5 20 371 https://staging.drfop.org/files/original/ffc8eca439bcae403581feacfc98144e.pdf 4193bb67ab6993250dcf123adae8278b DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_01_001.pdf Year 1964 Volume 8 Issue 1 Page Number(s) 1 - 2 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_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Measurement and Evaluation</h2> <h5>Herbert R. Lissner, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p>"I often say that when you can measure what you are speaking about and express it in numbers, you know something about it; but when you cannot measure it in numbers your knowledge is of a meagre and unsatisfactory kind; it may be the beginning of knowledge but you have scarcely in your thoughts advanced to the stage of science, whatever the matter may be."</p> <p>-<i>Lord Kelvin</i></p> <p>Most of us devote appreciable time in the course of daily activity to making evaluations and forming value judgments. Every time we make a purchase, watch television, eat a meal-the list is endless-we make evaluations. Factors considered may involve monetary costs, saving of labor and time, ethical principles, aesthetic enjoyment, and many other matters.</p> <p>In order to reach a final decision, it is usually necessary to combine, or even to counterbalance, evaluations made in many subsidiary categories. Those subgroups to which numbers can be applied, such as initial monetary cost and maximum attainable speed, are the easiest to consider, while those to which numbers cannot be easily assigned are more difficult to evaluate.</p> <p>The establishment of standards is a recognized aid in the making of evaluations. Standards may consist simply of a set of lower limits; any product which fails to meet them is automatically eliminated from consideration. Examples of this hurdle or barrier type are some of the standards of the Underwriters' Laboratories for electrical appliances. A variant of this kind of standard may involve an upper as well as a lower limit, such as the "go-no-go" type. Conversely, a standard may involve the expression of a ratio of the specific item to the ultimate attainable, so each evaluation is a rating indicating how closely the limit is approached. A standard of this type is involved in the grading of examinations. (Even then the relationship between the score and the practical application is not always clear; the "A" student is not always successful in later life.) An intermediate form of standard is a rank ordering of individual items, along some defined scale, thus allowing comparison of each item with the average and its fellows.</p> <p>All these types of standards are clearly of value, so the establishment of standards, at least tentatively, should generally precede the process of evaluation. In the production of materials and the fabrication of products of all kinds, industry and Government depend on established standards in making purchases, compliance testing, and the design of more complex products. For many years the American Society for Testing and Materials, the American Standards Association, numerous trade associations, and various Government agencies have sponsored development of standards and specifications.</p> <p>Now what has all this to do with artificial limbs and braces? Evaluation serves one primary purpose in this case-the improvement of the product, a special type of man-machine combination. If the artificial limb could duplicate exactly all the functions of the natural limb in spite of the limited resources of power, sensibility, and control remaining available to the amputee, presumably we would have an ideal prosthesis. Minimal standards can rule out gross malfunctions, frequent and hazardous physical breakdowns, and obvious discomfort. Reasonably accurate lower and upper boundaries of physical dimensions to match specific categories of amputees can be established from anthropometric data illuminated by the best experience of the industry. In another sense, the physical strengths and practical minimal wall thicknesses set lower limits to weights, while maximal tolerable weights and inertias can also be estimated. By specifying the functional capabilities of the human limb we can establish the maximum standards we would like to achieve with our replacement. (The frequent recent suggestions of servo systems or "man amplifiers," though, imply that merely human performance may not be an upper bound.)</p> <p>These standards of several types should be specified in many categories. Any problem, no matter how complex, can be approached by breaking it down into small segments which can be analyzed. It is only as we define the significant categories, establish and progressively refine standards, and make objective evaluations that further appreciable advances in artificial limbs and braces will be made.</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>Herbert R. Lissner, M.S. </b></td></tr><tr><td class="clsTextSmall"> Professor and Chairman of the Department of Engineering and Mechanics, and Coordinator, Biomechanics Research Center, Colleges of Engineering and Medicine, Wayne State University, Detroit, Mich. 48202; Chairman, Subcommittee on Evaluation, Committee on Prosthetics Research and Development.</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 Measurement and Evaluation Creator An entity primarily responsible for making the resource Herbert R. Lissner, M.S. * https://staging.drfop.org/files/original/1d1ceef5e0e7ae1a01db4bf1a14f920a.pdf 15dde9b5748aae3e70554e693a2ccc35 https://staging.drfop.org/files/original/7341a1c789bf50c28c6f291e6ce1b8f1.jpg a3415062e2c78119f25ba9e99a91aab7 https://staging.drfop.org/files/original/58d7d562a2d2d25b6b29f764f5d0cfb4.jpg 9323149b8c303a17391f937f755ab79f https://staging.drfop.org/files/original/91b42dd18f1fc3412b1263cdc9856b74.jpg 977982cad4750c82718536539f96a0c1 https://staging.drfop.org/files/original/6a553c553328022c82face981f32bc08.jpg 7be62c5f05196a9b3fcee0f6702c980c https://staging.drfop.org/files/original/be77138d9c5e8b93c403e5150d85485f.jpg b0ac7e722904c5644175eb02eb4e1fda https://staging.drfop.org/files/original/f9cc0bf598af3d0a6e01e53df4364432.jpg 43756341fd355ef896d2d087e0f4aa7d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_011.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 11 - 16 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_011.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_011.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Independent Control Harnessing in Upper Extremity Prosthetics</h2> <h5>Colin A. McLaurin, B.A.Sc. <a style="text-decoration:none;">*</a><br />Fred Sammons, B.A. <a style="text-decoration:none;">*</a><br /></h5> <p>Functionally, the well-designed and well-constructed body harness for an upper-extremity prosthesis serves a twofold purpose: first, it helps to hold the prosthesis in place; second, it transmits body power for operation of the prosthesis. </p> <p> For shoulder-disarticulation amputees and for high above-elbow amputees, the provision of an adequate functional harness presents a challenging problem particularly with respect to power transmission and control. The problem is especially difficult in the case of shoulder-disarticulation amputees because of the lack of a control source from humeral motion, which is the major source of power and control in the case of above-elbow amputees. The typical prosthesis for shoulder-disarticulation amputees utilizes shoulder motions and chest expansion. </p> <p>In the present limited state of the art of prosthetics, there are three minimal operations to be controlled in an upper-extremity prosthesis: lifting of the forearm, operation of the terminal device, and management of the elbow lock. </p> <p> Here in the United States, the usual harnessing method for shoulder-disarticulation and above-elbow amputees utilizes the so-called "dual-control" system.<a></a> Lifting of the forearm of the prosthesis and operation of the terminal device are so linked mechanically that a single control motion (shoulder motion in the case of shoulder-disarticulation amputees arm flexion in the case of above-elbow amputee) produces either operation, dependending on weather the wlbow is locked or unlocked.</p> <p> In shoulder amputees, operation of the elbow lock must be managed by various special arrangements; for example, elevation of the shoulder, expansion of the chest, or use of the chin to nudge the elbow-lock control. In above-elbow amputees, operation of the elbow lock in a dual-control system depends upon extension of the humerus and depression of the shoulder. </p> <p> In a triple-control system, operation of the terminal device is separated from lifting of the forearm of the prosthesis. Triple control has been a recognized method of harnessing upper-extremity amputees for many years, and standard harness patterns providing triple control can be found quite readily in prosthetics literature.<a></a> However, triple-control harnessing in actual application is seldom seen in the United States, although it is used extensively in Germany and elsewhere. A possible reason for lack of use in the States is that in early trials it was difficult for the patients to operate the controls independently. </p> <p>Recent experiments at Xorthwestern University in fitting bilateral shoulder-disarticulation amputees have resulted in a harnessing system that provides acceptable function using standard components. Success with some five or six cases renewed interest in "independent-control" harnessing for above-elbow amputees. </p> <p> In describing this experimental harnessing for bilateral shoulder-disarticulation amputees and above-elbow amputees, the term "independent control," rather than "triple control," is used in order to avoid confusion with the standard harness patterns for triple control. </p> <h4> Bilateral Shoulder-Disarticulation Amputees </h4> <p> The limited availability of control sites constitutes a serious restriction on the effectiveness of a harnessing system for bilateral shoulder-disarticulation cases. Shoulder motions are available on both sides, and chest expansion can be utilized. However, there may be only sufficient control motions to obtain acceptable function from one prosthesis. In this event, activities which require the use of two hands, such as eating with a knife and fork, are necessarily precluded. </p> <p> Major consideration is given to operation of the terminal device and lifting the forearm of the prosthesis. In addition, the elbow lock must be operated and the functions of wrist and shoulder positioning should be supplied. </p> <p> Although there is but one prosthesis, two shoulder sockets are used. On the side of the amputee on which the prosthesis is suspended, the socket must, provide weight-bearing at the top. This socket may be fitted well down toward the lower edge of the rib cage in order to provide good stability. The other socket, or shoulder cap, is designed specifically to provide independent control of the terminal device, and it is made as small and as light as possible. (<b>Fig. 1</b> and <b>Fig. 2</b>) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Shoulder disarticulation on the right and humeral neck amputation on the left. Amputation followed electrical burns. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Bilateral amelia with scoliosis and short left leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> Shoulder Joint </h5> <p> A passively adjustable shoulder joint is essential for ease in putting on a coat, for positioning the prosthesis so that it does not interfere when sitting in an armchair, and for positioning the prosthesis for eating, writing, and similar tasks. Humeral abduction and flexion may be combined in a single axis joint. The friction plate shown in (<b>Fig. 2</b>) includes two wedge-shaped discs ("Wilson-Riblett wedges") which can be rotated during the preliminary fitting to provide the optimum plane of motion for the shoulder joint (<b>Fig. 3</b>). When this is obtained, thev are locked into position. The amount of friction can be regulated by a self-locking nut and washer which hold the assembly together. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Schematic drawing showing principle of "Wilson-Riblett wedges." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> Forearm Lift </h5> <p> Because the weight-bearing socket has been extended downward over the rib cage, the chest strap may be positioned around the center of the rib cage where maximum excursion can be obtained. The harness pattern shown in <b>Fig. 1</b> uses chest expansion in series with scapular abduction of the prosthesis-litted side to lift the forearm The forearm lift cable terminates in a swivel fitting at the lift tab. Since excursion is usually limited, the lift tab should be positioned close to the elbow joint. II this is not possible, a pulley may be titled to double the effect of the excursion. But. of course, such an arrangement doubles the input toree requirement In <b>Fig. 2</b>. the forearm lift cable is fitted internally in a special groove cut in the locking quadrant ol the elbow unit </p> <h5> Terminal Device </h5> <p> With the chest strap fastened about the middle ot his rib cage, the amputee is free to move the scapula of his nonprosthesis-bcaring shoulder. Thus, a small shoulder cap. carefully lilted to the scapula, can provide independent control of the terminal device. An anterior elastic strap is usually required to hold the shoulder cap in position. In <b>Fig. 2</b>, the available excursion was limited, and therefore a step-up pulley was necessarv in order to achieve full opening of the terminal device, </p> <h5> Elbow Lock </h5> <p> Since operation of the elbow lock requires a relatively small amount of excursion and force, there are several ways in which it can be accomplished. The patient shown in <b>Fig. 1</b> originally was fitted with a cable which ran from the elbow lock, around a pulley high on the shoulder, and thence down to a waist belt, so that shoulder elevation was used, alternately, to lock or to unlock the elbow. Later, this was replaced by the nudge control (<b>Fig. 1</b>), which the amputee preferred. </p> <p> For the patient shown in <b>Fig. 2</b>, the prominent acromioclavicular joint was utilized by cutting a hole in the anterior part of the socket and positioning a lever so that forward motion of the clavicle moved the lever forward and downward to develop tension in the elbow-lock cable. </p> <h5> Wrist Unit </h5> <p> A standard passive wrist-rotation unit, which permits pre-positioning by the amputee, was provided in both cases (<b>Fig. 1</b> and <b>Fig. 2</b>). </p> <p> For many tasks, such as toilet care, wrist flexion is important. Flexion can be provided by building it into the prosthetic forearm (<b>Fig. 2</b>), or by using a nudge control and Bowden cable to operate the lock on a standard wrist-flexion unit (<b>Fig. 1</b>). In the latter case the lock for the wrist-flexion unit is operated by relative motion between cable and housing. In this application the cable is stationary and the housing pushes to open the lock. To achieve this, the cable guides must be drilled out to allow the housing to slide freely. The inner cable passes through a hole drilled in the locking lever on the wrist-flexion unit and is anchored to a post screwed to the cover of the wrist unit (<b>Fig. 4</b>). When the wrist unit is unlocked by pressure on the nudge control, tension in the terminal-device cable will cause the wrist to flex. If the terminal-device cable is relaxed, gravity will cause the wrist to extend. Thus a measure of active wrist flexion is obtained. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Modifications of wrist-flexion unit for use with nudge control. Refer to Figure 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Capabilities and Limitations </h4> <p> The harnessing arrangement just described provides reasonably acceptable prosthetic function without the use of perineal straps. Independent control of the terminal device apart from operation of the elbow allows maximum opening of the terminal device in all positions of elbow flexion and improves the performance rate, since it is not necessary to lock the elbow before using the terminal device. Also, there is no tendency for the terminal device to open when the elbow is being flexed. </p> <p> The amputee who is a skilled foot user may be able to put on or take off the prosthesis without assistance, particularly if Velcro straps are used (<b>Fig. 2</b>). If the amputee is not a skilled foot user, assistance is required in fastening the chest strap snugly. </p> <p> The prime objective in fitting this type of prosthesis to a severely disabled amputee is to provide at least a minimum of self-sufficiency in public. Problems of selfdressing are complex, and their solution can scarcely be achieved without the use of external power and devices which have not yet been developed. </p> <h4> Above-Elbow Amputees </h4> <p> The same three minimal operations (namely, operation of the terminal device, lifting of the forearm, and management of the elbow lock) must be controlled in the prosthesis for a unilateral above-elbow amputee. To avoid restriction of the sound arm, the axilla loop of the harness should provide stabilization only. Hence the shoulder motions available for prosthetic use are those that remain on the amputated side. These are scapular abduction, humeral flexion, and humeral abduction. It is conceivable that humeral extension and humeral abduction could be harnessed, but an entirely different harnessing configuration would be required. As in the case of the shoulder-disarticulation amputee, shoulder elevation can be used only in conjunction with a perineal strap or a firm waistband. Most above-elbow amputees can separate scapular and humeral motion, and the harnessing described here is specifically designed to utilize this independent control. </p> <p> In this harnessing system, lifting of the forearm of the prosthesis is activated by scapular abduction. The anchor point is a ring held in the center of the back by the axilla loop. The reaction point is attached high on the socket, so as to be independent of humeral flexion. If the reaction point is placed centrally near the top edge of the socket, rotation is minimized and humeral abduction can be used to increase the excursion. The cable is passed through the reaction point and terminates in a swivel at the forearm lift tab, the length and position of which should be carefully adjusted to make full use of the available excursion. (The cable housing at the reaction point serves only as a cable guide.) The suspension strap and elbow-lock strap are attached as shown in <b>Fig. 5</b>, the configuration being essentially the same as that used in the Northwestern University dual-control ring-type harness. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Congenital above-elbow amputee fitted with independent control. Scapular abduction is used for forearm lift. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Humeral flexion and abduction are harnessed to provide operation of the terminal device. Experiments indicate that the harness pattern shown in <b>Fig. 5</b> is preferable to that in which the control cable is attached solely to the harness ring. A Bowden cable is used, with the housing anchored on the humeral section and on the forearm in a manner similar to that of a standard below-elbow fitting, so that operation of the terminal device is independent of flexion of the elbow. </p> <p> Optimum results are obtained when the shoulder motions are used in combination. Maximum lift of the forearm is achieved when the humerus is abducted at the same time that the scapula is abducted. This means that the elbow is held close in to the body as the forearm is lifted-a motion that is not ideal for certain tasks, such as switchboard operation. Scapular abduction also tends to affect the terminal-device cable. Thus, when the elbow is held in full flexion, there may be some tension induced in the terminal-device cable, making it difficult to hold the hook closed without locking the elbow. Conversely, the hook is very easy to open fully in this position. </p> <p> Three amputees have been fitted with this type of harness and have been wearing it routinely for several months. In addition, one bilateral amputee has been fitted with dual control on one arm and independent control on the other. All the subjects had been users of prostheses. They learned the basic controls with about an hour's training and became proficient at the end of a week. </p> <p> This harnessing provides excellent terminal-device function throughout the full range of elbow flexion, without locking or even stabilizing the elbow. Since the terminal device is independent of the forearm lift, there is no tendency for the hook to open when the forearm is being raised. However, near the point of full flexion, the interaction of the harness straps does require considerable effort to avoid opening the hook. Moreover, the force available for lifting the forearm is adequate only for the lightest loads. </p> <p> After several months' wear, one of the amputees rejected the harness and was refitted with a different type of independent control (<b>Fig. 6</b>). The operation of the terminal device was left unchanged, but the forearm-lift and elbow-lock straps were interchanged so that shoulder depression was used to raise the forearm, and scapular abduction to operate the lock. This seemed to provide greater force for lifting the forearm, provided the humerus is not flexed more than about 20 deg. Operation of the terminal device appeared to be slightly improved. The amputee is still wearing the prosthesis routinely. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Same amputee as shown in Figure 5 fitted so the shoulder depression is used to lift the forearm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>References:</b></p> <ol> <li><p>Pursley, Robert J., <i>Haness patterns for upper-extremity prostheses</i>, Artificial Limbs, September 1955, p. 26. </p> </li> <li><p>Pursley, Robert J., <i>Harness patterns for upper-extremity prostheses</i>, Chap. 4 in <i>Orthopaedic appliances atlas</i>, Vol. 2, Edwards, Ann Arbor, Mich., 1960. </p> </li> <li><p>Taylor, Craig L., <i>The biomechanics of control in upper-extremity prostheses</i>, Artificial Limbs, September 1955, p. 4. </p> </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Pursley, Robert J., Haness patterns for upper-extremity prostheses, Artificial Limbs, September 1955, p. 26. </td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Chap. 4 in Orthopaedic appliances atlas, Vol. 2, Edwards, Ann Arbor, Mich., 1960. </td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, September 1955, p. 4. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Pursley, Robert J., Haness patterns for upper-extremity prostheses, Artificial Limbs, September 1955, p. 26. </td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Chap. 4 in Orthopaedic appliances atlas, Vol. 2, Edwards, Ann Arbor, Mich., 1960. </td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, September 1955, p. 4. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Fred Sammons, B.A. </b></td></tr><tr><td class="clsTextSmall">Research Therapist, Northwestern University Prosthetics Research Center, Chicago, Ill.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Colin A. McLaurin, B.A.Sc. </b></td></tr><tr><td class="clsTextSmall">Project Director, Northwestern University Prosthetics Research Center; Research Associate, Department of Orthopedic Surgery, Northwestern University, Chicago, Ill</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-15.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-16.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-17.