked in the rear. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>One way to get a good, snug fit for the socket is to take the wrapping of the upper part of the pelvis with the subject lying on his back on a cast table (<b>Fig. 4</b>, <i>A). </i>This position causes the viscera to move upward and backward and flattens the abdomen, thus reducing the distance from the anterior to the posterior wall of the cast and more sharply defining the iliac crests (<b>Fig. 4</b>, <i>B </i>and <i>C). </i>The cast of the lower pelvis is taken as a second step (<b>Fig. 4</b>, <i>D). </i>Snug fit is achieved by having the amputee bear weight on the stump as the cast hardens (<b>Fig. 4</b>, <i>E). </i>Three or four layers of plaster bandage are wrapped firmly around the upper part of the pelvis <i>{i.e., </i>from about 2 in. above the iliac crests to just above the pubic symphysis) and then, with tension, diagonally over the iliac crest on the amputated side and under the crest on the normal side (<b>Fig. 4</b>, <i>A </i>and <i>B). </i>After the wrap is complete, a block of firm sponge rubber 2 in. thick is placed under the patient's lumbosacral region to force the back portion of the cast against the body (<b>Fig. 4</b>C). By molding over the iliac crests with the hands while the cast is setting, and by pressing in firmly while the cast hardens, the operator obtains good suspension hooks.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Taking the cast. <i>A, </i>Wrapping the waistband area of the pelvis, patient supine on cast table, cast table set apart to facilitate wrapping; <i>B, </i>diagonal wrapping for distortion of the cast over the iliac crest on the side of the amputation; C, rubber pad under patient's lumbosacral region to give firm fit in that area, cast table closed; <i>D, </i>wrapping the stump area, a separate operation, patient standing; <i>E, </i>patient "sitting" on rubber pad to give weight-bearing impression. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the upper portion of the cast has set, the amputee stands, and the stump area is wrapped with plaster bandage. To unite the two portions completely, the bandage is applied back and forth over the stump with several turns around the upper section of the cast (<b>Fig. 4</b>, <i>D). </i>While the cast is setting, the amputee bears full weight on the sponge-rubber pad now placed under the stump area (<b>Fig. 4</b>, <i>E). </i>Weight-bearing at this time keys the body within the socket between the weight-bearing platform and the suspension hook over the iliac crest on the side of the amputation. Up-and-down motion of the body within the socket is thus minimized. There may be some gapping of the cast in the gluteal area and lateral to the pubic area, but such gapping will be closed with plaster when the cast is modified.</p> <p>When the cast has set, it is removed from the torso by cutting at the approximate midlines, front and back (<b>Fig. 5</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Cutting and removing the cast. <i>A, </i>Cast marked on mid-line, front view; <i>B, </i>cast cut along anterior and posterior mid-lines, rear view. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Check Prosthesis</h4> <p>The cast is rejoined, reinforced, split again, hinged posteriorly, provided with a buckled closure anteriorly, and attached to a pylon base (<b>Fig. 6</b>). To rejoin the two sections, they are aligned in their original position, and plaster bandage is wrapped around the outside. Plastic laminate, consisting of polyester resin, stockinet, and glass cloth, is applied over the plaster cast to strengthen it. Two layers of glass cloth about 4 in. wide are laid over the outside on the posterior mid-line. One layer of 8- to 10-in. stockinet is then pulled over the cast and tied at the opening for the normal leg. Polyester resin is painted over the fabric and allowed to cure, after which excess material is trimmed away.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The check prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast is now sawed along the posterior mid-line, and a hinge is fastened over the cut. When the hinge is secured, the cast is sawed along the front mid-line, and a buckle-and-strap arrangement is attached. A block of wood about 4x4x4 in., scooped out to fit the bottom of the cast roughly, is attached to the cast with "gunk," a mixture of resin and sawdust, to serve as the base for the pylon.</p> <p>The pylon must now be attached to the wood block in the proper alignment and the socket tried on the amputee for any necessary modifications. With the plaster socket on the amputee, marks are made on the side and front of the block to indicate the inclination of the peg. It should be so set that it will make the same angle with the floor at the beginning and end of the stance phase of walking and so that it will clear the normal leg in the swing phase. Typically, this will mean that the distal end of the pylon will be set somewhat forward as viewed from the side and somewhat lateral as viewed from the front. A hole is drilled in the middle of the block at the required angles, and a length of crutch-tipped dowelling is inserted.</p> <p>To test for discomfort, excursion, and restriction of body motion, the amputee now performs on the check prosthesis. He is asked to bend his body and normal leg in every direction, and the cast is cut down until there is complete freedom of motion. Taking care to leave the ischial seat intact, the medial side is cut away to relieve rubbing against the normal leg and the genitalia. The edges of the cast are then smoothed and flared with plaster, and gapping in the areas of the gluteus and pubis is similarly closed.</p> <p>If there is ramus contact, the amputee usually will complain of it. This detail can be checked by locating the ramus with a finger and having the amputee put full weight on the socket while dropping his pelvis on the normal side. If there is contact, the ischial seat and other weight-bearing areas should be built up with 1/8-in. layers of plaster until the ramus is sufficiently cleared. Fore-and-aft excursion can be detected by placing a finger alongside the tuberosity while the amputee steps back and forth on the prosthesis. Any fore-aft excursion will be reduced if the prosthetist slips a hand between the torso and either the anterior or the posterior wall of the socket. If the amputee then feels more secure, the anterior and posterior walls should be built up appropriately with plaster so laid that the forces are evenly distributed.</p> <p>If the body has not been sufficiently stabilized in the socket in the up-and-down direction, the prominences will move along and out of the relief pockets established for them, and chaffing and painful pressures will occur. As a final check on excursion, therefore, the amputee should be walked in the check socket. Two hours of walking is usually enough to prove any discomfort. Further refinements may then be necessary:</p> <ol> <li>If the musculature in the area of the iliac crest on the side of the amputation has atrophied, the extent of the hook in this region may need to be increased. An increase is indicated if a hand placed inside the socket under the hook makes the socket seem more secure on the amputee.</li><li>If, without causing discomfort, security is increased by inserting 1/8-in. pads between the stump and the weight-bearing area of the socket, the weight-bearing area should be built up accordingly.</li><li>If the body seems stabilized in the up-and-down direction but there is still pressure on the prominences, either the areas around the relief pockets must be built up with plaster, 1/8-in. at a time, or material must be sanded out of the pockets.</li></ol> <h4>The Male Model</h4> <p>A hollow model is now made in the check socket. After the inside of the cast has been coated with petroleum jelly, a section of 8-in. stockinet is pulled over the check socket and tied closed around the pylon base. Sufficient thin plaster is then poured into the cast through the waist opening to coat lightly both the check socket and the stockinet closing the end (<b>Fig. 7</b>). When the first layer of plaster has set, successive layers of somewhat thicker plaster are added until the model is approximately 1 in. to l 1/2 in. thick. When the shell has hardened, a quart more of plaster is poured in, the stockinet is pulled across the opening, and the cast is inverted and placed on a table so that the plaster seals the end. The completed male model is removed from the check socket and dried.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Making the male model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Plastic Socket</h4> <p>To prepare the model as a mold for construction of the plastic socket, a hole is cut in the top (the waist), and a mandrel of 1-in. pipe about 2 ft. long is inserted and fastened with "gunk." The edges of the mold are trimmed so that the flares are not more than 1/4 in., and the whole is smoothed with fine sandpaper. To the surfaces which will become the open ends of the completed socket wooden blocks approximately 1/2 to 1 in. are attached with "gunk" (<b>Fig. 8</b>). They will later be used to secure the layers of fabric to the mold. A 1/4-in. pad of dense sponge rubber is placed over what will be the weight-bearing area of the socket. This pad will later be transferred to the corresponding area of the completed socket. A truncated cone of polyvinyl alcohol film is then pulled over the cast and tied to the mandrel at one end and to the leg-opening surface at the other (<b>Fig. 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Wooden blocks bonded to the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Truncated cone of polyvinyl alcohol film drawn over the model and fastened top and bottom. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <!--Page 44--> <p>To reinforce the polyester resin, da-cron tricot (a very strong fabric with one-way stretch) and glass cloth are used in construction of the socket. The dacron waistband will be limber enough to allow the socket to open, while areas of force concentration, reinforced with the glass cloth, will be strong and rigid.</p> <p>Six layers of dacron tricot are used, each layer being stapled into place individually. The six layers of dacron are cut with enough material to wrap around the cast horizontally and with an overlap great enough to span the distance between the crests. These are fitted and seamed to pocket the stump area (<b>Fig. 10</b>). Beginning at the vertical line of the normal iliac crest, the end of the material is stapled to the wooden blocks at either end of the model. As it is brought across the abdominal area, then around the back, continuing to its starting point, the dacron is stapled to the blocks (<b>Fig. 11</b>), the excess length of material being allowed to hang free. Alternating with the dacron, four layers of glass cloth are laid up over the stump area, extending upward to the crest (<b>Fig. 12</b>), and the lay-up is finished off with the final two layers of dacron tricot (<b>Fig. 13</b>). When all the fabric has been applied in this way, the loose sections of dacron are brought across the front and stapled into position over a sheet of polyvinyl alcohol film (<b>Fig. 14</b> and <b>Fig. 15</b>). The film separator prevents the overlap from bonding to the underlying section.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Dacron tricot tailored to fit the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Securing the fabric to the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Glass cloth applied over the stump area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Final lay-up of dacron fabric. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Application of PVA funnel and film separator under overlap of waistband. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Film separator and overlapping fabric stapled into position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In order to get resin to the fabric under the film separator, it is helpful to place a polyvinyl alcohol funnel, approximately 2 to 3 in. wide and 2 ft. long, under the film separator before it is stapled into position (<b>Fig. 14</b>). The mouth of the funnel will be at the mandrel. After the film separator and the overlapping material have been stapled to the wooden blocks in final position, two similar funnels are placed over the front and back surfaces of the lay-up with the mouths at the mandrel (<b>Fig. 16</b>). A final truncated cone of polyvinyl alcohol film is pulled over the entire mold and tied in the area of the wooden blocks at the stump end (<b>Fig. 17</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. PVA funnels applied to front and back of lay-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Truncated PVA cone placed over entire lay-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The required quantity of resin is weighed, mixed with catalyst, promoter, and pigments, and introduced into the fabric through the funnels, after which the funnels are removed (<b>Fig. 18</b>). The polyvinyl alcohol bag is tied closed at the mandrel, and the resin is squeezed through the fabric. When the fabric is completely saturated, excess resin and air bubbles are worked out toward both ends by "roping" (<b>Fig. 19</b>). Sponge-rubber pads are then bound over the undercut areas with Ace bandage in order to guarantee close adherence of the lay-up to the mold (<b>Fig. 20</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Resin introduced through the funnels, funnels ready to be removed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Saturation of the fabric and removal of air bubbles by "roping." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Sponge-rubber pads applied to undercut areas to guarantee adherence to mold. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is released from the mold by cutting around the waist and around the opening for the normal leg approximately 1/2 in. from the final trim lines (<b>Fig. 21</b>). Care should be taken not to cut the hands on the sharp edges of the overlapping sections (<b>Fig. 22</b>). After the socket has been removed from the mold, the edges are trimmed on a sanding drum.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Cutting the socket free of the mold. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Removing the socket from the mold. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <!--Page 46--> <h4>The Trial Leg</h4> <p>The fixtures are attached to the socket, the socket is attached to a thigh section through the hip-joint assembly, and the thigh section is attached to the adjustable leg and the foot (<b>Fig. 23</b>, <b>Fig. 24</b>, <b>Fig. 25</b>, and <b>Fig. 26</b>). Attachments for the socket are the weight-bearing pad (<b>Fig. 23</b>), the belt-and-buckle arrangement, and the wooden base for the hip joint (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Finished socket with weight-bearing pad installed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Socket with wood block attached. Dotted lines indicate the saw lines. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Hip-joint assembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Trial prosthesis set up on the UC adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Wooden Base</h4> <p>A block of wood 4 x 4 x 4 in. for the base, hollowed out to fit the front-bottom corner of the socket, is bonded in place with "gunk." When the resin has cured, the front-bottom corner of the block is cut off as close to the socket as possible to provide a surface to which to attach the hip - joint bearing. When the socket is in its normal position, this attachment surface will face downward and forward at a 45-deg. angle to the floor, so that when the hip-joint bearing is attached its axis will be approximately perpendicular to the line of progression and parallel to the floor (<b>Fig. 25</b>).</p> <h4>Hip-Joint Assembly</h4> <p>The hip-joint assembly (<b>Fig. 25</b>) consists of a special bearing, a shaft, and two metal side-straps. The bearing, which is lined with a bronze bushing, is machined out of a block of aluminum and includes four tabs with screw holes for attachment to the base of the socket. The shaft and sidestraps of the hip-joint assembly are from a 3 1/2-in. standard prosthetic-knee assembly.</p> <h4>Thigh Section</h4> <p>The thigh section is made from a 6- x 6-in. block of wood 12 in. long, with a core drilled from the middle at the edge of one end through the center of the block at the other. This hole facilitates pulling out wood from the interior of the thigh section later. A line is marked off 2 in. from the cored edge at one end, and, starting at this line, a diagonal cut is made to the opposite corner at the other end. The 6- x 6-in. face becomes the knee end, the 2- x 6-in. surface the hip end, and the vertical surface (6 x 12 in.) the front face of the thigh.</p> <p>The sidestraps of the assembled hip joint are traced on the front face of the block equidistant from the sides, and the block is cut along these lines to extend somewhat beyond the side-straps and to flare out toward the end. The straps are then attached to the cut sides flush with the front of the block at the bolt end and so that the axis of the bolt will be approximately 3/4 in. above the top surface of the thigh block. The portion of the block which extends behind the axis of the hip joint is sawed as necessary to provide the platform for the hip-stop bumper (<b>Fig. 24</b>). To position the hip joint on the base, the amputee dons the socket and sits down.</p> <p>Viewed from the front, the prosthetic thigh should be approximately parallel to the normal thigh and as close to the mid-line as possible, and the hip joint should be parallel to the floor and high enough on the base so that the back edge of the hip-stop platform is flush with the chair. The position of the bearing is traced on the block, and the free end of the thigh section is marked 2 in. back from the normal knee axis.</p> <h4>Trial-Leg Assembly</h4> <p>The socket is removed from the patient, the thigh section is cut where it was marked, and the components of the trial leg are assembled. The adjustable leg is attached to the knee end of the thigh piece, and the socket is attached to the thigh with screws through the hip-joint bearing. To prepare the trial leg for alignment checks, a temporary hip-stop bumper, a temporary hip-flexion control <!--Page 48--> strap, and a kick strap are attached to the leg, and the knee joint is located in a stable position (<b>Fig. 26</b>).</p> <h4>Temporary Bumper</h4> <p>A bumper of foam-crepe shoe-sole material is tacked temporarily to the hip-stop platform in such a manner that when the socket is against the bumper the vertebral spine will be in its natural position.</p> <h4>Hip-Flexion Control Strap</h4> <p>One end of the hip-flexion control strap is attached laterally to the socket 2 in. behind the hip joint; the other is attached to the shank 3 in. below and 1/2 to 1 in. ahead of the knee joint.<a style="text-decoration:none;">*</a> The distance between these attachments is adjusted to provide the correct stride length.</p> <h4>Kick Strap</h4> <p>The temporary kick strap is attached to the front of the shank at the same level as the hip-flexion control strap, passes over the knee in front, and attaches to the front of the socket 3 in. above the hip joint. The length of the strap is adjusted to provide the correct balance between heel rise and knee extension. Knee stability will be satisfactory if, when the knee is in full extension, the knee joint falls behind the line projected from the hip joint to the back of the heel.</p> <h4>Adjustments</h4> <p>The prosthesis is now ready for sitting, standing, and walking adjustments. When the amputee is sitting, the prosthetic shank should be vertical, the knee axis approximately level with the normal knee center and the toe-out equivalent to that on the normal side. In the standing position, with a 2- to 3-in. standing base, the length of the leg should be such that the hips are level. The thickness of the hip bumper is adjusted to eliminate humping or arching of the spine. The patient now walks on the trial leg, and checks are made of knee stability, width of walking base, stride length, toe clearance, whip in the swing phase, and swing-phase control.</p> <h4>Knee Stability</h4> <p>Although the knee has been stabilized on the bench, a number of factors may affect it in action. If the knee buckles, it may be that the hip bumper is contacting too soon and that its thickness needs to be reduced. A knee axis too far forward also will cause buckling.</p> <h4>Walking Base</h4> <p>With the toe-out of the prosthesis consistent with the natural toe-out, the medial distance between the heels is the walking base. If this base is found to be over 2 to 3 in., it should be made narrower by moving the foot in. If the feet are not clearing each other sufficiently, the base should be increased to 2 to 3 in.</p> <!--Page 49--> <h4>Stride Length</h4> <p>The distance between toe-off and heel strike should be approximately the same for the two legs. Stride length is adjusted by shortening or lengthening the hip-flexion control strap.</p> <p>The thickness of the hip-stop bumper affects stride length. If the thickness of the bumper is increased, the angle at which the leg inclines forward at the end of the stance phase is reduced, and the stride is shortened. But bumper thickness should never be changed to improve control and stride length at the expense of comfort.</p> <h4>Toe Clearance</h4> <p>A number of factors are involved in toe clearance-the length of the leg, the inclination of the foot, the amount of knee flexion in the swing phase, and suspension. Leg length is first adjusted, but the limb should not be shortened more than an inch. If scuffing persists, it is due to other factors. If the knee is not bending sufficiently, the toe will drag, and kick-strap tension should be reduced. If drop-off is causing the toe to scuff, a hand placed between the socket and the crest of the ilium on the side of the amputation should eliminate it. In this case, either the suspension hook over the crest should be enlarged or the weight-bearing area should be built up with pads and the length of the leg reduced equiva-lently. Correction of scuffing may make the clearance too great, in which case leg length must be readjusted.</p> <h4>Whip</h4> <p>Whip in the Canadian-type hip-disarticula-tion prosthesis typically takes a form comparable to circumduction in the above-knee prosthesis. Circumduction can be reduced by rotating the knee bolt externally. The degree to which the knee axis can be rotated is limited by the extent the foot will move medially in the sitting position. It may thus be necessary to effect at least some external rotation at the hip joint by cutting a wedge (with the apex medially) from the hip-joint base.</p> <h4>Swing-Phase Control</h4> <p>With alignment established, refinements can be made in swing-phase control. Heel rise at the beginning of the swing phase should be limited through adjustment of the kick strap rather than of the knee-friction units. The compound-pendulum system of the prosthesis does not allow the hip-disarticulation amputee to walk as fast as he would like, and it has been found that tensing the kick strap increases his speed more effectively than does increasing knee friction. This may mean that there will be some impact at the end of the swing phase, but it usually is quite tolerable because the hip joint flexes as soon as the knee comes against the extension stop, and the energy which would otherwise lead to impact is thus absorbed. Stride length may require periodic adjustment as changes are made in swing-phase control.</p> <h4>Finishing the Prosthesis</h4> <p>The leg is now ready to be used either as a training leg, or, after sufficient attention has been given to fit and alignment, to be duplicated.<a></a> The only difference between duplicating the Canadian-type hip-disarticulation prosthesis and a standard above-knee prosthesis is that in the case of the former the thigh section rather than the socket is clamped in the jig.</p> <!--Page 50--> <p>The thigh section, shank, and foot are shaped and reinforced according to standard techniques<a></a>. Weight of the thigh section is reduced by pulling wood from the inside. The hip joint is faired to the wooden base on the socket with "gunk" and tied to the base with three layers of resin-impregnated glass cloth extending about an inch beyond the wooden block. This reinforcement is smoothed and finished with a light coat of lacquer. For ventilation, the socket is perforated with 1/8-in. holes at 1-in. intervals, and padded areas are covered with nylon-coated leather or leather substitutes. The permanent kick strap and hip-flexion control strap are installed, their connections to the limb being such as to allow the straps to rotate about the points of attachment. The hip-flexion control strap (<b>Fig. 27</b>) is made of 1-in. vinyon or dacron webbing sewed on either end of a 4-in. section of heavy elastic webbing. For attachment to the prosthesis, a piece of leather large enough to include a 1/4-in. metal grommet (such as is used in below-knee corsets) is sewed at each end of the hip-flexion control strap, and a clamping arrangement is installed on the webbing to permit length adjustment. The conventional kick strap is used, with the exception that it is attached proximally to the socket instead of to the thigh. Final adjustments are made to socket edges and to the permanent swing-phase controls.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Hip-flexion control strap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The last step in the construction and fitting of the Canadian-type hip-disarticulation prosthesis is to provide a cosmetic fairing for the thigh section. A truncated cone of sponge rubber is made to fit over the thigh section so that it extends from just above the knee to the socket. The rubber cone is in turn covered with leather or a leather substitute extending beyond the rubber fairing at both ends, so that the covering can be attached to the thigh at the bottom and to the front and side of the socket with snap fasteners (<b>Fig. 28</b>). In order to make the fairing neat in both the sitting and the standing positions, a triangle with a 3-in. side and with the apex on the hip-joint axis may be cut from the lateral side of the covering and a piece of light elastic webbing substituted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Cosmetic fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The procedures outlined for checking the prosthesis during construction and fitting can be applied equally well to the evaluation of hip-disarticulation prostheses.</p> <h4>Acknowledgment</h4> <p> The line drawings which accompany this article were prepared by Frank N. Todd, illustrator with the Biomechanics Laboratory at <!--Page 51--> the University of California at Berkeley. The halftones are by George Rybczynski, free-lance artist of Washington, D. C.</p> <p><b>References:</b></p> <ol> <li>Foort, J., <i>Fiberglas laminate reinforcement of wooden prostheses, </i>Prosthetic Devices Research Project, University of California (Berkeley), [Report tohe] Advisory Committee on Artificial Limbs, National Research Council, February 1956.</li> <li>Foort, J., and C. W. Radcliffe, <i>The Canadian typehip disarticulation prosthesis, </i>Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Prosthetics Research Board, National Research Council, March 1956.</li> <li>Radcliffe, Charles W., <i>Mechanical aids for alignmentof lower-extremity prostheses, </i>Artificial Limbs, May 1954. p. 23.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Foort, J., Fiberglas laminate reinforcement of wooden prostheses, Prosthetic Devices Research Project, University of California (Berkeley), [Report tohe] Advisory Committee on Artificial Limbs, National Research Council, February 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignmentof lower-extremity prostheses, Artificial Limbs, May 1954. p. 23.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">If the amputee is well adjusted to using a prosthesis and does not need the added stability offered by attaching the hip-flexion control strap below the knee, the distal end of the strap may be attached to the thigh section.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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 typehip disarticulation prosthesis, Prosthetic Devices Research Project, University of California (Berkeley), [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>James Foort, MASc. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Engineer, University of California Prosthetics Laboratory, U. S. Naval Hospital, Oakland, Calif.; formerly Research Engineer, Prosthetic Services Centre, Canadian Department of Veterans Affairs, Sunnybrook Hospital, Toronto.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-001.jpg Figure 2 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-002.jpg Figure 3 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-003.jpg Figure 4 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-004.jpg Figure 5 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-005.jpg Figure 6 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-006.jpg Figure 7 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-007.jpg Figure 8 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-008.jpg Figure 9 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-009.jpg Figure 10 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-010.jpg Figure 11 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-011.jpg Figure 12 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-012.jpg Figure 13 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-013.jpg Figure 14 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-014.jpg Figure 15 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-015.jpg Figure 16 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-016.jpg Figure 17 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-017.jpg Figure 18 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-018.jpg Figure 19 http://www.oandplibrary.org/al/images/1957_02_039/sp66d-019.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Construction and Fitting of the Canadian-Type Hip-Disarticulation Prosthesis Creator An entity primarily responsible for making the resource James Foort, MASc. * https://staging.drfop.org/files/original/4adf69aec72e4ae9b5f3bf92fb6ac8b3.pdf e0839880f8ec1ac27ea3e70c4edbdfd1 https://staging.drfop.org/files/original/98fe795c88fad17b1d74cc108c160e00.jpg 6a34b2e11bcae6cff2d976d346aacbc6 https://staging.drfop.org/files/original/14cf27cb8f5d81a47a7cdb8e6e214bce.jpg 3e5046beb80d00399c476ce991aba40d https://staging.drfop.org/files/original/4e626be5b3789221a3412f6af707dc27.jpg d7655bf11d81815becaf73e0db4bf62c https://staging.drfop.org/files/original/2fd9c9228f2c808801f701cc1a7d7b4d.jpg 43a265c5f229dad91a709b0c2e9f55f4 https://staging.drfop.org/files/original/1d59bded42f11085ee1da15a0877dad4.jpg 212923d2b7ef13ff8f521e29fdd1f5c4 https://staging.drfop.org/files/original/0ade1458ed51fa5f108d5b082568fdab.jpg 69820b21e500e18a75685ae782e8bbce https://staging.drfop.org/files/original/35d6d2556399148c9040f819b52e0a3b.jpg 82fcf4c1287fe7b335a8ed1da803ffe6 https://staging.drfop.org/files/original/81650d70907f304a16ab8defe11f7f60.jpg 3eb5943b2e2f96e74e96a92daf651c64 https://staging.drfop.org/files/original/f08db7f605fcd5595c184552c44e456e.jpg 599058d9e0aacadff3ce8baef49af00e https://staging.drfop.org/files/original/1d67bc6ae3ad9cbc0f6efc141f40cb13.jpg b86b89038edb944943cd90a2d336b82a https://staging.drfop.org/files/original/13d1cabd8d9f654969ba2b555d3d8dbc.jpg 404c4855866586a67f87b86a472d8c4b https://staging.drfop.org/files/original/1c87598af401dbf72d1d1d6649168efb.jpg c22e01cc312817431faf39508cc6eb4c https://staging.drfop.org/files/original/2ad5c4af43e2a75bade795051925730d.jpg 1d026a103663cb520c6fa6258ee3016c https://staging.drfop.org/files/original/d30525d8fcd51ba1c3970ba3ab2d2341.jpg ff652c1d6b200c7720ed45b3b7d8e8f5 https://staging.drfop.org/files/original/ccc86a0851bcad4c2f6c5eb0c6aeaf60.jpg 8da98cb540c35edd945fd7d842777491 https://staging.drfop.org/files/original/59877e8b7291ec5abdf5713e6e331a77.jpg 0139dfaba0fae4e4298266965017153a https://staging.drfop.org/files/original/03ba66d1000443a30f2de37b2ae3c698.jpg 39756cb1dceb16189fffde46ca165728 https://staging.drfop.org/files/original/7448bd0d7c079138df3101f8ed65e8b4.jpg 374c47d5ffc47c6009dd51df02816f30 https://staging.drfop.org/files/original/0f0a175b1c6c3f79e4d2767c9c0ca6d9.jpg 5536596629ec9f258ad85c1291617a29 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1962_02_025.pdf Year 1962 Volume 6 Issue 2 Page Number(s) 25 - 73 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1962_02_025.