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-18.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-19.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-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 Independent Control Harnessing in Upper Extremity Prosthetics Creator An entity primarily responsible for making the resource Colin A. McLaurin, B.A.Sc. * Fred Sammons, B.A. * https://staging.drfop.org/files/original/b21f639d8362d0faf7871fcd6b206981.pdf 00160730564941a88e1227cce0fc4cd6 https://staging.drfop.org/files/original/ae5fbb09b20594328d67143767a4b196.jpg 1f7187fd9cd02bd85bbacdc01a7d59b1 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_02_050.pdf Year 1963 Volume 7 Issue 2 Page Number(s) 50 - 52 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_02_050.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_02_050.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Limb-Deficient Child, a Review</h2> <h5>Charles H. Frantz, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p><i>The Limb-Deficient Child</i> is important as the first comprehensive summary of modern techniques in the relatively new field of child prosthetics. For until recent years, the consensus was that prosthetic fitting could wait "until the child is older"-an opinion based on the generally unsatisfactory attempts to care for the child amputee as if he were simply a small adult. The presentation made in <i>The Limb-Deficient Child</i> is based on the experience of the Child Amputee Prosthetics Project of the University of California at Los Angeles. The Project was started in 1955 and is supported by grants from the United States Department of Health, Education, and Welfare. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. <i>The Limb-Deficient Child</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Dr. Milo B. Brooks, who is the Medical Director of the Project, various members of the Project staff, and other persons closely associated with the Project are the contributors to <i>The Limb-Deficient Child</i>. The nine chapters of the book cover the role of the medical director, orthopedic considerations, psychosocial problems, preprosthetic evaluations, preprosthetic therapy, child prosthesis design and fitting, training, training the upper-extremity amputee, and lower-extremity training. There are numerous illustrations, the appendix contains various evaluation charts developed at the Child Amputee Prosthetics Project, and there is an index.</p> <p>Chapter I, "The Role of the Medical Director," describes the type of information desired from the referring physician and parents, stressing social information concerning the family organization, the child's general physical condition, and the type of amputation presented. A number of charts depict the normal development of children, with heights and weights for given ages. There is some discussion of the growth and development of limb-deficient children, the problems of limb dominance, and psychological adjustment. The etiology of congenital limb deficiencies is briefly discussed, and statistics are presented on cases studied at the Project. The thalidomide syndrome is briefly mentioned.</p> <p>Chapter II, "Orthopedic Considerations," discusses the relative importance of orthopedic management, the utilization of plas-ter-of-Paris cast techniques for correction, the use of braces, indications for surgical interference, the problem of scars, and the functional range of joints. Although very brief, the discussion on long bones, osteotomies, the problem of terminal overgrowth of long bones, neuromata, and the judgment and timing of surgical conversion of deficient extremities to more conventional types of stumps will be of interest to the orthopedist.</p> <p>This reviewer, however, is not in agreement with the attempt made in the discussion of the development of limbs to assign dermatome relationships to the limb buds.</p> <p>In general, this reviewer agrees with the brief classification of limb deficiencies, although it is incomplete from an anatomical standpoint. Perhaps future modifications may be in order to produce a more universal nomenclature, understandable to all who are interested in the limb-deficient child. The classification is followed by the prosthetics management of the terminal transverse deficiencies from wrist disarticulation (acheiria) up to amelia or shoulder disarticulation.</p> <p>Chapter III, "The Psychosocial Problems," gives a realistic discussion of parental guilt feelings and parental cooperation and emotional stability. There is discussion of the role of the physician in attempting to produce an environment of cooperation by the parents, an environment that is essential for success in treating the child amputee. The problems confronting the prosthetics team during the child's preadolescent and adolescent years are discussed, and the role of the social worker is clearly defined. This is an important chapter in the book.</p> <p>Chapter IV, "Preprosthetic Evaluations," discusses in detail the roles of the occupational therapist and the physical therapist. Reference is made to <i>The First Five Years of Life</i>, by Arnold Gesell and others, and it is highly desirable that therapists be well acquainted with this work. Chapter IV briefly describes the progress of motor kinesthetic development from the infant to the toddler. Techniques for determining the range of motion and the functional needs of the child are analyzed carefully. The chapter discusses the self-care needs of the child and relates them to the type of prosthesis indicated.</p> <p>In Chapter V, "Preprosthetic Therapy," the principles of joint motion, the correction of contractures, techniques of bandaging for shrinkage, the proper use of crutches, and skin care are elucidated and beautifully illustrated by photography.</p> <p>Chapter VI, "Child Prosthesis Design and Fitting," presents the important consideration of the growth of the child as contrasted to the adult. Materials for prostheses, such as plaster and polyester and epoxy resins, are discussed. The choice of terminal devices appropriate to the age and size of the child is clearly stated and well illustrated. Techniques for harnessing are demonstrated by photography. In addition, there are shown nonstandard types of prostheses for fitting upper-extremity phocomelic children. Unusual methods for operating elbow locks, by the phocomelic limb, buried in the humeral section of the prosthesis, are given special attention. The problems of upper-extremity amelia, both unilateral and bilateral, are discussed and shown in photographs, including cable systems and the various methods of hook-ups for the transmission of power. The problem of fitting a multihandicapped child is covered, together with some of the frustrating problems of finding power for terminal-device operation that is adequate in terms of the amount of energy expended. Stages of fitting lower-extremity amelic children from a small stationary bucket up to two prostheses are shown.</p> <p>In Chapter VII, "The Training Period," the training of the limb-deficient child is stressed, and rightly so. The child must know what the prosthesis will do for him. The chapter also emphasizes that one cannot go beyond the child's capabilities or his kinesthetic development for his years. One must not expect too much too soon in the avenues of function. There is a practical and well-illustrated discussion of clothing needs and modifications for ease of application. Illustrations also show how to reduce friction from the system through proper alignment of the cable-control assembly. Techniques to be employed by the unilateral and the bilateral amputee in applying and removing the prosthesis are excellently illustrated. The lower extremities are dealt with briefly with respect to the fitting of the socket, proper application-especially the fitting of a suction socket-and the problems involved with a patellar-tendon-bearing prosthesis and bilateral lower-extremity prostheses.</p> <p>Chapter VIII, "Training the Upper-Extremity Amputee," is well illustrated and goes into considerable detail. The environmental situation is discussed, and the necessary equipment is illustrated. In this reviewer's mind, there is some question about the discussion of training infants, because it is debatable whether one actually trains an infant or simply exposes him to experience in motor fields. There is discussion of the desirability of the presence of parents during training periods. Techniques for activating the components in stages by the young child are clearly presented, and action photographs show the functional capabilities of youngsters of various ages, both unilateral and bilateral types. Activities (aids to daily living) are well documented and very practical. This chapter should be especially interesting to occupational therapists.</p> <p>Chapter IX, "Training the Lower-Extremity Amputee," is much shorter than the preceding chapter. It gives a brief description of the progress of a youngster from infancy to an erect standing posture. Three phases of training are discussed with respect to the lower-extremity amputee. Comfort, fit, and skin tolerance are important during the first phase, with frequent inspection of the skin and prosthesis alignment. Independent ambulation is achieved during the second phase. During the third phase, faster ambulation, stair climbing, and walking up and down ramps and over uneven ground are mastered. This training is clearly illustrated by excellent photographs.</p> <p>Judging by its title, one would expect <i>The Limb-Deficient Child</i> to be a textbook on all facets of the child amputee. It is not such a text. It is a well-written presentation of the experiences of the Child Amputee Prosthetics Project of the University of California at Los Angeles. The problems of the limb-deficient child are much more far-reaching than this volume indicates.</p> <p>But the book is important as the first of its kind and should serve as a reference for physical and occupational therapists and for pros-thetists. It is a clear and very adequately illustrated narrative, with excellent photographs of children in action during their training periods, and photographs of prostheses. Harnessing patterns and cable operations are clearly depicted. There is much material here that should be of great assistance to therapists and prosthetists, particularly those who have broad experience with adult amputees. For with this text they can translate their past experience into the area of child amputees, especially those with congenitally malformed limbs.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles H. Frantz, M.D. </b></td></tr><tr><td class="clsTextSmall">Medical Co-Director, Area Child Amputee Program, Michigan Crippled Children Commission; Chairman, Subcommittee on Child Prosthetics Problems, CPRD, NAS-NRC, Washington, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_02_050/1963-Autumn-59.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Limb-Deficient Child, a Review Creator An entity primarily responsible for making the resource Charles H. Frantz, M.D. * https://staging.drfop.org/files/original/b25b9a939b4d5c4ae9c2f2acedbd696c.pdf b30d583cd18be4ab29c7f0440219cbfc https://staging.drfop.org/files/original/085e246a53c62b03b6a70a4a5358313e.jpg 7e93897e87d2197f2f94cc38f6151bab https://staging.drfop.org/files/original/bf1d9342409ad283c4fc51fe85e5c428.jpg 8f49557f305b3f91b7b067d1d2fb37d8 https://staging.drfop.org/files/original/2401bf3d7149007a01025885d08d12ae.jpg c566cc861e0b9018fe1dc2d38a6f166f https://staging.drfop.org/files/original/c726ce3e24b0aade2c6e4dafa6f1bc65.jpg b0f4603259af940f59a613343b3209e6 https://staging.drfop.org/files/original/521e1b62356225f950ec5636d3aa0e99.jpg dba0a9cfe630f9f2342e23e916484200 https://staging.drfop.org/files/original/253df5a8e8ea95d454b65a3804d794f2.jpg bb1cae0e839a9c04e07cecb7754caece https://staging.drfop.org/files/original/e5705786f693a02943d04c1e21474ff9.jpg 36fc5cade6ee7836f0dad674628a3d63 https://staging.drfop.org/files/original/c93272788dcc12626615e966d1932254.jpg 43b0d4a687d08e1b229d409a604aeb7a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_02_043.pdf Year 1963 Volume 7 Issue 2 Page Number(s) 43 - 49 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_02_043.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_02_043.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>Socket Flexion and Gait of an Above-Knee, Bilateral Amputee</h2> <h5>Edward Peizer, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Many factors affect the gait of an above-knee, bilateral amputee as he walks on his prostheses. Among the factors are his general health and strength, the length and condition of his stumps, the alignment of his prostheses, his comfort, and the type of knee units employed.</p> <p>While some of these factors are difficult to observe accurately, others lend themselves to objective measurement and evaluation by means of current bioengineering techniques. Not long ago, the Bioengineering Laboratory of the Veterans Administration Prosthetics Center had occasion to evaluate the gait of an above-knee, bilateral amputee, and in the course of the evaluation developed records that show graphically the "before" and "after" effect of increased hip flexion of about 10 deg. in both sockets.</p> <h3>Background</h3> <p>An above-knee, bilateral, 26-year-old, male amputee veteran, who was fitted with two suction sockets and two Hydra-Cadence knee units, was referred to the Bioengineering Laboratory for gait evaluation. The amputations resulted from an automobile accident; the patient was a vigorous young man in good health, with well-muscled, strong stumps. He weighed 158 lb. with prostheses, stood 5 ft. 8 in., had 12-in. stumps, and had worn constant-friction knee units for two years. In May 1962, he was fitted with one Hydra-Cadence unit, and approximately three months later was fitted with a second Hydra-Cadence unit.</p> <p>After he had worn both units for three or four months, evaluation indicated that, although he managed two suction sockets adequately, the two Hydra-Cadence units produced a jerkiness in his gait which was tentatively attributed to the higher energy requirements of the hydraulic units.</p> <p>The clinic team recommended that both Hydra-Cadence units be replaced with constant-friction units and requested the Bioengineering Laboratory to obtain photographic records of his performance on the Hydra-Cadence units for subsequent comparison with records to be obtained of his performance on the constant-friction units.</p> <p>On May 15, 1963, the amputee appeared at the Bioengineering Laboratory for evaluation. Preliminary examination of the prostheses indicated only marginal-if not inadequate- initial hip flexion. Observation of the subject's gait tended to confirm this impression; he seemed exceptionally "stable" and found it necessary to jerk his knee forward to initiate the swing phase. This produced a marked lurching pattern in his gait.</p> <p>The Bioengineering Laboratory recommended realignment of the prostheses, with particular emphasis on increasing initial hip flexion as a step which might improve function and obviate the necessity for refitting with constant-friction knee units. The clinic team concurred. A biomechanical analysis of the amputee's performance with his unaltered prostheses was conducted at the Laboratory on May 15. On May 24, 1963, after the amputee's prostheses were realigned by procedures which did not involve refabrication of the sockets, his performance was re-evaluated.</p> <h3>Procedures</h3> <p>The purpose of the two biomechanical evaluations was to identify changes in the gait pattern of the amputee which might have occurred as a result of changing the attitude of both sockets so as to increase initial hip flexion (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Socket realignment to provide 10 deg. of initial hip flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because of the length of the amputee's stumps (12 in.) and the need to maintain cosmetic acceptability, the maximum increase of hip flexion possible was from 0 deg. to 10 deg. This change in attitude was intended to increase the amputee's functional range in hip extension and thereby improve his control of knee stability during stance, with potential effects upon his speed of walking, his stride length, the smoothness of the path followed by his center of gravity, the application of his body weight to the floor, the characteristics of his push-off, and his knee flexion at toe-off. Since the change was simply an increase of flexion, and only in one plane, it was accomplished without the use of the VAPC adjustable coupling.<a></a></p> <p>Although the amputee normally walked with the aid of canes, he did not use them during the two evaluations.</p> <p>For each evaluation, the amputee walked along a level walkway, first in one direction and then in the other, thus making two transits of the walkway on each occasion. Run No. 1 and run No. 3 were made on May 15; run No. 4 and run No. 5 on May 24. Because of equipment failure on run No. 2, no data are shown for that run.</p> <p>He was targeted with reflective tape at the head, elbow, hip, knee, ankle, and shoe for photography from the side by an interrupted-light camera during the transits. Also, as he proceeded along the walkway, he stepped on a set of force plates (thus providing a measure of the application of his body weight to the floor). Simultaneously, the tachograph (<b>Fig. 2</b>) measured and recorded his acceleration and velocity. Descriptions of these procedures and devices appeared in Artificial Limbs in 1954.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Schematic diagram of the tachograph, a system for recording linear velocity. The subject wears a lightweight belt, to which is attached a fine cable that turns the rotor of a direct-current generator. Voltage produced by the generator is proportional to the velocity of the subject. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Results</h3> <h4>Average Velocity</h4> <p>Average velocities, determined by integrating the tachograph curves, are given below in fiftieths of an inch of galvanometer deflection. An increase in velocity may reflect easier initiation of swing phase, an increased push-off force, or greater stride length. <b>(Table 1)</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It can be noted that the patient's velocity was greater after realignment of his prostheses-substantially higher in run No. 4, and moderately higher in run No. 5. In <b>Fig. 3</b>, the velocity curves prior to realignment fall below the zero velocity level, indicating backward movement. In order to initiate the swing phase, it was necessary for the patient to incline his torso forward, with a consequent rearward thrust of the pelvis. The tachograph recorded this rearward thrust as a backward movement.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Tachograph recordings. Run No. 1 and run No. 3 were recorded on May 15, 1963, prior to realignment of prostheses; run No. 4 and run No. 5 on May 24, 1963, after realignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Average Stride Length</h4> <p>Stride length is the distance between consecutive heel contacts by the same leg. In this case, increased stride length may be regarded as a result of greater control and strength in hip extension, increased push-off force, and easier initiation of the swing phase.</p> <p><b>Average Stride Length</b></p> <blockquote><p>Prior to Realignment of Prostheses: 17.0 in.<br />After Realignment of Prostheses: 19.4 in.</p> </blockquote> <h4>Smoothness Of Gait</h4> <p>In addition to measuring velocity, the tacho-gram reflected other elements of the gait pattern. Thus the smoother wave forms recorded after realignment of the prostheses (<b>Fig. 3</b>) indicate less lurching and jerkiness in the gait pattern.</p> <h4>Anteroposterior And Vertical Displacements</h4> <p>No significant differences were observed in the displacement of the head, elbow, hip, and knee after realignment of the sockets. However, the ankle displacement curve (<b>Fig. 4</b>) indicated a more rhythmic oscillation of greater amplitude after the realignment. This motion reflects more normal timing and range of knee flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Pathways of targeted points on the amputee during ambulation, as determined by interrupted-light photography. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Knee Flexion</h4> <p>Knee flexion at toe-off and during the swing phase prior to realignment of the sockets was variable and at times very limited. After realignment of the sockets, the extent of knee flexion at toe-off and during the swing phase was more consistent and generally of more normal magnitude. <b>(Table 2)</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Floor Reaction Forces</h4> <p>In view of the variability of the patient's performance on the four runs, vertical load and fore-and-aft shear forces do not show consistent differences. Nevertheless, reference to <b>Fig. 5</b> indicates that:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Force-plate data. Vertical forces applied by the subject to the force plate during the stance phase are shown in the upper curves. Less time was required to apply the full body weight to the prosthesis after realignment. Fore-and-aft shear forces shown in the lower curves indicate the pattern of push-off and toe-off. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient applied his full body weight to the prostheses faster after the sockets were realigned. <b>(Table 3)</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Full body weight was applied to the prostheses in a smoother, less jerky fashion, as indicated by a diminution of the oscillations in the patterns representing performance after realignment.</p> <p>The smaller amplitude of the oscillations in the vertical load curves after realignment indicates decreased lurching in the stance phase and perhaps a smoother initiation of the swing phase on the contralateral side.</p> <p>The fore-and-aft shear load curves indicate greater horizontal forces after push-off with the realigned sockets. Moreover, the increased magnitude of the aft shear loads after toe-off before realignment indicates a greater degree of toe drag.</p> <h4>Motion-Picture Analysis</h4> <p>Motion pictures were made of the patient prior to and after realignment of the sockets. Analysis of the gait patterns indicated the following positive changes:</p> <ul> <li>Somewhat less anteroposterior pelvic lurch.</li> <li>More symmetrical arm swing.</li> <li>Somewhat longer step length.</li> <li>Narrower walking base.</li> <li>Easier initiation of the swing phase with increased hip flexion.</li> </ul> <p>Analysis of the motion pictures did not bring out any significant improvement in stability. However, this may have been masked by the obviously improved mobility.</p> <h3>Summary</h3> <p>The performance of an above-knee, bilateral amputee in level walking with two suction sockets and two Hydra-Cadence knee units was compared before and after increasing initial hip flexion approximately 10 deg. Before realignment, he had worn the assembly three or four months. However, the second evaluation was conducted on the same day as the realignment; consequently, the comparison does not represent a reliable index to the significance of the change. The observations disclose only immediate reactions; another evaluation after at least three months of wear should provide a more conclusive analysis.</p> <p>In general, the patient's performance revealed marked variations from run to run, making it difficult to select a truly representative performance for each test condition. For this reason, "before" and "after" data describing performance during the runs have been presented.</p> <p>The increased initial hip flexion was undertaken to increase the amputee's range and strength in hip extension. Analysis of the data disclosed mild improvements in:</p> <ul> <li>Stability.</li> <li>Velocity and stride length.</li> <li>Smoothness of gait pattern.</li> <li>Initiating the swing phase by increased push-off forces.</li> </ul> <p>The only significant change which could be identified in the symmetry of the motions of body segments was a more normal ankle displacement, reflecting improved knee flexion in the swing phase.</p> <p>A follow-up inquiry on August 20, 1963, disclosed that the patient, who was employed in a summer camp, was wearing his prostheses daily. Because of the hilly terrain where he was working, he was using two crutches rather than the two canes previously used. Despite his comments that the limbs were heavy and he wanted to have the socket fit re-checked, he regularly wore the prostheses from 8:00 a.m. to 11:00 p.m. daily and did considerable walking.</p> <p>This experience illustrates a tendency toward excessive concern for stability when fitting and aligning prostheses for above-knee, bilateral amputees, thereby imposing needless functional limitation.</p> <p>In this particular case, more than 10 deg. of initial hip flexion could have been tolerated without significant loss of stability. However, even the increase of 10 deg., the maximum in view of stump length and cosmetic requirements, had several beneficial effects on the patient's performance.</p> <p><b>References:</b></p> <ol> <li>Contini, Renato, <i>Prosthetics research and the engineering profession</i>, Artificial Limbs, September 1954, p. 47.</li> <li>Staros, Anthony, <i>Dynamic alignment of artificial legs with the adjustable coupling</i>, Artificial Limbs, Spring 1963, p. 31.</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">Contini, Renato, Prosthetics research and the engineering profession, Artificial Limbs, September 1954, p. 47.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Staros, Anthony, Dynamic alignment of artificial legs with the adjustable coupling, Artificial Limbs, Spring 1963, p. 31.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward Peizer, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Bioengineering Laboratory, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York 1, N. Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-51.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-53.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-52.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-56.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-57.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-54.jpg Figure 7 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-58.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-55.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 Socket Flexion and Gait of an Above-Knee, Bilateral Amputee Creator An entity primarily responsible for making the resource Edward Peizer, Ph.D. * https://staging.drfop.org/files/original/2454e632e42420f5fbd9bce3b94c5d26.pdf 3fb2fc0e82bf0e81ff3b766417726825 https://staging.drfop.org/files/original/0fbb48cc7f8be2062a6ef1860380b1db.jpg 10f58f606d2826e85a8834bcf4ce1618 https://staging.drfop.org/files/original/390aa04ec4ca8747dd76e9b7bd7ee923.jpg a420b9510857f5050d953cc7c1dee1ba https://staging.drfop.org/files/original/d6c388c96a97ee0286d3f33bcc663dd9.jpg a71b2664ba6bc532c8b584aafd92456d https://staging.drfop.org/files/original/2cc3677702fc63277a84b78b31553d0f.jpg 6bf6d709cea5e41e4181f8eb491dc322 https://staging.drfop.org/files/original/05e2635a31f6705d8964743ef1ab1c97.jpg cc7ec1ecaa1920e120445f96e23716d0 https://staging.drfop.org/files/original/67b2a42098ed37709567c9cd073a9523.jpg bc01ac1ea334653d58fecdd6f5232991 https://staging.drfop.org/files/original/4c7372b87bbc2e39ea813a2106c92c3f.jpg e272ccb3f9305d4b903f02dcd80224a3 https://staging.drfop.org/files/original/8ff31674a51e9a5d98c2f2188c482daa.jpg 396fb37a1bb92c6bcb2510bb162e656d https://staging.drfop.org/files/original/5abdff87ef605569db6e6ab85ad9b943.jpg c0a32d7611423c170a7177848c2b005b https://staging.drfop.org/files/original/3ec5b5db0ac4ca86109c5997049d32cb.jpg 522c4216b81d5039e308af4c1224f86b https://staging.drfop.org/files/original/b1431bea1bd1d049787c1fa4eb76a711.jpg 0fb3c0624d8f212d8e80f17509fc503a https://staging.drfop.org/files/original/bfbeba79a2bad347ee410568ae691658.jpg 19e99f2f82038d2f139eb8f7e65cbab7 https://staging.drfop.org/files/original/31ae0055d196b577a378c7c29d9c0ca6.jpg f164e0fce76adab851b700520eec3f55 https://staging.drfop.org/files/original/ecf043f5da4a407762cbc21b2649ac2a.jpg db341d796ac5ee6990d6d22dd0553957 https://staging.drfop.org/files/original/157812260024af546d8310f288656a54.jpg 2305349ac4bfcc69d72d871d8b8ba666 https://staging.drfop.org/files/original/ba2062e98c97e0ad3402067cb4590bed.jpg b8fb3650cf8864acf85624db8ba24d54 https://staging.drfop.org/files/original/f85cd06ba61564a5b292b694411a6b82.jpg f9189a9e041000dbde0205ca6ef3c979 https://staging.drfop.org/files/original/300196424114c54c85384a83479a82f4.jpg 8964e11122634a6bea8dc3b70d105b17 https://staging.drfop.org/files/original/c00ea5fedee712bef421e1419159012f.jpg ad2e82f7a0a3b3ed35a29be5c8b4bee0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_02_001.pdf Year 1963 Volume 7 Issue 2 Page Number(s) 1 - 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/1963_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_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>Limb Prosthetics Today</h2> <h5>A. Bennett Wilson, Jr., B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>Loss of limb has been a problem as long as man has been in existence. Even some prehistoric men must have survived crushing injuries resulting in amputation, and certainly some children were born with congenitally deformed limbs with effects equivalent to those of amputation. In 1958 the Smithsonian Institution reported the discovery of a skull dating back about 45,000 years of a person who, it was deduced, must have been an arm amputee, because of the way his teeth had been used to compensate for lack of limb. Leg amputees must have compensated partly for their loss by the use of crude crutches and, in some instances, by the use of peg legs fashioned from forked sticks or tree branches (<b>Fig. 1</b> and <b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Mosaic from the Cathedral of Lescar, France, depicts an amputee supported at the knee by a wooden pylon. Some authorities place this in the Gallo-Roman era. From Putti, V., Historic Artificial Limbs, 1930. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Pen drawing of a fragment of antique vase unearthed near Paris in 1862 which shows a figure whose missing limb is replaced by a pylon with a forked end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The earliest known record of a prosthesis being used by man was made by the famous Greek historian, Herodotus. His classic "History," written about 484 B.C., contains the story of the Persian soldier, Hegistratus, who, when imprisoned in stocks by the enemy, escaped by cutting off part of his foot, and replaced it later with a wooden version.</p> <p>A number of ancient prostheses have been displayed in museums in various parts of the world. The oldest known is an artificial leg unearthed from a tomb in Capua in 1858, thought to have been made about 300 B.C., the period of the Samnite Wars. Constructed of copper and wood, the Capua leg was destroyed when the Museum of the Royal College of Surgeons was bombed during World War II. The Alt-Ruppin hand (<b>Fig. 3</b>), recovered along the Rhine River in 1863, and other artificial limbs of the 15th century are on display at the Stibbert Museum in Florence. Most of these ancient devices were the work of armorers. Made of iron, these early prostheses were used by knights to conceal loss of limbs as a result of battle, and a number of the warriors are reported to have returned successfully to their former occupation. Effective as they were for their intended use, these specialized devices could not have been of much use to any group other than the knights, and the civilian amputees for the most part must have had to rely upon the pylon and other makeshift prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Alt-Ruppin Hand (Circa 1400). The thumb is rigid; the fingers move in pairs and are sprung by the buttons at the base of the palm; the wrist is hinged. Putti, V., Chir. d. org. di movimento, 1924-25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the use of ligatures was set forth by Hippocrates, the practice was lost during the Dark Ages, and surgeons during that period and for centuries after stopped bleeding by either crushing the stump or dipping it in boiling oil. When Ambroise Pare, a surgeon in the French Army, reintroduced the use of ligatures in 1529, a new era for amputation surgery and prostheses began. Armed with a more successful technique, surgeons were more willing to employ amputation as a lifesaving measure and, indeed, the rate of survival must have been much higher. The practice of amputation received another impetus with the introduction of the tourniquet by Morel in 1674, and removal of limbs is said to have become the most common surgical procedure in Europe. This in turn led to an increase in interest in artificial limbs. Pare, as well as contributing much in the way of surgical procedures, devised a number of limb designs for his patients. His leg (<b>Fig. 4</b>) for amputation through the thigh is the first known to employ articulated joints. Another surgeon, Verduin, introduced in 1696 the first known limb for below-knee amputees that permitted freedom of the knee joint (<b>Fig. 5</b>), in concept much like the thigh-corset type of below-knee limb still used by many today. Yet, for reasons unknown, the Verduin prosthesis dropped from sight until it was reintroduced by Serre in 1826 and. until recently, was the most popular type of below-knee prosthesis used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Artificial leg invented by Ambroise Pare (middle sixteenth century). From Pare, A, Oeuvres Completes, Paris, 1840. From the copy in the National Library of Medicine. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Verduin Leg (1696). From MacDonald, J., Am. J. Surg., 1905. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After Pare's above-knee prosthesis, which was constructed of heavy metals, the next real advance seems to be the use of wood, introduced in 1800 by James Potts of London. Consisting of a wooden shank and socket, a steel knee joint, and an articulated foot, the Potts invention (<b>Fig. 6</b>) was equipped with artificial tendons connecting the knee and the ankle, thereby coordinating toe lift with knee flexion. It was made famous partly because it was used by the Marquis of Anglesea after he lost a leg at the Battle of Waterloo. Thus it came to be known as the Anglesea leg. With some modifications the Anglesea leg was introduced into the United States in 1839. Many refinements to the original design were incorporated by American limb fitters and in time the wooden above-knee leg became known as the "American leg."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anglesea Leg (1800). Below knee at left above knee at right. Knee, ankle, and foot are articulated. From Bigg, H. H.. Orthopraxy, 1877. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Civil War produced large numbers of amputees and consequently created a great interest in artificial limbs, no doubt inspired partly by the fact that the federal and state governments paid for limbs for amputees who had seen war service.</p> <p>J. E. Hanger, one of the first Southerners to lose a leg in the Civil War, replaced the cords in the so-called American leg with rubber bumpers about the ankle joint, a design used almost universally until rather recently. Many patents on artificial limbs were issued between the time of the Civil War and the turn of the century, but few of the designs seem to have had much lasting impact.</p> <p>During this period, with the availability of chloroform and ether as anesthetics, surgical procedures were greatly improved and more functional amputation stumps were produced by design rather than by fortuity.</p> <p>World War I stirred some interest in artificial limbs and amputation surgery but, because the American casualty list was relatively small, this interest soon waned and, because of the economic depression of the Thirties, some observers think, very little progress was made in the field of limb prosthetics between the two World Wars. Perhaps the most significant contributions were the doctrines set forth and emphasized by Haddan and Thomas, a prosthetist-surgeon team from Denver, that fit and alignment of the prosthesis were the most critical factors in the success of any limb and that much better end-results could be expected if prosthetists and physicians worked together.</p> <p>Early in 1945, the National Academy of Sciences, at the request of the Surgeon General of the Army, initiated a research program in prosthetics. The initial reaction of the research personnel was that the development of a few mechanical contrivances would solve the problem. However, it soon became evident that much more must be known about biomechanics and other matters before real progress could be made. Devices and techniques based on fundamental data have materially changed the practice of prosthetics during the past dozen years. However, the best conceivable prosthesis is but a poor substitute for a live limb of flesh and blood, and so the research program is still continuing. Fiscal support for research and development by some 20 laboratories is provided by the Veterans Administration, the Vocational Rehabilitation Administration, the National Institutes of Health, the Children's Bureau, the Army, and the Navy. The over-all program is coordinated by the Committee on Prosthetics Research and Development of the National Academy of Sciences-National Research Council.</p> <p>Soon after the close of World War II, the Artificial Limb Manufacturers Association, which had been formed during World War I, engaged the services of a professional staff to coordinate more effectively the efforts of individual prosthetists. Known today as the American Orthotics and Prosthetics Association, this organization consists of some 415 limb and brace shops, and plays a large part in keeping individual prosthetists and orthotists advised of the latest trends and developments in prosthetics and orthotics.</p> <p>In 1949, upon the recommendation of the Association, the American Board for Certification of Prosthetists and Orthotists was established to ensure that prosthetists and orthotists met certain standards of excellence, much in the manner that certain physicians' specialty associations are conducted. Examinations are held annually for those desiring to be certified. In addition to certifying individuals as being qualified to practice, the American Board for Certification approves individual shops, or facilities, as being satisfactory to serve the needs of amputees and other categories of the disabled requiring mechanical aids. Certified prosthetists wear badges and shops display the symbol of certification (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Symbol of certification by the American Board for Certification in Orthotics and Prosthetics. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The research program, with the cooperation of the prosthetists, has introduced a sufficient number of new devices and techniques to modify virtually every aspect of the practice of prosthetics. To reduce the time lag between research and widespread application, facilities have been established within the medical schools of three universities for short-term courses in special aspects of prosthetics. Courses are offered to each member of the prosthetics-clinic team-the physician, the therapist, and the prosthetist. Also, special courses are offered to vocational rehabilitation counselors and administrative personnel concerned with the welfare of amputees. Approximately 2,100 physicians, 1,900 therapists, and 1,400 prosthetists have been enrolled in these courses during the period 1953 through 1962.</p> <p>Prior to 1957 medical schools offered little in the way of training in prosthetics to doctors and therapists. To encourage the inclusion of prosthetics into medical and paramedical curricula, the National Academy of Sciences organized the Committee on Prosthetics Education and Information, and as a result of the efforts of this group many schools have adopted courses in prosthetics at both undergraduate and graduate levels.</p> <p>Today there are approximately 200 amputee-clinic teams in operation throughout the United States. Each state, with assistance from the Vocational Rehabilitation Administration, carries out programs that provide the devices and training required to return the amputee to gainful employment. The Children's Bureau, working through a number of states, has made it possible for child amputees to receive the benefit of the latest advances in prosthetics. The Veterans Administration provides all eligible veterans with artificial limbs. If the amputation is related to his military service, the beneficiary receives medical care and prostheses for the remainder of his life. The Public Health Service, through its hospitals, provides limbs and care to members of the Coast Guard and to qualified persons who have been engaged in the Maritime Service.</p> <p>In addition to these Government agencies that are concerned with the amputee, there are several hundred rehabilitation centers throughout the United States that assist amputees, especially those advanced in age, in obtaining the services needed for them to return to a more normal life.</p> <p>Thus, through the cooperative efforts of Government and private groups, considerable progress has been made in the practice of prosthetics and there is little need for an amputee to go without a prosthesis.</p> <h3>Reasons For Amputation</h3> <p>Amputation may be the result of an accident, or may be necessary as a lifesaving measure to arrest a disease. A small but significant percentage of individuals are born without a limb or limbs, or with defective limbs that require amputation or fitting (like that of an amputee).</p> <p>In some accidents a part or all of the limb may be completely removed; in other cases, the limb may be crushed to such an extent that it is impossible to restore sufficient blood supply necessary for healing. Sometimes broken bones cannot be made to heal, and amputation is necessary. Accidents that cause a disruption in the nervous system and paralysis in a limb may also be cause for amputation even though the limb itself is not injured. The object of amputation in such a case is to improve function by substituting an artificial limb for a completely useless though otherwise healthy member. Amputation of paralyzed limbs is not performed very often but has in some cases proven to be very beneficial. Accidents involving automobiles, farm machinery, and firearms seem to account for most traumatic amputations. Freezing, electrical burns, and power tools also account for many amputations.</p> <p>Diseases that may make amputation necessary fall into one of three main categories-vascular, or circulatory, disorders; cancer; and infection. The diseases that cause circulatory problems most often are arteriosclerosis, or hardening of the arteries, diabetes, and Buerger's disease. In these cases not enough blood circulates through the limb to permit body cells to replace themselves, and unless the limb, or part of it, is removed the patient cannot be expected to live very long. In nearly all these cases the leg is affected because it is the member of the body farthest from the heart and, in accordance with the principles of hydraulics, blood pressure in the leg is lower than in any other part of the bod}'. Vascular disorders are, of course, much more prevalent among older persons. Considerable research is being undertaken to determine the cause of vascular disorders so that amputation for these reasons may at least be reduced if not eliminated, but at the present time vascular disorders are the cause of a large number of lower-extremity amputations.</p> <p>In many cases amputation of part or all of a limb has arrested a malignant or cancerous condition. In view of present knowledge, the entire limb is usually removed. Malignancy may affect either the arms or legs. Much time and effort are being spent to develop cures for the various types of cancer.</p> <p>Since the introduction of antibiotic drugs, infection has been less and less the cause for amputation. Moreover, even though amputation may be necessary, control of the infection may allow the amputation to be performed at a lower level than would be the case otherwise.</p> <p>Recently, "thalidomide babies" have been given extensive press coverage; however, thalidomide is by no means the sole cause of congenital malformations. Absence of all or part of a limb at birth is not an uncommon occurrence. Many factors seem to be involved in such occurrences, but what these factors are is not clear. The most frequent case is absence of most of the left forearm, which occurs slightly more often in girls than in boys. However, all sorts of combinations occur, including complete absence of all four extremities. Sometimes intermediate parts such as the thigh or upper arm are missing but the other parts of the extremity are present, usually somewhat malformed. In such cases amputation may be indicated; however, even a weak, malformed part is sometimes worth preserving if sensation is present and the partial member is capable of controlling some part of the prosthesis. Extensive studies are being carried out to determine the reasons for congenital malformations.</p> <h3>Losses Incurred</h3> <p>Many of the limitations resulting from amputation are obvious; others less so. An amputation through the lower extremity makes standing and locomotion without the use of an artificial leg or crutches difficult and impracticable except for very short periods. Even when an artificial leg is used, the loss of joints and the surrounding tissues, and consequently loss of the ability to sense position, is felt keenly. The sense of touch of the absent portion is also lost, but in the case of the lower-extremity amputee this is not quite as important as it might seem because the varying pressure occurring between the stump and the socket indicates external loading. In the upper-extremity amputee, sense of touch is more important.</p> <p>Most lower-extremity amputees cannot bear the total weight of the body on the end of the stump, and other parts of the anatomy must be found for support.</p> <p>Muscles attached at each end to bones are responsible for movement of the arms and legs. Upon a signal from the nervous system muscle tissue will contract, thus producing a force which can move a bone about its joint (<b>Fig. 8</b>). Because muscle force can be produced only by contraction, each muscle group has an opposing muscle group so that movement in two directions can take place. This arrangement also permits a joint to be held stable in any one of a vast number of positions for relatively long periods of time. How much a muscle can contract is dependent upon its length, and the amount of force that can be generated is dependent upon its circumference.