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1962_02_025.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Construction of the Patellar-Tendon-Bearing Below-Knee Prosthesis</h2> <h5>Bryson Fleer <a style="text-decoration:none;">*</a><br />A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>The first and most obvious requirement of any below-knee prosthesis is to furnish a suitable extension of the stump to the ground in such a way as to provide adequate support for the body weight with as little involvement as possible of other parts of the residual anatomy. In the interest of appearance as well as of function, there is a need secondarily for some reasonably faithful simulation of the normal leg, otherwise known as the "shank." Each of these requirements may be met in either of two ways. In one the structural member may be endoskeletal (the pylon), in which case the skeletal form may be covered with some suitable camouflage designed to give natural appearance. In the other, the structural element may be exoskeletal (crustacean), in which case the shell-like supporting member may itself be so shaped as to provide the desired appearance of naturalness. In either case, there is needed some acceptable means of attaching prosthesis to stump in a way that will satisfy the additional requirements of weight-bearing, comfort, and stability both in standing and in the stance phase of walking. As has been found through several centuries of observation and experiment, this is best accomplished by attaching the prosthesis via the medium of a sleeve, or socket, so shaped and so fitted as to accommodate prevailing features of local anatomy and physiology and into which the stump may be inserted.</p> <p>Of all the methods, and variations of methods, that are available for the construction of sockets advantageously fitted to the irregular surfaces of the below-knee stump, most fall into one or another of three classes.<a></a> One of these involves the forming, or shaping, of materials (such as aluminum or other metals). A second involves the negative carving, or excavation, of some suitable material (such as wood). And the third involves the molding of some material (such as leather). Because the hand-shaping of metals, like the hand-carving of wood, is at best difficult and time-consuming, and also because the skill needed for doing either may be developed only through long periods of apprenticeship, metals and wood have in recent years both been on the decline as materials of choice in the fabrication of sockets. Although the molded leather socket has persisted owing to its comparative ease of fabrication, it too is being displaced because of undesirable properties (such as its tendency to deform under load and its inclination toward perspiration absorption and consequent odor). Profoundly encouraging this transition has been the advent of plastics technology and the introduction of plastic-laminating techniques into the field of limb prosthetics. The lighter, cleaner, stronger sockets of plastic laminate, much more easily made and with considerably more precision, have now all but replaced other types of sockets in new fittings of below-knee prostheses.</p> <p>Fabrication of the plastic-laminate below-knee socket involves the taking of a suitable impression (the negative cast) of the particular stump concerned; the preparation of a positive model (male replica) from the negative mold; modification of the model in such a fashion that in the final socket (to be made from the rectified model) the weight of the body will be distributed over the respective areas of the stump according to their relative tolerance, or lack of tolerance, for weight-bearing; and, finally, the layup, lamination, curing, and finishing of the plastic socket itself. Should liners or other special features be wanted for particular cases, they are incorporated in the layup, as will be seen later.</p> <p>While the method of construction described here is applicable in the fabrication of a variety of below-knee sockets, it is intended more specifically for the construction of the plastic below-knee socket in which the purpose is to utilize to fullest extent the patellar ligament as one of the principal weight-bearing areas.</p> <h4>Construction of Socket and Liner</h4> <p><b>Taking the Negative Cast</b></p> <p>Unlike numerous other below-knee sockets heretofore recommended, the socket for the patellar-tendon-bearing (PTB) prosthesis is intended to remain at all times in intimate contact with the entire surface of the below-knee stump. The stump is therefore contained firmly in the socket throughout its length, and accordingly the cast is taken not while the patient is bearing weight on the stump (as has sometimes been done in the construction of certain "open-end" sockets) but while he is seated, relaxed, the leg hanging naturally over the edge of the support (say a table), and the knee flexed naturally about 30 deg. Whatever special effects are induced by the hands of the operator as he takes the cast are intended not to produce a "weight-bearing shape" but to emphasize the special points of weight-bearing to be anticipated in a PTB socket.</p> <p>Although of possible impression materials there is available a substantial number, the most suitable, the least expensive, and the most workable for the present purpose is the old orthopedic standby, plaster of Paris. Judging from past practice, and from long usage in limb prosthetics generally, one may suppose that there are a number of satisfactory ways of taking a plaster impression, each perhaps with certain advantages and disadvantages peculiar to itself. Experience seems to suggest that for PTB sockets the most useful and practical means of cast-taking is to wrap the stump with plaster-impregnated bandage. Use of the bandage offers, among other things, the opportunity of regulating the tightness of the cast by controlling the tension applied to the bandage while it is being wrapped.</p> <p>With the amputee seated appropriately, somewhat as in <b>Fig. 1</b>A there is applied to the stump a thin cast sock of such size and length as to fit snugly and to come up well over the knee. To the top of the sock on either side of the thigh are attached, by harness clamps, the ends of a piece of 1-in. webbing passing around the patient's waist and just long enough to support the cast sock under comfortable tension. As in the cast-taking technique commonly used to produce other forms of below-knee sockets, the prosthetist must now identify and outline the bony prominences and other landmarks, both those known to be unusually sensitive to pressure (and hence requiring buildup in the model in order to give relief in the socket) and those especially well adapted to weight-bearing (those requiring reduction of the model and hence buildup in the socket), in this case particularly the patella and the patellar ligament (<b>Fig. 1</b><i>B</i>). To do so, the fitter moistens the cast sock and outlines the areas concerned with indelible pencil so that, subsequently, the tracings will be transferred first to the negative mold and then to the positive model.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Preparations for taking the negative cast. <i>A, </i>Patient seated with stump relaxed and knee flexed easily (about 30 deg.), cast sock applied and retained well above knee, prosthetist identifying (by palpation) bony landmarks and other pertinent features to be outlined by indelible pencil; <i>B, </i>the areas generally marked out for later use in modification of the model-some expected to be weight-bearing, some more or less pressure-sensitive and hence in need of relief. See text. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In all cases, at least nine areas are identified. These include the patella itself (<b>Fig. 1</b><i>B, a</i>), the mid-point (<b>Fig. 1</b><i>B, b</i>) of the patellar ligament (approximately at the level of the medial tibial plateau), the tubercle of the tibia (<b>Fig. 1</b><i>B, c</i>), the head of the fibula (<b>Fig. 1</b><i>B, d</i>), the anterior crest of the tibia (<b>Fig. 1</b><i>B, e</i>), the distal end of the fibula (<b>Fig. 1</b><i>B, f</i>), the antero-distal end of the tibia (<b>Fig. 1</b><i>B, g</i>), the medial flare of the tibia (<b>Fig. 1</b><i>B, h</i>), and the medial border of the tibia (<b>Fig. 1</b><i>B, i</i>). Marked only if they are prominent or sensitive to pressure are the anterior prominences of the lateral and medial tibial condyles, the lateral border of the tibia, and any other sensitive areas that might suggest the presence of bone spurs, adherent scar tissue, neuromas, or similar conditions.</p> <p>When the necessary marking has been completed, the patient having maintained his stump as much as possible in the original position of knee flexion without external rotation of the femur, a few rolls of 4-in. plaster bandage are laid out conveniently beside a basin of clean, cool water. As needed, each strip of plaster bandage is immersed in the water for about four seconds, squeezed to remove excess water, and applied to the stump over the marked cast sock. The wrap is begun with one or two layers of bandage running lengthwise (<b>Fig. 2</b><i>A</i>), beginning in front and just above the top of the patella, passing down and around the end of the stump, and continuing up the back of the stump to the posterior crease of the knee. Thereafter a series of circumferential wraps (<b>Fig. 1</b><i>B</i>) is begun at the upper border of the patella and made to spiral down, then up, the stump so that half the width of the bandage (2 in.) overlaps each successive layer. Each layer is smoothed carefully as it is applied, and the wrapping is continued until the shell thus formed has a thickness of about 1/8 in. in the proximal third. Additional layers are applied over the distal portions until about six rounds have been completed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Taking the negative cast. <i>A, </i>Beginning of the wrap with plaster bandage, strips extending well above knee, front and rear; <i>B</i> completion of the spiral wrap (see Fig. 3). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>While the amputee continues to maintain the original angle of knee flexion with relaxed musculature, the plaster is smoothed over the surface and worked in around the prominences and depressions by means of the hands until the plaster begins to harden. At this point, the fingers and thumbs of the operator are called upon to outline the patellar tendon and to compress the popliteal tissues, as shown in <b>Fig. 3</b>, and considerable experience and judgment are required to establish just how much pressure should be applied and in what direction. The thumbs are placed in such a position as to make a 45-deg. angle with the long axis of the tibia, and their ends are directed upward and inward midway between the lower edge of the patella and the tubercle of the tibia. Meanwhile, the fingers, wrapped around the knee, force the cast into the popliteal area, the forefingers being at the level of the posterior crease of the knee. Contact with the sides of the knee is maintained to prevent bulging, but distortion of the sides and pressure on the hamstring tendons are to be avoided. Pressure should be firm but not so great as to cause finger fatigue (a sign that too much pressure is being exerted). Both prosthetist and patient attempt to remain as motionless as possible while the plaster hardens beyond the possibility of permanent deformation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Use of the hands to shape cast while plaster is hardening. Thumbs compress bandage in and around patella, fingers force cast into popliteal area. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Casting the Positive Model</b></p> <p>When the plaster has hardened completely, finger pressure is released, but the cast is allowed to remain in place for an extra minute or two, whereupon the harness clamps are released and the cast sock is reflected down over the cast, the amputee flexes his knee to 90 deg., and the prosthetist, with his hands in the same position as when forming the cast, removes the whole cast from the stump by an anteroposterior rocking motion induced while simultaneously pulling downward (<b>Fig. 4</b>). The cast sock, bearing the indelible markings, is allowed to remain in the cast, and the latter is then filled to the top with fluid plaster of Paris of the usual consistency. Into the center of the still-liquid plaster is inserted lengthwise (to a depth of not more than 6 in.) an 18-in. length of 1/2-in. iron pipe (approx. 1 in. O.D.) to serve as a mandrel in future bench operations. When the plaster has set for 20 to 30 minutes, the wrap cast is stripped off after it has been cut lengthwise down the posterior surface, and the model is ready for modification in accordance with the outlines originally marked on the cast sock.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Removal of the cast. Because of the depressions made in the cast purposely, a rocking motion is required to get cast off stump. Knee flexion helps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Modification (Rectification) of the Positive Model</b></p> <p>With the exception of those areas where the wrap cast was purposely distorted by the prosthetist's fingers and thumbs (around the patellar ligament, just under the lower edge of the patella, in the popliteal space, and so on), the positive plaster model now constitutes a faithful reproduction of the stump. It remains to revise the model in such a way that, when a socket is laminated over it, the shape of the socket will be that required to distribute the weight of the body over those areas best suited to weight-bearing while at the same time relieving sensitive areas from responsibility for bearing more weight than will be comfortable. This is accomplished by carefully carving away plaster where additional force transfer will be acceptable and by building up the model (with shaped patches of leather or other suitable material) in areas expected to be incapable of accommodating any appreciable part of the load. Guidance in this operation is to be had from the indelible outlines previously transferred first from cast sock to cast and then from cast to model.</p> <p>Although the original compression of the cast in the vicinity of the patellar ligament and around the tibial tubercle represents a preliminary step in shifting the anticipated load in the direction of the ligament midway between the lower border of the patella and the upper margin of the tibia, further modification of the model in this area is now required to intensify the effect. Accordingly, the model is cut away, as shown in <b>Fig. 5</b>, to form a channel at least 1/2 in. deep, on a radius of about 1 in., and extending horizontally across the front about 1 1/2 in., just short of the thumb prints on either side of the tibial crest. Smooth contours are obtained by sanding rough spots with a piece of wire screen.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Initial step in modification of the positive model - undercutting to enhance support on patellar ligament. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another stump area normally capable of bearing a portion of the body weight is the anteromedial flare at the proximal end of the tibia. As shown in <b>Fig. 6</b><i>A</i>, then, the model is shaved down in this area. At the deepest point of the resulting concavity, at least 1/8 in. should be removed (depending at least in part upon the amount of soft tissue overlying the stump in this area), and the edges should be smoothed out into continuous surfaces of gentle curvature. Since adequate vector forces cannot be exerted upon the anteromedial surface of the tibial condyles without corresponding vector forces on the lateral side, and since in any event the PTB socket is designed to provide, if possible, mediolateral stability without the necessity for sidebars, knee joints, corsets, and so forth, the lateral surface of the model is now also shaved down, as shown in <b>Fig. 6</b><i>B</i>. Depending upon the individual characteristics of the particular stump concerned, 1/8 in. to 3/8 in. of plaster is removed, beginning about 3/4 in. below the border of the head of the fibula and continuing to within 1/2 in. of the end of the fibula.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Successive steps in modification of the positive model. <i>A, </i>Reduction for enhanced support on medial tibial condyle; <i>B, </i>the same to provide lateral support against fibula; C, the same to avoid pressure on anterior crest of tibia. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Just as the PTB socket is expected to furnish adequate mediolateral stability, so it also must provide enough anteroposterior stability to come under full control of the knee of the wearer on the side of the amputation. Relatively comfortable and yet adequate fixation of the stump within the socket in the anteroposterior direction is effected by trimming down the anteromedial and anterolateral surfaces of the model almost throughout the length of the remaining tibia (<b>Fig. 6</b><i>C</i>). The result is a wedgelike support along both sides of the front of the tibia, which, then, must be backed up by corresponding but opposite forces to the rear of the socket in the popliteal area. As seen in <b>Fig. 7</b>, the popliteal area of the model is thus shaved down to the depth of the fingerprints, the upper portion of the model in this vicinity being rounded out to give a flare to the posterior brim of the socket. Finally, should it be the intention that the ultimate socket provide some amount of end-bearing, thin layers, up to about 1/4 in., of plaster may be shaved from the end surface of the model. If only the closed socket with no appreciable end-bearing is sought, the end of the model is simply smoothed with sandpaper, as is the whole model in any case to provide a finished job.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Further modification of the model. Popliteal area is shaved away to provide countersupport against forces from the front, thus improving anteroposterior stability of socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The model having been thus reduced to obtain the proper distribution of the loads to be anticipated in the socket, it is now equally necessary to build up those areas needing more or less relief from the pressure of weight-bearing. These ordinarily include the head and the end of the fibula, the prominent crests of the medial and lateral tibial condyles, the tibial crest throughout its length, and the antero-distal end of the tibia. In general they will already be outlined on the model from the indelible markings on the cast sock. Skived patches of leather carefully trimmed to fit (<b>Fig. 8</b>) are used to provide the modification needed. They are bonded to the plaster in the places needed, and the rectified model is then ready for use in fabrication of the plastic-laminate socket. The drawings of <b>Fig. 9</b> present for comparison the shapes of stump, original stump model, and stump model after rectification.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Build-up of positive model to furnish relief in pressure-sensitive locations. Skiving of the leather patches provides a smooth transition from plaster to build-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Contours at successive levels overlaid to show comparative shapes of stump, of stump model as made from the cast, and of stump model after suitable rectification (modification). The specific shapes vary from patient to patient, of course, depending upon individual differences. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>The Soft Insert</b></p> <p>To accommodate any inadvertent irregularities in the socket, or any minor incongruities between stump and socket, and because in general it has been found desirable to provide a comparatively soft and pliable liner in below-knee fittings, lamination of the socket itself is preceded by fabrication of an insert made of medium-weight horsehide (4 to 6 oz.) and 1/8-in. sponge rubber. Although the making of the liner and the lamination of the socket may be reviewed as two separate operations, they are, as will be seen, actually carried out as two successive steps in the layup, reinforcement, and lamination of the socket. Since the socket and its liner are both prepared <i>over </i>the rectified model, the innermost layers are the ones designed first, and hence the first step is to lay up the leather insert.</p> <p>The modified plaster model having been placed in the bench vise upside down and held there, in the vertical position, by means of the mandrel of iron pipe, there is cut from medium-weight horsehide a piece in the shape of an isosceles trapezoid such that the two parallel sides are 2 in. longer respectively than the proximal and distal circumferences of the model, the other dimension being about 2 in. longer than the model, and the direction of stretch of the leather being in the same direction as are the parallel sides (<b>Fig. 10</b><i>A</i>). With the smooth side in, the leather is fitted to the model, the intended seam line being so placed as to follow the posterior centerline. While the leather sheet is held in place by a suitable number of harness clamps (<b>Fig. 10</b><i>B</i>), the seam is marked with pencil. The sheet having then been removed from the model, it is sewed along the mark, the clamps being removed one at a time as the sewing proceeds. After the seam has been trimmed neatly throughout its length to within 1/8 in. of the stitching, the leather sleeve is replaced on the model, the work is removed from the vise, and the proximal extension of the leather is tucked and stapled to the top surface of the model (<b>Fig. 10</b><i>C</i>). An approximation of the final trim line of the socket is now drawn around the top of the leather-covered model (<b>Fig. 11</b>), and the whole is replaced in the vise, the mandrel again serving as the means of support.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Preparation and layup of the leather insert, or socket liner. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Proximal trim line of the leather liner. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To form an end pad for the socket, there is now cut from a 1/8-in. sheet of sponge rubber (Kemblo) a disc large enough to fit neatly over the end of the model, the diameter of the disc being usually equal to the average diameter of the stump (<b>Fig. 12</b><i>A</i>). The distal end of the liner and one side of the rubber pad are now coated with cement (Stabond T-161), allowed to dry until the cement is tacky, and then placed together so that the pad will conform to the shape of the end of the model. Unless the curvature of the model is extreme, the pad will conform when pressed into place. Should it not conform well, a dart or two will suffice to correct any difficulty in arriving at a smooth transition between rubber and leather. In either event, the periphery of the Kemblo end pad is now skived with a sanding drum (<b>Fig. 12</b><i>B</i>) so that the outer edge will be flush with the horsehide.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Construction of the socket end pad. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Padding of the sidewalls of the model is now undertaken by the successive application, beginning on the anterior surface, of a circumferential series of fitted strips of Kemblo running the length of the model. To begin, there is first cut a strip of Kemblo 2 in. wide and long enough to overlap the end pad 1/2 in. and to extend beyond the model about an inch proximally. The anterior surface of the leather liner and of the end pad are coated with cement,<a style="text-decoration:none;">*</a> as is also one surface of the first strip of Kemblo. When the surfaces are tacky, the Kemblo strip is placed in the position representing the anterior crest of the tibia and allowed to extend over the end cap about half an inch (<b>Fig. 13</b><i>A</i>). Carefully pressed into place so as to conform to all of the irregular areas, the edge of the first strip constitutes the pattern for one edge of the second. So that when finally cemented in place the second strip will fit as snugly as possible against the edge of the first, one edge of the applied first strip is marked with chalk (<b>Fig. 13</b><i>B</i>), and the second strip is laid along the model parallel to the longitudinal axis and so that one edge just overlaps the chalked edge (<b>Fig. 13</b><i>C</i>). The chalkline thus transferred to the new strip marks the trim line for tailoring to the contours of the model (<b>Fig. 13</b><i>D</i>). When the new strip has been trimmed as marked, it is cemented in place, and the process is repeated until the entire surface of the liner has been overlaid with a smooth covering of Kemblo. Where the strip ends overlap the end of the model, they are skived on the sanding drum, and a second end pad, like the first, is cemented over the end of the padded model. Skiving of the second end pad to be flush with the longitudinal strips of Kemblo completes the layup and fabrication of the soft insert (<b>Fig. 13</b><i>E</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Layup of the soft liner of sponge rubber (Kemblo). One edge of the first strip (<i>A</i>) becomes the pattern (<i>B, C, D</i>) for the second, and so on, until the entire model is overlaid with a smooth and neatly fitted covering (<i>E</i>). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>The Plastic Shell</b></p> <p>The next step is the lamination of the plastic shell over the soft liner but readily separable from it after construction of the shell is complete. As in the case of plastic-laminate sockets for other levels of amputation, use is here made of sleeves fabricated from sheeting of polyvinyl alcohol (PVA). Since in the construction of the below-knee socket it is desired to keep the liner separate from the plastic shell, two sleeves are used-the first to form a separator between liner and shell and the second, as usual, to enclose the whole layup-and-resin combination as a means of impregnating the reinforcing materials. Since neither sleeve need be more than an approximate fit for the model, two identical ones are fabricated to the dimensions shown in Figure 14. After the outer surface of the socket liner has been coated liberally with talc (to prevent sticking), the first PVA sleeve is stretched over the model and liner and trimmed around the distal end where it parts company with the surface of the liner (<b>Fig. 15</b><i>A</i>). A half-inch annular area of PVA adhesive is now painted around the cut edge (<b>Fig. 15</b><i>B</i>), and the open section is covered with another piece of PVA neatly bonded to form an end for the sleeve (<b>Fig. 15</b><i>C</i>). At the proximal end of the model the other end of the PVA sleeve is tied tightly about the mandrel, and any loose material is trimmed away to give a neat layup (<b>Fig. 15</b><i>D</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Application of PVA separator over socket liner and model </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The model and overlying liner, thus covered with the PVA separator, are now ready for layup of the laminations and reinforcing materials to be incorporated into the plastic shell, or socket. Three pieces of 1/2-oz. Dacron felt, cut to the same pattern as used for the leather liner (<b>Fig. 10</b><i>A</i>), are sewed as shown in <b>Fig. 16</b><i>A </i>and pulled over the model one after the other, the seams lying on the posterior aspect of the model. Then, under the last layer of felt, in the vicinity of the postero-proximal margin, there are placed five rectangular pieces of Dacron felt (<b>Fig. 16</b><i>B</i>) measuring 2 in. by 4 in., the purpose being to thicken and reinforce the posterior edge of the socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Layup of reinforcing materials for plastic socket. <i>A, </i>Layers of Dacron felt in place; B, extra material added in posteroproximal area; <i>C, </i>application of Fiberglas cloth and cast sock over Dacron. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A strip of Fiberglas cloth wide enough to cover the proximal half of the model is now wrapped around the Dacron so as to overlap itself by at least an inch, and a light cotton cast sock is slipped over the distal end of the model to hold the Fiberglas reinforcement in place (<b>Fig. 16</b>C). When the second PVA sleeve has been stretched over the whole and tied tightly about the mandrel, the layup is complete and ready for application of the resin-catalyst mixture.</p> <p>A quantity of the resin (200-400 grams, depending on socket size), prepared according to the recipe given in Appendix A, is poured into the open, distal end of the second PVA sleeve and thoroughly worked down into the fibers of the laminating materials. The open end of the sleeve is tied off, and working is continued to remove air and to complete impregnation by the familiar process of "stringing." To ensure that undercut areas and all other irregular contours of the model are reproduced in the final socket, the layup is now wrapped, as appropriate, with strips and pads of sponge rubber or with pressure-sensitive tape, whichever is more convenient (<b>Fig. 17</b><i>A</i>). Left thus undisturbed, the resin will cure at ambient room temperature in about 30 minutes, whereupon it is allowed to lose any heat of reaction and to return to room temperature.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Plastic lamination and initial finishing of the PTB socket. <i>A, </i>Layup encased in second PVA bag, impregnated well with resin, and undercut areas bound down by wraps of sponge rubber; <i>B, </i>removal of socket and liner from model after curing of resin is complete; C, specifications for trimming the top brim of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It remains now but to free the socket and liner from the plaster model. This is accomplished by trimming along the proximal edge of the layup (<b>Fig. 17</b><i>B</i>) at a 45-deg. angle until the underlying sponge rubber is just exposed. The shell is then readily slipped off the model, as the liner in turn may be slipped out of the socket. With liner removed temporarily, the proximal brim of the socket is now trimmed as shown in <b>Fig. 17</b>C.</p> <h3>Preparation of Socket for Alignment</h3> <p>The socket thus produced must next be properly aligned with respect both to the residual anatomy of its intended wearer and to the rest of the prosthesis, including the prosthetic foot and the shoe to be worn over it. Although the below-knee prosthesis may be so aligned, as it has been for a great many years, by the simple expedient of "aligning by eye" (that is, simply by trial and error and by observation of the static and dynamic behavior of the amputee-prosthesis combination), the whole procedure is made much easier (and the resulting relationships much more readily amenable to duplication if need be) by application of one of the more modern tools of prosthetics practice. Recommended for use in the present instance is the below-knee adjustable shank developed at the University of California. As may be seen in <b>Fig. 18</b>, the UC below-knee adjustable shank consists essentially of a steel plate perforated with a rather large number of countersunk screw holes and supported on a crossed-bar mechanism in which two identical and graduated bars cross each other back to back at a fixed angle of 90 deg. and in which each bar is capable of sliding across the other at the point of intersection, or of rotating about the longitudinal axis of the other, or of doing both simultaneously in an infinite variety of combinations of sliding and tilting. Each bar is held in position by a pair of opposing setscrews, such that loosening of any one screw permits both sliding of the bar to which that screw is attached and rotatory motion about the companion bar. The net result is a kind of universal joint in which, within the limits required, any combination of anteroposterior and mediolateral shifting horizontally may be had together with any combination of anteroposterior and mediolateral tilting. Included with the device is a pylon shank for temporary service during alignment, and a clamp on the shank portion provides for attachment of the foot and for adjustable foot rotation with respect to socket orientation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. The University of California below-knee adjustable shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Attachment of Socket to Adjustable Shank</b></p> <p>Since the below-knee adjustable shank is intended for use in combination with the socket shell, and since the latter is asymmetrical in all directions on the outside as well as on the inside, there is now required some practical means of attaching the socket rigidly to the shank. Experience shows that such an attachment is best arrived at by first sinking the socket into a hollow block of wood of suitable size and shape. For purposes of reference, here and throughout the remaining stages of construction, the socket is first marked with vertical centerlines representing, respectively, the anteroposterior and mediolateral planes. As shown in Figure 19, the lines are established by connecting, in side and rear views, the estimated center points of the top and of the bottom of the socket, the proximal center point for the anteroposterior plane (<b>Fig. 19</b><i>A</i>) being taken at the level of the posterior brim of the socket while the corresponding center in the lateral view (<b>Fig. 19</b><i>B</i>) is taken slightly above the indentation provided for the patellar ligament.