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Schematic drawing of muscular action on skeletal system. The motion shown here is flexion, or bending, of the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Muscles that activate the limbs must of course pass over at least one joint to provide a sort of pulley action; some pass over two. Thus, some muscles are known as one-joint muscles, others as twro-joint muscles. When muscles are severed completely, they can no longer transmit force to the bone and, when not used, wither away or atrophy. It will be seen later that these facts are very important in the rehabilitation of amputees.</p> <h3>Types of Amputation</h3> <p>Amputations are generally classified according to the level at which they are performed (<b>Fig. 9</b>). Some amputation levels are referred to by the name of the surgeon credited with developing the amputation technique used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Classification of amputation by level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Lower-Extremity Amputations</h4> <p><i>Syme's Amputation</i></p> <p>Developed about 1842 by James Syme, a leading Scottish surgeon, the Syme amputation leaves the long bones of the shank (the tibia and fibula) virtually intact, only a small portion at the very end being removed (<b>Fig. 10</b>). The tissues of the heel, which are ideally suited to withstand high pressures, are preserved, and this, in combination with the long bones, usually permits the patient to bear the full weight of his body on the end of the stump. Because the amputation stump is nearly as long as the unaffected limb, a person with Syme's amputation can usually get about the house without a prosthesis even though normal foot and ankle action has been lost. Atrophy of the severed muscles that were formerly attached to bones in the foot to provide ankle action results in a stump with a bulbous end which, though not of the most pleasing appearance, is quite an advantage in holding the prosthesis in place. Since its introduction, Syme's operation has been looked upon with both favor and disfavor among surgeons. It seems to be the consensus now that "the Syme" should be performed in preference to amputation at a higher level if possible. In the case of most women, though, "the Syme" is undesirable because of the difficulty of providing a prosthesis that matches the shape of the other leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Excellent Syme stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Below-Knee Amputations</i></p> <p>Any amputation above the Syme level and below the knee joint is known as a below-knee amputation. Because circulatory troubles have often developed in long below-knee stumps, and because the muscles that activate the shank are attached at a level close to the knee joint, the below-knee amputation is usually performed at the junction of the upper and middle third sections (<b>Fig. 11</b>). Thus nearly full use of the knee is retained- an important factor in obtaining a gait of nearly normal appearance. However, it is rare for a below-knee amputee to bear a significant amount of weight on the end of the stump; thus the design of prostheses must provide for weight-bearing through other areas. Several types of surgical procedures have been employed to obtain weight-bearing through the end of the below-knee stump, but none has found widespread use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical, well-formed, right below-knee stump. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Knee-Bearing Amputations</i></p> <p>Complete removal of the lower leg, or shank, is known as a knee disarticulation. When the operation is performed properly, the result is an efficient, though bulbous, stump (<b>Fig. 12</b>) capable of carrying the weight-bearing forces through the end. Unfortunately, the length causes some problems in providing an efficient prosthesis because the space used normally to house the mechanism needed to control the artificial shank properly is occupied by the end of the stump. Nevertheless, prostheses have been highly beneficial in knee-disarticulation cases. Development of adequate devices for obtaining control of the shank is currently under way, and such devices should be generally available in the near future.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Typical knee-disarticulation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Several amputation techniques have been devised in an attempt to overcome the problems posed by the length and shape of the true knee-disarticulation stump. The Gritti-Stokes procedure entails placing the kneecap, or patella, directly over the end of the femur after it has been cut off about two inches above the end. When the operation is performed properly, excellent results are obtained, but extreme skill and expert postsurgical care are required. Variations of the Gritti-Stokes amputation have been introduced from time to time but have never been used widely.</p> <p><i>Above-Knee Amputations</i></p> <p>Amputations through the thigh are among the most common (<b>Fig. 13</b>). Total body weight cannot be taken through the end of the stump but can be accommodated through the ischium, that part of the pelvis upon which a person normally sits.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical, well-formed above-knee stump. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Hip Disarticulation and Hemipelvectomy</i></p> <p>A true hip disarticulation (<b>Fig. 14</b>) involves removal of the entire femur, but whenever feasible the surgeon leaves as much of the upper portion of the femur as possible in order to provide additional stabilization between the prosthesis and the wearer, even though no additional function can be expected over the true hip disarticulation. Both types of stump are provided with the same type of prosthesis. With slight modification the same type of prosthesis can be used by the hemipelvectomy patient, that is, when half of the pelvis has been removed. It is surprising how well hip-disarticulation and hemipelvectomy patients have been able to function when fitted with the newer type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Patient with true hip-disarticulation amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Upper-Extremity Amputations</h4> <p><i>Partial-Hand Amputations</i></p> <p>If sensation is present the surgeon will save any functional part of the hand in lieu of disarticulation at the wrist. Any method of obtaining some form of grasp, or prehension, is preferable to the best prosthesis. If the result is unsightly, the stump can be covered with a plastic glove, lifelike in appearance, for those occasions when the wearer is willing to sacrifice function for appearance. Many prosthetists have developed special appliances for partial-hand amputations that permit more function than any of the artificial hands and hooks yet devised and, at the same time, permit the patient to make full use of the sensation remaining in the stump. Such devices are usually individually designed and fitted.</p> <p><i>Wrist Disarticulation</i></p> <p>Removal of the hand at the wrist joint was once condemned because it was thought to be too difficult to fit so as to yield more function than a shorter forearm stump. However, with plastic sockets based on anatomical and physiological principles, the wrist-disarticulation case can now be fitted so that most of the pronation-supination of the forearm-an important function of the upper extremity-can be used. In the case of the wrist disarticulation (<b>Fig. 15</b>), nearly all the normal forearm pronation-supination is present. Range of pronation-supination decreases rapidly as length of stump decreases; when 60 per cent of the forearm is lost, no pronation-supination is possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. A good wrist-disarticulation stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Amputations Through the Forearm</i></p> <p>Amputations through the forearm are commonly referred to as below-elbow amputations and are classified as long, short, and very short, depending upon the length of stump (<b>Fig. 9</b>). Stumps longer than 55 per cent of total forearm length are considered long, between 35 and 55 per cent as short, and less than 35 per cent as very short.</p> <p>Long stumps retain the rotation function in proportion to length; long and short stumps without complications possess full range of elbow motion and full power about the elbow, but often very short stumps are limited in both power and motion about the elbow. Devices and techniques have been developed to make full use of all functions remaining in the stump.</p> <p><i>Disarticulation at the Elbow</i></p> <p>Disarticulation at the elbow consists of removal of the forearm, resulting in a slightly bulbous stump (<b>Fig. 16</b>) but usually one with good end-weight-bearing characteristics. The long bulbous end, while presenting some fitting problems, permits good stability between socket and stump, and thus allows use of nearly all the rotation normally present in the upper arm-a function much appreciated by the amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Amputation through the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Above-Elbow Amputation</i></p> <p>Any amputation through the upper arm is generally referred to as an above-elbow amputation (<b>Fig. 9</b>). In practice, stumps in which less than 30 per cent of the humerus remains are treated as shoulder-disarticulation cases; those with more than 90 per cent of the humerus remaining are fitted as elbow-disarticu-lation cases.</p> <p><i>Shoulder Disarticulation and Forequarter Amputation</i></p> <p>Removal of the entire arm is known as shoulder disarticulation but, whenever feasible, the surgeon will leave intact as much of the humerus as possible to provide stability between the stump and the socket (<b>Fig. 17</b>). When it becomes necessary to remove the clavicle and scapula, the operation is known as a forequarter, or interscapulothoracic, amputation. The very short above-elbow, the shoulder-disarticulation, and the forequarter cases are all provided with essentially the same type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. A true shoulder disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Postsurgical Period</h3> <p>The period between the time of surgery and time of fitting the prosthesis is an important one if a good functional stump, and thus the most efficient use of a prosthesis, is to be obtained. The surgeon and others on his hospital staff will do everything possible to ensure the best results, but ideal results require the wholehearted cooperation of the patient.</p> <p>It is not unnatural for the patient to feel extremely depressed during the first few days after surgery, but after he becomes aware of the possibilities of recovery, the outlook becomes brighter, and he generally enters cooperatively into the rehabilitation phase.</p> <p>As soon as the stump has healed sufficiently, exercise of the stump is started in order to keep the muscles healthy and reduce the possibility of muscle contractures. Contractures can be prevented easily, but it is most difficult and sometimes impossible to correct them. At first exercises are administered by a therapist or nurse; later the patient is instructed concerning the type and amount of exercise that should be undertaken. The patient is also instructed in methods and amount of massage that should be given the stump to aid in the reduction of the stump size. Further, to aid shrinkage, cotton-elastic bandages are wrapped around the stump (<b>Fig. 18</b>) and worn continu- ously until a prosthesis is fitted. The bandage is removed and reapplied at regular intervals- four times during the day, and at bedtime. It is most important that a clean bandage is available for use each day.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Compression wrap for above-knee amputation. The wrap of elastic bandage aids in shrinking the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee is taught to apply the bandage unless it is physically impossible for him to do so, in which case some member of his family must be taught the proper method for use at home.</p> <p>To reduce the possibility of contractures, the lower-extremity stump must not be propped upon pillows. Wheel chairs should be used as little as possible; crutch walking is preferred, but the above-knee stump must not be allowed to rest on the crutch handle (<b>Fig. 19</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Actions to be avoided by lower-extremity amputees during the immediate postoperative period. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Phantom Sensation</h4> <p>After amputation the patient almost always has the sensation that the missing part is still present (<b>Fig. 20</b>). The exact cause of this is as yet unknown. The phantom sensation usually recedes to the point where it occurs only infrequently or disappears entirely, especially if a prosthesis is used. In a large percentage of cases, moderate pain may accompany the phantom sensation but, in general, this too eventually disappears entirely or occurs only infrequently. In a small percentage of cases severe phantom pain persists to the point where medical treatment is necessary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. One form of the "phantom" sensation. Here the two toes seem to reside in the stump itself. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Time of Fitting</h4> <p>Surgeons increasingly have become aware that best results are obtained with artificial limbs when they are fitted as early as possible after surgery, that is, when pain and soreness have disappeared. This time will vary, depending upon type of amputation and condition of the patient. The earliest time is about six weeks after the operation. Below-knee stumps as a rule require a longer healing period than above-knee and upper-extremity stumps. An elderly patient whose legs have been amputated by reason of vascular insufficiency usually requires a longer healing period than an otherwise-healthy young person whose legs have been amputated as the result of an accident.</p> <h3>Prostheses for Various Types of Amputation</h3> <p>Much time and attention have been devoted to the development of mechanical components, such as knee and ankle units, for artificial limbs, yet by far the most important factors affecting the successful use of a prosthesis are the fit of the socket to the stump and the alignment of the various parts of the limb in relation to the stump and other parts of the body.</p> <p>Thus, though many parts of a prosthesis may be mass-produced, it is necessary for each limb to be assembled in correct alignment and fitted to the stump to meet the individual requirements of the intended user. To make and fit artificial limbs properly requires a complete understanding of anatomical and physiological principles and of mechanics; craftsmanship and artistic ability are also required.</p> <p>In general, an artificial limb should be as light as possible and still withstand the loads imposed upon it. In the United States willow and woods of similar characteristics have formed the basis of construction for more limbs than any other material, though aluminum, leather-and-steel combinations, and fibre have been used widely. Wood construction is still the type most used in the United States for above-knee prostheses, but plastic laminates similar to those so popular in small-boat construction are the materials of choice for virtually all other types of prostheses. Plastic laminates are light in weight, easy to keep clean, and do not absorb perspiration. They may be molded easily and rapidly over contours such as those found on a plaster model of a stump. Plastic laminates can be made extremely rigid or with any degree of flexibility required in artificial-limb construction. In some instances, especially in upper-extremity sockets, the fact that most plastic laminates do not permit water vapor to pass to the atmosphere has caused discomfort, but recently a porous type has been developed by the Army Medical Biomechanical Research Laboratory (formerly the Army Prosthetics Research Laboratory). Except experimentally, its use thus far has been restricted to artificial arms. Of course, most of the mechanical parts are made of steel or aluminum, depending upon their function.</p> <p>As in the case of the tailor making a suit, the first step in fabrication of a prosthesis is to take the necessary measurements for a good fit. If the socket is to be fabricated of a plastic laminate, an impression of the stump is made. Most often this is accomplished by wrapping the stump with a wet plaster-of-Paris bandage and allowing it to dry, as a physician does in applying a cast when a bone is broken (<b>Fig. 21</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Steps in the fabrication of a plastic prosthesis for a below-knee amputation. A, Taking the plaster cast of the stump; B, pouring plaster in the cast to obtain model of the stump; C, introducing plastic resin into fabric pulled over the model to form the plastic-laminate socket; D, the plastic-laminate socket mounted on an adjustable shank for walking trials; E, a wooden shank block inserted in place of the adjustable shank after proper alignment has been obtained; F, the prosthesis after the shank has been shaped. To reduce weight to a minimum the shank is hollowed out and the exterior covered with a plastic laminate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast, or wrap, is removed from the stump and filled with a plaster-of-Paris solution to form an exact model of the stump which-after being modified to provide relief for any tender spots, to ensure that weight will be taken in the proper places, and to take full advantage of the remaining musculature- can be used for molding a plastic-laminate socket. Often a "check" socket of cloth impregnated with beeswax is made over the model and tried on the stump to determine the correctness of the modifications.</p> <p>For upper-extremity cases the socket is attached to the rest of the prosthesis and a harness is fabricated and installed for operation of the various parts of the artificial arm. For the lower-extremity case the socket is fastened temporarily to an adjustable, or temporary, leg for walking trials (<b>Fig. 22</b>). With this device, the prosthetist can easily adjust the alignment until both he and the amputee are satisfied that the optimum arrangement has been reached. A prosthesis can now be made incorporating the same alignment achieved with the adjustable leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Using the above-knee adjustable leg and alignment duplication jig. Top, Adjusting the adjustable leg during walking trials; Center, the socket and adjustable leg in the alignment duplication jig; Bottom, replacement of the adjustable leg with a permanent knee and shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>There are many kinds of artificial limbs available for each type of amputation, and much has been written concerning the necessity for prescribing limbs to meet the needs of each individual. This of course is true particularly in the case of persons in special or arduous occupations, or with certain medical problems, but actually limbs for a given type of amputation vary to only a small degree. Following are descriptions of the artificial limbs most commonly used in the United States today.</p> <h4>Lower-Extremity Prostheses</h4> <p><i>Prostheses for Syme's Amputation</i></p> <p>Perhaps the major reason Syme's amputation was held in such disfavor in some quarters was the difficulty in providing a comfortable, sufficiently strong prosthesis with a neat appearance. The short distance between the end of the stump and the floor made it extremely difficult to provide for ankle motion needed. Most Syrae prostheses were of leather reinforced with steel side bars resulting in an ungainly appearance (<b>Fig. 23</b>). Research workers at the Prosthetic Services Centre at the Department of Veterans Affairs of Canada were quick to realize that the use of the proper plastic laminate might solve many of the problems long associated with the Syme prosthesis. After a good deal of experimentation, the Canadians developed a model in 1955 which, with a few variations, is used almost universally in both Canada and the United States today (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Syme prosthesis with side bars mounted on medial and lateral aspects of the shank. This type of construction has been virtually replaced by plastic laminates. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. The Syme prosthesis adopted by the Canadian Department of Veterans Affairs. The posterior opening extends the length of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Necessary ankle action is provided by making the heel of the foot of sponge rubber. The socket is made entirely of a plastic laminate. A full-length cutout in the rear permits entry of the bulbous stump. When the cutout is replaced and held in place by straps, the bulbous stump holds the prosthesis in place. In the American version (<b>Fig. 25</b>), a window-type cutout is used on the side because calculations show that smaller stress concentrations are present with such an arrangement.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Two views of the Canadian-type Syme prosthesis as modified bj the Veterans Administration Prosthetics Center, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In those cases where, for poor surgery or other reasons, full body weight cannot be tolerated on the end of the stump, provisions can be made to transfer all or part of the load to the area just below the kneecap. When this procedure is necessary, it can be accomplished more easily by use of the window-type cutout.</p> <p><i>Prostheses for Below-Knee Amputations</i></p> <p>Until recently most below-knee amputees were fitted with wooden prostheses carved out by hand (<b>Fig. 26</b>). A good portion of the body weight was carried on a leather thigh corset, or lacer, attached to the shank and socket by means of steel hinges. The shape of corset and upper hinges also held the prosthesis to the stump. The distal, or lower, end of the socket was invariably left open. Other versions of this prosthesis used aluminum, fibre or molded leather, as the materials for construction of the shank and socket, but the basic principle was the same. Many thousands of below-knee amputees have gotten along well with this type of prosthesis, but there are many disadvantages. Because the human knee joint is not a simple, single-axis hinge joint, relative motion is bound to occur between the prosthesis and the stump and thigh during knee motion when single-jointed side hinges are used, resulting in some chafing and irritation. To date it has not been possible to devise a hinge to overcome this difficulty. Edema, or accumulation of body fluids, was often present at the lower end of the stump. Most of these prostheses were exceedingly heavy, especially those made of wood.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Below-knee prosthesis with wood socket-shank, thigh corset, and steel side bars. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In an attempt to overcome these difficulties, the Biomechanics Laboratory of the University of California, in 1958, designed what is known as the patellar-tendon-bearing (PTB) below-knee prosthesis (<b>Fig. 27</b>). In the PTB prosthesis no lacer and side hinges are used, all of the weight being taken through the stump by making the socket high enough to cover all the tendon below the patella, or kneecap. The patellar tendon is an unusually inelastic tissue which is not unduly affected by pressure. The sides of the socket are also made much higher than has usually been the practice in the past in order to give stability against side loads. The socket is made of molded plastic laminate that provides an intimate fit over the entire area of the socket, and is lined with a thin layer of sponge rubber and leather. Because it is rare for a below-knee stump to bear much pressure on its lower end, care is taken to see that only a very slight amount is present in that area. This feature has been a big factor in eliminating the edema problem in many instances. The PTB prosthesis is generally suspended by means of a simple cuff, or strap, around the thigh just above the kneecap, but sometimes a strap from the prosthesis to a belt around the waist is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Cutaway view of the patellar-tendon-bearing leg for below-knee amputees. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the socket has been made, it is installed on a special adjustable leg (<b>Fig. 28</b>) so that the prosthetist can try various alignment combinations with ease. When both prosthetist and patient are satisfied, the leg is completed uti- lizing the alignment determined with the adjustable unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Trial below-knee adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The shank recommended is of plastic laminate and the foot prescribed is usually the SACH (solid-ankle, cushion-heel) design but other types can be used.</p> <p>It is now general practice in many areas to prescribe the PTB prosthesis in most new cases and in many old ones, and if side hinges and a corset are indicated later, these can be added.</p> <p>Stumps as short as 2-1/2 in. have been fitted successfully with the PTB prosthesis.</p> <p>In special cases, such as extreme flexion contracture, the so-called kneeling-knee, or bent-knee, prosthesis may be indicated. The prosthesis used is similar to that used for the knee-disarticulation case.</p> <p><i>Prostheses for the Knee-Disarticulation and Other Knee-Bearing Cases</i></p> <p>Because of the bulbous shape of the true knee-disarticulation stump, it is not possible to use a wooden socket of the type used on the tapered above-knee stump. To allow entry of the bulbous end, a socket is molded of leather to conform to the stump and is provided with a lengthwise anterior cutout that can be laced to hold the socket in position (<b>Fig. 29</b>). Because of the length of the knee-disarticulation and supracondylar stump, it is not possible to install any of the present knee units designed for above-knee prostheses and, therefore, heavy-duty below-knee joints are generally used. Most prosthetists try to provide some control of the shank during the swing phase of walking by inserting nylon washers between the mating surfaces of the joint to provide friction and by using checkstraps. Better devices for control of the knee joint are being developed and should be available in the near future.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Typical knee-disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Above-Knee Cases</i></p> <p>The articulated above-knee leg is in effect a compound pendulum actuated by the thigh stump. If the knee joint is perfectly free to rotate when force is applied, the effects of inertia and gravity tend to make the shank rotate too far backward and slam into extension as it rotates forward, except at a very slow rate of walking. The method most used today to permit an increase in walking speed is the introduction of some restraint in the form of mechanical friction about the knee joint. The limitation imposed by constant mechanical friction is that for each setting there is only one speed that produces a natural-appearing gait. When restraint is provided in the form of hydraulic resistance, a much wider range of cadence can be obtained without introducing into the gait pattern awkward and unnatural motions.</p> <p>Throughout the past century much time and effort have been spent in providing an automatic brake or lock at the knee in order to provide stability during the stance phase and to reduce the possibility of stumbling. Stability during the stance phase can be obtained by aligning the leg so that the axis of the knee is behind the hip and ankle axes. For most above-knee amputees in good health, such an arrangement has been quite satisfactory, but an automatic knee brake is indicated for the weaker or infirm patients.</p> <p>The prosthesis prescribed most commonly today for the above-knee amputee consists of a carved wooden socket, a single-axis knee unit with constant but adjustable friction, a wooden shank, and a SACH foot. The shank and socket are reinforced with an outer layer of plastic laminate to reduce the amount of wood required and thus keep weight to an optimum.</p> <p>When an automatic brake is indicated, the Bock, the "Vari-Gait" 100, and the Mortensen knee units (<b>Fig. 30</b>) are the ones most generally used. All are actuated upon contact of the heel with the ground. The Bock and "Vari-Gait" units can be used with almost any type of foot, while a foot of special design is necessary when the Mortensen mechanism is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Some examples of weight-actuated knee units. A, Bock "Safety-knee"; B, Vari-Gait knee; C, Morten-sen leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The "Hydra-Cadence" above-knee leg (<b>Fig. 31</b>) was until recently the only unit available that provided hydraulic friction to control the shank during the swing phase of walking. In addition to this feature, incorporated in the Hydra-Cadence design is provision for coordinated motion between the ankle action and the knee action. After the knee has flexed 20 deg., the toe of the foot is lifted as the knee is flexed further, thus giving more clearance between the foot and the ground as the leg swings through. Other hydraulic units recently made available are the Regnell (a Swedish design) and the DuPaCo. Still others are in advanced stages of development.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. The Hydra-Cadence Leg without cosmetic cover. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of methods for suspending the above-knee leg are available. For younger, healthy patients, the suction socket (<b>Fig. 32</b>A) is generally the method of choice. In this design the socket is simply fitted tightly enough to retain sufficient negative pressure, or suction, between the stump and the bottom of the socket when the leg is off the ground. Special valves are used to control the amount of negative pressure created so as not to cause discomfort. No stump sock is worn with the suction socket. A major advantage of this type of suspension is the freedom of motion permitted the wearer, thus allowing the use of all the remaining musculature of the stump. Another important advantage is the decreased amount of piston action between stump and socket. Additional comfort is also obtained by elimination of all straps and belts.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Above-knee sockets and methods of suspension. A, Total-contact suction socket; B, above-knee leg with Silesian bandage for suspension; C, above-knee leg with pelvic belt for suspension. Most above-knee sockets have a quadrilateral-shaped upper portion as shown. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In some cases additional suspension is provided by adding a "Silesian Bandage," (<b>Fig. 32</b>B), a light belt attached to the socket in such a way that there is very little restriction to motion of the various parts of the body.</p> <p>Patients with weak stumps and most of those with very short stumps will require a pelvic belt connected to the socket by means of a "hip" joint (<b>Fig. 32</b>C). Because the connecting joint cannot be placed to coincide with the normal joint, certain motions are restricted. Pelvic-belt suspension is generally indicated for the older patient because of the problems encountered in donning the suction socket, especially that of bending over to remove the donning sock.</p> <p>Shoulder straps, at one time the standard method of suspending above-knee prostheses, are still sometimes indicated for the elderly patient.</p> <p>Prior to the introduction of the suction socket into the United States soon after the close of World War II, virtually all above-knee sockets had a conical-shaped interior and were known as plug fits, most of the weight being borne along the sides of the stump. Such a design does not permit the remaining musculature to perform to its full capabilities. In the development of the suction socket, a design known as the quadrilateral socket (<b>Fig. 32</b>) evolved, and now is virtually the standard for above-knee sockets regardless of the type of suspension used. When the pelvic belt or suspender straps are used, the socket is fitted somewhat looser than in the case of the suction socket, and the stump sock is generally worn to reduce skin irritation from the pumping action of the loose socket. Most of the body weight is taken on the ischium of the pelvis, that part which assumes the load when an individual is sitting.</p> <p>The quadrilateral socket, because of the method employed to permit full use of the remaining muscles, does not resemble the shape of the stump but, as the name implies, is more rectangular in shape. Until recently the standard method of fitting a quadrilateral socket called for no contact over the lower end of the stump, a hollow space being left in this area. Although this method was quite successful there remained a sufficient number of cases that persistently developed ulcers or edema over the end of the stump. Experiments involving the use of slight pressure over the stump-end led to the development of what is known as the plastic total-contact socket (<b>Fig. 32</b>A). As the name implies, the socket is in contact with the entire surface of the stump. The total-contact socket has helped to cure most of the problem cases and is now being used routinely in many areas.</p> <p>In fitting the above-knee prosthesis, the prosthetist carves the interior of the socket using measurements of the stump as a guide. When a satisfactory fit has been achieved the socket is usually mounted on an adjustable leg for alignment trial, after which the wooden shank and the knee are substituted for the adjustable unit and the leg is finished by applying a thin layer of plastic laminate over the shank and the thigh piece.</p> <p>In the case of the total-contact socket, the prosthetist obtains a plaster cast of the stump, usually with the aid of a special casting jig (<b>Fig. 33</b>), and thus obtains a model of the stump over which the plastic socket can be formed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Special jig developed by the Veterans Administration Prosthetics Center to facilitate casting above-knee stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Hip-Disarticulation and Hemi-pelveclomy Cases</i></p> <p>A prosthesis (<b>Fig. 34</b>) developed by the Canadian Department of Veterans Affairs in 1954 and modified slightly through the years has become accepted as standard practice. In the Canadian design a plastic-laminate socket is used, and the "hip" joint is placed on the front surface in such a position that, when used with an elastic strap connecting the rear end of the socket to a point on the shank ahead of the femur, stability during standing and walking can be achieved without the use of a lock at the hip joint. The location of the hip joint in the Canadian design also facilitates sitting, a real problem in earlier designs.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Hip-disarticulation prosthesis, known as the Canadian-type because its principle was originally conceived by workers at the Department of Veterans Affairs of Canada. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A constant-friction knee unit is most often used with the hip-disarticulation prosthesis, but some prosthetists have reported successful use of hydraulic knee units.</p> <p>The hemipelvectomy patient is provided with the same type of prosthesis but the socket design is altered to allow for the loss of part of the pelvis.</p> <h4>Upper-Extremity Prostheses</h4> <p>The major role of the human arm is to place the hand where it can function and to transport objects held in the hand. The energy for operation of the hand substitute in upper-extremity prostheses is derived from relative motion between two parts of the body. Energy for operation of the elbow joint, when necessary, can be obtained in the same way. The stump, of course, is also a source of energy for control of the prosthesis in all except the shoulder-disarticulation and fore-quarter cases. Force and motion can be obtained through a cable connected between the device to be operated and a harness across the chest or shoulders.</p> <p><i>Hand Substitutes-Terminal Devices</i></p> <p>All upper-extremity prostheses for amputation at the wrist level and above have, in common, the problem of selection of the terminal device, a term applied to artificial hands and substitute devices such as hooks. In some areas of the world there is a tendency to supply the arm amputee with a number of devices, each designed for a specific task such as eating, shaving, hairgrooming, etc. In the United States such an approach has been considered too clumsy, and opinion has been that the terminal device should be designed so that most upper-extremity amputees can perform the activities of daily living with a single device, or at most with two devices.</p> <p>The so-called split hooks are much more functional than any artificial hand devised to date. The arm amputee must rely heavily upon visual cues in handling objects and the hook offers more visibility. The hook also offers more prehension facility, and can be more easily introduced into and withdrawn from pockets than a device in the form of a hand. Therefore, the hook is used in manual occupations and those avocations requiring manual dexterity. When extensive contact with the public is necessary and for social occasions, the hand is of course generally preferred. Many amputees have both types of devices, using each as the occasion warrants. Two basic types of mechanism have been developed for terminal-device operation- voluntary-opening and voluntary-closing. In the former, tension on the control cable opens the fingers against an elastic force; in the latter, tension in the control cable closes the fingers against an elastic force. Each type of mechanism has its advantages and disadvantages, neither being superior to the other when used in a wide range of activities. Both hands and hooks are available with either type of mechanism.</p> <p>The major types of terminal devices are shown in <b>Fig. 35</b> and <b>Fig. 36</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Voluntary-closing terminal devices. A, APRL-Sierra Hand; left, cutaway view showing mechanism; right, assembled hand without cosmetic glove; B, APRL-Sierra Hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Voluntary-opening terminal devices. The wide range of models offered by the D. W. Dorrance Company includes sizes and designs for all ages. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Wrist-Disarticulation Case</i></p> <p>One of the problems in fitting the wrist disarticulation in the past has been to keep the over-all length of the prosthesis commensurate with the normal arm. The development of very short wrist units, especially for wrist-disarticulation cases, has materially reduced this problem. However, these units are available in only the screw, or thread, type, and cannot be obtained in the bayonet type which lends itself to quick interchange of terminal devices.</p> <p>The socket for the wrist-disarticulation case need not extend the full length of the forearm and is fitted somewhat loosely at the upper, or proximal, end to permit the wrist to rotate. A simple figure-eight harness and Bowden cable are used to operate the terminal device <b>Fig. 37</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Typical methods of fitting below-elbow amputees with medium to long stumps. Above, the figure-eight, ring-type harness is most generally used Where possible flexible leather hinges and open biceps cuff or pad are used. When more stability between socket and stump is required, rigid (metal) hinges and closed cuffs can be used (inserts A and B). In insert C, fabric straps are used for suspension in lieu of a leather billet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Long Below-Elbow Case</i></p> <p>The prosthesis for the long below-elbow case is essentially the same as that for the wrist-disarticulation patient except that the quick-disconnect wrist unit can be used when desired.</p> <p><i>Prostheses for the Short Below-Elbow Case</i></p> <p>The socket for the short below-elbow stump, where there is no residual rotation of the forearm, is usually fitted snugly to the entire slump, and often rigid hinges connecting the socket to a cuff about the upper arm are used to provide additional stability. Either the figure-eight harness or the chest-strap harness may be used, the latter being preferred when heavy-duty work is required since it tends to spread the loads involved in lifting over a broader area than is the case with the figure-eight design.</p> <p>A wrist-flexion unit, which permits the terminal device to be tilted in toward the body for more effective use, can be provided in the short below-elbow prosthesis but is seldom prescribed for unilateral cases.</p> <p><i>Prostheses for the Very Short Below-Elbow Case</i></p> <p>Often the very short below-elbow case cannot control the prosthesis of the short below-elbow type through the full range of motion, either because of a muscle contracture or because the stump is too short to provide the necessary leverage.</p> <p>When a contracture is present that limits the range of motion of the stump, a "split-socket" and "step-up" hinge may be used. With this arrangement of levers and gears, movement of the stump through one degree causes the prosthetic forearm to move through two degrees; thus, a stump that has only about half the normal range of motion can drive the forearm through the desired 135 deg. However, when the step-up hinge is used, twice the normal force is required. When the stump is incapable of supplying the force required, it can be assisted by employing the "dual-control" harness wherein force in the terminal-device control cable is diverted to help lift the forearm. When the elbow stump is very short or has a very limited range of motion, an elbow lock operated by stump motion is employed to obtain elbow function.</p> <p>Recently a number of prosthetists have reported success in fitting very short below-elbow cases with an arm which is bent to give a certain amount of preflexion. This type of fitting, which was developed in Munster, West Germany, eliminates the necessity for using the rather clumsy step-up hinges and split socket, thus providing improved prosthetic control without a disadvantageous force feedback. Furthermore, the harness is not necessary for suspension of the prosthesis. The maximum forearm flexion may be limited to about 100 deg., but this does not appear to be a significant disadvantage to unilateral amputees (<b>Fig. 38</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Comparison of split socket and Munster-type fitting of short below-elbow case. A, Split socket and step-up hinge provides 140 deg. of forearm flexion; B, Munster-type fitting permits less forearm flexion but enables the amputee to carry considerably greater weight with flexed prosthesis unsupported by harness. Courtesy New York University College of Engineering Prosthetic and Orthotic Research. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Elbow-Disarticulation Case</i></p> <p>Because of the length of the elbow-dis-articulation stump, the elbow-locking mechanism is installed on the outside of the socket. Otherwise the prosthesis and harnessing methods (<b>Fig. 39</b>) are identical to those applied to the above-elbow case.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Typical prosthesis for the elbow-disarticulation case. The chest-strap harness with shoulder saddle is shown here, but the above-elbow figure-eight is also used. See Figure 40. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Above-Elbow Case</i></p> <p>For the above-elbow prosthesis to operate efficiently, it is necessary that a lock be provided in the elbow joint, and it is, of course, preferable that the lock is engaged and disengaged without resorting to the use of the other hand or pressing the locking actuator against an external object such as a table or chair.</p> <p>Several elbow units that can be locked and unlocked alternately by the same motion are available. This action is usually accomplished by the relative motion between the prosthesis and the body when the shoulder is depressed slightly and the arm is extended somewhat. The motion required is so slight that with practice the amputee can accomplish the action without being noticed. These elbow units contain a turntable above the elbow axis that permits the forearm to be positioned with respect to the humerus, supplementing the normal rotation remaining in the upper arm and thus allowing the prosthesis to be used more easily close to the mid-line of the body.</p> <p>The elbow units described above are available with an adjustable coil spring to assist in flexing the elbow when this is desired. The flexion-assist device may be added or removed without affecting the other operating characteristics.</p> <p>The plastic socket of the above-elbow prosthesis covers the entire surface of the stump. The most popular harness used is the figure-eight dual-control design wherein the terminal-device control cable is also attached to a lever on the forearm so that, when the elbow is unlocked, tension in the control cable produces elbow flexion, and, when the elbow is locked, the control force is diverted to the terminal device (<b>Fig. 40</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Typical prosthesis for the above-elbow case. The figure-eight harness is shown here but the chest-strap harness with shoulder saddle may also be used. See Fig. 39. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The chest-strap harness may also be used in the dual-control configuration.</p> <p><i>Prostheses for the Shoulder-Disarticulation and Forequarter Cases</i></p> <p>Because of the loss of the upper-arm motion as a source of energy for control and operation of the prosthesis, restoration of the most vital functions in the shoulder-disarticulation case presents a formidable problem; for many years a prosthesis was provided for this type of amputation only for the sake of appearance. In recent years, however, it has been possible to make available prostheses which provide a limited amount of function (<b>Fig. 41</b>). To date it has not been possible to devise a shoulder joint that can be activated from a harness, but a number of manually operated joints are available. Various harness designs have been employed but, because of the wide variation in the individual cases and the marginal amount of energy available, no standard pattern has developed, each design being made to take full advantage of the remaining potential of the particular patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Typical prosthesis for the shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Bilateral Upper-Extremity Amputees</i></p> <p>Except for the bilateral, shoulder-disarticu-lation case, fitting the bilateral case offers few problems not encountered with the unilateral case. The prostheses provided are generally the same as those prescribed for corresponding levels in unilateral cases. Artificial hands are rarely used by bilateral amputees because hooks afford so much more function. Many bilateral cases find that the wrist-flexion unit, at least on one side, is of value. The harness for each prosthesis may be separated, but it is the general practice to combine the two (<b>Fig. 42</b>). In addition to being neater, this arrangement makes the harness easier for the patient to don unassisted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Harness for the bilateral below-elbow/ above-elbow case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some prosthetists have claimed success in fitting bilateral shoulder-disarticulation cases with two prostheses. Because of the lack of sufficient sources of energy for control, most cases of this type are provided with a single, functional prosthesis and a plastic cap over the opposite shoulder which provides an anchor for the harness and also fills this area to present a better appearance (<b>Fig. 43</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Special harness arrangement for the bilateral shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Learning to Use the Prosthesis</h3> <p>To derive maximum benefit from his prosthesis, the amputee must understand how it functions and learn the best means of controlling it. A patient may be of the opinion that he is getting along very well when, in reality, he could do much better. Use of the prosthesis can best be learned under the supervision of an instructor who has had special training.</p> <p>All amputees using an artificial limb for the first time will need some instruction. In some instances, when a prosthesis is replaced with one of a different design, special instruction will be required. The time required for training depends upon the complexity of the device and the physical condition and degree of coordination of the patient. The time required will vary from a few hours to several weeks. In many instances amputees themselves have become excellent trainers, but more often such training is given by physical or occupational therapists. Usually, physical therapists instruct lower-extremity patients and occupational therapists teach upper-extremity cases.</p> <p>During the period of instruction, the trainer is careful to observe any effects the use of the prosthesis has on the patient, especially at points where the prosthesis is in contact with the body. Any changes are reported immediately to the physician in charge.</p> <h4>Lower-Extremity Cases</h4> <p>One of the major goals in training the leg amputee is to enable him to walk as gracefully as possible. Training of the leg amputee is begun as soon as the clinic team is satisfied with fit and alignment, and preferably while the artificial leg is in an unfinished state, or "in the rough." Thus, should there be need for changes in alignment as training progresses, they can be made readily. Often training can be started on an adjustable leg.</p> <p>A patient with a Syme amputation needs a minimum of training. The average below-knee case will require somewhat more, though usually not extensive, unless other medical problems are present. The training required is usually quite extensive for patients who have lost the knee joint.</p> <p>The ability to balance oneself is the first prerequisite in learning to walk, and so it is balance that is taught first to the above-knee amputee. Two parallel railings are used to give the patient confidence and reduce the possibility of falling (<b>Fig. 44</b>). Balancing on both legs is practiced first, then on each leg. Walking in a straight line between the parallel bars is repeated until the patient no longer requires use of the hands for support. Walking in a straight line is practiced until the gait is even and smooth.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Above-knee patient being trained to walk by a physical therapist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a rhythmic gait has been accomplished, more difficult tasks are learned, such as pivoting, turning, negotiating stairs and ramps, and sitting on and arising from the floor.</p> <p>Most unilateral above-knee patients can use their prostheses quite well without the necessity for a cane. However, in the case of short, weak stumps it may be advisable to employ a cane for additional support and stability. If a cane is necessary, it should be selected to meet the needs of the patient, and it must be used properly if ungainly walking patterns are to be avoided. Canes with curved handles and made from a single piece of wood should be used. The shaft should not show any signs of buckling under the full load of the body weight, and should be just long enough so that the elbow is bent slightly when the bottom of the cane rests near the foot. The cane is used on the side opposite the amputation to help maintain balance but is not used to the extent that body weight is centered between the good leg and the cane (<b>Fig. 45</b>). Continued use of the cane in this manner usually results in a limp that is difficult to overcome. It has been found that, for bio-mechanical reasons, it is helpful for the amputee to carry a briefcase or purse on the side of the amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Above-knee patient being taught correct use of cane. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Training the Hip-Disarticulation Cases</i></p> <p>The training of hip-disarticulation cases follows much the same pattern as that for above-knee cases. With the advent of the Canadian-type prosthesis, the training procedure has been considerably simplified. Some special precautions must be taken to avoid stumbling while ascending stairs.</p> <p><i>Special Considerations for Bilateral Leg Cases</i></p> <p>As would be expected, bilateral-leg cases pose special problems in addition to those of the unilateral cases and, therefore, a good deal of time will usually be required in training. Patients with two good below-knee stumps will seldom require canes. Some bilateral above-knee amputees can get along without canes, but as a general rule at least one cane is required.</p> <h4>Upper-Extremity Cases</h4> <p>The first objective in the training program for upper-extremity amputees is to ensure that the patient can perform the activities encountered in daily living, such as eating, grooming, and toilet care. When this goal has been attained, attention is devoted to any special training that might be required in vocational pursuits (<b>Fig. 46</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Upper-extremity amputees performing vocational tasks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before the prosthesis is put to useful purposes, the patient is shown how the various mechanisms are controlled and is made to practice these motions until they can be performed in a graceful manner and without undue exertion. In general, the arm amputee soon becomes so adept in these procedures that they are carried out without conscious thought. During this period, the functioning of the prosthesis, especially of the harness and control cables, is watched carefully by the instructor and constantly rechecked to ensure maximum performance.</p> <p>Only when the patient has mastered use of the various controls is practice in the handling of objects and the performance of activities of daily living undertaken.</p> <h3>Care of the Stump</h3> <p>Even under the most ideal circumstances the amputation stump, when called upon to operate a prosthesis, is subjected to certain abnormal conditions which, if not compensated for, may lead to physical disorders which make the use of a prosthesis impossible.</p> <p>Lack of ventilation as a result of encasing the stump in a socket with impervious walls causes an accumulation of perspiration and other secretions of glands found in the skin. In addition to the solid matter in the secretions, bacteria will accumulate in the course of a day. Both the solid matter and bacteria can lead to infection, and the solid matter, though it may appear to be insignificant, may result in abrasions and the formation of cysts. For these reasons cleanliness of the stump and anything that comes in contact with it for any length of time is of the utmost importance, even when sockets of the newer porous plastic laminate are used.</p> <p>The stump, therefore, should be washed thoroughly each day, preferably just before retiring. A soap or detergent containing hexa-chlorophene, a bacteriostatic agent, is recommended, but strong disinfectants are to be avoided. To be fully effective, the bacteriostatic agent must be used daily. Some six or seven daily applications are necessary before full effectiveness is obtained, and any cessation of this routine lowers the agent's ability to combat the bacteria. A physician who is himself an amputee has suggested that after an amputee takes a bath, the stump should be dried first in order to minimize the risk of introducing infection to it by the towel.</p> <p>When the prosthesis is used without a stump sock, the stump should be thoroughly dry as moisture may cause swelling that will result in rubbing and irritation. For such cases, it is especially desirable for the stump to be cleansed in the evening.</p> <p>The stump sock should receive the same meticulous care as the stump. The socks should be changed daily and washed as soon as they are taken off. In this way the perspiration salts and other residue are easier to remove. A mild soap and warm water are used to keep shrinkage to a minimum. Woolite (a cold-water soap) and cold water in recent trials have given excellent results. A rubber ball inserted in the "toe" during the drying process ensures retention of shape.</p> <p>Elastic bandages should be washed daily in the same manner as stump socks, but should not be hung up to dry; rather they should be laid out on a flat surface away from excessive heat and out of the direct rays of the sun. Hanging places unnecessary stresses on the elastic threads, and heat and sunlight accelerate deterioration.</p> <p>It is of the utmost importance that any skin disorder of the stump-no matter how slight- receive prompt attention, because such disorders can rapidly worsen and become disabling. The amputee should see a physician for treatment. He should also see his pros-thetist; it may be that adjustment of the prosthesis will eliminate the cause of the disorder. In no case should iodine or any other strong disinfectant be used on the skin of the stump.</p> <p>Sometimes the skin of the stump is rubbed raw by socket friction. When this happens, the skin should be gently washed with a mild toilet soap. After the stump has been rinsed and dried, Bacitracin ointment, or some other mild antiseptic, should be applied, and the area covered with sterile gauze. The prosthesis should be completely dry before it is put on. If such abrasions occur frequently, the pros-thetist should be informed. If there is the slightest sign of infection, the amputee should see a physician.</p> <p>Small painless blisters should not be opened; they should be washed gently with a mild soap and left alone. Large, painful blisters should be treated by a physician.</p> <h4>Bandaging the Stump</h4> <p>The stump is usually kept wrapped in an elastic bandage from the time healing permits until the time the prosthesis is delivered. Also, bandaging is recommended when for some reason it is impracticable or impossible for the patient to wear his limb routinely. It is there- fore highly desirable for the amputee, or at least one member of his family, to be able to apply the bandages. Many amputees can wrap their stumps unaided and, indeed, prefer to do so. Others prefer and, in some instances, require the help of another person.</p> <p>Recommended methods for applying elastic bandages for below-knee, above-knee, below-elbow and above-elbow patients are shown in <b>Fig. 47</b>, <b>Fig. 48</b>, and <b>Fig. 49</b>, respectively. These illustrations first appeared in a booklet entitled "Industrial Amputee Rehabilitation," prepared by Dr. C. O). Bechtol under the sponsorship of Liberty Mutual Insurance Co. of Boston.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Recommended method of applying elastic bandage to the below-knee stump. The bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Recommended method of applying elastic bandage to the above-knee stump. The stump is kept in a relaxed position, and the bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Elastic bandages applied properly to upper-extremity stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Care of the Prosthesis</h3> <p>In addition to the care required in keeping the inside of the socket clean, which has been stressed, best results can be obtained only if the prosthesis is maintained in the best operating condition. Like all mechanical devices, artificial limbs can be expected to receive wear and be discarded for a new device, but the length of useful life can be extended materially if reasonable care is taken in its use. An example often quoted is that of two identical automobiles. The car given the maintenance recommended by the manufacturer and operated with care will outlast many times the vehicle given spotty maintenance and operated with disregard for the heavy stresses imposed. So it is with artificial limbs. Some amputees require a new prosthesis every few years, or even more often, while others who follow the manufacturer's instructions, apply preventive maintenance practices, and have minor problems corrected without delay, have received satisfactory service from their limbs for periods as long as twenty years.</p> <p>Manufacturers' instructions vary with the design of the device. They consist mainly of lubrication practices and should be followed closely. Too much lubricant can sometimes produce conditions as troublesome as excessive wear. Looseness of joints and fastenings should be corrected as soon as it is detected, for the wear rate increases rapidly under such a condition. Any cracks that appear in supporting structures should be reinforced immediately in order to avoid complete failure and the necessity for replacement. The foot should be examined weekly for signs of excessive wear.</p> <p>A point often overlooked by leg amputees, but nevertheless one of the factors affecting optimum use of the artificial limb, is the condition of the shoe. Badly worn or improper shoes can have adverse effects on the stability and gait of the wearer. This is a matter that requires especially close attention in the case of child amputees.</p> <p>Hooks and artificial hands should be treated with the same care that the normal hand is given. Because the sensation of feeling is absent in the terminal device, the upper-extremity amputee is all too prone to use hooks to pry and hammer and to handle hot objects that are deleterious to the hook materials. Hands with cosmetic gloves should be washed daily, and of course hot objects and staining materials should be avoided.</p> <h3>Special Considerations in Treatment of Child Amputees</h3> <p>Only a few years ago it was seldom that a child amputee was fitted with a prosthesis before school age and often not until much later. In recent years experience has shown that fitting at a much earlier age produces more effective results.</p> <p>If there are no complicating factors, children with arm amputations usually should be provided with a passive type of prosthesis soon after they are able to sit alone, which is generally at about six months of age. Certain gross two-handed activities are thus made possible, crawling is facilitated, the child becomes accustomed to using and wearing the prosthesis, and moves easily into using a body-operated prosthesis as his coordination develops soon after his second birthday.</p> <p>Lower-extremity child amputees should be fitted with prostheses as soon as they show signs of wanting to stand. The development of muscular coordination of child amputees is the same as for nonhandicapped children and, therefore, this phase may take place as early as eight months or as late as 20 or more months.</p> <p>Children, especially when fitted at an early age, almost always adapt readily to prostheses. As the child grows, the artificial limb seems to become a part of him in a manner seldom seen in adults (<b>Fig. 50</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Children with upper-extremity amputations performing two-handed activities. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Except for the very young, children's prostheses follow much the same design as those for the adult group. Special devices and techniques have been developed for initial fitting of infants and problem cases.</p> <p>Regardless of where the child amputee resides, or the extent of his parents' financial resources, he need not go without the treatment and prostheses required to make full use of his potentials. To ensure that such services are available, the Children's Bureau of the De-partment of Health, Education, and Welfare has assisted a number of states in establishing well-organized child-amputee clinics, and the facilities of these states are available to residents of states where such specialized services are not to be had. There is an agency in each slate that can advise the parents of the proper course of action.</p> <p>Most children can be treated on an outpatient basis, but for the more severely handicapped many of the clinics have facilities for in-patient treatment. The clinic team for children is often augmented by a pediatrician and a social worker, and sometimes by a psychologist.</p> <p>Training very young children is one of the most difficult problems of the clinic team. Although the learning ability of young children may be rapid, their attention span is of such short duration that extreme patience is required. Regardless of the ability of the therapist, successful results cannot be achieved without complete cooperation of the parents. The mental attitude of the parents is reflected in the child, and all too often children have rejected prostheses because the parents, consciously or subconsciously, could not accept the fact that a prosthesis was needed. Parents of children born with a missing or deformed limb often experience a sense of guilt, a feeling that only adds to an already difficult problem. The guilt feeling is unwarranted, inasmuch as the knowledge of the causes of congenital defects -and appropriate preventive measures- is very limited. The recent discovery of the effects of thalidomide suggests that other causes may be found.</p> <p>As a rule, lower-extremity amputees present fewer problems than the upper-extremity cases. It is natural for the child to walk, and almost invariably the lower-extremity patient adapts rather quickly. Parents, however, should keep close observation of the walking habits of the child, the condition of his stump, and the state of repair of his prosthesis, and above all they should present the child before the clinic at the recommended times. A gradual change in walking habit may indicate that the child has outgrown the prosthesis or that excessive wear of the prosthesis has taken place. Any unusual appearance of the stump should be reported to the physician immediately so that remedial steps may be taken, thereby avoiding more complicated medical problems at a later date. Children give a prosthesis more wear and tear than do adults and it is important that the prosthesis be examined carefully at regular intervals and needed repairs made as soon as possible-not only to ensure the safety of the child but to avoid the necessity for major repairs at a later date.</p> <p>Many upper-extremity child amputees adapt readily to artificial arms-some even want to sleep with the arm in place-but in many cases the child will need a great deal of encouragement before he will accept the device and make use of it. At first the unilateral amputee may feel that the prosthesis is a deterrent rather than an aid, but with the proper encouragement this feeling is reversed.</p> <p>Parents can help by continuing the training given in the clinics. From the beginning the artificial arm should be worn as much as possible. Young children should be given toys that require two hands for use and older children should be given household chores that require two-handed activities. In the latter case not only does the child learn to appreciate the usefulness of the prosthesis, but he also gains a feeling of being a useful member of the family and thus a better mental attitude is created.</p> <p>The child amputee should not be sheltered from the outside world but encouraged to associate with other children and, to the extent that he can, to take part in their activities. Of course there are certain limitations, but the number of activities that can be performed with presently available prostheses is amazing. It goes almost without saying that the child should receive no more special attention than is necessary, and should be made to perform the activities of daily living of which he is capable.</p> <p>It has been shown that it is preferable for the child amputee to attend a regular school rather than one for the handicapped. Most child amputees can and do take their place in society and the transition from school to work is much easier if they are not shown unnecessary special consideration. Nonhandicapped children soon accept the amputee and make little comment after the initial reaction.</p> <p>Here again the arm amputee is apt to be faced with the most problems. Some public school officials have hesitated to admit arm amputees wearing hooks for fear that the child may use them as weapons. This attitude is unrealistic. If such incidents have occurred, they are rare indeed. However, arm prostheses should be removed when the child is engaged in body-contact sports such as football.</p> <p>Cleanliness of the stump, prosthesis, and stump sock is just as important for children as for adults. The same procedures as those outlined on pages 35-36 are recommended.</p> <h3>Special Considerations in the Treatment of Elderly Patients</h3> <p>Persons who have had amputations during youth or middle age seldom encounter additional problems in wearing their prostheses as they become older. However, for those patients who have an amputation in later life many unusual problems are apt to be present. Most amputations in elderly patients are necessary because of circulatory problems, almost always affecting the lower extremity. For many years the wisdom of fitting such patients with prostheses was debatable, the thought being that the remaining leg, which in most cases was subject to the same circulatory problems as the one removed, would be overtaxed and thus the need for its removal would be hastened. Energy studies in recent years have shown that crutch-walking is more taxing than use of an artificial limb. Experience with rather large numbers of elderly leg amputees has shown that failure of the remaining leg has not been accelerated by use of a prosthesis, and stumps that have been fitted properly have not been troublesome. As a result more and more elderly patients are benefiting by the use of artificial limbs. A rule of thumb used in some clinics to decide whether or not to fit the elderly patient is that if he can master crutch-walking he should be fitted. This measure should be used with discretion because in some instances patients who could not meet the crutch-walking requirement have become successful wearers of prostheses.</p> <p>Most clinic teams feel that if the patient can use the prosthesis to make him somewhat independent around the house, the effort is fully warranted.</p> <p>Artificial legs for the older patients, as a rule, should be as light as possible. Except for the most active patients, only a small amount of friction is needed at the knee for control of the shank during the swing phase of walking because the gait is apt to be slow. Suction sockets are rarely indicated because of the effort required in donning them. A quadrilateral-shaped socket is used with one stump sock and a pelvic belt. Silesian bandages have been used successfully, allowing more freedom of motion and increased comfort.