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Anteroposterior and mediolateral center-lines of the socket, intended for reference in alignment. In each of the two views, the approximate "center" of the brim and the estimated "center" of the bottom of the socket are connected by straight lines, except that in the lateral view the proximal center point is taken just above the level of the indentation provided for the patellar ligament. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A cylindrical socket block of willow, about 6 in. long and about 6 in. in diameter, is now drilled through along the longitudinal axis of the cylinder (parallel to the grain) with a 2-in. bit, and one end of the tubular aperture is carved out so as to receive the lower end of the socket to a depth of 3 or 4 in. and in such a way that the socket will rest easily in the block with 5 deg. of adduction (<b>Fig. 20</b><i>A</i>) and 5 deg. of initial flexion (<b>Fig. 20</b><i>B</i>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Positioning of the socket in the socket block to give 5 deg. of adduction and 5 deg. of initial flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The distal surface of the socket shell, roughened to improve adhesion, is now bonded into the block in the predetermined position by use of a mixture of resin and sawdust (or other filler). When the bond has hardened thoroughly, the lower end of the socket block is sawed across squarely at such a level as to leave only about an inch of wood below the end of the socket shell.</p> <p>With the socket attachment plate and the slide-tilt unit of the below-knee adjustable shank (<b>Fig. 18</b>) centered and level, the socket block is now set upon the attachment plate in an orientation such that the mediolateral center plane of the socket (posterior reference line) lies in the same direction as the lower pair of setscrews of the slide-tilt unit (<b>Fig. 21</b>). Thereafter the socket block is moved upon the attachment plate in the anteroposterior direction until a plumb line dropped from the anteroposterior centerline of the socket at the level of the midpatellar tendon lies 1 1/2 in. in front of the centerline of the upper tube clamp (<b>Fig. 21</b><i>A</i>). Similarly, the block is then moved in the mediolateral direction until a plumb line dropped from the center of the posterior brim of the socket lies 1/2 in. lateral to the centerline of the upper tube clamp (<b>Fig. 21</b><i>B</i>). While the block is held in this position temporarily, a pencil line is drawn about the attachment plate onto the base of the block, the socket and block are removed from the adjustable shank, and excess wood is cut away from the block to produce the result shown in <b>Fig. 22</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Orientation of socket and socket block upon adjustable shank using socket centerlines for reference. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Socket and socket block after removal of excess wood from the latter. Circle on base marks position of socket-attachment plate for reattachment of adjustable shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the block thus partially trimmed, the adjustable shank is replaced against the bottom of the block in the same relative position as before, and the block is attached to the plate of the shank by means of not fewer than six 3/4-in. flat-head wood screws (No. 10), which, incidentally, will seat nicely into the countersunk holes in the attachment plate. The particular position chosen in the individual case is, of course, as already described and as shown in <b>Fig. 20</b> and <b>Fig. 21</b>, and the net spatial relationships of socket to adjustable shank shall be such that, to begin with, all of the adjustment setscrews are near the middle of their ranges of possible adjustment.</p> <p><b>Choice and Preparation of the Prosthetic Foot (With Shoe)</b></p> <p>Although in the construction of the patellar-tendon-bearing below-knee prosthesis use might be made of any one of a variety of foot-ankle units commercially available, the most satisfactory results are usually obtained with the nonarticulated SACH foot (Solid Ankle, Cushion Heel), in which a heel wedge of compressible but resilient material provides shock absorption and the equivalent of plantar flexion at heel contact while a solid wooden core (or keel) properly shaped at the ball of the foot furnishes needed support during roll-over and push-off in the stance phase of walking. <b>Fig. 23</b> presents schematically the familiar SACH foot as seen through a transparent shoe properly fitted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. The SACH foot, in transparent shoe, schematic. <i>A, </i>Heel contact; <i>B, </i>plantar flexion immediately after heel contact, heel wedge compressed. Rocker shape of keel at the ball of the foot gives support during roll-over and furnishes needed assistance at toe-off. Flexible toe piece permits normal toe-break in the shoe. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Generally, choice of SACH foot in the individual case depends on three factors: shoe size, height of the patient, and relative stiffness of the heel wedge. At present, oversize SACH foot blanks, left and right, are available in three ranges of shoe size (6-8, 8-10, 10-12) and two degrees of stiffness of the heel insert ("firm" and "medium"). As for heel stiffness, "medium" is generally recommended for below-knee amputees weighing up to 140 lb., "firm" for those exceeding 140 lb. As for Table 1, which presents the recommended size of foot blank as related to shoe size and height of patient, it should be noted that, as in most aspects of lower-extremity prosthetics, no hard and fast rules exist and that in any case borderline sizes have to be worked out as compromise. Ultimate choice of foot-blank size and heel-cushion stiffness should always be based on evaluation of the needs of the individual patient.</p> <p>Once the foot blank has been selected, it remains to shape the foot (<b>Fig. 24</b>) until it fits properly into the intended shoe. Although in the oversize blank the general contours of the foot are provided for by the manufacturer, so that in general only slight modifications are required, certain precautions need to be exercised. For example, the portion of the foot above the top of the shoe should not be reduced until the final wooden shank has been installed. Similarly, no material should be removed from the lower third of the heel contour lest the distance from heel to toe-break be made too small for a tight fit. Conversely, certain size reductions are usually essential, especially on the lower surface of the arch of the foot, in the toe area, and in the heel cushion above the lower third of the heel, all as shown in <b>Fig. 24</b>. In particular, the lower surface of the arch of the foot must be so reduced that it can never come into compression contact with the arch of the shoe (<b>Fig. 23</b>). Required here is a minimum clearance of 1/8 in., for otherwise motion may be restricted or the shoe damaged. In like manner, the dorsal surface of the arch of the foot should be reduced until the lacing gap of the shoe matches that of the shoe on the remaining normal foot, but not to the extent that fitting in this area might be loose.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Shaping of the SACH foot blank to the requirements of the shoe. Failure to maintain tightness in the areas indicated, or to provide relief in the others, leads to abnormal gait regardless of the care taken in construction of the rest of the prosthesis </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Just as the arch of the foot must be prevented from binding against the insole of the shoe, so the toe portion of the foot blank must be reduced so that expansion under compression will not restrict motion in the toe of the shoe. Finally, the upper two thirds of the heel insert must be shaped to give about 1/8 in. of clearance from the lateral, medial, and posterior brims of the counter of the shoe, a feature which permits the heel wedge to expand under compression without binding against the shoe (<b>Fig. 23</b>).</p> <p>A subtle feature in the shaping of the heel wedge is that the rearmost point of the heel should be fashioned to lie 1/4 in. lateral to the anteroposterior midline of the foot (<b>Fig. 25</b>) so that later, when the necessary toe-out is introduced, the point of the heel will automatically return to a position directly in the line of progression.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Shaping of the heel of the SACH foot to accommodate proper toe-out in the finished prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>All of these shaping operations are of course best carried out by means of a cone or drum sander, the sanding being done as much as possible in a direction parallel to the direction of the laminations at all points. A spindle speed of at least 1750 r.p.m. is desirable; and in the course of fitting, a thin sock should be placed over the boot whenever the foot is inserted into the shoe for trial.</p> <p>There remain now but two final adjustments-the first having to do with heel elevation (distance between bottom of heel and the surface upon which the ball of the foot rests when the top surface of the foot is parallel to the supporting surface) and the second with heel-cushion stiffness. Currently, SACH foot blanks are manufactured with a heel elevation of 11/16 in. If, when the shaped foot and companion shoe are held on a surface with top of foot parallel to that surface, there should be undue compression of the heel wedge, the heel elevation may be increased (by not more than 3/16 in.) by sanding the lower surface of the foam crepe shoe-sole material in the heel area. Should compression of the heel wedge be inadequate under the same circumstances, shims of crepe shoe-sole material, leather, or any other firm but flexible material may be shaped and bonded to the bottom of the heel.</p> <p>If needed at all, the second adjustment (heel-cushion stiffness) awaits attachment of the foot (with shoe) to the rest of the assembly (<i>i.e.</i>, to the bottom of the adjustable shank). Accordingly, the foot-attachment plug of the adjustable unit is now bolted to the flat, top surface of the foot, and the distance between foot and adjustable unit is established with an appropriate length of aluminum-alloy tubing 1.625 in. O.D., 1.510 in. I.D. Attachment of the proximal end of the tube is by insertion into the clamp at the bottom of the adjustable unit. To clamp the distal end of the tubing about the foot-attachment plug, the lower end of the tubing is split, the tubing is slipped over the plug, and the assembly is fixed together with the tube clamp furnished with the adjustable shank. Preliminary toe-out of the foot is obtained simply by loosening the tube clamp, rotating the foot so that the line of progression is parallel to the anteroposterior (bottom) slide bar of the adjustable unit, and resetting the tube clamp. Should the unit be too short when tried on the patient, the foot is removed, annular spacers are added, the foot is replaced, and the clamp tightened again. If the unit is found to be too long, the foot is removed and a shorter length of aluminum-alloy tubing is substituted.</p> <p>With the socket-and-block combination, the adjustable unit, the tubular pylon, and the foot-and-shoe combination thus assembled, the amputee dons the socket and stands upon it, weight distributed equally between heel and ball of foot. If all has been done well, the orientation in the parasagittal plane will be such that, when the prosthesis stands unloaded, the longitudinal axis of the shank will be inclined some 2 to 3 deg. anteriorly (<b>Fig. 26</b>, solid outline) whereas when the amputee stands upon the prosthesis the longitudinal axis of the shank will rotate posteriorly until it lies in a vertical plane (<b>Fig. 26</b>, dotted outline). The change in relative position brought about by addition of the wearer's weight represents of course an initial compression of the heel wedge. Over and above initial compression is that needed and acceptable at heel contact during the stance phase of walking. In general, the heel should compress about 3/8 in. at heel contact (<b>Fig. 23</b><i>B</i>). Should, in any particular case, any of these values prove to be appreciably larger or smaller than the recommended compression values, the heel cushion must be replaced by a stiffer or a softer cushion, whichever applies. The procedure for so doing is set forth in Appendix B.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Trial below-knee leg showing proper anterior tilt of shank (2 to 3 deg.) in the unloaded condition (without weight of wearer). Dotted outline shows return of the long axis of the shank to the vertical when amputee stands upon the prosthesis (initial compression of heel wedge). Should these relationships not prevail upon examination, a change in heel stiffness is indicated (Appendix B). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Making the Supracondylar Cuff</b></p> <p>All prior conditions having been met satisfactorily, the assembly shown in Figure 26 is now ready for preliminary alignment on the amputee. But before any alignment can be undertaken it is first necessary to fabricate the means of socket suspension-the supracondylar cuff fitting about the distal flares of the femur and resting in front upon the upper margin of the patella (<b>Fig. 27</b>). Though in some cases it may be necessary later to resort to jointed sidebars and thigh corset, with or without still additional paraphernalia, the simple cuff, with its side tabs attached to the socket posteriorly, commonly suffices in actual prosthetic use and, in any case, serves adequately the purposes of final fitting and alignment.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Finished PTB prosthesis using supracondylar cuff as only means of suspension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To make the cuff, including the tabs, a suitable piece of pearled elk leather is first cut out along the pattern labeled <i>a </i>in <b>Fig. 28</b>. Since ultimately closure of the cuff is to be by buckle on the lateral side, and since it is desired to have the smooth side of the leather outside, the orientation of pattern and material must be chosen properly. One side of the pattern is of course for right amputees, the other side for left amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Patterns (one half actual size) for preparing supra condylar cuff. a, Pattern for the cuff itself; <i>b, </i>pattern for the buckle billet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Rubber cement is now applied to the rough side of the leather part just cut, and two pieces of Dacron webbing 1/2 in. wide and 4-1/2 in. long are bonded to the leather tabs (<b>Fig. 29</b>) as insurance against excessive stretching. A piece of horsehide large enough to cover cuff and tabs is then selected, the rough side is covered with rubber cement, and the horsehide is bonded in place as a liner. When this laminate has set, the elk leather, Dacron webbing, and horsehide are sewed together along the edges, and the horsehide and webbing are trimmed flush with the elk leather.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Application of Dacron webbing to cuff side tabs to prevent undue stretching of the leather. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the cuff itself has been completed, a buckle billet is cut from a scrap of horsehide according to the pattern labeled <i>b </i>in <b>Fig. 28</b>, the ends of the piece are skived on the rough side, a slot for the buckle is cut out, a 5/8-in. buckle is inserted in the slot, and the billet is lapped back on itself, rough side in, and bonded together with rubber cement. The billet containing the buckle is then glued and sewed to the pearled elk surface of the cuff, as shown in <b>Fig. 30</b>. Finally, six or seven 3/16-in. holes are punched in the tabs at 3/8-in. intervals, and buckle holes of suitable size are punched into the strap of the cuff on 1/2-in. centers (<b>Fig. 27</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Installation of buckle and buckle billet on condylar cuff. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Attaching Cuff to Socket</b></p> <p>As will be noted in <b>Fig. 27</b>, one intention of the condylar cuff is that it shall bring about tension in the side tabs as the knee is extended throughout the range and that it shall permit the side tabs to relax as the knee flexes in sitting or in the swing phase of walking. Thus the points of attachment of the side tabs are pivots, the axes of rotation being behind the anatomical knee axis. Since the cuff must pull in against the patella over a full 60 deg. of knee flexion in the swing phase, while for comfort in sitting the tabs must relax throughout an additional 30 deg. to give 90 deg. of knee flexion (<b>Fig. 31</b>), the optimum points of attachment of tabs to socket must be arrived at by trial of the socket and cuff on the patient for whom they are intended.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Positioning of cuff side-tab attachments such as to provide tab tension throughout 60 deg. of knee flexion in the swing phase of walking and tab relaxation throughout an additional 30 deg. to accommodate comfortable sitting with knee flexed a full 90 deg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee first dons the cuff so that the tabs are on either side of the knee and fastens it comfortably. He then dons the socket over a stump sock, being careful to obtain proper seating of the stump, and stands on the prosthesis with weight evenly distributed on two legs. While this condition is maintained, the tabs are pulled down on either side of the knee and approximated to their natural position on the sides of the socket. The hole nearest the level of the tibial plateau but behind the average anatomical knee axis is selected on each side and the points marked through the holes with a pencil (<b>Fig. 32</b>). By means of self-tapping screws, the necessary buttons are attached temporarily at the points indicated, pending final alignment and walking trials. When all adjustments are complete, the buttons are attached permanently by means of rivets.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Attachment of side-tab buttons at position determined in Figure 31. The usual position, arrived at by trial and error, is behind the average anatomical knee axis at the level of the tibial plateau. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Preliminary Alignment</h3> <p>From the alignment established at the time of assembly of socket, adjustable shank, and foot (pp. 36-42) it is now necessary to arrive at the optimum alignment for the given case, a requirement demanding ultimately the participation of the amputee himself. Since the positioning of the socket in the block, the orientation of the adjustable unit, and the characteristics of the foot are all mutually interdependent in defining the "net" optimum alignment, it is imperative that no attempt be made to correct a fault at a given point without considering the possibility of thus upsetting position relationships at another. The whole process of alignment is in fact a series of checks and rechecks, and it is the responsibility of the prosthetist to determine the site of faults, if any, and to make appropriate corrections as the process advances in stepwise fashion. As has been seen, use of the below-knee adjustable shank makes it possible to orient a below-knee socket to any necessary combination of fore-and-aft positioning, side-wise positioning, fore-and-aft tilting, or side-wise tilting. But because each setscrew fixes not only the lengthwise positioning of its own bar but also the rotatory positioning of the companion bar, it is essential, in the course of successive adjustments, to reset the <i>same </i>screw as was first loosened (not its opposing counterpart) and to recheck any preceding adjustment to make certain that it has not been disturbed.</p> <p>The amputee having first donned the socket-shank combination (together with the condylar cuff for suspension and with the intended shoe on the prosthetic foot), a preliminary approach to alignment on the individual is made in four steps, as shown in Figure 33. While anteroposterior tilting is avoided, mediolateral sliding is accomplished. While anteroposterior sliding is avoided, mediolateral tilting at the desired angle is established. While mediolateral tilting is avoided, anteroposterior sliding is carried out to the extent desired. While mediolateral sliding is avoided, anteroposterior tilting is accomplished. To avoid any unintentional disorientation, each operation is followed by a check of the previous setting. Additional minor adjustments are made as needed until the alignment of the prosthesis upon the wearer is such that the toe-out of the prosthesis matches that of the normal foot, that the amputee can stand erect, hips level, with weight equally distributed between the two feet and with heels not more than 4 in. apart, and that in standing in one position between parallel bars (or with the aid of crutches) he can shift his weight comfortably with adequate control of both mediolateral balance and of knee flexion-extension.</p> <p>Of the principal faults sometimes encountered at the time of preliminary alignment of the trial prosthesis on the patient, some have to do with spatial relationships in the frontal plane (<b>Fig. 34</b>), others with relative positioning of parts in the parasagittal plane (<b>Fig. 35</b>). If, for example, there should be a gap at the brim of the socket on the lateral side, accompanied by undue pressure at the medial brim, the pylon of the adjustable shank may be found to be either vertical (<b>Fig. 34</b><i>A</i>, foot necessarily flat on the floor) or tilted laterally (<b>Fig. 34</b><i>B</i>, foot resting incorrectly on lateral edge of sole). In the first case, the remedy consists in shifting the socket medially by means of the adjustable unit (<b>Fig. 34</b><i>A</i>). In the second, elimination of the trouble is to be found in tilting the socket laterally, again by means of the adjustable unit (<b>Fig. 34</b><i>B</i>). When, in <b>Fig. 34</b><i>B</i>, the pylon shall have assumed a vertical position in the medio-lateral plane, the socket will have settled into a satisfactory fit near its proximal end. Similar, but opposite, corrections are made should undue pressure be found to prevail on the lateral brim of the socket, it being kept in mind that the long axis of the shank pylon must always lie in a vertical plane (foot flat on floor).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Two faults in mediolateral alignment sometimes found during initial trials of prosthesis on amputee. <i>A, </i>Pylon vertical (foot flat on floor) but socket too far lateral; <i>B, </i>same situation but with pylon tilted laterally so that foot rests on outside edge of sole only. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Faults in anteroposterior alignment sometimes found during initial trials of prosthesis on amputee. <i>A, </i>Knee forced backward, shank pylon tilted posteriorly so that too much weight is borne on heel; <i>B, </i>knee forced backward but with shank pylon vertical (foot flat); <i>C, </i>heel off floor, all weight borne on ball of foot; <i>D, </i>knee forced forward by virtue of too much anterior tilt in socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the parasagittal plane, a number of faults may be observed from time to time with individual patients (Fig. 35). For example, it may be found that application of the wearer's weight forces the knee backward, the shank pylon tilting posteriorly in one case (<b>Fig. 35</b><i>A</i>), standing vertical in another (Fig. 35<i>B</i>).</p> <p>Should a shift of the socket block forward on the adjustable shank prove not to correct the difficulty shown in <b>Fig. 35</b><i>A</i>, it may be that the heel cushion in the foot is too soft, in which case the heel wedge must be replaced by stiffer material according to the procedure outlined in Appendix B. When, on the contrary, the knee is forced backward while the pylon remains in a vertical plane (<b>Fig. 35</b><i>B</i>), then adequate correction should be obtained simply by tilting the socket-block combination anteriorly upon the adjustable unit. Occasionally, the weight of the amputee forces the socket forward while the pylon remains vertical (<b>Fig. 35</b><i>D</i>). When such a relationship prevails, it is usually corrected by tilting the socket posteriorly. And finally it may happen that, when the amputee stands erect in the prosthesis, the heel is not in contact with the base of support (<b>Fig. 35</b><i>C</i>), which of course means that all of the weight is borne on the ball of the foot instead of being distributed equally between heel and ball. Tilting the socket anteriorly usually corrects this undesirable arrangement.</p> <p><b>Fig. 35</b></p> <p>It should now perhaps be noted that, in the process of preliminary trials on the patient, none of the indicated adjustments should be more than a minor adjustment. The necessity for any gross adjustment at this point in the procedure reflects some inadvertence in the conduct of the preceding steps of construction, and in such a rare case it may be better for the prosthetist to start over, or at least to retrace his own performance from socket casting to assembly of the adjustable leg. In any event, it will be obvious that the orientation of the socket in the wooden block, the position of the block with respect to the adjustable shank, the orientation of the adjustable unit itself, and the design of the SACH foot are all interdependent and that each of these factors contributes to the final result, so that a change in any one feature affects the behavior of all the others. Accordingly, successful alignment of the PTB prosthesis is still partly a matter of art and thus calls for extraordinary skill and judgment on the part of the prosthetist. Throughout the preliminary tests it should be remembered that the wearer of the PTB prosthesis is expected to walk with the knee on the side of the amputation flexed some 5 to 8 deg. and with weight borne over the middle third of the prosthetic foot in midstance. If any major changes are made in the initial alignment, then over-all height should be checked, since an increase in anterior tilt reduces the effective length of the prosthesis while an increase in posterior tilt tends to increase it.</p> <h4>Dynamic Alignment</h4> <p>Despite the apparent implications of the nomenclature, dynamic alignment of the PTB prosthesis is less an actual alignment as such than it is a check to make certain that the alignment established in the static condition of standing is satisfactory when the amputee undertakes normal, level walking along a substantially straight line of progression. The features sought in dynamic alignment are essentially the same as those sought under static conditions, though the criteria are different. If, indeed, the requirements of static alignment have been met fully, and if the particular case involved presents no gross deviations from the characteristics of the average below-knee amputee, then the chances are that dynamic alignment will amount to no more than a confirmation, at most a minor revision, of the spatial relationships already existing.</p> <p>Since, however, no amputee-prosthesis combination, however carefully worked out, can be expected to perform in an optimum way without the active and cultivated participation of the wearer, no attempt at checking out the dynamic alignment of a PTB prosthesis is apt to be valid until the amputee has become familiar not only with what is to be expected from the prosthesis but also with what responsibility he, the wearer, has in the management of the limb. Accordingly, the patient is first encouraged to experiment (at first between parallel bars) with simple weight-bearing on the limb, with active knee flexion-extension, with standing and sitting, with short and simple steps including roll-over on the prosthesis, and finally, when he has gained some confidence, with straight and level walking without benefit of parallel bars or crutches. Meanwhile, the prosthetist and trainer continue to make such minor adjustments as seem indicated by observation of dynamic conditions. Thus, the indoctrination of the patient and the final details of alignment are carried out together, sometimes alternately, sometimes successively, until both patient and clinic team are satisfied that the best possible job has been done. Some of the problems that project themselves occasionally during dynamic alignment are depicted in <b>Fig. 36</b>, <b>Fig. 37</b>, and <b>Fig. 38</b>, and the final antero-posterior position of the socket with respect to the shoe is shown in <b>Fig. 39</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Check of foot and socket in mediolateral plane during walking. <i>A, </i>Proper alignment in front view; <i>B, </i>correction for undue pressure at medial brim of socket, rear view. Compare with Figure 34<i>A.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Check of anterior tilt of socket (and hence of initial knee flexion). Too much initial flexion, as here, may cause loss of knee stability at heel contact <i>(A) </i>or lack of support (drop-off) at the end of the stance phase (<i>B</i>), or both. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Check of posterior tilt of socket. Too little initial knee flexion (excessive posterior tilt of the socket) may cause early arrest of knee flexion after heel contact, or a prolonged period of unstable weight-bearing on the heel, or an excessive shift of the body weight to the ball of the foot accompanied by premature heel rise at midstance <i>(A). </i>Inadequate knee flexion may also give rise to scuffing of the toe during swing-through <i>(B).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Ultimate anteroposterior position of socket with respect to shoe. A plumb line dropped from the anteroposterior centerline of the socket at the level of the midpatellar tendon should pass just ahead of the breast of the heel of the shoe. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because in the practical matter of walking comfortably, effortlessly, and with acceptable appearance the details of alignment in the anteroposterior direction are more critical than those having to do with the mediolateral, it is recommended that the latter always be attended first, the anteroposterior adjustments being left until the very last. As in all other steps of alignment, each successive change should be followed at once by a check on the preceding one so that no correction coming later can upset another made earlier, except with the full knowledge of the prosthetist (as is sometimes necessitated in compromise situations where one advantage is to be gained only at the expense of another). In all cases, the patient should be allowed to walk upon the adjustable shank long enough (days, if need be) to demonstrate that all adjustments are at an optimum for the particular physico-anatomical circumstances then prevailing. When the prosthetist is convinced that he has attained the best possible set of conditions, the alignment is duplicated in the finished prosthesis by means of the UC adjustable alignment-duplication jig.</p> <h3>Alignment Duplication</h3> <p>The so-called "alignment-duplication jig" of the University of California, intended originally for duplication of the alignment of above-knee prostheses, consists of two adjustable, viselike clamps so mounted side by side upon a firmly fixed, tubular base as to be capable of being moved along the length of the base as required or of being fixed in any selected positions along the base in any chosen linear relationship to each other. One clamp is intended to position and hold the thigh portion and artificial knee of an above-knee prosthesis, while the other holds and positions the shank-foot combination. To be interposed between the two clamps, mounted on the same base, and movable along the base between the clamps, is a bracket intended as a guide for a miter saw whenever the saw is needed. When the bracket is in place, it is so oriented that the saw will make a cut normal to the long axis of the tubular base.