</p> <p>For the elderly below-knee cases, the patellar-tendon-bearing prosthesis is being used quite successfully.</p> <h3>Cineplasty</h3> <p>In 1896 the Italian surgeon, Vanghetti, conceived the idea of connecting the control mechanism of a prosthesis directly to a muscle. Several ideas involving the formation of a club-like end or a loop of tendon in the end of a stump muscle were tried out in Italy. Just prior to World War I the German surgeon, Sauerbruch, devised a method of producing a skin-lined tunnel through the belly of the muscle. A pin through the tunnel was attached to a control cable, and thus energy for operation of the prosthesis was transferred directly from a muscle group to the control mechanism. With refinements the Sauerbruch method is available for use today, but it must be used cautiously.</p> <p>Although tunnels have been tried in many muscle groups, the below-elbow amputee is the only type that can be said to benefit truly from the cineplasty procedure. A tunnel properly constructed through the biceps can supply power for operation of a hand or hook, and there need be no harnessing above the level of the tunnel. Thus, the patient is not restricted by a harness and the terminal device can be operated with the stump in any position. Training the tunneled muscle and care of the tunnel require a great deal of work by the patient; thus if the cineplasty procedure is to be successful the patient must be highly motivated.</p> <p>Some female below-elbow amputees have been highly pleased with results from a biceps tunnel, but as a rule cineplasty does not appeal to women.</p> <p>Cineplasty is not indicated for children. Sufficient energy is not available for proper operation of the prosthesis and the effects of growth on the tunnel are not known.</p> <p>Tunnels have been tried in the forearm muscles but the size of these muscles is such that the energy requirements for prosthesis operation are rarely met. While tunnels in the pectoral muscle are capable of developing great power, in the light of present knowledge the disadvantages tend to outweigh the advantages. It is extremely difficult to harness effectively the energy generated, and very little, if any, of the harness can be eliminated. It is true that an additional source of control can be created, but with the devices presently available little use can be made of this feature.</p> <p>No application for cineplasty has been found in lower-extremity amputation cases.</p> <p>Still another type of cineplasty procedure is the Krukenberg operation, whereby the two bones in the forearm stump are separated and lined with skin to produce a lobster-like claw. The result, though rather gruesome in appearance, permits the patient to grasp and handle objects without the necessity of a prosthesis. Because sensation is present, the Krukenberg procedure has been found to be most useful for blind bilateral amputees. Although prostheses can be used with Krukenberg stumps when appearance is a factor, the operation has found little favor in the United States.</p> <h3>Agencies That Assist Amputees</h3> <p>For several centuries at least, governments have traditionally cared for military personnel who received amputations in the course of their duties. But only in recent years, except in isolated cases, has the amputee in civilian life had much assistance in making a comeback. Today there are available services to meet the needs of every category of amputee. Aside from the humanitarian aspects of such programs, it has been found to be good business to return the amputee to productive employment and, in the case of some of the more debilitated, to provide them with devices and training to take care of themselves.</p> <p>The Armed Services provide limbs for mili- tary personnel who receive amputations while on active duty, and many of these cases are returned to active duty. After the patient has been discharged from military service, the Veterans Administration assumes responsibility for his medical care and prosthesis replacement for the remainder of his life. The U. S. Public Health Service, through its Marine Hospitals, cares for the prosthetics needs of members of the U. S. Maritime Service.</p> <p>Each state provides some sort of service for child amputees. If sufficient facilities are not available within a state, provisions can be made for treatment in one of the regional centers set up in a number of states with the help and encouragement of the Children's Bureau of the Department of Health, Education, and Welfare. With assistance from the Vocational Rehabilitation Administration of the Department of Health, Education, and Welfare, every state operates a vocational rehabilitation program designed to help the amputee return to gainful employment. Recently some of these programs have been extended to render assistance to housewives and the elderly as well.</p> <p>Private rehabilitation centers, almost universally nonprofit and sponsored largely by voluntary organizations, greatly augment the state and federal programs.</p> <p>Information concerning rehabilitation centers serving a particular area may be obtained from the Association of Rehabilitation Centers, Inc., 828 Davis Street, Evanston, Ill.</p> <p><b>References:</b></p> <ol> <li>Alldredge, R. H., <i>Amputations and prostheses</i>, Chapter 12 in <i>Christopher's Textbook of surgery</i>, 5th ed., W. B. Saunders Co., Philadelphia, 1949.</li> <li>American Academy of Orthopaedic Surgeons, <i>Orthopaedic appliances atlas</i>, vol. 2, Artificial Limbs, J. W. Edwards, Ann Arbor, Michigan, 1960.</li> <li>Batch, Joseph W., August W. Spittler and James G. McFaddin, <i>Advantages of the knee disarticulation over amputations through the thigh</i>, J. Bone and Joint Surg., Boston, 36A. :921-930, October 1954.</li> <li>Brunnstrom, Signe, <i>The lower extremity amputee</i>, in Bierman and Licht's <i>Physical medicine in general practice</i>, Hoeber-Harper, New York, 1952</li> <li>DeLorme, Thomas, Progressive resistive exercise, Appleton and Co., New York, 1951.</li> <li>Eisert, Otto and O. W. Tester, <i>Dynamic exercises for lower extremity amputees</i>, Arch. Phys. Med. and Rehab., 25:11, November 1954.</li> <li>Gillis, Leon, <i>Artificial limbs</i>, Pitman Medical Publishing Co., Ltd., London, 1957.</li> <li>Hitchcock, William E., <i>Notes on the diagnosis and treatment of above-knee fitting problems</i>, Prosthetics Education, Post-Graduate Medical School, New York University, New York, August 1957.</li> <li>Kerr, Donald and Signe Brunnstrom, <i>Training of the lower-extremity amputee</i>, ed. Charles C Thomas, Springfield, Ill., 1956.</li> <li>Klopsteg, Paul E., Philip D. Wilson, et al, <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>MacDonald, J., Jr., <i>History of artificial limbs</i>, Am. J. Surg., 19:76-80, 1905.</li> <li>Motis, G. M., <i>Final report on artificial arm and leg research and development</i>, Northrop Aircraft, Inc., Hawthorne, Calif., Final report to the Committee on Artificial Limbs, National Research Council, February 1951.</li> <li>Slocum, D. B., <i></i>An atlas of amputations, C. V. Mosby Co., St. Louis, 1949.</li> <li>University of California (Berkeley and San Fran- cisco), Biomechanics Laboratory, <i>Manual of below-knee prosthetics</i>, 1959.</li> <li>University of California (Los Angeles), Depart- ment of Engineering, <i>Manual of upper extremity prosthetics</i>, 2nd ed., W. R. Santschi, ed., 1958.</li> <li>University of California (Los Angeles), School of Medicine, Prosthetics Education Program, <i>Manual of above-knee prosthetics</i>, Miles H. Anderson and Raymond E. Sollars, eds., January 1, 1957.</li> <li>University of California Press (Berkeley and Los Angeles), <i>The limb-deficient child</i>, Berton B lakes-lee, ed., 1963.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr., B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Technical Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Avenue, 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/1963_02_001/1963-Autumn-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Limb Prosthetics Today Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr., B.S.M.E. * https://staging.drfop.org/files/original/ef9c33fd77b148aa90de4a15eba38d63.pdf 6b120f4df1e3a107e3d3c68bef3540f9 https://staging.drfop.org/files/original/aecc71c9f63ca3de9635b49186ef0fe2.jpg ee0dd270acf130106c5b30ef3f556f83 https://staging.drfop.org/files/original/9c3a89cb7f7730cd4c6b56b7590d7391.jpg f4cec16ef9035d5921c41f90ca28bcd6 https://staging.drfop.org/files/original/b5fd66a485fcb7d48eb30a63f5504417.jpg 5b69122a27795a14bcb9a1cb7a594a03 https://staging.drfop.org/files/original/17d159b930dfb31d71d62c5ee691ba0d.jpg 2a72b8f6ae90f2e9e1524ac5f30529c3 https://staging.drfop.org/files/original/eb00ea2eaae4f210b268d565e63c7e0d.jpg 54fc0b54bbd8edad785ea19df297b698 https://staging.drfop.org/files/original/640dd4eb6ba2ed2b6c98f608c29c713b.jpg b9543354d744c53f2572778988313b32 https://staging.drfop.org/files/original/b2d38ec808677879975c23042b055df4.jpg aa1d9e01ee14c6de2fde688835090f3a https://staging.drfop.org/files/original/3bb75593aa89a50b825f8368f7f92b73.jpg 347a553c959fa12bd1f4978f9eecf597 https://staging.drfop.org/files/original/d9d8ecde312bfe6431d3e6d17c56d6cb.jpg aec588355a2ba508857a04c899f7bb26 https://staging.drfop.org/files/original/9464bc47067b808f2c144ad6714d4c83.jpg ba3630b2632efa359fc9d1889de8e90d https://staging.drfop.org/files/original/3fbbfc9c24383b1570eb5768ffc83c89.jpg 1798118642ea00b00689a5bfed53f585 https://staging.drfop.org/files/original/5270bfa0fa18365e770ebb78a42d2436.jpg 91718b4d11f9d8da1db4a041219b78b1 https://staging.drfop.org/files/original/4fe6516dbb0072232e7634731bd5069e.jpg 954bd4f2762fc59a0fd590821ab51073 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_005.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 5 - 10 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_005.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Preliminary Report on the Amputee Census</h2> <h5>Harold W. Glattly, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>What is the magnitude of the amputee population of the United States? What is the composition of this group of physically handicapped individuals in terms of their sex, ages, and sites of amputation? What proportion of amputations is caused by disease? By trauma? By tumor? The answers to these questions are today more a matter of opinion than of documented fact since statistics relating to amputees that are based on large numbers of cases collected from all states of the Union have never heretofore been available.</p> <p>In the interest of developing certain basic descriptive data concerning the amputee population of the United States, the Amputee Census was initiated in October 1961 as a joint project of the Committee on Prosthetics Education and Information and the American Orthotics and Prosthetics Association. The rationale of utilizing the limb facilities of this country as the data source for the Census is based upon the assumption that a relatively high percentage of new amputees visit these shops for the purpose of being fitted with a prosthetic device. It is believed that this percentage is materially higher today than it was in 1946, at which time a federally sponsored prosthetics research program was initiated. Since that date there has been a very marked improvement in the function and comfort of prostheses, and amputees who formerly were unable to pay for a replacement device now find that there are several Government agencies to assist them. These include the federally supported State Bureaus of Vocational Rehabilitation, the Children's Bureau, the Veterans Administration, and the Workmen's Compensation programs. It has been variously estimated by both surgeons and prosthetists that between 80 and 90 per cent of all new amputees desire a prosthesis. It is hoped that some spot checks can be made in a few large medical centers to document this estimate.</p> <p>The project title, Amputee Census, is strictly speaking a misnomer (although it is a concise expression of the hoped-for result), since no national or regional head count of amputees is involved. In that only new amputee cases are included in this study, it will be possible to establish annual rates of amputation by age and cause. By applying life-expectancy tables to these rates, it is hoped to develop information that will bear upon the size of our amputee population. For example, it is obvious that there is a very wide disparity in the life expectancy of a 55-year-old man in good health who loses a limb by reason of an accident as compared with a man of the same age who suffers an amputation of his leg as the result of vascular disease. This quantitative study will not be undertaken until the census has been completed in the fall of 1964.</p> <p> Two simple data-collection forms were devised that can be executed in a matter of minutes by limbshop personnel ( <b>Fig. 1</b> and <b>Fig. 2</b> ). The participating limbshops were provided with bound books of these serially numbered forms. The books consist of original data slips that are retained by the facilities and carbon copies in the form of self-addressed and stamped postcards to be mailed to the National Academy of Sciences. It will be noted in <b>Fig. 1</b> and <b>Fig. 2</b> that the upper left-hand corners of the data cards are blocked out. It is in this space that the name of the amputee appears on the original forms retained by the facilities. Since the cards are serially numbered, it will be possible at some future time to identify certain types of amputees for further study. In the upper right-hand corner is a symbol consisting of three capital letters that identify each facility. The code to these symbols is known only to the staff of CPEI, and the limbshops have been assured that no information concerning their volume of cases will be disclosed to anyone. ( <b>Fig. 3</b> , <b>Fig. 4</b> , <b>Fig. 5</b> , <b>Fig. 6</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1. Amputee Census Card No. 1. Data form for single amputations and multiple amputations that result from a single cause at the same time.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2. Amputee Census Card No. 2. Data form for multiple amputations that occur serially at different times from the same or different causes.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig 4</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The participating facilities were instructed to fill out a card on each new amputee case for whom an original prosthetic device of some type was provided. Amputees furnished with a replacement for a worn-out or otherwise unusable limb are not recorded in this study. The card shown in ( <b>Fig. 1</b> ) is used for single amputations and for multiple amputations that occur simultaneously from a single cause. The card shown in ( <b>Fig. 2</b> ) is prepared for those cases that have had more than one amputation at separate times from either the same or different causes. Examples of this type of case include: </p> <ol> <li>An individual who is a left, below-knee amputee due to an injury who, years later, becomes a right. above-knee amputee due to vascular disease.</li><li>An individual who is a left, below-knee amputee due to vascular disease and is converted into an above-knee case a year later.</li></ol> <p> Since this card amounted to only three per cent of the total data forms received, an analysis of these cases will not be accomplished until the end of the project. ( <b>Fig. 7</b> , <b>Fig. 8</b> , <b>Fig. 9</b> , <b>Fig. 10</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 7</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The following data items are entered on the census forms:</p> <ul> <li>State of Residence.</li> <li>Age.</li> <li>Sex.</li> <li>Date of Amputation.</li> <li>Date Prosthesis Furnished.</li> <li>Site of Amputation:</li> <li>Upper Extremity:<ul> <li>(SD) Shoulder disarticulation (includes fore-quarter cases and very short above-elbow stumps that require fitting as an SD).</li> <li>(AE) Above elbow.</li> <li>(E) Elbow disarticulation.</li> <li>(BE) Below elbow.</li> <li>(W) Wrist disarticulation.</li> </ul></li> <li>Lower Extremity:<ul> <li>(HD) Hip disarticulation (includes hemipelvec-tomies and above-knee stumps so short that they must be fitted as an HD).</li> <li>(AK) Above knee.</li> <li>(KB) Knee-bearing (includes knee disarticulations, Gritti-Stokes, etc.).</li> <li>(BK) Below knee.</li> <li>(S) Syme's operation or ankle disarticulation. (Partial-hand and partial-foot amputations are not included in the census.)</li> </ul></li> <li>Cause of Amputation:<ul> <li>Trauma-amputations due to physical and thermal injuries.</li> <li>Disease-amputations due to vascular diseases and infections.</li> <li>Tumor-refers to all types of growths for which an amputation is performed.</li> <li>Congenital-only cases that are fitted with a prosthesis are included. The type of prosthesis is used to determine the level of "amputation." It is recognized that the data card is not appropriate for certain types of congenital amputees.</li> </ul></li> </ul> <p>The statistical material that is presented in this preliminary report on the Amputee Census is based upon the data forms received from the prosthetics facilities during the 16-month period from October 1, 1961, through January 31, 1963. During this time, 8,416 new cases were reported. This sampling of the amputee population of the U. S. is sufficiently large so that the distribution by sex, age, side of amputation, levels of amputation, and causes of these new amputations is already well established. This conclusion is based upon the fact that the percentages presented in this report are almost identical to those that were obtained from an analysis of the first 5,000 cases. It is thus possible in this initial census report to present in graphic and tabular form (Figs. 3-13) a simple description of the group of individuals upon whom amputations are presently being performed. The following comments and observations on this statistical material are noteworthy: ( <b>Fig. 11</b> , <b>Fig. 12</b> , <b>Fig. 13</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The disparity in the amputation rates for males and females is due primarily to the facts that: <ol> <li> Amputations in males by reason of injury are nine times as frequent as in females. This is due to the vocational and avocational hazards to which males are more liable ( <b>Fig. 8</b> ). </li><li> Amputations in males by reason of disease are 2.6 times as frequent as in females ( <b>Fig. 8</b> ). </li></ol> </li><li> Amputations due to tumor are roughly comparable between the sexes ( <b>Fig. 8</b> ). </li><li> Congenital deformities of the extremities that are fitted with prostheses occur with almost equal frequency in males and females ( <b>Fig. 8</b> ) </li><li> There is no significant difference in the incidence of left- and right-sided amputations in either the upper or lower extremities ( <b>Fig. 7</b> ). </li><li> There is a surprisingly large number of lower-extremity amputees over 70 years of age who are being fitted with prostheses. In this series, they number 1,020, or 13.2 per cent, of the total number of reported cases. It will be noted that there are four who are over 90 years of age ( <b>Fig. 5</b> ). </li><li> The incidence of malignancy resulting in amputation is fairly constant for individuals between 21-60 years of age. The decade 11-20 years has an indicated rate of twice that of any other ten-year period ( <b>Fig. 12</b> , <b>Fig. 13</b> ). </li><li>In this series there were 162 cases of multiple amputations that occurred from the same cause at the same time. Twenty-two were bilateral upper-extremity cases, 132 were bilateral lower-extremity amputations, and eight involved one upper and one lower extremity.</li><li>During the 16-month report period there were 1,798 cases of below-knee amputations for disease. It is believed that the vast majority of this group falls into the vascular insufficiency category. During this same period there were 2,520 cases due to disease in which the initial amputation was above the knee. There is no reason to doubt but that similar numbers of below-knee and above-knee amputations for vascular disease have been performed in years past during comparable periods of time. Although theoretically the site of amputation in vascular disease is based on the level of vascular sufficiency in the extremity, it may be that too many surgeons are overly concerned with the possibility that amputations at the below-knee level will later require re-amputation above the knee. This possibility is suggested by the fact that in this series there were only 12 instances in which below-knee amputations due to disease were re-amputated at a later date. This is an extremely low incidence, considering the number of below-knee amputations that are performed annually for vascular conditions. A clinical study may be needed that is designed to define better the criteria that bear upon the decision as to the level of amputation in cases of lower-extremity vascular disease. The advantages of preserving the knee joint are obvious, especially in the older age group.</li><li>The reader must recognize that the foregoing statistical material relates only to new amputee cases. The statistics are not valid for the amputee population at large due to the wide variation in the life expectancy of various types of amputees.</li></ol> <h4>Acknowledgments</h4> <p>The Committee on Prosthetics Education and Information wish to express their appreciation to the owners and managers of the participating prosthetics facilities who made this study possible and to the officers, directors, and staff of the American Orthotics and Prosthetics Association for their full cooperation in this project.</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>Harold W. Glattly, M.D. </b></td></tr><tr><td class="clsTextSmall">Executive Secretary, Committee on Prosthetics Education and Information of the Division of Medical Sciences, NAS-NRC. This Committee is jointly supported by the Training Division, Vocational Rehabilitation Administration, Department of Health, Education, and Welfare, and the Prosthetic and Sensory Aids Service, Veterans Administration.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-2.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-3.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-4.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-5.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-6.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-7.jpg Figure 7 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-11.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-10.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-8.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-9.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-12.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-13.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-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 A Preliminary Report on the Amputee Census Creator An entity primarily responsible for making the resource Harold W. Glattly, M.D. * https://staging.drfop.org/files/original/de497b398ace75dc2d796c805105fa2b.pdf 27d26b0e9c1554ef1390a967e60ce082 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_001.