</p> <p>Once the clamps have been set so as to accommodate as precisely as possible a thigh socket, adjustable knee unit, shank, and foot in the relative positions established in alignment trials, the component parts of the final prosthesis may be substituted for the adjustable devices without upsetting the prevailing alignment. Similarly, the alignment of an existing prosthesis may be duplicated in a new prosthesis simply by setting up the alignment jig to match the first limb and then making the second limb to match the setting of the jig. When the desired orientation of socket and knee block with respect to shank and foot has been attained, the saw is used to cut the planes representing the intended juncture of the two segments.</p> <p>Application of this device to the below-knee case, including the case of the patellar-tendon-bearing prosthesis, is readily accomplished by introduction of a special fixture called the "ankle bracket." Mounted on the base in the same way as the clamps, it is used in place of one of them, that one being simply shoved out of the way temporarily (<b>Fig. 40</b>). Drilled through the top of the ankle bracket is a 3/8-in. hole whose axis is such that, when the bracket is in place, the axis is parallel to the base tubes of the jig. When, in the below-knee case, static and dynamic alignment with the adjustable leg satisfy both prosthetist and amputee, the SACH foot is removed from the adjustable shank, and the distal end of the shank is attached to the ankle bracket by means of an Allen-head screw (<b>Fig. 41</b>). Since toe-out of the foot must be re-established after the final shank piece has been properly substituted for the adjustable shank, the prevailing relationship of the foot to the socket is keyed before the foot is removed from the adjustable leg. Using a straightedge and one of the bonding lines of the foot for reference, the prosthetist first marks points on the front and back brims of the socket (<b>Fig. 42</b>). Thus later, when the final shank has been aligned and cemented into place, the foot may be replaced in the same relative position of toe-out as established in the alignment trials on the adjustable shank.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. University of California alignment-duplication jig for above-knee prostheses, as adapted for below-knee alignment duplication through substitution of the ankle bracket (cross-hatched) for one of the adjustable clamps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Attachment of adjustable shank (with socket and socket block) to ankle bracket of alignment-duplication jig. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Recording toe-out of foot before removing foot from adjustable shank. Same toe-out must be reestablished later. See Figure 50. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since, when the ankle bracket is fixed to the base, the axis of the hole through the bracket is parallel to the long axis of the base, so also then is the long axis of the shank parallel to the base tubes when subsequently the shank has been bolted to the ankle bracket. The orientation of the socket being thus established, the socket clamp is brought up into position alongside the socket (<b>Fig. 43</b>), care being taken to see that the clamp is then not less than 10 in. from the end of the base tubes (so that later it can be backed out of the way). The socket clamp is there locked to the base tubes, and the clamping thumbscrews are run down carefully but firmly so as to clamp the socket without at the same time placing any distorting strains upon the shank. The relative positions of shank and socket are thereby established in the jig for later reproduction in the finished prosthesis. To establish the over-all length of the final prosthesis, the positions of the ankle bracket and of the socket clamp are then recorded from the scale running the length of the base tubes of the jig.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Setting of socket clamp to the orientation previously established by the ankle bracket. At least 10 in. should be allowed at socket end so that socket clamp and socket may later be moved out of the wav. See Figure 45. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the socket thus fixed in the clamp and with the clamp and ankle bracket secured to the base of the jig, the adjustable shank is now removed, first from the ankle bracket and then from the wooden base of the socket (<b>Fig. 44</b>). The saw guide is mounted near the base of the socket (<b>Fig. 45</b>), and a cut (not more than 1/4 in. from the end of the base) is made (<b>Fig. 46</b>) so as to produce a surface normal to the axis of the jig. The clamp holding the socket is moved out of the way, a partly hollowed, wooden shank block is now attached to the ankle bracket by means of the same Allen-head screw as before (<b>Fig. 47</b>), and a cut is made to produce a surface which, like the bottom surface of the socket base, will be normal to the long axis of the jig (<b>Fig. 48</b>). When the sawing is completed, the saw guide is removed from the jig, and shank and socket block are brought together by sliding the socket clamp back to its original position on the tubular base.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Removal of the adjustable shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Installation of saw guide on same base as other fixtures. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Making saw cut on bottom of socket block. Remove not more than 1/4 in. at thinnest point about periphery. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Attachment of shank block to ankle bracket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Making saw cut on top of shank block. Length of block after cutting shall be such that it may be substituted for the adjustable shank and pylon without significant change in over-all length of the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If all has been done properly, the top surface of the wooden shank and the bottom surface of the socket block will now meet comfortably all around the periphery. When that is the case, the mating surfaces are spotted with glue, brought together firmly, and held in place by locking the fixtures to the base tubes (<b>Fig. 49</b>). To avoid inadvertent dripping of glue onto the equipment, the base of the jig may be draped loosely with scraps of paper, rag, or waste. When the glue has set firmly, the whole unit is removed from the jig, and the foot is attached to the shank (<b>Fig. 50</b>) in the same position (with respect to the socket) as before (reference lines match). Thereafter the leg is ready for final shaping and finishing (<b>Fig. 51</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Shank and socket block glued together in relationship established by jig fixtures. Dripping glue is caught by waste thrown over jig base. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Attachment of foot to shank with same relative toe-out as existed in trial leg using adjustable shank. Compare with Figure 42. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Assembled prosthesis ready for external finishing. Orientation of parts is that established in trials of static and dynamic alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Finishing the Prosthesis</h3> <p>Since it is inconvenient, if not actually impossible, to determine in advance exactly how the shank block and the socket block are going to line up in the finished prosthesis, and since ultimately, in the interest of weight-saving, it is desirable to carve out the shank block to the thinnest possible shell compatible with strength requirements, it is necessary to break apart the temporary attachment of shank and socket, but not until essential landmarks have been recorded for the purpose of later reassembly in the same relative positions as established in the alignment jig. Similarly, finishing the foot and ankle (distal part of shank) requires another removal of the foot, but not until the necessary reference position has been recorded on the work itself. To begin, the toe-out of the foot is marked with pencil, as shown in <b>Fig. 52</b><i>A</i>, and the foot is removed by unscrewing the attachment bolt. Because in the shaping of the distal end of the shank, and in its preparation for the lamination to follow (page 56), some material usually has to be shaved off the outside of the shank in the ankle area, the pencil mark on the anterior aspect is carried onto the base with a sharp tool, such as an awl or a penknife (<b>Fig. 52</b><i>B</i>). In order that the later plastic-laminate covering may form a smooth transition from shank to foot, a line is now scribed around the periphery of the bottom of the shank about 1/16 in. from the edge (<b>Fig. 52</b><i>C</i>), and the shank is ground down smoothly to the line.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. Preliminary steps in the finishing of the PTB prosthesis. <i>A, </i>Marking the established toe-out of foot with respect to shank; <i>B, </i>foot removed, reference mark transcribed to bottom surface of shank to avoid obliteration in next step; C, 1/16-in. annular ring marked about bottom surface of shank block as guide line for shaving down ankle area; <i>D, </i>ankle area shaved down, reference lines marked to record orientation of shank and socket block (after whole limb has been shaped on outside to match contours of the remaining leg of patient); <i>E, </i>shank block removed from socket block and routed out to form shell uniformly 1/4<i> </i>in. thick all around. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rest of the external surface of shank and socket block are now ground down to approximate the contours of the natural counterpart (preferably to match the shape of the remaining leg of the particular individual for whom the prosthesis is intended), and reference marks are made front and rear to indicate the established relationship of socket and shank (<b>Fig. 52</b><i>D</i>). The temporary, glued attachment of socket block and shank is now carefully broken apart by a sharp knife, and the inside of the shank is routed out (by routing machine or by hand) until the walls are uniformly only 1/4 in. thick (<b>Fig. 52</b><i>E</i>). Thereafter socket block and shank are glued back together, this time with intent of permanency, the front and back reference lines being made to match up as in the original attachment.</p> <p>To provide additional strength and at the same time to give the prosthesis a pleasant, perhaps even realistic, finish, the whole socket-shank combination is now covered with a suitable plastic laminate of Fiberglas cloth, nylon stockinet, and polyester resin, the latter appropriately tinted to simulate the color of the human skin. The technique is essentially the same as in other plastic-laminating procedures now in widespread use in prosthetics, for example in the making of the PTB socket itself (page 73).</p> <p>The socket-shank unit, less the foot, being supported on a mandrel held in a vise (F<b>Fig. 53</b>), a disc of Kemblo is first bonded to the bottom of the shank to protect it from resin and to close the foot-bolt hole. Then a sheet of Fiberglas cloth wide enough to extend from the foot base to within 2 in. of the socket brim is wrapped around the unit and is in turn covered with two layers of nylon stockinet, the first being made to spiral in the interest of increased strength (<b>Fig. 54</b>). A PVA sleeve made in the usual manner is now pulled over the layup, and the fibrous layers are impregnated with polyester resin in the fashion described earlier (page 36). When the resin has cured, the excess (including the ends of the PVA sleeve) is trimmed off at top and bottom (at ankle and at socket brim), and the foot is replaced with the same degree of toe-out as before.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 53. Application of disc of Kemblo to end of shank prior to layup and lamination. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 54. Layup for lamination of socket-shank combination. <i>A, </i>First of two layers of nylon stockinet twisted over layer of Fiberglas cloth; <i>B, </i>second layer of nylon stockinet applied and tied off at both ends. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As a final finishing touch, the superior plane of the foot (which will now be somewhat larger than the end of the shank) is scored around with a pencil (<b>Fig. 55</b>), and the foot is sanded down in the vicinity of the ankle to give a smooth transition to the shank. The result is a finished prosthesis ready for trial on the amputee to determine, among other things, the necessity, if any, for further support, or added stability, or improved suspension in the form of conventional sidebars and thigh corset. Should the supracondylar cuff already prepared prove adequate, the amputee should be able to perform with an optimum of comfort, function, and appearance both in standing and in normal walking on a level surface. In the event it should <i>not </i>for any reason, the prosthetist proceeds with the construction of additional equipment.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 55. Scribing foot at ankle line for sanding to provide smooth transition between foot and shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The PTB Prosthesis in Special Cases</h3> <p>The design of the so-called "patellar-tendon-bearing" below-knee socket is such that, ordinarily, the socket itself provides adequate stability in both the anteroposterior and the mediolateral directions and is itself adequately suspended from the limb of the wearer by no more than the supracondylar cuff already described. With proper relief in the rear for the hamstring tendons, and with high enough side and front walls, there develops no insurmountable problem in knee flexion-extension, either in walking or in sitting, and the amputee is thus free of all impedimenta otherwise characteristic of the articulated below-knee prosthesis. In a comparatively small percentage of cases, however, special anatomical and/or physiological circumstances invalidate the simple cuff suspension and the equally simple means of support and stabilization typical of the true PTB prosthesis. In such cases there is no alternative but to resort to the thigh corset and metal sidebars, and sometimes even to the ischial seat and the waist belt, despite the known advantages of the PTB socket. Since improvement of weight-bearing characteristics and inherent stability as offered by the patellar-tendon-bearing socket in no way alters the problem of the moving center of rotation of the normal knee, and since single-axis mechanical knee joints are for various reasons still found to be the most satisfactory under all conditions of use, introduction of the thigh corset and sidebars to improve stability, or to assume some of the weight, or both, presents the same problems as have prevailed heretofore. To date the most useful approach to this problem, when corset and sidebars are unavoidable, has been the development of an improved and simplified method of arriving at the best compromise location of single-axis joints with respect to the moving axis of the normal knee.</p> <p><b>Use of Side Joints and Thigh Corset</b></p> <p><i>Theoretical Considerations</i></p> <p>Single-axis side joints must be aligned on the shank and corset of the below-knee prosthesis so that they effectively stabilize the prosthesis on the stump and allow the amputee to sit comfortably. This is a complicated problem, first because the anatomic joint is not a single-axis joint and, second, because the exact path of a series of "instant centers," degree by degree, during knee motion is impractical to determine in each specific case. Even an average anatomic center may be estimated only roughly in the posterior portion of the femoral condyles. Thus at any one position of the single-axis mechanical joints, the center of rotation of the joints and the center of rotation of the knee will inevitably be incongruent during part or all of knee flexion and will give rise to some relative movement between the stump and the components of the prosthesis as the knee and side joints move from full extension to flexion at 90 deg. The task is to place the joints in a compromise position that will offer the best function and eliminate discomfort resulting from this relative motion. This may be done either by reducing the motion or by having the motion relieve pressures which would otherwise cause discomfort.</p> <p>The effect of a particular position of the side joints with respect to the socket and corset can best be understood by investigating the effect of making a change from a position assumed to be the optimum one. Since movements result from a combination of several factors, total motion is a complex problem. In a hypothetical situation, it would be possible to have knee flexion occur either with the stump held tightly in the socket<a style="text-decoration:none;">*</a> and all motion occurring between thigh and corset or with the thigh fixed in the corset and motion occurring between stump and socket. Of these two extreme hypothetical situations, and the many possible variations in between, the one which will be considered is that in which the stump is fixed in the socket and in which relative motion occurs between the thigh and upper side arms of the joints. This condition most nearly approximates the real situation and forms the basis for the joint-location procedure described below.</p> <p><b>Fig. 56</b><i>A</i> shows a hypothetical situation in which the socket is held fixed and the stump is not allowed to move relative to the socket. In the fully extended position, the upper sidebar is parallel to the shaft of the femur, and the mechanical joint center is placed directly above the average position of the anatomic center. The anatomic center, although it actually varies in position from high in the thigh during hyperextension to near the center of the femoral condyles at 90 deg. of flexion, is assumed to maintain a single axis of rotation for comparison with the mechanical center during this analysis. Alternatively, one may consider the effect of a tiny range of motion and study the slight motion of the thigh corset on the thigh caused by a mechanical joint center higher than the instant center of rotation during this tiny knee motion. As the thigh flexes, the mechanical sidebar tends to move relatively anteriorly on the thigh (for 90 deg. of flexion, distance <i>A</i>) and to be drawn distally along the thigh (distance <i>B</i>). As a result, pressure is created between the thigh corset and the posterior aspect of the thigh because the stump is fixed in the socket. The stump might be forced against the anterior part of the brim (the patellar-tendon area of the stump), though by assumption the stump cannot move in the socket. Thus the conical thigh corset moves distally away from the conical thigh, thereby releasing pressure by allowing a greater perimeter of corset for a given level and perimeter of thigh.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 56. Relative motion to be expected between thigh and thigh corset (stump fixed in socket) during 90 deg. of knee flexion when single-axis mechanical joints are placed in any of six positions relative to a hypothetical average anatomic joint center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 56</b><i>B </i>shows the effects of placing the mechanical joint below the average anatomic center (or instant center for a tiny motion). With flexion, the sidebar tends to move posteriorly on the thigh (for 90 deg., distance <i>C</i>) and to move proximally on the thigh (distance <i>D</i>). As a result, pressure is created anteriorly between corset and thigh, or else by reaction forces the socket is pressed upward against the stump. In this case, the conical corset is forced proximally, engaging the thigh more tightly and thus further increasing pressure on the thigh. Because such motion is sharply limited, the reaction on the sidebars in effect attempts to push the socket forward and thus increases pressure on the posterior popliteal area of the stump. Clearly this situation is unsatisfactory.</p> <p><b>Fig. 56</b><i>C</i> shows the effect of placing the mechanical joint in front of the average anatomic center. With flexion, the sidebar tends to be forced posteriorly (distance <i>E</i>) and distally (distance <i>F</i>) with respect to the thigh. As a result, pressure tends to be created anteriorly between corset and thigh, but the corset is withdrawn distally down the thigh so that its fit is loosened and hence the anterior pressure on the anterior portion is partially or wholly relieved.</p> <p><b>Fig. 56</b><i>D </i>shows the effect of placing the mechanical joint behind the average anatomic center. With flexion, the sidebar tends to be forced anteriorly (distance G) and proximally (distance <i>H</i>) with respect to the thigh. As a result, pressure is created posteriorly between corset and thigh, and the conical corset is forced proximally until it can go no farther, whereupon reaction forces the socket forward to cause pressure in the popliteal area.</p> <p><b>Fig. 56</b><i>E</i> shows an interesting special case in which the mechanical joint is located on a 45-deg. anterior diagonal through the anatomic center. In this case, the sidebar is drawn distally downward on the thigh (distance <i>I</i>), but there is no tendency for the sidebar to move either anteriorly or posteriorly with respect to the thigh. Thus there is no anterior or posterior pressure between corset and thigh. The distal motion would indicate that the corset might pull the stump anteriorly and cause pressure on the patellar tendon. In practice, the conical corset merely moves distally so as to relieve pressure on the thigh.</p> <p>A similar analysis of the situation shown in <b>Fig. 56</b><i>F</i> would indicate that in this situation (posterior diagonal) posterior pressure between corset and thigh would be created by the substantial movement / (anterior movement of the sidebar). There would be no tendency for the stump to be pushed anteriorly or posteriorly against the socket brim or for the corset to move on the thigh.</p> <p><i>Optimum Mechanical Relationship Between Joint Axis and Average Knee Axis</i></p> <p>Relative movement in the mechanical joint position as compared with that in the anatomic joint position must first be understood. The prosthetist can then establish the best position for the joint axis by deciding what motions to suppress and what motions to allow. However, when the conical corset is attached to the upper side arms of the joints, proximal motion of the side arms will be suppressed so that reaction forces on the arms will cause commensurate forward movement of the socket against the stump and lead to pressure in the popliteal area. This factor must be borne in mind when the motions of the upper side arms of the mechanical joints are considered in establishing the best position. The hypothesis above of fixation of the stump in the socket may now be modified.</p> <p>There are two situations in which the mo-Lions between the prosthesis and the stump are of particular significance: when the amputee sits (a major fraction of the waking hours of most amputees) and when the prosthesis is swinging through during walking.</p> <p><i>Sitting. </i></p> <p>When the amputee sits, some motion between prosthesis and amputee will occur because of the inevitable incongruity. This being so, it is better to permit joint movement to draw the stump slightly out of the socket, and perhaps to move it forward so that roll formation and pinching between the corset and the back of the socket are reduced; yet forward motion should not press the rigid bony areas against the socket wall. In order to lift the stump, the mechanical joints must pull the corset up against the back of the thigh as the amputee sits. This will occur when the upper joint arms move anteriorly with respect to the thigh (as in <b>Fig. 56</b><i>A</i>, <i>D</i>, and <i>F</i>). To move the slump forward or avoid forcing the socket forward as the amputee sits, the upper joint arms should move distally with respect to the thigh (as in <b>Fig. 56</b><i>A</i>, <i>C</i>, and <i>E</i>). Thus, theoretically, a satisfactory position for the mechanical joints will be directly above the average anatomic joint axis, as in <b>Fig. 56</b><i>A</i>, if it is assumed that the amount of forward motion and upward motion should be approximately the same.</p> <p><i>Swing Phase. </i>For swing-phase control, and freedom from chafing, there should be little or no motion between the stump and the socket. Thus, the mechanical joint axis should be as close as practical to the instantaneous anatomic joint axis during the 60 or 65 deg. of knee motion in the swing phase. Because the instant center seems to move substantially during full extension, and especially during hyperextension, the alignment in slight initial flexion and the training of the amputee to maintain slight flexion at heel contact are considered to be important steps in reducing incongruities between axes and thus in reducing chafing.</p> <p>If the prosthesis is to function satisfactorily both during sitting and during the swing phase, the mechanical axis should be above the average anatomic axis but not so far above as to introduce too much relative motion between stump and socket during walking.</p> <p>All the foregoing analyses are based on consideration of the knee as if it could be averaged over 65 deg. of swing or 90 deg. between sitting and standing to behave as a single-axis joint. But, as is shown in the preceding article by Murphy and Wilson (page 4), the knee joint is actually made up of two complex bony surfaces-the femoral condyles and the tibial condyles. The femoral condyles are two convex surfaces separated by an anteroposterior groove, while the tibial condyles are two concave surfaces which fit their femoral counterparts. Further, these bony surfaces are separated by cartilages and fluids and are connected in complex ways by ligaments, so that analysis by x-rays alone may be inadequate.</p> <p>The femoral condyles roll and slide on the tibial condyles as the knee joint moves. The amount of sliding and rolling determines the axis of rotation of the knee joint at any instant. A shift in the axis of rotation may sometimes help and sometimes oppose required function. If the path of the knee axis were exactly known, the best position for the single-axis knee joint could be positively stated, and joints fully satisfying the functional requirements could be designed. As noted above, such refinements for each individual case seem impractical. However, experience has shown that the mechanical joints can be located accurately enough when use is made of the procedures proposed below, based on consideration of the knee as a single-axis joint at an average location.</p> <p>A typical relationship between socket, joints, and thigh corset in the finished prosthesis is shown in <b>Fig. 57</b>. The back brim of the socket will be trimmed to the patellar-tendon level. With the joints flexed 90 deg., the posterodistal edge of the thigh corset will be 1 in. behind the posterior brim of the socket and at the same level as or slightly above the posterior brim of the socket. The joints are approximately on a mediolateral axis parallel to the back wall of the socket, midway between the patellar-tendon protuberance and the posterior wall, and the axis is approximately 2-1/4 in. above the level of the mid-patellar tendon.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 57. Typical relationship between socket, joints, and thigh corset in a below-knee prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Side-Joint Locating Chart</i></p> <p><b>Fig. 58</b> is a chart based on the theoretical analysis given above. The chart can be used for correct positioning of the side joints on a below-knee prosthesis. It indicates the motion to be expected between the upper sidebar (the corset will be attached later) and the femur (<b>Fig. 59</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 58. Chart for determining location of joint axis of sidebars in below-knee prostheses. The motion referred to is that of the upper straps of the sidebars with respect to the thigh as the amputee sits from the standing position (Figs. 59 and 60). Outline of distal end of femur is considered to be mean actual size. The open circle, represents the average anatomic knee center; the closed circle is the optimum position for the mechanical joints. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 59. Compromise location of upper sidebar straps in optimum position for comfortable walking as well as for comfortable sitting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Procedure:</i></p> <ol> <li>After the socket is aligned on the adjustable leg and foot, the lateral lower sidebar is attached to the socket temporarily in the position indicated in Figure 57 so that the center of the joint is 2-1/4 in. above the midpatellar-tendon level and midway between the patellar-tendon protuberance and the posterior wall of the socket. Only one attachment point is used, namely, at the bottom of the sidebar, the bar being secured above by wrapping masking tape around the socket. The single attachment point at the lower end of the sidebar allows the joints to be moved back and forth during trials and simplifies a change in position up or down. The upper bar is not shaped or attached to the corset at this time. </li><li>The amputee stands and extends the mechanical joint. The position of the front and top edges of the sidebar on the thigh is marked with a skin pencil. </li><li>The amputee sits on a hard chair with his knee flexed 90 deg., and a check is made to see that the posterior brim of the socket and its lining are properly trimmed and that the stump is well seated in the socket. </li><li>While the amputee is sitting in this position, the upper sidebar is moved until the front edge is parallel to the line on the thigh marked in Step 2. A second mark is made on the thigh along the front and top edges of the sidebar. </li><li>The relative motion as evidenced by the difference in position of the marks in Step 4 as compared with Step 2 is measured. </li><li>On the chart (<b>Fig. 58</b>) is entered, in accordance with the scales shown, the data obtained in Step 5. This information will indicate in true scale the approximate location of the mechanical joint center with respect to the femur, as shown in typical true size by the dotted outline. </li><li>The direction in which to move the joint to improve its position is now estimated. The optimum compromise position is located a short distance above and slightly behind the average anatomic center. On the basis of experience with adult amputees, the upper sidebars of the mechanical joint should move distally on the thigh approximately 1/4 in. with 90 deg. of knee flexion. A motion between 1/4 and 1/2 in. is allowable. Motion greater than 1/2 in. results in the stump being forced forward excessively or the corset moving distally excessively after the sidebars are attached to the corset. The upper sidebars should move toward the front of the corset approximately 1/2 in. with 90 deg. of knee flexion. This motion is equivalent to a stump withdrawal with knee flexion after the sidebars are attached to the corset.</li></ol> <p>If the movements are not within the suggested limits, the joint is moved as indicated by the chart to bring them within these limits, and a recheck is made by the same procedures.</p> <p>When the joint has been properly located, both sidebars are riveted to the socket so that a line connecting the centers of the medial and lateral joints would coincide with the axes of the joints themselves and would be parallel to the floor and to the posterior wall of the socket. The upper sidebars are shaped to fit the thigh with the joints coaxial. Particular attention should be paid to the shaping of the upper bars over the femoral condyles because a close fit here helps to suspend the prosthesis. At this point the corset is cut to shape and is temporarily attached to the upper sidebars of the joints with binding screws.</p> <p><i>Example (<b>Fig. 60</b>):</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 60. Example of use of chart shown in Figure 58, chart reduced from actual size. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>Step 5 indicates a relative motion of 1 in. posteriorly and 1 in. distally along the thigh. </li><li>Enter data on chart as shown to locate point <i>A. </i>Point <i>A </i>represents the probable position of the mechanical joint relative to the femur. </li><li>The femur outline is actual size in <b>Fig. 58</b>. Therefore the movement required to relocate the joint in the assumed optimum position <i>B </i>may be scaled directly from the drawing in Figure 58 (not in the reduced example, <b>Fig. 60</b>). In this example, the joint axis shown is moved posteriorly a distance of 1-1/8<i> </i>in. and proximally a distance of 3/8 in.</li></ol> <p><i>Fabrication of Thigh Corset and Joint Cover</i></p> <p>Just as an encasement for any other part of the body must be made to conform to the shape of the part and must have enough elasticity and pliability to meet the requirements of necessary body activity, so the thigh corset of the below-knee prosthesis must be custom-cut to the particular size and shape of the thigh for which it is intended and it must be strong enough and yet flexible enough to meet the changing demands placed upon it. Because of its special combination of properties, leather has for many years been the material of choice in the construction of thigh corsets, almost to the exclusion of all other possible materials. Though from time to time in the history of prosthetics there have been introduced a good many variations intended to provide this or that beneficial feature, the basic construction of the modern-day thigh corset remains unchanged. It amounts to the custom fabrication of a comparatively long leather cuff, laced in the front, and furnished with the usual tongue to protect the thigh from local compression and constriction by the lacing. A common error is to make the corset too short, the amount of purchase on the thigh then being inadequate to provide the degree of stability required.</p> <p>In the method of corset fabrication currently recommended for use when corset and sidebars are needed with the PTB prosthesis, the first step is to prepare, from appropriate measurements of the patient, a suitable paper pattern of the surface of the thigh in the area between the lesser trochanter and the condyles of the femur. While the optimum length of the corset varies somewhat with the height of the individual, in general it may be said that the pattern should extend upward some 8 in. from about 2 in. above the midpatellar level on the lower end. Accordingly, the circumference of the thigh is taken at these levels, and the corresponding measurements are carried forward to the pattern step by step.</p> <p>A square of paper of suitable weight and texture (ordinary kraft wrapping paper, for example) and measuring 2 ft. on a side is first folded in half (<b>Fig. 61</b><i>A</i>). Along the fold are marked with pencil the two points corresponding respectively to the top and bottom margins of the corset (distance between points corresponds to intended length of corset). From one mark there is extended, parallel to the edge of the paper, a line of length equal to half the selected circumference of the proximal portion of the thigh. From the other there is extended a similar line of length equal to half the selected circumference of the thigh in the distal area. With the ends of these two lines as reference, a third line is now drawn to join them, all as shown in <b>Fig. 61</b><i>A</i>, and a line (broken line in <b>Fig. 61</b><i>A</i>) is then drawn to connect the points of bisection of the proximal and distal circumference measurements, the latter line representing the ultimate location of the upper straps of the jointed sidebars.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 61. Preparation of corset pattern. <i>A, </i>Paper folded in half, top and bottom margins of corset marked, lines parallel to edge projected to the extent of half the circumference of thigh at upper margin and half the circumference of thigh at lower margin respectively, ends of lines connected by straightedge, top and bottom circumferences joined by straightedge at points of bisection (broken line); <i>B, </i>paper opened at centerfold, reference lines transcribed to opposite side, proximal margin modified to match sine curve with maximum deviation of 1/2<i> </i>in. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The paper pattern is now opened at the fold to reveal the isosceles trapezoid shown in <b>Fig. 61</b><i>B</i>, and the proximal margin is cut roughly in the shape of a sine curve of 1/2 in. maximum deviation. Similarly, the distal margin is cut to the dimensions shown in <b>Fig. 62</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 62. Distal margin of corset pattern outlined to match requirements of popliteal space, location of upper straps of single-axis sidebars marked for future reference. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the pattern has been completed, it is laid upon a selected piece of 7-oz. cowhide (or English bridle) in such a fashion that, when the leather has been cut out, it will fit upon the thigh (left or right as required) with the rough side in, with opening toward the front, and with the high side of the proximal margin lateral. By means of a straightedge, the locations of the upper straps of the sidebars are transferred to the leather for future reference in the construction of the corset, and the leather is cut out along the lines of the pattern.</p> <p>The piece of cowhide, shaped as already described, is now applied to the thigh of the amputee smooth side out and held in place by pressure-sensitive tape or some other suitable means. The upper straps of the two sidebars are bent and shaped in such a way as to follow as closely as possible the external contours of the thigh (to assist in stabilization during the stance phase and in limb suspension during the swing phase), and the proximal ends are trimmed off as necessary so that the straps will extend to about 3/4 in. below the top of the corset (thus providing maximum leverage while leaving room for finishing the top of the corset). Then, for purposes of later attachment of the upper straps of the sidebars to the corset, each upper strap is drilled with three holes 1/8 in. in diameter and so spaced along the length of each strap that the first is 1/2 in. from the proximal end, the second is about 2 in. above the center of the ballbearing race on the distal end, and the third is half way between the other two (<b>Fig. 63</b>). The two upper sidebar straps, thus drilled to accommodate screw-type fasteners, are now placed against the corset, one on each side and each along one of the two guide lines outside the centerline, and the positions of the two top holes are marked through to the leather. The straps are removed, 1/8-in. holes are punched through the leather at the points indicated, and the two upper straps are attached, each by means of its top hole only.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 63. Preparation of upper sidebar straps for later attachment to leather thigh corset. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To set temporarily, subject to later revision if necessary, the bottom (distal) attachment holes of the straps, the amputee stands, the prosthetist positions each strap directly over the corresponding guide lines, and the bottom hole of each strap is marked through to the leather with pencil (<b>Fig. 64</b><i>A</i>). The amputee then sits with knee flexed 90 deg., the straps are once again positioned over the guide lines (<b>Fig. 64</b><i>B</i>), and the bottom holes are again marked through to the leather (at the new position). The holes for the bottom attachments are now punched through the leather at the proper height but midway between the two points marked on each side (<b>Fig. 64</b><i>C</i>). The process amounts to bisecting the angle between the positions of the bars in standing and their positions during sitting with knee flexed 90 deg. When the lower attachments have been completed, subject to final adjustment, the prosthetist proceeds with the remaining details of corset construction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 64. Tentative attachment of upper sidebar straps to corset. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>While the amputee stands upon the socket-shank-foot unit, the leather corset is wrapped about the thigh in the intended position, edges in front, and the edges are marked for trimming so that, thereafter, they will be 1-1/4 in. apart (<b>Fig. 65</b>). The corset is removed from the patient, the edges trimmed as marked, and 1/4-in. holes for the lacing are punched along each edge on 1-in. centers along lines 3/8 in. from the edges (<b>Fig. 65</b>). Now the amputee dons the corset and laces it up with a suitable length of nylon parachute cord singed at each end to prevent fraying. While he stands thus, any necessary adjustments are made in the trim lines at top and bottom, the intent being to have the front lower edge fit closely about the patella and just above it while in the back there is enough relief to avoid bunching of the flesh when the patient sits. Should the alignment of the sidebar straps prove to be faulty for any reason, re-alignment should be carried out before proceeding further.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 65. Trimming of front edges of corset, placement of lacing holes in proper position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the fitting is thus far satisfactory, a tongue is provided out of the same kind of leather (cowhide) as was used for the corset itself, and the entire component is lined with cream horsehide of medium weight (4 to 6 oz.). To form the tongue, a piece of cowhide is cut long enough to extend from top to bottom of corset and wide enough to extend 1 in. beyond the rows of eyelets on either side (<b>Fig. 66</b>). One of the long edges is then skived so that, when that edge is later sewed to the body of the corset, there will be a smooth transition from corset to tongue such as not to cause any unnecessary irritation when the unit is worn. To line that portion of the corset between the fixed side of the tongue and the edge on that side (<b>Fig. 67</b>), a piece of medium-weight horsehide is cut 2 1/2 in. wide and long enough to extend from top to bottom of lacer. One of the long edges is skived, and the strip is then bonded (with rubber cement) to the inside surface of the corset, smooth side facing in and skived edge lying 2 1/4 in. in from the edge (which leaves about 1/4 in. of surplus horsehide for later trimming).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 66. Relative size and shape of corset tongue. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 67. Lining of corset tongue area on fixed side of tongue. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The tongue of cowhide is now placed smooth side out (toward the front of the corset) over the horsehide lining of the edge of the lacer and with skived edge about 2 1/4 in. in from the edge of the corset. When a smooth transition has thus been attained by whatever local adjustment is necessary, both tongue and liner are sewed along the long side. The smooth side of the lacer and the corresponding smooth side of the tongue thus face each other to avoid any otherwise unnecessary bunching or wrinkling of tongue or corset.</p> <p>The next step is to line with medium-weight horsehide the entire remaining internal surface of corset and tongue. To do so, the corset (together with the tongue) is laid out flat on the bench, rough side down. Thereupon is placed, rough side up, a piece of medium-weight horsehide large enough to cover the entire piece of work. Thus horsehide liner and corset-tongue combination are placed smooth side to smooth side. When the liner has been cut out to correspond roughly to the shape of the corset, the two pieces are sewed together across the top, the seam line starting where the tongue joins the corset and ending about 1 in. short of the opposite side. Thereafter the whole piece is inverted (<b>Fig. 68</b>) so that the horsehide falls over the cowhide corset and tongue to form a smooth liner, smooth side of horsehide in, smooth side of cowhide out. The entire facing surfaces are then bonded together with rubber cement, the edges are sewed around carefully, and any excess is trimmed close to the seams. On the side opposite the base of the tongue, a final seam is sewed down the edge of the corset just inside the row of eyelet holes, and the latter are then cut through the horsehide liner. Into the punched holes are then installed the metal grommets for the lacing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 68. Lining of entire internal surface of corset and tongue. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To protect the clothing from excessive wear, specially designed leather covers are commonly placed over the upper flanges of the sidebars and over the housings of the ball-bearing races. For this purpose use is made of cowhide one third the thickness of the leather used to make the basic part of the corset. By appropriate use of the pattern shown in <b>Fig. 69</b>, one cover is made for each side of the corset, one medial and one lateral. When the sidebars have been riveted in place permanently through all three holes on each side (with 1/8-in. copper rivets), the covers are set in place, the distal portions being doubled back upon themselves and glued together with rubber cement. After the upper portions of the covers have been sewed to the corset on both sides, any excess is trimmed off, and a rivet is installed at about the point shown in <b>Fig. 70</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 69. Pattern for side-joint covers, half actual size. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 70. Installation of side-joint covers for protection of clothing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Finally, as protection against the effects of moisture and bacteria, all of the leather parts are coated with nylon solution according to the usual techniques <a></a>.</p> <p><b>Auxiliary Belt Suspension</b></p> <p>In below-knee prosthetics, the conventional thigh corset (and sidebars) may serve any of three purposes to varying extents and in varying combinations. It may be needed to provide necessary additional stability not to be had from the below-knee socket alone. It may provide needed suspension over and above that furnished by the supracondylar cuff. It may be needed to furnish additional weight-bearing over and above that provided by the PTB socket. Or it may be required for any of these purposes in one combination or another. Occasionally, additional suspension is needed for the PTB prosthesis with or without the thigh corset, and in such cases use is made of the pelvic belt in any of several forms. In all cases the belt fits about the iliac fossa on the normal side and extends downward on the side of the amputation to connect to the prosthesis itself. When, in addition to thigh corset and side joints, the pelvic belt is needed, it is attached to the prosthesis above the mechanical axes of the artificial knee joints. When the belt suspension is required on a limb without thigh corset or sidebars, it is attached to the limb either just below the brim of the socket or else to the supracondylar cuff, whichever is applicable. In general, the pelvic belt serves to reinforce the suspension provided by the supracondylar cuff, not the other way round. The supracondylar cuff is always tried first. Whenever it suffices, no pelvic belt is required.</p> <p>To prepare the pelvic belt and associated suspensory attachments for the below-knee prosthesis, use is made of the patterns shown in <b>Fig. 70</b> and usually of one or the other of those shown in <b>Fig. 72</b>. First there is cut from 2-in. cotton webbing a length 3 in. shorter than the waist measurement. It forms the belt component labeled "waistband" in <b>Fig. 73</b><i>A</i>. Next a 7-in. length of 2-in. elastic webbing is cut to form the tensile element of the vertical support (<b>Fig. 74</b>). Then there are cut from 6-oz. cowhide or pearled elk one piece according to pattern <i>A</i> (<b>Fig. 71</b>), two pieces according to pattern <i>B </i>(<b>Fig. 71</b>), and two pieces according to pattern <i>C </i>(<b>Fig. 71</b>). These form respectively the boomerang-shaped portion of the waistband (section <i>A </i>in <b>Fig. 73</b><i>A</i>), the buckle billets (5/8-in. buckles) to be installed on the belt (<i>B </i>in <b>Fig. 73</b><i>B</i>) and at the proximal end of the elastic suspensor (<i>B </i>in <b>Fig. 74</b>), and the two elements labeled "sections <i>C</i>" in <b>Fig. 73</b><i>C</i>. When, in addition to the thigh corset and sidebars, the pelvic belt is required, suspension is by virtue of the inverted Y-strap shown in <b>Fig. 74</b>, the forked section being fashioned according to pattern <i>D </i>of <b>Fig. 72</b> and the ends of the fork being attached to the prosthesis above the mechanical axes of the artificial knee joints, as already pointed out (page 61). When pelvic suspension is required in the absence of thigh corset and sidebars, section <i>D </i>(<b>Fig. 72</b>) is replaced by section <i>E </i>(<b>Fig. 72</b>), or the elastic vertical suspensor (<b>Fig. 74</b> and <b>Fig. 75</b>) may be attached directly to the anterior aspect of the supracondylar cuff (<b>Fig. 75</b>) without the necessity for sections <i>D </i>or <i>E </i>(<b>Fig. 72</b>). Details of fabrication technique for these several variations in auxiliary suspension are readily to be had from Figures 71 through 75.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 72. Patterns (one half actual size) for suspension straps when <i>(D) </i>thigh corset and sidebars are used and <i>(E) </i>when thigh corset and sidebars are not used. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 73. Details of assembly of the pelvic belt. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 74. Details of suspensor strap when pelvic belt is used in addition to thigh corset and sidebars. When thigh corset and sidebars are not required, section <i>D </i>(Fig. 72) is replaced by section <i>E </i>(Fig. 72). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 71. Patterns for construction of the pelvic belt shown in Figure 73, half actual size. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 75. Arrangement of suspensor strap when auxiliary support from pelvic belt is used in conjunction with the supracondylar cuff but without thigh corset and sidebars. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As for details of actual construction, section <i>A </i>(<b>Fig. 73</b>) is first bonded to the waistband with rubber cement with an overlap of 1 1/2 in. the bonded side being on the side of the amputation (<b>Fig. 73</b>C). The skived ends of the leather sections <i>B </i>(<b>Fig. 71</b>) are lapped back on each other, each piece is threaded with a 5/8-in. buckle, and the billets so formed are applied, one to section <i>A </i>(<b>Fig. 73</b>) and one to the proximal end of the elastic vertical sus-pensor (<b>Fig. 74</b>). The billets (<i>B</i>) having been fixed in place with rubber cement, the forked section <i>D </i>(or the U-shaped section <i>E) </i>is cemented to the distal end of the elastic webbing, as shown in <b>Fig. 74</b>, and the ends of the fork (or of the inverted U) are attached to the socket just below its brim on the medial and lateral sides. When belt suspension is intended simply to supplement the cuff-suspension system, less corset and sidebars, the vertical section shown in <b>Fig. 74</b> is attached directly to the anterior portion of the supracondylar cuff (<b>Fig. 75</b>). In every case all leather parts are backed with a lining of horsehide, and all segments are sewed around, excess horsehide being trimmed off close to the stitching.</p> <h3>Conclusion</h3> <p>In the construction or manufacture of any piece of apparatus or equipment, for whatever purpose, there may occur to the experienced craftsman any number of variations in technique to effect the same result-some in the interest of economy perhaps, some possibly with the intent of making the task easier, conceivably some with the idea of improving reliability in a stepwise procedure and hence of reducing the possibility for error, some perhaps for other reasons. Just so with the patellar-tendon-bearing, total-contact, below-knee socket. The particular method herein described for construction of the PTB socket, and of associated equipment for use in special cases, is not, therefore, the only possible method. It is simply the one which, in U. S. experience covering more than four years, has proved to be successful and the one most widely used. It is entirely possible that desirable changes in the recommended technique of construction, or with respect to the materials used, will be apparent at once to prosthetists and others. There is, indeed, nothing particularly sacred about the actual stepwise procedure described for fabrication, or about the actual materials suggested, so that it is reasonable to expect changes here and there as the application of the PTB prosthesis comes more and more into widespread use.</p> <p>Whatever changes in materials or fabrication technique may in the future be found to be useful, however, it is essential that the principles utilized in the PTB socket-in its design and in its application with respect to the wearer and to the rest of the prosthesis- be held inviolate if success is to be attained in the majority of cases. Features such as the ledge for weight-bearing on the patellar tendon, the high sidewalls for increased medio-lateral stability in standing and walking, the relief for the hamstring tendons during knee flexion in sitting and in the swing phase of walking, the firm but gentle contact of stump with socket throughout its length as well as at the terminal end, the soft liner and end pad for shock absorption, and the subtle aspects of alignment in slight adduction and slight initial knee flexion are all based on systematic analysis of physical and anatomical fact and are therefore indispensable to the usefulness of the true patellar-tendon-bearing below-knee prosthesis. If, in the otherwise average below-knee case, any one of these details is lacking, difficulty in one form or another will ensue, in which case other and undesirable expedients have to be devised and the inherent advantages of the PTB prosthesis-freedom from the restrictions imposed by additional equipment-are at best seriously discounted and may in fact be lost entirely.</p> <p>Although precision and meticulous workmanship are generally acknowledged to be essential requirements in the successful construction and fitting of any limb prosthesis, they are in the PTB limb especially in need of emphasis. Since the self-stabilizing, total-contact, patellar-tendon-bearing, below-knee socket is intended to be manageable by the wearer with little or no external assistance, all features of measurement, of fit, and of orientation are particularly critical, so that even a minor fault may result in gross deviation from proper performance. The eventual outcome of any PTB fitting is thus not only a matter of formal instructions but also of the exercise of sound judgment on the part of the clinic team in each and every individual case. General experience to date has indicated that the added investment in time and precaution almost always results in a satisfied and successful wearer. Failure to attend details almost always gives rise to failure and disappointment.</p> <h3>Appendix A</h3> <p><b>Formulation of Polyester Laminating Resin</b></p> <p>(for Each 100 Grams)</p> <p>Into 100 gms. of polyester resin mix thoroughly 2 gms. of ATC catalyst. Then mix in color paste according to manufacturer's recommendation. Add 10 drops of Naugatuck Promoter No. 3. Mix thoroughly.</p> <h3>Appendix B</h3> <p><b>Procedure for Changing Heel-Cushion Stiffness in SACH Foot</b></p> <p>In the event the amputee, standing on the socket-shank-foot-shoe combination, demonstrates proper heel elevation (11/16 in.) but too hard or too soft a heel cushion during walking, the heel wedge must be replaced with another, either softer or harder as the case may be. The amputee first steps out of the socket, the shoe is removed from the foot, and the remaining unit is placed on a level bench with a block of wood 11/16 in. deep under the heel (<b>Fig. 1</b><i>A</i>). By means of an ordinary carpenter's square, a vertical reference line is marked on one side of the socket block in the vicinity of the anteroposterior midline so that, after the wedge has been replaced, the prosthetist can be certain that the same orientation of the socket has been re-established.</p> <p>The edge of the sole around the heel is not marked in such a way as to locate the anterior point of the existing heel cushion (<b>Fig. 1</b><i>B</i>), the shank is clamped in a wood vise heel up, and the entire heel cushion is cut out with a sharp knife, the sole being peeled back first, the wedge itself later. Ant irregularities in the cut surfaces are smoothed with a fine file, and the new wedge is inserted, longest lamination next to the sole, and to such an extent that the point falls as nearly as possible into the position previously occupied by the point of the old wedge.</p> <p>Thereafter the whole unit is remobed from the vise and placed upon the bench with the 11/16-in. heel block under the heel as before. Movement of the new wedge forward or backward, as required, re-establishes the original alignment, as indicated again by the square (<b>Fig. 1</b><i>C</i>). When all is in order, the new wedge is cemented into place with Stabond T-161, and the heel is again shaped in the way previously recommended.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Pattern for preparation of the PVA sleeves. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Preliminary alignment of trial leg in four successive steps using the adjustment facilities of the UC below-knee adjustable shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Anderson, Miles H., John J. Bray, and Charles A. Hennessy, <i>The construction and fitting of lower-extremity prostheses, </i>Chap. 6 in <i>Orthopaedic appliances atlas, </i>Vol. 2, Edwards, Ann Arbor, Mich., 1960.</li> <li>DeFries, Myron G., and Fred Leonard, <i>Bacterio-static nylon films, </i>Appl. Microbiology, 3 (No. 4): 238 (1955).</li> <li>Leonard, Fred, T. B. Blevins, W. S. Wright, and M. G. DeFries, <i>Nylon-coated leather, </i>Ind. Eng. Chem., 45:773 (1953).</li> <li>Murphy, Eugene F., <i>The fitting of below-knee prostheses, </i>Chap. 22 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>University of California, Biomechanics Laboratory (Berkeley and San Francisco), <i>Manual of below-knee prosthetics, </i>November 1959.</li> <li>University of California, Biomechanics Laboratory (Berkeley and San Francisco), <i>The patellar-tendon-bearing below-knee prosthesis, </i>1961.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">DeFries, Myron G., and Fred Leonard, Bacterio-static nylon films, Appl. Microbiology, 3 (No. 4): 238 (1955).</td></tr><tr><td class="clsTextSmall"><b> 3.</b> </td><td class="clsTextSmall">Leonard, Fred, T. B. Blevins, W. S. Wright, and M. G. DeFries, Nylon-coated leather, Ind. Eng. Chem., 45:773 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Particularly if the socket wall were rigid and lacking a soft lining.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Application of cement within the 1/2-in. border around the estimated trim line is avoided at all times.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Anderson, Miles H., John J. Bray, and Charles A. Hennessy, The construction and fitting of lower-extremity prostheses, Chap. 6 in Orthopaedic appliances atlas, Vol. 2, Edwards, Ann Arbor, Mich., 1960.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The fitting of below-knee prostheses, Chap. 22 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Staff Engineer, CPRD, NAS-NRC, 2101 Constitution Ave, Washington 25, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Bryson Fleer </b></td></tr><tr><td class="clsTextSmall">Staff Editor, CPRD, NAS-NRC, 2101 Constitution Ave, Washington 25, D.C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-15.jpg Figure 15 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-16.jpg Figure 16 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-17.jpg Figure 17 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-18.jpg Figure 18 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-19.jpg Figure 19 http://www.oandplibrary.org/al/images/1962_02_025/tmp62D-20.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Construction of the Patellar-Tendon-Bearing Below-Knee Prosthesis Creator An entity primarily responsible for making the resource Bryson Fleer * A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/dbe2ac19d37adf6c68bc2cc2d6d7a9ee.pdf bab704eb64cc2396fb9d10d50719dee6 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1982_03_001.pdf Text Any textual data included in the document <h2>Continuing Education: Past, Present, and Future for AAOP</h2> <h5>Charles H. Dankmeyer, Jr., CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>In 1978 the American Board For Certification in Orthotics and Prosthetics, Inc. (ABC) and the American Academy of Orthotists and Prosthetists (AAOP) reached an agreement which provided that AAOP would administer the continuing education program begun by ABC. The program is very similar to its original format developed by ABC, and remains a voluntary program. The Academy is responsible for processing applications, developing the standards to be met by the participants, and developing a recognition system for successful participants. ABC continues to accredit appropriate educational programs submitted to it and to designate the number of continuing education credits awarded for each program.</p> <p>The reason the organizations reached this agreement is two-fold. First, since the continuing education program that ABC was administering had no effect on certification outside of deciding the number of credit hours to be awarded for each program, ABC believed it should not be providing recognition to successful participants in a voluntary continuing education program. Second, AAOP believed that part of its responsibility was education. Since AAOP was directly involved in providing seminars, it seemed appropriate that AAOP should administer a continuing education program and provide recognition for successful participants.</p> <p>It should be remembered that both groups agreed to the continuing education program being administered by AAOP only to the extent that it did not affect certification. It should also be borne in mind that AAOP has no influence on the number of credits awarded or the approval of programs for credit.</p> <p>I stress that any continuing education program developed within the Academy does not affect an individual's certification by ABC. This emphasis is made because this is an area of grave misunderstanding by Academicians. Many members believe that if an individual does not participate in the continuing education program, he will lose his certification. Such is not the case. Any program developed by AAOP will affect only the membership within AAOP and not an individual's certification. The certification of an individual and the continuing certification of an individual remains the province of ABC.</p> <p>At the 1981 AAOP annual meeting the membership voted to convert the existing voluntary continuing education program to a mandatory program. This move by the membership has caused AAOP to search for an acceptable system for mandatory continuing education. Many approaches to converting the existing voluntary program to a mandatory one have been examined. None have been deemed acceptable.</p> <p>There are many problems within the continuing program which could lead to injustices for Academicians participating in a mandatory program. One of the things necessary, if we are to have a successful mandatory continuing education program, is the capability for an individual to plan ahead in meeting his continuing education requirements. Currently, there exists no publication which permits an Academician to sit down and look at all of the seminars and special programs being put on by other paramedical groups which may be acceptable for continuing education. Even if such a publication were available, there would be no listing of the number of credits allowed for each of these programs. Many programs which may well be suitable for credit are never even submitted to ABC to be approved. Program organizers are often not concerned about the need of orthotists or prosthetists to meet continuing education requirements and therefore never submit their programs for approval by ABC. Therefore, AAOP cannot recognize an Academician's attendance at many of the seminars and programs that are given locally by therapists and physicians groups. Additionally, there are extenuating circumstances which affect some Academicians' attendance at seminars.</p> <p>For example, I received a letter from an individual who was concerned that his membership in the Academy would be in jeopardy because he was unable to attend seminars on Saturday. As you know, most seminars are held on Friday, Saturday, and Sunday. This particular individual is a practicing Orthodox Jew and is unable to attend any seminars held on the Sabbath. It seems to me that it is in the best interest of the Academy to attempt to develop a program which will accommodate all individuals and not require them to travel in order to participate in the continuing education program. Such a program would allow individuals several choices to meet continuing educational requirements.</p> <p>I would suggest that reading of the AOPA Journal, <i>Orthotics and Prosthetics</i>, and clinical participation be the two mainstay requirements to maintain membership in the Academy. In fact under the current continuing education program, Journal reading is an acceptable means of obtaining credit. How does one know someone has really read the Journal? Journal reading could be verified by providing a group of questions at the end of a selected article within each issue. Academicians wishing to participate in a continuing education program would complete the questionnaire at the end of the selected article and return it to the National Office for approval. Although such a system appears to be a very minimal requirement, it would demonstrate that participants had at least read <i>Orthotics and Prosthetics</i>. There is currently such a system being used in a publication entitled <i>Contemporary Orthopedics</i>. This should satisfy the needs of those individuals who are unable to travel to seminars. Those individuals who decided to travel to seminars and meetings should be allowed to apply for credit for seminars attended. Therefore, they would not need the credits earned by responding to the questionnaires.</p> <p>An additional alternative could be a self-assessment examination. This could be required every three years of individuals who had not participated in a continuing education program designed around Journal reading or seminar attendance. Such a self-assessment examination could be structured in a manner which reported back to the individual his results without affecting his membership in the Academy. At the very least it would identify areas in which an Academician needed work. It is difficult to imagine that the Academy would be telling an Academician that he needed to bone up on a specific subject, because Academicians are currently practicing orthotics and prosthetics. To say that an Academician required additional work in a specific area is to say that orthotists and prosthetists are providing inadequate services. This is the same tack which therapists and physicians have taken with their mandatory continuing education programs. In essence, all of these programs state that practitioners who do not fulfill the requirements of the program are not maintaining competency.</p> <p>I do not believe that this is the case for orthotists and prosthetists. I believe that most orthotists and prosthetists have met the challenge of modern day orthotics and prosthetics practice. I further believe that if we are attempting to require continuing competency, and not continuing education, we should change our goals.</p> <p>The goal of all continuing education programs is to provide that practitioners maintain current standards which will benefit their patients. No continuing education program requires that a practitioner who attends a program utilize the material presented in that program. In other words, you can make someone sit down and listen to a different way of doing things, but you cannot make him practice it. This being the case, I do not believe that a mandatory continuing education program is in the best interest of the Academicians or the patients we serve. I suggest that continuing education not be a requirement for membership in the Academy. I further suggest that those practitioners who believe the ranks should be periodically reviewed for competency expend their efforts on obtaining a mandatory continued competency system.</p> <p>Continuing education is indeed the route that all other medical professions have followed. Continued competency remains the burr in every medical profession's side.</p> <p>To develop a continuing education program and to require that individuals participate in such a program appears to be the route that we must follow. I personally do not agree that this is the correct route. However, such a program has been requested by the membership. Academicians, I request that you submit to me your thoughts on such a mandatory continuing education program as a requirement for membership in the Academy.</p> <b>*<em>Charles H. Dankmeyer, Jr., CPO </em></b><em> Chairman, Continuing Education Committee President, Dankmeyer, Inc. Baltimore, MD<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 1 - 2 Year 1982 Volume 6 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Continuing Education: Past, Present, and Future for AAOP Creator An entity primarily responsible for making the resource Charles H. Dankmeyer, Jr., CPO * https://staging.drfop.org/files/original/da38b7a72d5f0f1d6ac21325f1e039c0.pdf edff63be99e2d8d729cbef998b406a52 https://staging.drfop.org/files/original/d2651974fba7f87f92cd366e455eb4c5.jpg 0f355eb01031549a7c829b5af0d3f97f https://staging.drfop.org/files/original/3cfe30bd191e924a3452548f324e3ab5.jpg 47d785dd2b06ea09755b1fc2db9ef7db https://staging.drfop.org/files/original/4b1a2b96b627fa58481925790ad1945d.jpg bc16cafb9de766ae75e4542da415a35e https://staging.drfop.org/files/original/6ce24c5ca94ed61c1f0b3605e1ea6609.jpg f33c04d0c9047f47f04324fda1775b97 https://staging.drfop.org/files/original/fc25931e137ae824d29d27f46056a337.jpg 14c2a7ea1bf14353dd93b0c7e0608750 https://staging.drfop.org/files/original/1db4cd12acf584900a88521b27b26e22.jpg 23a84ca687819185cd051e2b72a42df3 https://staging.drfop.org/files/original/c3b1f79a3aaf3398396bb240f223b4de.jpg 9d5cd10084e101a37287eb8a11b4dca5 https://staging.drfop.org/files/original/469379a388c74aff071a488496e54792.jpg 17f0c07a2d134591296da907616f4734 https://staging.drfop.org/files/original/d1b3a3a68b94f6ca40969ed5ddbfc33d.jpg c6317785d951bc3b1b237c59ba182c51 https://staging.drfop.org/files/original/18fc4dd5386650d70edc02d759d56432.jpg 482a6131207eda8a57c2ad534f20a1ee https://staging.drfop.org/files/original/1d28451c642c56ef2e891b7eb76b1000.jpg 9dc47a9c6572d79510690e5ca31ff324 https://staging.drfop.org/files/original/020cd4e30afb76ef85d5f9af5a444a4b.jpg 687f1e7b639a806faa83626517e263d3 https://staging.drfop.org/files/original/f5f456fe9b7abda81bee843c15ee1a12.jpg 5d3d1d2068fe0eaa7339520b499663f8 https://staging.drfop.org/files/original/10b792b285121de0002ec3efd54edc8b.jpg 1b42f34eeda78a19f81c150ffa6edd06 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_015.pdf Text Any textual data included in the document <h2>Contoured Adducted Trochanteric-Controlled Alignment Method (CAT-CAM): Introduction and Basic Principles</h2> <h5>John Sabolich, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Since 1969, it has become increasingly evident that quadrilateral sockets have serious bio-mechanical problems. Even my old-timer above-knee prosthetic patients seem to be more comfortable in their ancient plug sockets, although transverse rotational stability was not as good. Fundamental to these objections is the lack of adequate stabilization in the frontal plane, which results in the gluteus medius gait most AK amputees demonstrate.</p> <p>In order to stabilize the upper trunk and pelvis in normal gait, the gluteus medius and abductors on the stance side must fire vigorously when the contralateral side is in swing phase. However, we are dealing with a patho-mechanical situation when we consider the case of the above-knee amputee. No longer are bones and ligaments positively connecting the hip to the floor. There is an intervening pseudo-joint, "the patient socket interface." We now have part of the femur inside a gelatinous semifluid mass, the human thigh.</p> <p>When the abductors fire, what is most likely to occur in a rectangular socket with a wide M-L dimension and no bony areas for the socket to lock against medially? The answer we have discovered, is that the femur tends to abduct. In quadrilateral sockets, the ischial tuberosity is sitting on top of the ischial seat and is free to shift about (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-01.jpg"><b>Fig. 1</b></a>). As the gluteus medius pulls the femur into abduction, the pelvic slides medially on the ischial seat and makes the abduction worse. The unsupported femur has little choice than to drift into an abducted attitude within the wide M-L quadrilateral container. Pain at the distal femur and at the proximal medial area is due to this abducted position and excessive soft tissue pressure medially.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-01.jpg">Figure 1. No bone block and no real force system to prevent femoral or ischial drift. Ischial tuberosity acts as a fulcrum. Pelvis can rotate as well as the femur abduct.</a></strong><br /> <p>We now have a perfect set-up for the classical above-knee "lateral trunk leaning" gait familiar to prosthetists. The patient has to lean to the side to position his upper torso over the base of support (the abducted distal femur) during stance phase, since the prosthesis is falsely placed under him (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-02.jpg"><b>Fig. 2</b></a>). The patient executes this maneuver to prevent excessive pressure on the lateral distal femur and the medial proximal soft tissue. In essence, the patient must walk in a fashion similar to a person who has two sound legs with one leg out to the side in abduction.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-02.jpg"><strong>Figure 2. Patient must lean lateral over distal abducted femur, use inertia, or muscular tightening to prevent pain on lateral distal femur.</strong></a><br /> <p>To the best of my recollection, I began questioning the validity of the quadrilateral socket theory in 1969 when I was a student at New York University. Dr. H. Richard Lehneis, C.P.O., of that institution taught that it is not necessary to put most of the patient's weight on the ischial tuberosity and, if the truth were known, most of the weight is probably borne by the peripheral tissue and gluteal mascula-ture. Moreover, at heel strike, when the largest inertial forces are placed on the above-knee residual limb, the ischial tuberosity is not on the ischial seat due to the flexed hip.<a style="text-decoration: none;">*</a></p> <p>This concept was reinforced in my mind by the idea that if the majority of the amputee's weight was borne by the ischial tuberosity on the quadrilateral socket's flat ischial seat, one would only be able to obtain a tangental force at best, which would bring to bear tremendous force on a very small part of that bony prominence, and consequently cause great discomfort. Placing extra force in the neurovascular bundle anteriorly, Scarpa's triangle, with the purpose of pushing the ischial tuberosity up onto the ischial seat, has never made much sense to me. This seems to be the worst place to apply pressure and can not have a positive effect on circulation. These thoughts confirmed my concern that the quad socket theory had serious biomechanical problems and spurred my subsequent efforts.</p> <p>We began to close the M-L dimension of the socket by adding material to the lateral and medial sides to try to force the femur into adduction. We also began opening up the A-P dimension, not only to reduce the pressure on the neurovascular structures of the Scarpa's triangle, but also to compensate for the reduced diameter in the M-L dimension, and thus to maintain the original circumference. (Prosthetists naturally tend to be fearful of such modifications since they have been taught to tighten the A-P to keep the ischial tuberosity on the ischial seat.) In addition, I began to slant the ischial seat in the frontal plane upward laterally at about a 30° angle, rather than leaving it horizontal, so as to increase the weight bearing of the gluteal muscles, and thus rely less on the ischial tuberosity. These are some examples of early attempts to change the quadrilateral design and may be considered as our first generation efforts.</p> <p>In early 1981, the Sabolich Prosthetics Center sponsored a seminar to investigate non-quadrilateral alternatives for A.K. management. Participating in this seminar, among others, was Ivan Long, CP., developer of the concept of Long's Line and an associated socket design.<a></a> The information learned from Mr. Long was of the greatest benefit in advancing our efforts. However, for reasons that will become apparent in this article, we found it essential to proceed on a different track that experience has shown was necessary to make this program work for us. After this seminar, the Sabolich Center continued research study of non-quadrilateral above-knee designs.</p> <p>Over 900 non-quadrilateral sockets have been fit on a documented basis in Oklahoma City to patients ranging from six months to 103 years of age. X-rays (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-03.jpg"><b>Fig. 3</b></a>) and Xerography have been impressive, showing the femur to be in a much improved adduction attitude. We have made major changes in shape and contour, especially in the last three years. We have coined the acronym CAT-CAM, which stands for Contoured Adducted Trochanteric-Con-trolled Alignment Method, to describe the second generation design which is covered in the remainder of this article.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-03.jpg"><strong>Figure 3. Weight bearing x-rays comparing CAT-CAM and quadrilateral sockets.</strong></a><br /> <p>This design includes undercutting of the trochanter and a special fossa in which the ischial tuberosity and descending ramus can rest, giving this bony prominence three-dimensional support within the socket. No more consideration is given to the transverse angle of the posterior wall relative to the medial wall (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-04.jpg"><b>Fig. 4</b></a>). The Scarpa's triangle is virtually eliminated, as are the adductor longus and rectus channels, and the ischial seat. The ischial tuberosity still bears some measure of vertical loading since it rests on an angled surface. The old principles of the quadrilateral design simply do not function, since we are dealing with a completely different design in shape, contour, and biome-chanical principles. The socket is so different that it looks somewhat like a quadrilateral socket turned sideways with a large A-P and narrowed M-L.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-04.jpg"><strong>Figure 4. Comparison of CAT-CAM and quadrilateral sockets in a transverse view. Since the femur and ischial tuberosity are fixed in position, the adductor longus tendon has to shift a small amount. Note mild O.K.C. (Oklahoma City) channel about the femur.</strong></a><br /> <p>A number of prosthetists have come to our facility to learn these techniques on a one-on-one basis. We have gained much information and feedback from the other prosthetists who have participated in these informal educational efforts. However, this process is not altogether appropriate and has come to be tremendously time consuming. We feel that in the future, education should be administered to several prosthetists at once in an organized and structured course by one or another of the schools. In March, 1985, a preliminary course was taught at UCLA after two years preparation and the writing of a manual. This effort confirmed, in the minds of those involved, the necessity of such a course, and also the necessity of further efforts upon the part of the teaching staff involved to perfect techniques and teaching material. Moreover, it should be borne in mind that the acronym CAT-CAM embraces a number of varying concepts advanced by a number of prosthetists working in common directions and these differences must be reconciled into one technique to be taught. In the strongest possible terms, and in view of the problems some prosthetists have had, we can not recommend using the CAT-CAM method without a hands-on instructional course.</p> <h3>CAT-CAM Theory</h3> <p>The CAT-CAM holds the femur in adduction primarily by two means. First, the ischial tuberosity and part of the inferior ramus of the ischium rest inside the socket proper, and bear laterally directed forces which work in conjunction with medially directed forces borne by the femur (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-05.jpg"><b>Fig. 5</b></a>). Medially directed forces bearing on the proximal portion of the femur in the trochanteric and sub-trochanteric region act to hold the ischial tuberosity on an inclined medial-posterior surface within the socket, while forces on the mid and distal portion of the femur act to maintain the proper adduction angle. Actually, it could be described as a wedging or "locking effect." (Imagine yourself holding the ischial tuberosity of a skeleton in the cupped palm of your hand and pushing the femur into adduction with your opposing hand; thus, the "locking effect.") The lateral surface of the socket proximal to the greater trochanter is contoured intimately into the soft tissue distal of the iliac crest. It is hypothesized that medially directed forces in this area, working in conjunction with the medially directed forces on the lateral surface of the femur and laterally directed forces borne by the ischial tuberosity, create a three-point pressure system to lock the femur into adduction and reduce motion that can occur when the ischium is free to shift about.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-05.jpg"><strong>Figure 5. Ischial tuberosity is locked in the socket to provide a counter force against femoral shift.</strong></a><br /> <p>Second, the narrow socket means that the pressure bearing areas of the socket bear directly against the skeletal elements, thus reducing motion lost through intervening soft tissues. A wide socket M-L cannot provide this locking phenomenon since the femur can fall away from the supporting surfaces.</p> <p>In the transverse plane, the medially directed force of the ischial tuberosity is posterior to the laterally directed force of the trochanter and femoral shaft. One might assume, therefore, that the socket would twist or whip about its long axis. This does not happen, and apparently the adductor longus tendon and other medial proximal tissues anteriorly generate enough counter force to resist this tendency. Also, the ischial tuberosity creates a posteriorly directed force (since it is nestled in the posterior medial corner of the socket), resisting this tendency. Last, this tendency is checked by a new medial trimline (described later) which captures the medial portions, or the inferior ramus of the ischium, which are almost exactly opposite the trochanter.</p> <p>The exact weight bearing mechanism of the CAT-CAM socket with its wide A-P diameter and decreased emphasis on ischial tuberosity weight bearing is unclear. However, it is assumed that the femur is capable of bearing some measure of the patient's weight due to the increased adduction angle. It is also assumed that hydrostatic weight bearing plays an important role and that the ischial tuberosity still bears a measure of weight.</p> <p>In general, we have discovered that the prosthetic foot should be placed considerably lateral of a plumb line through the ischial tuberosity, but not always under the center of the hip joint or distal femur as with "Long's Line." This line changes position with how well the ischial tuberosity is locked in the socket and how narrow the mid and distal M-L dimensions can be molded. This alignment line also changes from patient to patient and depends on gluteal muscle strength, ischial ramus shape, femoral length, and subcutaneus tissue thickness. The prosthetist is now able to align the prosthesis in a normal physiological and anatomical fashion because the femur is no longer in abduction.</p> <p>The Berkeley Adjustable Shank is very useful in determining this critical relationship. By outsetting the foot more than with quadrilateral designs, the patient must adduct his femur to get his feet close together again. With the femur in abduction, as in the quadrilateral socket, a patient would be standing with his prosthesis scissored over his sound leg if he tried to stand with his femur in normal adduction angle. One cannot use a standard unchangeable line and always obtain the same adduction angle as with the contra-lateral femur, since the shorter the femur, the greater the adduction angle must be in order to place the distal femur under the center of the hip joint resulting in hyper-adduction. This was the reason I abandoned this line in favor of an adjustable line utilizing the Berkeley Adjustable Shank. This has resulted in much better alignment.</p> <p>One may ask, "If everything is stabilized in the M-L direction, then what about in the A-P plane?" Afer all, this is of the utmost importance at heel strike in order to stabilize the prosthetic knee and to help propel the patient over the foot. Our experience has not shown this to be a problem. In fact, if anything, an increase in A-P stability has been noted. We hypothesize two ways by which this might be explained.</p> <p>First, the majority of the muscle activity about the hip is in the A-P direction. The flexors and extensors are allowed to expand naturally, filling the socket quickly, and thus firmly stabilizing it (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-06.jpg"><b>Fig. 6</b></a>). Also, this change in contour allows the A-P muscles to function naturally, increasing their size and strength. We have noted many cases of hypertrophy of the A-P muscle groups rather than atrophy. No longer are these muscles being squeezed, stifling their motion and effectiveness. Even suction sockets seem to hold on better since the tissues are not being deformed in an unnatural fashion, causing air pockets and channels to form. Second, the ischial bone is inside the socket, creating a solid posterior stop as opposed to simple soft tissue pressure, aiding A-P control at heel strike (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-07.jpg"><b>Fig. 7</b></a>). Distally, CAT-CAM's become more round, again aiding A-P control.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-06.jpg"><strong>Figure 6. Most muscles function in the A-P plane. The CAT-CAM socket gives these muscles room for their normal dynamics.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-07.jpg"><strong>Figure 7. The ischial tuberosity is free to shift about in the A-P plane as well as the M-L plane when sitting on top of the ischial seat.</strong></a><br /> <p>We have noted several interesting phenom-enons during this research effort. The first I have dubbed the "lateral pylon lean syndrome." Sometimes during dynamic alignment on the adjustable shank, the pylon has to lean laterally in order for the patient to be comfortable. The pylon can be brought vertical by increasing the socket adduction. This turns out to be a temporary solution and does not solve the real problem. This eventually results in pain in the perineum. What is actually happening is that the ischial tuberosity is slipping out of the socket proper and migrating medially on the proximal brim. As a result, the femur falls into abduction, or more realistically, the superior lateral portion of the socket drifts laterally on the patient, the medial superior brim digs in, the pylon leans laterally, and the proximal lateral brim gaps. The problem is not one of alignment at all, but of ischial containment (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-08.jpg"><b>Fig. 8</b></a>). This happens when the socket is too tight in the M-L plane. This happened with sockets fitted after the 1981 seminar when circumference charts were used to determine socket M-L. These resulted in the ischial tuberosity being on top of the medial brim and that is why the brims of such sockets were so wide and thick. The intention was to get the ischium in the socket, but in actual practice it invariably ended up on top. This is no longer necessary due to improved measurement techniques used to determine true M-L.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-08.jpg"><strong>Figure 8. When the CAT-CAM socket is too tight, the ischial tuberosity shifts medially, the femur abducts and the lateral superior brim gaps.</strong></a><br /> <p>Secondly, it seems that the shorter the femur and the greater the volume of the residual leg, the more noticeable is the "CAT-CAM effect." This is due to the favorable comparison of the CAT-CAM sockets versus quadrilateral sockets. The shorter the femur and the greater the relative amount of soft tissue in which it can move, the more obvious the problems of the quadrilateral socket become. However, even with long and lean residual legs, patients still notice the difference in comfort and adduction associated with the CAT-CAM method. A common statement is "it feels more solid," "it feels like its under me again," or "my leg goes where I want it to go." Also, the short residual limbs simply have much more peripheral tissue containment in which to bear vertical and horizontal loading, since the CAT-CAM extends much higher and contains more tissue, especially gluteal.</p> <p>Third, we have virtually eliminated use of hip joints even on very short sub-trochanteric above-knee patients. The adducted femur and the high lateral wall, snugly pressing into the intraillio-trochanteric region, help stabilize the M-L and tend to reduce the need for external support.</p> <p>Fourth, to the question of sitting: will there be a lot of gapping anteriorly? Not if the socket is dimensionally correct. Bending forward at the hip is actually enhanced due to increased room anteriorly, and with the new flexible brim described next, the problem is completely eliminated.</p> <p>Fifth, both the modified version of the Swedish Flexible design, with medial and lateral framing, and the new Total Flexible Brim (T.F.B.) mesh with CAT-CAM principles perfectly as both allow increased function of the A-P muscle groups (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-09.jpg"><b>Fig. 9</b></a>). The CAT-CAM with T.F.B., is preferred because of its superior sitting comfort, adaptability, and dynamic comfort without sacrifice of A-P muscle freedom. The T.F.B., which allows the entire upper three-fourths of the posterior wall and the entire proximal portion of the socket to be flexible and allows a flexible anterior window, is actually opposite of the Swedish Flexible design, which has its greatest measure of flexibility concentrated in the mid-thigh. The T.F.B. is possible because the ischial bone is no longer on top of the posterior or medial seat, but down in the socket, so it does not tend to collapse or push the flexible seat distally. Instead, the tuberosity forces out against the side of the socket as does the trochanter, adductor longus tendon, and peripheral tissues. This can be thought of as one trying to hold his body in place in a V-shaped vertical tunnel or shaft by pushing out on the walls of the tunnel with one's hands and feet. The residual leg pushes out in all directions at once, thus there is no collapse of the flexible posterior brim. For the first time in prosthetics, the proximal thigh is actually allowed to deform naturally during sitting and to change contour dynamically while ambulating. I feel this is important since a great deal of pain complaints are related to the proximal areas. This flexible brim has also allowed us to become much more aggressive and make a major change by extending the posterior and posterior-medial brims higher to capture the ramus and ischial tuberosity more effectively. It has also allowed us to actually slant the medial brim superiorly to better capture the ischium and ramus while relieving the pubis.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-09.jpg"><strong>Figure 9. Three views of the Total Flexible Brim (T.F.B.) CAT-CAM.</strong></a><br /> <p>Sixth, bilateral above-knee patients gain additional benefit from the CAT-CAM design. Our bilateral patients who rejected their quadrilateral socket accept the CAT-CAM enthusiastically. They benefit from the extra space provided in the perineal area by the narrowed M-L (especially with male patients). Even the old round plug sockets gave more room in the perineal area (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-10.jpg"><b>Fig. 10</b></a>). The shaded area in <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-10.jpg"><b>Fig. 10</b></a> demonstrates the extra area available for the genitalia from plug sockets over the quadrilateral socket represented by the rectangles. The CAT-CAM, of course, allows even more room in this area due to its opposite shape and contour.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-10.jpg"><strong>Figure 10. Graphical representation of the amount of room afforded in the perineum by a non-quadrilateral socket.</strong></a><br /> <p>Seventh, the CAT-CAM has great advantages for the geriatric patient for several reasons. We have had our worst difficulties with quadrilateral socket on people with poor muscle tone. The shortcomings of the quadrilateral design become more obvious in the older population. The sharp angles of the adductor longus channel, the posterior medial corner, the medial brim, and the Scarpa's triangle of the quadrilateral socket were almost never really comfortable. With the CAT-CAM, these patients seem to have improved vascular flow; their residual limbs feel warmer after removing the prosthesis. This seems reasonable since the neurovascular bundle is not being choked off with a large bulge in the Scarpa's triangle. The A-P is not being choked but opened up. We hope to conduct comparative temperature and later Doppler blood flow analysis of this phenomenon. For the extremely large geriatric patient population, this alone might be one of the single greatest benefits of research with CAT-CAM design. When the Total Flexible Brim is added, we have not only greater comfort, but further increase in circulation.</p> <p>Eighth, we have noted that a large percentage of patients who were switched to CAT-CAM comment about energy savings. They do not seem nearly as tired after walking the same distance in the CAT-CAM as with their old prosthesis. This is probably first due to less lateral displacement of the center gravity. Second, patients do not have to fight to keep the femur from hitting painfully against the socket distally by tightening their musculature. Third, with more boney contact inside the socket and thus a more solid purchase, the prosthesis moves quickly without delay from false motion.</p> <p>Ninth, we have found that by undercutting the greater trochanter, a much better purchase and counter force to the ramus and tuberosity can be generated with less M-L play and, I suspect, some vertical component of weight can be borne on the flare of the trochanter much like that of the medial tibial shelf in the below knee. Also, now that the femur is actually adducted, we are now probably picking up a vertical component of force on the lateral shaft of the femur.</p> <p>Tenth and most important, after the 1981 seminar, we used a chart that related circumference of soft peripheral tissue to the desired medial lateral dimension of the socket. We found many fallacies with this method. The reason for this is that one cannot rely on circumference measurements to indicate the proper diameters between the ischial tuberosity and sub-trochanter, or the ramus and sub-tro-chanter. In our work, we found that it was absolutely necessary to obtain both of these measurements to obtain consistent results. A patient may be very fleshy and obese, but that in no way changes the anatomical dimension of the bony structures. The reverse is true with a thin patient. This was one of the most difficult stumbling blocks to obtaining truly good results. It seemed that when using this chart, the tuberosity was usually up on top of the medial superior shelf, which acted as an ischial seat, and this explained why the medial brims at the 1981 seminar were flat and 1 1/2" to 2" wide. In effect, the medial brim became an ischial seat. The sockets fabricated at the 1981 seminar still had the ischial tuberosity out of the socket proper and superior medial lateral diameters that were too narrow, resulting in M-L socket shift. True, the ischial tuberosity was no longer on the posterior shelf, but we had simply moved the tuberosity to the top of the medial shelf. The narrow M-L did provide better adduction of the femur, but not as good as when the ischial tuberosity and ramus are totally locked in the socket, providing a medial stop.</p> <p>The reason for this was discovered with more research. Namely, that it is incorrect to rely on what a patient measures in circumference at the perineal or ischial level, and to expect to extrapolate the medial-lateral dimension of the socket. I had two years of severe problems in this area until we dropped the circumference chart and adopted methods to determine exact measurements through xerography, x-rays, and anatomical measurements. Only then was I able to obtain consistent results, symmetrical adduction of the femur, and stabilization of the proximal socket to prevent lateral socket shift.</p> <p>Eleventh, through the course of our research, we have defined three ischial tuberosity-ramus types. We call these different configurations: alpha, beta, and gamma types (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-11.jpg"><b>Fig. 11</b></a>). These classifications are valuable since they can be used to predict to what extent we will be able to control femoral adduction comfortably. The more purchase one can obtain by locking against the medial border of the ischial-ramus, the less the pressure that comes to bear on the soft medial proximal tissues, and the less the M-L shift of the socket.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-11.jpg"><strong>Figure 11. The well defined high slope of the alpha type usually results in improved femoral adduction and M-L control. At the other extreme is the gamma type which is more difficult to grasp properly with the socket.</strong></a><br /> <p>The alpha type is the most desirable, since it has a medial side which slants up at a sharp angle, making it more appropriate for good M-L purchase, and also making it easier to slip into the socket. The beta type has more sloping sides, making purchase somewhat more difficult.</p> <p>The gamma is the poorest type for purchase. We tend to have some pressure problems in the medial proximal area with the gamma types due to M-L socket shift. It is difficult to get this wide bone inside the socket proper. This necessitates widening the medial lateral dimensions of the socket so the wide gamma tuberosity will slip into the socket. With the gamma types, we usually have to settle for a less ad-ducted femur than the patient exhibits on the contralateral side.</p> <p>Another very important point that finally emerged as research continued was that, not only ischial tuberosity, but medial inferior ramus containment was very important to stabilize the socket from lateral shift. The reason for this is that, while the ischial tuberosity is more posterior, and thus helps prevent anterior shift of the socket at heel strike, the ramus is a greater asset when it comes to prevention of M-L shift of the socket and is in a much better anatomical and mechanical position to provide a true medially directed force to the socket, since it is more diametrically opposite the trochanter and sub-trochanteric regions than is the ischial tuberosity.</p> <p>We have had some problems in the beginning with CAT-CAM due to inexperience. However, these have fallen below the one percent range. I find this one percent figure extremely interesting since most patients, especially older people, tend to reject new designs. We found almost none of this phenomenon, however, in switching from quadrilateral to CAT-CAM. We did experience problems due to low back pain in two very old patients. This problem is probably due to the fact that the quadrilateral sockets worn for years and associated with an abducted femur, allowed the lumbar spines to drift to one side. Apparently, fitting the CAT-CAM sockets suddenly pulled the lumbar spines in the opposite directions, inducing low pack pain.</p> <p>During the early years, we sometimes had to fit many transparent check sockets to the same patient before we had successful outcomes. With increased experience and the formulation of rational guidelines and more exacting anatomical measurements, this necessity has been greatly reduced. However, one should expect to spend a great deal more time fitting CAT-CAM design sockets due to the intimate bony contouring.</p> <p>A comprehensive CAT-CAM program should include use of comparative x-rays, which aid in modification and establishment of the angle of correction, as well as transparent diagnostic sockets, video gait analysis, and biofeedback as described in the next paragraph. We also recommend that previous quadrilateral patients undergo an intensive program of abductor strengthening with a prosthetically knowledgeable physical therapist, who will also later teach them not to laterally trunk bend from habit. The full benefit of the CAT-CAM socket is not achieved if the patient has been using a quadrilateral socket long enough to weaken his gluteus medius and abductor mechanism. If the femur tends to be in abduction (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-12.jpg"><b>Fig. 12</b></a>), the gluteus medius is slack and not under normal tension, causing it to have a poor mechanical advantage and makes this muscle effectively weak.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-12.jpg"><strong>Figure 12. The gluteus medius is not effective when the femur is in abduction.</strong></a><br /> <p>We have developed a CAT-CAM program to strengthen the gluteus medius muscle through the use of myoelectric biofeedback during gait training. Pressure sensitive electrodes are mounted to the patient over the gluteus medius, and the biofeedback unit emits an audible signal proportional to the electrical activity generated by the muscle when it fires. Using this method, the patient can actually listen to the muscles fire and begin to force himself to use the abductors more. The stronger this abductor mechanism becomes and the more training the patient receives, the less the classical A.K. "lateral trunk lean" during stance phase is observed. This is an important phase of the program and a very effective way to not only strengthen the gluteus medius, but to do so dynamically while the patient is ambulating. We also explain to the patients the reason why they must trunk lean laterally in a quadrilateral socket and use a video system to provide visual feedback to enable them to see themselves walk. This works very well since people seem to react better to watching themselves walk incorrectly and correcting it voluntarily, than to have a practitioner telling them what they are doing wrong. With former quadrilateral patients, do not expect this lean to go away completely because the habit is so well entrenched; however, it can be greatly reduced if not eliminated.</p> <h3>Future Plans</h3> <p>In late 1985 or early 1986, we will introduce the SCAT-CAM, or Skeletal CAT-CAM, which is a highly bone and muscle contoured design. We have been working on this design for three years and it looks considerably different than CAT-CAM (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-13.jpg"><b>Fig. 13</b></a>). We feel this approach is the next logical step with the evolution of CAT-CAM and are very pleased with the results. SCAT-CAM is actually a third generation CAT-CAM exhibiting, among other refinements, a highly relieved lateral wall with Oklahoma City channel (O.K.C.), which is actually a trough for the entire femoral shaft along with full length of the lateral wall (<a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-14.jpg"><b>Fig. 14</b></a>). I feel this is a major advance, since it attempts to capture the femur in the A-P direction and to prevent A-P and transverse pseudo movement.</p> <a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-13.jpg"><strong>Figure 13. Evolution in shape from the quadrilateral socket (right) to the SCAT-CAM socket (left).</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-14.jpg"><strong>Figure 14. Cross-sectional view of the SCAT-CAM socket.</strong></a><br /> <p>The O.K.C. fossa is provided in a SCAT-CAM to place the ischial tuberosity in a hollowed out relief as opposed to the angular shelf of the second generation CAT-CAM. This fossa enhances the locking effect A-P and M-L. A transparent diagnostic socket is very helpful to properly locate this fossa placement. Also, the medial superior wall has undergone drastic changes to allow relief for the pubis, but still quickly slant superiorally posterior of the pubis to trap even more of the inferior ramus of the ischium and tuberosity. This gives a much improved medial superior locking counter force than a horizontal medial brim. It takes on the shape of a letter "V." With the SCAT-CAM, the pubis can be relieved in the vortex of the "V," while the medial border of all but the inferior apex of the ramus and all of the ischial tuberosity are caught in the arms of the "V."</p> <p>The use of direct anatomical measurements instead of the circumference chart has resulted in a drastic change in general contour where the superior medial-lateral dimension is wider to catch the bony areas, then quickly reduces in M-L dimension and becomes very narrow distal to the sub-trochanteric area, resulting in superior adduction control of the femur. Another important change was with the radius of the superior medial brim. We have changed from a 90° to a gentle upward sloping brim, which prevents the ramus and tuberosity from sliding or shifting out of the socket. With the SCAT-CAM, even more vertical loads are possible on the ischium than with quads sockets since the forces can be wrapped around this complex and curved ischial-ramus bone, which in essence can now be used for vertical posterior and medial loading.</p> <p>We are planning a research program which we hope will contain the following studies:</p> <p><i>Quantitative</i></p> <ol> <li> <p>X-ray with comparative study of femur adduction-abduction angles.</p> </li> <li> <p>Digitally timed video comparison of gait A-P and lateral analysis.</p> </li> <li> <p>Myoelectric measurements of major muscle groups, especially the abductors.</p> </li> <li> <p>Dynamic oxygen consumption rates to monitor energy expenditure.</p> </li> <li> <p>Relative Doppler blood flow in distal residual leg.</p> </li> <li> <p>Temperature of skin in both sockets after controlled time factor.</p> </li> <li> <p>Data on acceptance rates.</p> </li> <li> <p>Atrophy data or hypertrophy comparisons.</p> </li> <li> <p>Determination of the weight bearing mechanism.</p> </li> </ol> <p><i>Qualitative</i></p> <ol> <li> <p>Video comparisons.</p> </li> <li> <p>Patient comments.</p> </li> </ol> <h3>Conclusion</h3> <p>Even though the CAT-CAM and SCAT-CAM are diametrically opposite to the quadrilateral in design and precept, I believe these new principles will eventually be widely accepted and deeply penetrate the prosthetic field. I encourage practitioners to insist on weight bearing x-rays as part of a comprehensive prosthetic program, which lend credibility to our premise by exposing internal problems which result in external manifestations. My sincere hope is that the prosthetic community will not take this article to be controversial, but as a statement of what we have discovered and felt compelled to share.</p> <h3>Acknowledgments</h3> <p>The main source of strength in perpetuating my interest in CAT-CAM has come from the support of my father, Lester J. Sabolich, C.P.O., Thomas Guth, CP., Mike Wilson, C.P.O., and Dr. Ernest Burgess. These people have supported this project from early on and deserve much credit.</p> <p>I would also like to credit Ivan Long, C.P. who defined his alignment principles in 1975 and thus started us on the right track. Enough credit cannot be given this man!</p> <p>Also I thank my wife Lee, who has not complained about many lonely evenings during this research project.</p> <p>I thank the entire staff of Sabolich Prosthetics Orthotic Center. Without these people, none of this research could have been achieved. Only they understand the grit of many failures and garbled plastic in the trash.</p> <p>I thank all of the prosthetists who have worked with us and tried this method. Their feedback has been invaluable.</p> <p>Last, special credit goes to Chuck Childs, C.P.O., who could see the profound effect of this method and was in hot pursuit of it when he was taken from us.<br /><br /><b>Footnote</b> Dr. Lehneis states that the first person to indicate that the ischial tuberosity was more efficient biomechanically if it was in the socket proper was a German man by the name of Schnur in the early 1950's.<br /><br /><em><b>*John Sabolich, C.P.O. </b> John Sabolich, C.P.O., is Vice-President of Sabolich, Inc., 1017 N.W. 10th Street, Oklahoma City, Oklahoma 73106.<br /><br /></em></p> <p><b>References:</b></p> <ol> <li>Long, I., "Allowing Normal Adduction of Femur in Above-Knee Amputations," <i>Orthotics and Prosthetics</i>, Vol. 29, No. 4, pp. 53-54, December, 1975.</li> </ol> Page Number(s) 15 - 26 Year 1985 Volume 9 Issue 4 Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-07.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/1985_04_015/1985_04_015-08.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-01.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-13.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1985_04_015/1985_04_015-14.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Contoured Adducted Trochanteric-Controlled Alignment Method (CAT-CAM): Introduction and Basic Principles Creator An entity primarily responsible for making the resource John Sabolich, C.P.O. * https://staging.drfop.org/files/original/5a4fc207f88a465ad37dcf6b41150096.pdf 479c711e6dc5b0867b71528e3903ffe9 https://staging.drfop.org/files/original/d9ff1b62874d00a6e00a0d672fb43173.jpg 0e51c21a9139763ce305a13968b0cec8 https://staging.drfop.org/files/original/470d0172053dbf6511badf4a238ae5be.jpg 15352b6afae30f74a1a8e9f9ad3f67b6 https://staging.drfop.org/files/original/407855162477bbeecc14efd62661a52c.jpg 724072469eb262d7f443f6bfd29433f7 https://staging.drfop.org/files/original/ea665054cf74df0afd40296eaa419d88.jpg 18d5adb11fc47556e504851627efe5d5 https://staging.drfop.org/files/original/115a307852ee295ff5a6479530d3b830.jpg 57a34343d50ccf4fd7303046f6a9bdcc https://staging.drfop.org/files/original/e9eb5b5f48d616e1dd25a731a081527f.jpg f8fd1d577ec78d9e1f12a765caf2a199 https://staging.drfop.org/files/original/f751c384bf9fac833690768a5251a514.jpg 0f1756a2ea50caf1741b0411c7bdf878 https://staging.drfop.org/files/original/00a80e563c204095cf4122ec59ed733c.jpg 129961f2dc91933885eded5d7c503983 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_008.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 8 - 19 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_008.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_008.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>Contributions of the Lower-Extremity Prosthetics Program</h2> <h5>Edmond M. Wagner, M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>When, in 1945, the National Research Council launched its program for improvement of artificial legs, the original concept was that the major portion of the work would in all probability consist simply of devising mechanically improved artificial knees, ankles, and feet and of applying new materials to existing designs. But it soon became apparent that, if any appreciable success were to be had, the scope of the work would have to be broadened considerably. For new items that were designed failed Lo satisfy the amputee, and there were insufficient fundamental data on which to base improvements. Such information as was available on the mechanics of the lower extremity was either incomplete or else not presented in such form as to be useful to designers.</p> <p>The character of the fit was shortly found to be a matter of paramount importance in determining the success or failure of a given device. But fitting itself was based largely on the personal experience of individual fitters, and there were in existence no formalized standards or rules for guidance in obtaining proper fit. Moreover, the results of testing of devices were too often based on the impressions of only a few amputees and casual observers, either or both generally not qualified to express a competent opinion. There was not even general agreement on some of the principles involved in the surgery of amputations. Before any real progress could be made, information had to be secured in all these fields and coordinated with data from others.</p> <p>The task of obtaining the required information was assigned by the National Academy of Sciences to a number of subcontractors. At the outset, basic research on problems concerned in lower extremities, including studies on surgery, pain,<a></a> and fitting,<a></a> was placed with the University of California at Berkeley.<a></a> To assist designers and fitters, and to provide a record of the devices and techniques being used in the limb industry, a review of prior art was carried out at Northwestern University,<a></a> and the Surgeon General of the Army sent to Europe a commission<a></a> to study and report on the prosthetics art as practiced in various other countries. Solutions attempted in the past for many problems in leg design are cataloged and described in the Northwestern report<a></a> and in the report of the European commission .<a></a> Development of devices was undertaken by Goodyear Tire and Rubber Company;<a></a> Vickers, Inc.,<a></a> Detroit; C. C. Bradley and Son;<a></a> Catranis, Inc.;<a></a> Adel Precision Products;<a></a> A. J. Hosmer Corporation;<a></a> Northrop Aircraft;<a></a> the U.S. Naval Hospital at Oakland, California;<a></a> National Research and Manufacturing Company;<a></a> the Aero-Medical Laboratory of the U.S. Air Force, Wright-Patterson Air Force Base; the Army Prosthetics Research Laboratory, Walter Reed Army Medical Center; and the University of California at Berkeley . <a></a> Later in the program, the Denver Research Institute<a></a> of the University of Denver carried out an investigation of below-knee prostheses, some additional basic data have been supplied by New York University<a></a> and by the Prosthetic Testing and Development Laboratory of the Veterans Administration in New York City, and another commission<a></a> was sent to Europe to observe progress abroad after 1945. Testing and evaluation of devices has been developed and carried out at New York University,<a></a> and the Orthopedic Appliance and Limb Manufacturers Association has cooperated in general program guidance.</p> <h3>Development of Basic Data</h3> <p>Because prior to 1945 little study had been conducted on the characterislics of human locomotion, because of the complexity of the problem, and because of its highly specialized nature, it was necessary first to devise special equipment for collecting information which, ultimately, would lead to determination of the mechanical and physiological changes occurring during various activities of the lower extremity. A number of pieces of unusual apparatus, such as force plates, a glass walkway (<b>Fig. 1</b> and <b>Fig. 2</b>), and special photographic equipment were designed,<a></a> and from the data collected using this equipment it was possible to determine such factors as the forces and moments in human and artificial legs and the roles played by major muscle groups under a series of conditions. From such findings it has been possible to describe fully the phenomenon of human locomotion and thus to establish a set of realistic criteria for the design and evaluation of artificial-leg components. Aside from applicability to the field of prosthetics, the data collected are useful also to designers of leg braces and to the medical profession in the treatment of pathological gait.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The University of California glass walkway. With this device, motion pictures taken from a single camera yield sufficient information to determine relative motions of various segments of the body during level walking. Subject shown here is wearing an above-knee experimental leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Normal subject prepared for participation in studies using the University of California glass walkway. Some targets are mounted on levers to amplify motions otherwise of small magnitude. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The major portion of this work was performed at the University of California, Berkeley, and many of the results have been documented in reports and in the journal literature. Of the many reports issued, most, such as those of Cunningham<a></a>, of Bresler and Berry<a></a> and of Radcliffe,<a></a> generally cover a single phase of the subject.</p> <h3>Creation of Design Objectives</h3> <p>From study of the basic data, and from careful review of current practices, it has been possible to set up a listing of design objectives for leg prostheses, it being understood that above all the prosthesis must satisfy the amputee. Arranged in generally decreasing order of importance, these requirements are as follows:</p> <ol> <li>Security from fall.</li><li>Minimum consumption of energy in normal walking</li><li>Appearance of the walking pattern to compare favorably with that of a normal person.<br /> a. Smooth swing phase, including deceleration of the prosthesis at the end of extension, control of heel rise at the end of flexion, and deceleration of the prosthesis just prior to heel contact.<br /> b. Smooth stancephase, includingattainmentof full extension without final snapping action.<br /> c. Ability to change gait to maintain smooth, normal-appearing gait.</li><li>Ability to extend the leg under load at any time.</li><li>Proper phasing of the locking action, if used, with all portions of the stance and swing phases.</li><li>Performance of incidental operations—such as going up and down stairs and ramps, turning, and sitting down—with reasonable ease and smoothness.</li></ol> <p>A listing of the features desired of leg prostheses at three functional levels (<b>Table 1</b>) has finally evolved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Improvement of Fitting and Alignment</h3> <p>As a result of the early attempts to improve existing knee-brake devices, it was found that fitting and alignment were together often more of a determining factor in amputee acceptance than was the performance of the device itself. In the two trips to Europe,<a></a> various techniques and several mechanical aids for obtaining greater uniformity in fitting were observed. These techniques and devices have been analyzed, and from the resulting knowledge, together with information from the basic studies, improved methods of fitting and aligning above- and below-knee legs have been formulated. All of these observations have been published in a report of the University of California at Berkeley .<a></a></p> <p>In order to make these principles of fitting and alignment easier to apply, an adjustable leg (page 23) for above- and below-knee prostheses, with provisions for individual adjustment of major elements, was designed by the project at Berkeley and turned over to the limb industry. This leg, once adjusted, can be worn by an amputee for periods of a few days to determine if the fitting is satisfactory. To transfer to the permanent prosthesis the measurements thus determined by the adjustable leg, there has been designed a fixture which holds the elements of the prosthesis in position while they are being assembled with the predetermined alignment. With these two devices, which are now available commercially, fittings become quite exact. The ease with which minor adjustments can be made in the adjustable leg makes it possible to try variations in fitting which, previously, were avoided because of the time and expense involved. Moreover, the adjust- able leg has the psychological advantage of demonstrating to the amputee that the fit of the device he is obtaining is the optimum for him.</p> <h3>Methods Of Suspension</h3> <p>A major factor involved in fitting of both above- and below-knee legs is the socket. On the first trip to Europe,<a></a> a number of exceptionally well-fitted suction sockets (page 29) were observed in Germany. This type of suspension had been tried previously in the United States<a></a> and in England with poor results. The successful cases seen in Germany in 1946, however, prompted another trial of the technique in the United States. A thorough study of the shape of the socket and other features involved in fitting of suction sockets was undertaken at the University of California at Berkeley.<a></a> As a result of the successful conclusion of this work, the suction socket has since been widely applied by the United States limb industry and has been accepted by the Veterans Administration as an improved method of fitting prostheses for above-knee amputees where there are no contraindications. The knowledge gained in perfecting the technique of suction-socket fitting and in determining the optimum shape of the suction socket has contributed to improvement in the fitting of other sockets. Development work is now proceeding on suction sockets for below-knee amputees.</p> <p>In addition to the work on suction sockets, a "soft" socket for below-knee amputees, consisting of a thin, resilient pad under a conventional leather or plastic socket lining in a plastic or wooden socket, has reached the testing stage at New York University.</p> <h3>Schools for Prosthetists and Surgeons</h3> <p>Since the suction socket was as much a technique as a device, it was determined that, if the suction socket was to be as successful in general practice as it had been in the development period under the supervision of the University of California, the technique had to be taught to limbfitters throughout the United States. Accordingly, plans were laid for a series of schools to be held in various cities in the United States. A course of instruction was laid out, and under the auspices of the Veterans Administration, with the assistance of the Orthopedic Appliance and Limb Manufacturers Association, a series of schools was held throughout the country. The Veterans Administration, by requiring that fitters and surgeons have certificates from one of these schools before suction sockets could be provided beneficiaries, ensured that the best practices were provided. Establishment of these schools was an important advance, for it provided a mechanism for bringing to the commercial limb industry and medical pro- fession the new techniques and ideas developed. Their success has led to expansion of the principles of the clinic-team approach for handling both upper- and lower-extremity cases.</p> <p>In connection with the suction-socket schools, manuals were issued on how to fit suction sockets. They constituted the first attempt to present, in a manner that would be useful to the limbfitter, data developed in the program. Their success has led to the issuance of manuals on other subjects.</p> <h3>Amputation Surgery</h3> <p>In the early investigations, it became apparent that relative difficulty of fitting rather than surgical considerations often dictated the site of amputation. This circumstance led to a study of the sites of election and to a consideration of whether some changes might not be advisable. Studies have since clearly shown that the longer the stump the more function and control can be obtained-a matter that has not always been fully appreciated. In the above-knee amputee, the increased length of stump is particularly important, since it is one of the governing factors in obtaining stability of the prosthesis in abduction. In the above-knee amputation, it has also been found advantageous to tie the muscles together across the bottom of the stump or otherwise to attach muscles to the bone to aid in obtaining stability in abduction. These new concepts are leading to a revision of amputation practices. There will, no doubt, be other such advances in amputation surgery as more is learned about body mechanics.</p> <h3>Pain Studies</h3> <p>Pain, both phantom and real, has always been a troublesome problem in amputee management. In order to obtain a clearer understanding of and possible solutions to the pain syndrome, a project was instituted at the University of California. Although practical applications of methods to alleviate pain and eliminate phantom pain have been meager to date, the mechanism of pain radiation has been elucidated, and the results<a></a> form the basis for future work in this field.</p> <h3>New Devices</h3> <p>One of the most important parts of the lower-extremity program is the development of new devices. Consequently, device development has been one of the major efforts. In the early stages of the program especially, there was an urgent demand from new Service-connected amputees for improved devices. At the time, the data from the basic studies at the University of California were not available. But because of the urgent demand, a program for invention and development of devices was undertaken simultaneously with the program for developing basic data. While most of these devices were unsuccessful, the time, money, and effort expended developing them were not entirely wasted. For in trying these devices, much needed information was developed, and the need for long-range research on several items of a basic nature was pointed out. As the data were collected at the University of California, devices were pro- duced incorporating features which seemed desirable.</p> <p>A great deal of effort was expended in attempting to perfect a knee lock for above-knee amputees. But most of these designs were abandoned for one reason or another after a few models had been made and tried on amputees. The particular difficulty in obtaining smooth and reliable action in a knee lock was found to reside in the method of control. In addition to knee locks, considerable effort has been expended on coordinated motion between the knee and ankle, toe pickup, transverse rotation in the leg, and control of the swing phase. Numerous devices incorporating such features have been made. Both mechanical and hydraulic devices, with varying degrees of complexity, have been tried.</p> <p>Of all the knee locks tried to date, only two, the Stewart-Vickers (<b>Fig. 3</b>) and the Henschke-Mauch (<b>Fig. 4</b>), appear to have reached the point of having commercial possibilities. More recently, however, there have been indications that proper swing-phase control, coupled with alignment stability or limited stability over the first few degrees of flexion, are all that the average above-knee amputee may need. The more or less elaborate knee locks might therefore be indicated for special cases, for older persons, or for those who prefer "the best" and can afford it. Both Stewart and Henschke-Mauch have swing-phase control devices incorporated in their designs, and both have under test legs in which only the swing phase is controlled.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Schematic diagram of the Stewart-Vickers hydraulic leg incorporating knee lock, swing-phase control, and coordinated motion between ankle, shank, and thigh. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Schematic diagram of the Henschke-Mauch hydraulic leg incorporating knee lock and swing-phase control. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another lower-extremity device now under test is the University of California four-bar-linkage or polycentric knee (<b>Fig. 5</b>). The four-bar-linkage knee is not a new idea, but the UC version has been so designed that the toggle action existing in prior designs to provide extreme stability as the knee approaches full extension has been eliminated. Instead, it depends for its stability on alignment in fitting. It has the advantage, like many other four-bar linkages, of providing at the start of flexion a pivot point about 6 in. above the actual knee joint-a feature which provides a very favorable mechanical advantage for the amputee to start the leg to flex.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Schematic diagram of the University of California four-bar-linkage (polycentric) knee showing change in center of rotation of shank as knee is flexed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the UC leg the swing phase is controlled by a radial-vane type of damping device in which hydraulic fluid passes from one side of the vane to the other through suitable needle valves. Hence this device is responsive to gait change and limits excessive heel rise as cadence is increased.</p> <p>The limbshop at the U.S. Naval Hospital, Oakland, California, has developed and had accepted by ACAL a complete above-knee leg featuring a very simple mechanical device for controlling the swing phase in connection with a more or less conventional knee bolt (<b>Fig. 6</b>). This type of swing-phase control is not nearly so responsive to gait change as are the hydraulic units, but it marks a definite advance in the design of artificial knees. Also featured in the Navy leg are a plastic shank and the so-called "Navy functional ankle." The latter (<b>Fig. 7</b>) uses a rubber block with different degrees of hardness at front and rear to provide for plantar flexion and dorsiflexion and at the same time to permit some rotation about the vertical axis of the leg. It is anticipated that the Navy above-knee leg will be available commercially early this summer.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. U.S. Navy variable-friction knee. As flexion takes place, projection <i>A </i>of the knee block rotates until it contacts lever arm C, which induces additional friction about the knee bolt to limit heel rise. As extension occurs, projection <i>B' </i>rotates to contact lever arm <i>D, </i>which induces additional friction to decelerate the shank (terminal deceleration). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. U.S. Navy functional ankle. Single cable extends through rubber block of different degrees of stiffness at front and back. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To summarize the work done on new devices for lower extremities, there is now available a large store of information on devices which have been tried and found lacking in one respect or another. With what is now known about performance desired in above-and below-knee legs, it is possible that a review of past developments, coupled with some changes based on present knowledge, may lead to the development of more acceptable leg prostheses. At this time, however, only the Navy functional ankle and the swing-phase control have been accepted as completed devices. Others appear very close to acceptance.</p> <h3>Testing and Evaluation</h3> <p>Throughout the early stages, the development of new devices in the lower-extremity program was retarded by the lack of techniques and organization for objective testing and evaluation. Until the data on the mechanics of walking had been developed, it was almost impossible to set up means for objective evaluation because no satisfactory standards of comparison were available. In addition to this lack of standards, it became apparent early in the program that some means had to be established for testing, under a controlled set of conditions, the devices which appeared ready for production. A testing laboratory at New York University was therefore set up. With its entry into the program, there was obtained a much better evaluation of the desirability of the devices proposed and a much better idea of their mechanical performance . <a></a> It was soon found that most of the devices submitted had minor mechanical shortcomings, and as a result many devices which two or three years ago appeared almost ready for release are only now approaching that point. The field-testing procedure has avoided premature release of several supposedly completed items and has indicated the need for more information on several basic points. It has thus proven to be a very valuable step in the development program, and the information gained in the field tests has fully justified the time and cost of field-testing.</p> <h3>Clinical Program</h3> <p>When the program for development of new devices had reached a certain stage, it became apparent that, if there could be instituted a clinical program to try devices on various amputees under as nearly identical conditions as possible, progress would be much more rapid. Information was also needed to confirm conclusions about the suitability of certain devices for various sites of amputations and for various physical and mental characteristics of the amputee and to determine new types of devices which might be needed under certain sets of conditions. Among others, such questions as the need for, or suitability of, a knee lock, or whether limited stability coupled with swing-phase control would be better, needed investigation and decision.</p> <p>A clinical study was therefore set up under the direction of the University of California at the U.S. Naval Hospital, Oakland, with certain facilities provided by the Surgeon General of the Navy. It is expected that, by providing a complete staff of surgeons, prosthetists, physiotherapists, engineers, and research workers, with the opportunity for controlled fitting and follow-up of patients, rapid progress will be made in improving fitting and alignment techniques, in surgical procedures, and in the development of improved devices.</p> <h3>Development Program</h3> <p>Since the establishment of the lower-extremity clinic, a development group, staffed with people skilled in lower-extremity prosthetic art, including representatives from the industry, has been established. This group has headquarters at the U.S. Naval Hospital at Oakland, California, in close proximity to the clinic. It is expected that they will complete the development of some of the devices partially completed in the past and develop new devices, possibly combining or utilizing some of the ideas and data resulting from development work on these new devices. It is expected that this group will bring the program for new devices somewhere near its required level within the next two years.</p> <h3>Conclusion</h3> <p>Because the improvement of leg prostheses has required research and investigation in many fields, and because of the broad scope of much of the work, its full usefulness will not be realized until some time in the future. Time and study are required to analyze the data and to apply the results of such analyses. Nevertheless, the basic data developed under the ACAL program have already been useful, not only in the design of above- and below-knee prostheses but also in the design of leg braces, and they have proved extremely helpful in the diagnosis of pathological gait. Among the developments of more or less immediate practical applicability are the new techniques introduced for fitting and aligning above- and below-knee prostheses. Devices to facilitate adjustments in fitting so that optimum results can be attained quickly have been developed and introduced to the industry, as has also the equipment for transferring the dimensions determined for the prosthesis.</p> <p>As a result of efforts of ACAL, the suction socket for the above-knee amputee has come into general use in the United States. In addition, the principles developed in the suction-socket program have helped to improve techniques used with other types of sockets, thus contributing generally to the well-being of the leg amputee. Experience gained in the suction-socket program has led either directly or indirectly to the development of the clinic-team concept which is proving so useful in the management of amputees of all types.</p> <p>Certain changes in the surgical procedures of amputation have been suggested, especially in regard to the so-called "sites of election" and to stabilization of the above-knee stump in adduction. Study of the nature and propagation of pain in stumps has yielded results which should be the basis for future advances in treatment and prevention of pain arising from amputation.</p> <p>Outgrowths of the lower-extremity clinical study may be expected to confirm, apply, and develop further the principles of fitting and alignment, to advance further the use of the suction socket, to improve the fitting of conventional above- and below-knee sockets and the "soft" socket for below-knee amputations, and to develop prostheses for other types of amputations. With the above-knee clinic established, the work in surgery, prescription, fitting, and training of the amputee is likely to advance even more rapidly than has been the case in the past.</p> <p>The development of devices with increased function, reliable enough and with benefit enough to the amputee to justify the increased complexity and cost, has proven difficult.</p> <p>Many devices have been built, tested, and found wanting in one detail or another mechanically or else have proven too costly to be practical at the present time. Although thus far only two devices, the Navy variable-friction knee and the Navy functional ankle, have been accepted by ACAL and made ready for distribution, several experimental ones appear to be almost ready for general use. The groundwork in the field of lower-extremity prosthetics has been laid. By 1956 we should see the appearance of many more, and more practical, accomplishments resulting from the preceding eight years of pioneering work.</p> <p><b>References:</b></p> <ol> <li>Adel Precision Products Corp., Burbank, Calif.,ubcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>The development of a hydraulically operated artificial leg for above knee amputations, </i>1947.</li> <li>Bradley, C. C, and Son, Inc., and Catranis, Inc.,yracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and fool position; toe pick up and foot providing lateral, plantar and dorsal flexion, </i>1947.</li> <li>Bresler, B., and F. R. Berry, <i>Energy characteristicsof normal and prosthetic ankle joints, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</li> <li>Catranis, Inc., Syracuse, N. Y., Subcontractor'sinal Report to the Advisory Committee on Artificial Limbs, National Research Council, in preparation, 1954.</li> <li>Cunningham, D. M., <i>Components of floor reactionsduring walking, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950.</li> <li>Denver Research Institute, University of Denver,enver, Colo., Subcontractor's Final Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>A program for the improvement of the below-knee prosthesis with emphasis on problems of the joint, </i>August 1953.</li> <li>Eberhart, Howard D., Verne T. Inman, and Borisresler, <i>The principal elements in human locomotion, </i>Chapter 15 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Eberhart, Howard D., and Jim C. McKennon, <i>Suc-tion-sockei 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. 9. Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs, </i>Chapter 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Goodyear Tire and Rubber Company, Akron, Ohio,ubcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], <i>The development of a fool prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, </i>1947.</li> <li>Hosmer Corp., A. J , Santa Monica, Calif., Sub-ontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Hydraulic weight bearing knee lock for knee disarticulation amputations, etc., </i>1947.</li> <li>National Research and Manufacturing Company,an Diego, Calif , Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], <i>An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, </i>1947.</li> <li>New York University, Prosthetic Devices Study, Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, </i>March 1953.</li> <li>Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A report on prosthesis development, </i>1947.</li> <li>Northwestern Technological Institute, Evanston,11., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, </i>1947.</li> <li>Parmelee, Dubois D., U. S. Patent 37,637, February, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</li> <li>Radcliffe, C. W., <i>Information useful in the design ofdamping mechanisms for artificial knee joints, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</li> <li>Radcliffe, C. W., <i>Use of the adjustable knee and align-ment 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>Saunders, J. B., V. T. Inman, and H. D. Eberhart, <i>The major determinants in normal and pathological gait, </i>J. Bone and JointSurg., <b>36A </b>(3):543 (1953).</li> <li>Stewart, John H. F., U. S. Patent 2,478,721, August 9, 1949.</li> <li>United States Naval Hospital (Amputation Cen-er), Oakland, Calif., <i>Construction, filling and alignment manual for the U.S. Navy soft socket below knee prosthesis, </i>printer's date 9-29-53.</li> <li>University of California (Berkeley), Prostheticevices 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> <li>University of California (Berkeley), Prosthetic</li> <li>Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>Summary of European observa-tions, summer, 1949 </i>[by H. D. Eberhart <i>el al.], </i>October 1949.</li> <li>University of California (Berkeley), Prostheticevices 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), Prostheticevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Studies relating to pain in the amputee, </i>June 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>13.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Goodyear Tire and Rubber Company, Akron, Ohio,ubcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a fool prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 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>References</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon, Suc-tion-sockei 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. 9. Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices 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>16.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Information useful in the design ofdamping mechanisms for artificial knee joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 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>26.</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>18.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart, The major determinants in normal and pathological gait, J. Bone and JointSurg., 36A (3):543 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Summary of European observa-tions, summer, 1949 [by H. D. Eberhart el al.], October 1949.</td></tr><tr><td class="clsTextSmall"><b> 26.</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>17.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Use of the adjustable knee and align-ment 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></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Bresler, B., and F. R. Berry, Energy characteristicsof normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 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>5.</b> </td><td class="clsTextSmall">Cunningham, D. M., Components of floor reactionsduring walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 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>19.</b> </td><td class="clsTextSmall">Stewart, John H. F., U. S. Patent 2,478,721, August 9, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and Borisresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Summary of European observa-tions, summer, 1949 [by H. D. Eberhart el al.], October 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>13.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Denver Research Institute, University of Denver,enver, Colo., Subcontractor's Final Report to the Advisory Committee on Artificial Limbs, National Research Council, A program for the improvement of the below-knee prosthesis with emphasis on problems of the joint, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">New York University, Prosthetic Devices Study, Report to the Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 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>21.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston,11., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">National Research and Manufacturing Company,an Diego, Calif , Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Adel Precision Products Corp., Burbank, Calif.,ubcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, The development of a hydraulically operated artificial leg for above knee amputations, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Catranis, Inc., Syracuse, N. Y., Subcontractor'sinal Report to the Advisory Committee on Artificial Limbs, National Research Council, in preparation, 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>2.</b> </td><td class="clsTextSmall">Bradley, C. C, and Son, Inc., and Catranis, Inc.,yracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and fool position; toe pick up and foot providing lateral, plantar and dorsal flexion, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">United States Naval Hospital (Amputation Cen-er), Oakland, Calif., Construction, filling and alignment manual for the U.S. Navy soft socket below knee prosthesis, printer's date 9-29-53.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Hosmer Corp., A. J , Santa Monica, Calif., Sub-ontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Hydraulic weight bearing knee lock for knee disarticulation amputations, etc., 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</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>15.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U. S. Patent 37,637, February, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">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>15.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U. S. Patent 37,637, February, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">University of California (Berkeley), Prosthetic</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Saunders, J. B., V. T. Inman, and H. D. Eberhart, The major determinants in normal and pathological gait, J. Bone and JointSurg., 36A (3):543 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Goodyear Tire and Rubber Company, Akron, Ohio,ubcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a fool prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 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>Edmond M. Wagner, M.E. </b></td></tr><tr><td class="clsTextSmall">Consulting engineer, 930 Rosalind Road, San Marino, California; 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_008/May-1954OCRBatch1-2.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-3.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-4.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-5.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-6.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-7.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-8.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-9.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 Contributions of the Lower-Extremity Prosthetics Program Creator An entity primarily responsible for making the resource Edmond M. Wagner, M.E. * https://staging.drfop.org/files/original/ab7543cd7a89fbb0411d1f34a0263db8.pdf c5354e4247d698b974287ba4eb8c3224 https://staging.drfop.org/files/original/9425bc5ffbf07ebf9c14b731a150ced2.jpg 35a7c0b562014d4fb50dec04e1a2648b https://staging.drfop.org/files/original/9f1ee7129f74d4da85370f348fdb1836.jpg ff2b1aea5b56e7f14acf06a7b8d20da9 https://staging.drfop.org/files/original/4d370fefd91e735d6fb3ee03340951f3.jpg 9f95d03a610ddbb83b1ad23e3450dfd0 https://staging.drfop.org/files/original/963256fd362491bd682b123274398c06.jpg 6418500d7da7c502d4faec1731934241 https://staging.drfop.org/files/original/011d4c628e420168bd0745099f67527b.jpg f292217f59299efecabdeccec457d0ab https://staging.drfop.org/files/original/0d2ed862497f922a0790d0b16cef7986.jpg 2ab9a719c52fc5660d4b56961d2e5209 https://staging.drfop.org/files/original/354d1f58233229ce31c57886ff84b30f.jpg b44e5eff696f208e7c962ed258e16579 https://staging.drfop.org/files/original/cb80d5a12a017e33e08e597ffb4c58af.jpg e1c1fb775ede1e64579fb7405aa8a5d9 https://staging.drfop.org/files/original/06bfecf29692e230dbfd93c908ce83fa.jpg b482408d3255d9e24ad276d2e4ba913a https://staging.drfop.org/files/original/0265d09264022def5d0709d4d7100463.jpg 769232d27df084123462e0300b6af339 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_026.pdf Text Any textual data included in the document <h2>Conventional Fitting of an Unconventional Orthosis</h2> <h5>Donald L. Fornuff, C.P.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>Amyoplasia Congenita</i> (Arthrogryposis Multiplex Congenita) is a congenital abnormality of muscle development which is characterized by marked stiffness and severe deformity in many joints of the limbs—hence, the term arthrogryposis, which means "bent joints." (<a href="/files/original/9425bc5ffbf07ebf9c14b731a150ced2.jpg"><b>Fig. 1</b></a> and <a href="/files/original/9f1ee7129f74d4da85370f348fdb1836.jpg"><b>Fig. 2</b></a>).</p> <p><a href="/files/original/4d370fefd91e735d6fb3ee03340951f3.jpg"><b>Fig. 3</b></a> shows one of our recent patients, a young woman from South America with arthrogryposis, who was seeking greater range of motion with her present left exoskeletal arm orthosis, combined with easier operation and better cosmesis. Her previous orthosis consisted of a left modified laminated shoulder cap with a large cut out for both the left arm and left breast. The shoulder cap extended from the left clavicle over the shoulder to the soft tissue area between the rib cage and the crest of the ilium on the left side. Set on the superior border of the shoulder cap was a nudge control unit which was used to lock and unlock the elbow and was operated by her chin (<a href="/files/original/963256fd362491bd682b123274398c06.jpg"><b>Fig. 4</b></a>). A flexion-abduction joint was used at the shoulder. The elbow joint was an outside locking type. A custom made wrist unit served to receive a terminal device. Quarter inch (1/4")—7 cm diameter adjustable rods were the connecting members from the acromion to the elbow and from the elbow to the wrist unit. Operation of the terminal device was accomplished by means of a perineal strap on the left side. A chest strap was used as a means of suspension. Some major considerations for change were: type of socket, improved harness and a more efficient cable system.</p> <h3>Socket</h3> <p>We felt a more comfortable, cosmetically acceptable, and efficient working, above-elbow type socket would be a large improvement over the heavy, bulky, and ill-fitting shoulder socket she was now wearing. Consequently, the patient was casted as if for an above-elbow type prosthesis, with anterior and posterior wings at the proximal end of the socket and an open end distally (<a href="/files/original/011d4c628e420168bd0745099f67527b.jpg"><b>Fig. 5</b></a>).</p> <h3>Harness</h3> <p>Without a doubt, the two most uncomfortable and least cosmetic harnesses a woman could wear would be a perineal strap and a chest strap. This patient was unfortunately burdened with both. Our solution was to use a conventional A/E harness in conjunction with the A/E type socket with modification of the control attachment strap, which ran from the harness ring through a 1 inch hanger of the control cable, across the back and attaching to the axilla (<a href="/files/original/0d2ed862497f922a0790d0b16cef7986.jpg"><b>Fig. 6</b></a>). This modification serves two purposes: (1) it prevents the harness from rising on the back, which would be uncomfortable, and (2) it promotes cable operation efficiency by maintaining the cable flow through the lower third of the scapula, where maximum excursion occurs as a result of scapular abduction (which is the motion being used for the function of this orthosis).</p> <h3>Cable Control System</h3> <p>A conventional A/E dual control system was used (<a href="/files/original/354d1f58233229ce31c57886ff84b30f.jpg"><b>Fig. 7</b></a> and <a href="/files/original/cb80d5a12a017e33e08e597ffb4c58af.jpg"><b>Fig. 8</b></a>).</p> <h3>Elbow Lock Control</h3> <p>Operation of the elbow lock (E-500 outside locking joints) was facilitated by slight modification of the locking mechanism. Instead of using an elbow lock strap, the cable from the elbow lock was attached proximally to a nudge control unit similar to what was used on her previous orthosis (<a href="/files/original/06bfecf29692e230dbfd93c908ce83fa.jpg"><b>Fig. 9</b></a>).</p> <h3>Forearm</h3> <p>The forearm consisted of a threaded aluminum rod held onto the lower locking strap of an outside locking joint by means of an adjustable bracket which allows for shortening or lengthening of the forearm as necessary. At the distal end of the forearm, an adapter was placed to receive a wrist flexion unit, into which a hook was placed (<a href="/files/original/0265d09264022def5d0709d4d7100463.jpg"><b>Fig. 10</b></a>). The forearm set-up was not an original idea, but was modified slightly to provide more range of motion.</p> <h3>Summary</h3> <p>Again, the overall idea was not an original one, but we feel the modifications which were improved upon and a good idea are worth sharing. With this device, combining both the working knowledge and components of prosthetics and orthotics, we made the life of this patient easier and more functional. We felt we met our original goals, which were to improve her range of motion, give her easier operation, improve cosmesis, and provide a more comfortable fitting orthosis.</p> <h3>Acknowledgment</h3> <p>Thanks to Mr. G. Robinson of Robins Aid, who had the original ideas for this orthosis.</p> <em><b>*Donald L. Fornuff, C.P. </b> Donald L. Fornuff, CP. is with the Prosthetics and Orthotics Department at the Institute of Rehabilitation Medicine of the New York University Medical Center, 400 East 34th Street, New York, New York 10016.<br /><br /><br /></em> Page Number(s) 26 - 29 Year 1985 Volume 9 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_01_026/1985_01_026-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Conventional Fitting of an Unconventional Orthosis Creator An entity primarily responsible for making the resource Donald L. Fornuff, C.P. * https://staging.drfop.org/files/original/e93a25eb7775adeeac14c21fb0384c79.png 71399ee10d2c4113f22875e536f2b838 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 Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL www.copelaos.org Contact Name/Title Bounlanh Phayboun - Director Address P.O. Box 6652 Khouvieng Rd. City Vientiane Countries Served Laos Regions: AsiaCountries: Laos PDRSpecific cities, regions, or groups of people: All patients with physical disabilities in Lao PDR.Age Group: Adults, ChildrenFees Charged: Sometimes Postal Code 100 Email cope@laopdr.com Organization Type Including ID and tax status Non-profit Services Provided Prosthetic Fitting, Orthotic Fitting, Medical Equipment / Supplies, Education, Prosthetic Fabrication, Orthotic Fabrication, Medical / Surgical Care, Rehabilitation / TrainingThere is a facility/physical building for patient care at the specified location. Need I Financial Assistance Need II Volunteers: Prosthetists, Orthotists, Physicians, Therapists Need III Materials, Components, and Equipment: New, Equipment 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 Cooperative Orthotic and Prosthetic Enterprise https://staging.drfop.org/files/original/3737624fef3a56640de26ee5e3002198.pdf 15dcba40ce0ee64a88813bdb9436da11 https://staging.drfop.org/files/original/90b09bc05fe9f54eac7fb5d364a84b1c.jpeg bf517f01325ef5bfd382d9f9221d3ade https://staging.drfop.org/files/original/f21dd604b9586a00f2668ad4a7c12771.jpg 6fb57a7aca27799becfcbf804eeb70ed 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_01_006.pdf Text Any textual data included in the document <h2>Cross-Diagonal Closure Of Pelvic And Spinal Appliances</h2> <h5>Louis Ekus, CO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The pelvic region with its numerous bony prominences, subcutaneous structures, and varied contours, has long been a useful site for the stabilization of many different orthoses and prostheses. The Milwaukee orthosis, body jackets, prostheses for hemipelvectomy and hip disarticulation amputees, to name a few, often maintain high internal forces as components of complex three-point pressure systems. Due to the nature of these devices, the internal forces are often quite different on the patient's opposing sides. Most practitioners are already aware that when the differences in the forces from right to left sides becomes large enough, relative motion of the two sides of the appliance becomes a difficult problem. This motion, in the superior or inferior direction in the frontal plane, causes skin breakdown, irritations, torsional stress on the devices and, thus, provides less than optimal function. In hip disarticulation and hemipelvectomy prostheses, "pumping" can be attributed to a great extent to the lack of the closures to maintain effective apposition of the two sides of the socket. The cross-diagonal closure is one way of dealing with this undesirable movement effectively.</p> <p>When the attachment points of closure straps are placed horizontally across from one another, as in conventional practice, the long axis of the straps is perpendicular to the direction of the relative movement between the two sides. A large amount of this motion can then occur with little increase in the distance between these points. This fact, in addition to the high degree of compression and migration of the tissue in the pelvic region, contributes greatly to the problem. In this case, the unwanted action can take place due to a lack of increased tension on the closure straps at the onset of the motion. However, if the points are placed so that the long axis of the straps will <i>not</i> be perpendicular to the direction of movement, the distance change between these points per unit of motion is much greater.<a style="text-decoration: none;">*</a> This will cause a rapidly increasing tension on the straps, hence restricting additional movement.</p> <p>Each strap in the cross will restrict translation in one direction; motion in the other direction will bring the attachment points closer together, and the strap will loosen. Application of the cross introduces a strap for the limitation of motion in both directions (<a href="/files/original/90b09bc05fe9f54eac7fb5d364a84b1c.jpeg"><b>Fig. 1</b></a>).</p> <p>When applied to prostheses, a visible difference in the amount of relative motion possible could be noted between the conventional closure and the cross-diagonal closure (<a href="/files/original/f21dd604b9586a00f2668ad4a7c12771.jpg"><b>Fig. 2</b></a>). The appliances with the crossed type were no more difficult to don and doff than the corresponding conventional types. This closure is presented here because of the similarities in the pelvic sections of both prostheses and orthoses along with the similarities in the problems that accompany each. The cross-diagonal closure may be utilized as an important new method of optimizing increased effectiveness and patient comfort.</p> <b>Footnote</b> This physical phenomenon is explained trigonometrically by the fact that the difference in the sine functions of a one degree (1°) change (0° to 1°) near the horizontal is much larger than the difference in the sine function of a one degree (1°) change near the vertical (89° to 90°).<br /> <div style="width: 400px;"><br /><em><b>*Louis Ekus, CO </b> Currently medical student at the School of Medicine, Universidad del Noreste, Tampico, Mexico; formerly a staff orthotist, Institute of Rehabilitation Medicine, New York University Medical Center.</em></div> <div style="width: 400px;"><br /><br /></div> Page Number(s) 6 - 6 Year 1981 Volume 5 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1981_01_006/1981_01_006-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 2 http://www.oandplibrary.org/cpo/images/1981_01_006/1981_01_006-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Cross-Diagonal Closure Of Pelvic And Spinal Appliances Creator An entity primarily responsible for making the resource Louis Ekus, CO * https://staging.drfop.org/files/original/e55fe02d0cf8042e8e390517f507f005.png 9879f15cbcbb416d004b012e4155375c 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 Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. URL <a href="https://www.designedtolivelatvia.com">www.designedtolivelatvia.com</a> Contact Name/Title Katie Leatherwood - Director City Riga Countries Served Latvia Regions: EuropeCountries: LatviaAge Group: Adults, ChildrenFees Charged: No Postal Code 1010 Phone 371 20621308 Email Katie@designedtolivelatvia.com Organization Type Including ID and tax status Non-profit Not-for-profit Type 501(c)(3), Christian ministry Services Provided Prosthetic Fitting, Orthotic Fitting, Education, Prosthetic Fabrication, Orthotic Fabrication, Rehabilitation / Training Need I Financial Assistance Need II Materials, Components, and Equipment Need III Materials, Components, and Equipment: New, Disassembled, Equipment, Used Additional Info & Comments Designed to Live is a mercy ministry of Bridge Builders International. O&P services are provided to those that would benefit but are unable to get them, due to transportation issues or qualification criteria. Designed to Live works from a mobile care unit to provide O&P services when transportation is a factor. Designed to Live collaborates with local O&P providers to enhance care and education and to avoid encroachment on private and governmental practices.Beyond O&P services, Designed to Live seeks to empower those affected by physical disability through social, emotional, physical, and spiritual involvement. We hope to empower those with disability to live a life of meaning and significance. 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 Designed to Live