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 1 - 4 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Transition</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p> With this issue, <i>Artificial Limbs </i>embarks upon a new pattern of activity, changing from monographs covering major aspects to issues with articles on more diversified topics related to artificial limbs. A brief review of the philosophy and contents of prior publications may illuminate the logic of this transition. </p> <p> In nearly every issue, stress has been laid upon the management of the amputee through a clinic team. This noble idea, arising from the follow-up of the cases fitted immediately after the suction-socket schools in 1947, was destined to have a profound impact not only upon prosthetics but also, through this program and many parallel developments, upon the management of other disabilities as well. </p> <p> Early issues, many of them now out of print, were devoted to explanations of the total program of research, development, and evaluation in the fields of upper- and lower-extremity prosthetics. In a series of monographs, with copious references, <i>Artificial Limbs </i>has considered nearly every important level of amputation and has discussed the medical and psychological management of amputees, whether typical cases or those with special problems. Other related journals and reference books have become available to the clinician and to the research scholar. </p> <p> With the establishment of this solid base of reference literature, both in previous issues of this journal and elsewhere, it now seems appropriate to deviate from the classic monograph style so as to permit relatively more rapid publication and greater freedom in pursuing timely yet widely varied topics. In the past, one of the major causes for frustrating delay in the publication of this journal has been the necessity to wait upon the last manuscript needed to round out a comprehensive monograph. Those concerned with the policy of the journal, of course, have long recognized that more rapid publication of a reasonably useful document could be obtained with far less effort and suspense. A series of manuscripts, each individually worthy yet not necessarily directly related to the others, could simply be accumulated until the bundle "weighed enough to print." </p> <p> The articles in this transitional issue, however, are related to the background of past issues and to other publications of the Committee on Prosthetics Research and Development. In the traditional role of the editorial or lead article, this is an attempt to correlate the articles in this issue, to comment on them, and to stimulate each reader to apply them to his problems. </p> <p> Dr. Glattly's preliminary report on a survey of amputees, conducted with the cooperation of the prosthetics profession of this country, discloses a number of fascinating facts yet leads to interesting speculations. Obviously, the information in the article is related to the important considerations of methods of treatment for each level of amputation covered in past monographs and in the "case studies" issue of Spring 1957. Improved prostheses are available for every level of amputation; but perhaps more important are the principles of management valid for all levels which have evolved since World War II. The great preponderance of geriatric amputees in civilian practice points up the value of the report arising from a conference sponsored by CPRD in 1961-<i>The Geriatric Amputee. </i>At the other extreme, the number of child or juvenile amputees emphasizes the importance of the work of CPRD's Subcommittee on Child Prosthetics Problems and of the slowly growing number of special children's clinics engaged in a cooperative program. Fortunately, high-level and bilateral upper-extremity amputees are relatively limited in number, but they especially emphasize the need for auxiliary power, as discussed in the record of a conference held at Lake Arrowhead, California, in 1960 under the auspices of CPRD-<i>The Application of External Power in Prosthetics and Orthotics.</i> </p> <p> Indeed, the entire problem of amputation emphasizes the role of the Committee on Prosthetics Education and Information in widely disseminating information to the medical and paramedical professions through their professional schools, and local and national meetings, and by exhibits, publications, films, and slides. In fulfilling its important role, CPEI will join CPRD in sponsoring <i>Artificial Limbs, </i>beginning with the next issue. Dr. William J. Erdman, II, a member of CPEI, will join the Editorial Board. </p> <p> Mr. Colin A. McLaurin's article on independent-control harnessing for upper-extremity prostheses is clearly related to previous issues on the upper-extremity problem as a whole, harnessing for artificial arms, and discussions of problem cases. Elbow flexion independent of operation of the terminal device has long been sought, as shown by the patent literature in this country and by the German literature of World War I. Immediately after World War II, many of the amputees working with Northrop Aircraft in the relatively warm climate and casual atmosphere of Los Angeles preferred to sacrifice independent control in favor of simplicity of harnessing. However, the amputees fitted in the relatively cooler German climate by Professor Hepp after his return from his 1951 trip to the United States laboratories were more willing to accept his expert judgment that some form of "triple control" was important for function. Thus they were more willing to tolerate the more restrictive type of harness. As a result of experience with problem cases seen at the Rehabilitation Institute of Chicago and at the Michigan Area Child Amputee Center at Grand Rapids, Mr. McLaurin and Mr. Sammons have decided that independent control is important for selected amputees. Their suggestions, presented in one of the major articles of this issue, deserve careful consideration. </p> <p> The article on porous laminates in this issue, by Mr. Hill and Dr. Leonard of the Army Prosthetics Research Laboratory, is closely related to the discussion of perspiration and its consequences in a past issue on dermatological problems of amputation stumps. Readers of that classic will no doubt remember the cartoons of gremlins representing perspiration and bacteria attacking the stump within the typical air-tight socket. Porous sockets in the past have been only imperfectly approximated with porous, wicklike stump socks worn within wooden or metal shells, sometimes with numerous drilled holes, or in sockets molded of leather, which is slightly porous but undesirable from so many other hygienic aspects. The typical above-knee suction sockets of lacquered solid wood or of molded plastic laminate, both completely impermeable, have been worn without a stump sock. An early goal of the Sarah Mellon Scaife Foundation Fellowship on Orthopedic Appliances at Mellon Institute, in 1947 and following, was the development of a porous-plastic material. Though techniques of the time for attaining porosity were not satisfactory, the project made an important indirect step-the introduction to the orthotics and prosthetics field of epoxy laminate which later proved to be a key feature in the early development of porous laminates. After many years of effort, techniques only recently have been developed for the production of porous laminates of polyester resins as well as epoxy. </p> <p> The adjustable coupling for alignment of lower-extremity prostheses, developed by Messrs. Staros and Gardner of the Veterans Administration Prosthetics Center, is obviously related to the early issue of May 1954 in which tools to aid in achieving alignment based upon biomechanical principles were discussed by Professor Radcliffe. The adjustable coupling is particularly useful in aligning prostheses containing special knee joints intended for better control of the limb, though it is also applicable in alignment of the patellar-tendon-bearing below-knee prosthesis. The present coupling, useful though it is, seems only a step toward a light, expendable coupling which may be left in the prosthesis, thus obviating the need for transfer of alignment. </p> <p> Though amputees represent a relatively small fraction of the disabled of the country, the serious physical and psychological aspects of their problems demand special attention. Neglect of these severely disabled persons has sometimes, as at the end of World War II, been the cause of public criticism and emotional or even unjust reactions. It is gratifying that, since then, the systematic and steady work of many devoted individuals and organizations has led to the body of knowledge outlined in the literature now available and to many thousands of persons being trained through intensive short courses in the field, and thus to the present happier state when this highly specialized publication may move from a series of monographs to the greater freedom enjoyed by other journals. </p> <p> Eventually, it is hoped to cover such other problems as fluid mechanisms and children's prosthetics, to provide a review of clinical experience, and to enter the much broader and more complex field of bracing, or orthotics. Also, it will be a pleasure to consider for publication voluntary contributions, without placing continual pressure upon a few devoted contributors. In the meantime comments will be appreciated from our readers throughout the world. </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>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York 1, N Y.; member, Editorial Board, Artificial Limbs.</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 Transition Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * 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/ccbc8e8342b60cf117d2442be749ee76.pdf d2de9f9448bd61ff2b51f687800f4a75 https://staging.drfop.org/files/original/7f9444dc519a091e1db52b684898c6db.jpg 6afb0224ae498983295cf105bb24caa4 https://staging.drfop.org/files/original/ad7aeee90ad4b78b31d43fbf60f65bb5.jpg 1550d02824220fe557f6b80f17c281e0 https://staging.drfop.org/files/original/922c2880e12be056594b986dfdbd15a3.jpg a166685936c6108e3903c0431a34abd7 https://staging.drfop.org/files/original/3253f23949aff1f7c8b4ba003dd92266.jpg e59b2ac12c4f8f4acb25825f5c1d9fee https://staging.drfop.org/files/original/ecfadd74e96dda725a1a4968b7cd779c.jpg 7b83a2d864810382914b0008b234cb73 https://staging.drfop.org/files/original/96c1d8c5bbcd9e5572639a0399ccb2c4.jpg 7263f38aa629d269c19aa7052e919b85 https://staging.drfop.org/files/original/137df3362cb0370deeaedf5f2c513a9f.jpg d65819c948eccca57d976a570ce49d1d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1962_02_074.pdf Year 1962 Volume 6 Issue 2 Page Number(s) 74 - 85 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1962_02_074.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1962_02_074.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Experience with Patellar-Tedon-Bearing Below-Knee Prostheses</h2> <h5>Frank A. Witteck, B.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>In the latter part of 1958, prothetists of the Limb and Brace Section of the U. S. Veterans Administration Prosthetics Center, New York City, were indoctrinated in the technique of fabricating the patellar-tendon-bearing (PTB) cuff-suspension below-knee prosthesis. Preliminary experience encouraged VAPC to institute in the spring of 1959 a form of clinical study. Selection of the patients fitted with the PTB prosthesis was not rigorous, potential wearers being recruited from among veteran beneficiaries having an approved request for a new or a spare below-knee prosthesis. Availability for follow-up examinations was an important consideration, and many patients otherwise acceptable were excluded because, as it turned out, they were unable, for one reason or another, to make themselves available for the several necessary one-hour follow-up visits to the VAPC clinic. Several patients sent to VAPC from other VA Regional Offices were included in the study even though the distance from residence to fitting facility posed problems.</p> <p>Although from the standpoint of fitting the study was concluded in November 1960, follow-ups continued through September 1961. During the 21-month period, 53 adult, male, below-knee amputees were selected for participation. With a few exceptions, all had been wearing conventional below-knee prostheses-carved wood socket, side joints, and leather thigh corset, or lacer. Two had only recently undergone amputation, and their initial fittings were with the PTB prosthesis. Fifteen cases out of the 53 were selected for discussion in some detail in this summary. They represent the types of adult male amputees seen in Veterans Administration clinics throughout the country. In addition to those amputees who present no problems and who are therefore fitted successfully with a minimum of difficulty, there are included those who had been wearing a prosthesis with a thigh corset that furnished either partial or full ischial weight-bearing, those whose previous prostheses had sockets of varying types (<i>i.e.</i>, soft, slip, suction, etc.), those who had worn a number of different types of prostheses over the years, and those who had worn the same prosthesis for 15 years. Included also are recent amputees who were to be fitted for the first time, as well as one typical bilateral below-knee amputee who benefited by use of PTB fitting concepts.</p> <h3>Fifteen Case Histories</h3> <h4>Case 5 (J. D.)</h4> <p>Case 5, a 43-year-old dock checker 5 ft. 11 1/2 in. tall and weighing 178 lb., lost his left leg below the knee as a result of a mortar-shell explosion. Simultaneously, he lost some muscle power in his left hand. While the patient was hospitalized from March 1945 to March 1947, a revision was performed on the stump, and first fitting was with a prosthesis having a wood socket large enough for two stump socks to be worn. A long thigh corset had a strap-and-buckle arrangement to facilitate harnessing with the right hand. Succeeding prostheses were of the same type. Gait was fair.</p> <p>When the patient was first seen at VAPC, his stump was 4 in. long and conical. There was evidence of chronic infection in the vicinity of the patellar tendon, the skin over the patella and over the medial tibial condyle was tender, and there was some scarring over the head of the fibula. In February 1960, a PTB prosthesis with side joints and thigh corset was delivered, but the patient did not report for follow-up examination until the following August. At that time he returned the prosthesis and requested fitting with the conventional type. Although he had worn the prosthesis only occasionally on weekends for a few hours at a time, he complained of excessive piston action and irritation of the skin in the popliteal area and claimed that he could not take time off from his job for the necessary socket modifications.</p> <p>The clinic recommended that a conventional type of below-knee prosthesis be fabricated for this patient because of his inability to cooperate through no fault of his own.</p> <h4>Case 9 (A. E.)</h4> <p>Owing to complications of diabetes, Case 9, a 44-year-old postal worker and part-time stevedore weighing 190 lb. and standing 5 ft. 10 in., underwent a left below-knee amputation in 1944. The prostheses issued over the years were always of the conventional type with carved wood socket, side joints, and thigh corset.</p> <p>When, in October 1959, the patient was first seen by the VAPC clinic, the 6-in. stump was in excellent condition, quadriceps and hamstring muscle groups were adequate. Gait was poor, and training was recommended. A PTB prosthesis was delivered in late October 1959, but the patient failed to report for any follow-up examinations until June 1960, whereupon it was discovered that the prosthesis had been worn during the first three months only. The patient claimed that during the following five-month period he had never been able to come in for socket modifications. Gait was still poor. A new PTB prosthesis was prescribed and finally delivered in October 1960, and the patient was cautioned to use it gradually until he could wear it for eight-hour periods without difficulty. When seen again in March 1961, the patient claimed that he could wear the prosthesis after work and on weekends with little or no difficulty but that he found the conventional prosthesis with sidebars and thigh corset better for the heavy labor in both his regular and his after-hours jobs. The clinic team felt that the use of the two different prostheses was a reasonable approach in this case. It was recommended that this procedure be followed until the PTB prosthesis could be worn full time without difficulty. A follow-up made several months later showed that the patient was able to put aside the conventional prosthesis and wear the PTB type comfortably.</p> <h4>Case 15 (D.H.)</h4> <p>Case 15, a 54-year-old information officer weighing 220 lb. and standing 6 ft. 3 in., had his right leg amputated in September 1944 as a result of wounds from shellfire. A final surgical revision was performed in December 1944 leaving a stump 7 1/2 in. long. The prostheses worn had all been of the conventional type- carved wood socket, side joints, and thigh lacer.</p> <p>The patient was fitted with a PTB prosthesis in November 1958 prior to the institution of the study. He received a second, or spare, prosthesis in the summer of 1959 and at that time accepted a job assignment in the Midwest. Thereafter his prosthetic needs were accommodated by a shop in his new location.</p> <p>The patient is extremely active and does not spare his prosthesis. The SACH foot, for example, required replacement after several months of use. Because of wear, at least four socket inserts were made within a six-month period. Although the horsehide linings were worn through in the areas of weight-bearing, there was no stump discomfort. According to a letter report, both the SACH foot and the socket insert had to be replaced again because of wear. Despite these difficulties, the patient was extremely pleased with the PTB prosthesis and continued to use it.</p> <h4>Case 17 (F. H.)</h4> <p>In June 1947, Case 17, a 42-year-old salesman weighing 185 lb. and standing 6 ft. 3 1/2<i> </i>in., had his right leg amputated below the knee owing to gunshot wounds. Because of pain in the stump, he later underwent surgery twice for removal of neuroma, and a sympathectomy also was performed. Referred to the VAPC clinic in March 1959 by another VA Regional Office, he complained of stump pain which could be relieved only by not wearing the prosthesis, a slip-socket type worn over three stump socks. Examination of the 6 1/2-in. stump revealed a reddened scar in the popliteal area and discoloration and sensitivity in the vicinity of the fibular head such that slight tapping with the fingers produced shooting pains in the stump.</p> <p>The initial prescription for this patient was a soft-socket prosthesis with a thigh corset designed for ischial weight-bearing. The prescription was filled in April 1959, but having worn the prosthesis only four hours the patient complained of pain and numbness in the stump. He felt that the thigh corset was cutting off circulation and "choking" the stump. Because the patient claimed that he could take weight-bearing on the stump, the thigh corset was loosened, whereupon he walked painlessly. Upon re-evaluation of the case, the prescription was modified to PTB fitting. But before the PTB prosthesis could be delivered the patient was hospitalized for pancreatitis, and delivery could not be made until June 1959. In the three months thereafter, several socket modifications were required-in the area of the tibial crest, about the medial tibial condyle, and in the region of the patellar tendon. Discharged from the hospital and back at work, the patient reported that he was comfortable and free of stump pain with the PTB prosthesis. But later, in February 1960, the patient was reported to have died, cause not given.</p> <h4>Case 19 (W.H.)</h4> <p>Case 19, a 41-year-old VA prosthetics specialist weighing 190 lb. and standing 5 ft. 8 in. tall, suffered irreparable damage to both legs in March 1944 as a result of gunshot wounds. Amputation of both legs below the knee was necessitated. Revision of the stumps was carried out in July 1944.</p> <p>This patient was able to tolerate almost full end-bearing on both stumps (3 1/2 in.), and accordingly conventional prostheses were made with closed-end sockets to take advantage of the ability to carry weight on the stump ends. Some years later, when SACH feet were used on his prostheses, the patient complained of insecurity and a poor gait pattern. Hence, the feet and ankles used subsequently were of the conventional type.</p> <p>A pair of PTB prostheses was provided in November 1959, the initial fittings being attempted without side joints and thigh corsets. But it was quickly determined that there was mediolateral instability and a tendency for the knee to hyperextend. Inasmuch as the patient obviously did not have to rely upon full thigh corsets for weight-bearing, whereas side joints were indicated, a combination of side joints with reverse thigh bands (<b>Fig. 1</b>) was tried. This arrangement was found to be effective both in providing mediolateral stability and in preventing hyperextension of the knee. When, on one of his infrequent visits to the Center, the patient returned to the shop for modification of the sockets, the distal ends of both were modified to permit insertion of additional pads for increased weight-bearing, the new inserts being prepared from a rubber of durometer higher than that used formerly.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Case 19 Posterior view of bilateral PTB prostheses with side joints and anterior thigh bands. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The modified prostheses are now worn for periods of five to six hours per day, but major use is still made of the older prostheses. The "weaning process" is a slow one.</p> <h4>Case 21 (J. M.)</h4> <p>Case 21, a 36-year-old, 140-lb. telephone coordinator 5 ft. 11 in. tall, suffered irreparable injuries to his right leg when he stepped on a landmine. Amputation of the leg below the knee was performed early in 1944. There was no further surgery. For eight years the patient had been wearing, with little or no difficulty, a conventional below-knee prosthesis with a modified thigh corset giving ischial weight-bearing.</p> <p>The stump, 6 3/4 in. long, was conical in shape. Pressure on a sensitive area over the posterodistal aspect of the stump just above the end radiated pain up the thigh, apparently along the course of the sciatic nerve. There was the usual atrophy of the thigh on the side of the amputation, but knee motion was good.</p> <p>Upon delivery of a PTB prosthesis in August 1959, the patient's initial comments referred to a change in gait pattern-to the inability to take a full step as he could with his old prosthesis. During the first 90 days of use, several socket modifications were made, relief being given about the medial tibial condyle, the crest of the tibia, and the distal end of the stump. To accommodate stump shrinkage, the patellar-tendon area was built up to restore proper weight-bearing. A spare socket insert, to permit change of liner every day, was provided in an attempt to alleviate a perspiration problem.</p> <p>The patient continued to wear his prosthesis without incident until June 1960, at which time a spare PTB prosthesis was prescribed. The major complaint after 30 days of wear of this limb had to do with excessive perspiration. The horsehide liner showed signs of cracking, and a vinyl plastic ("Doe-Lon") was substituted for the horsehide. Washing and drying this insert at the end of each day minimized the adverse effects of perspiration on the liner.</p> <p>At last report the patient was still wearing his new prosthesis and had no wish to return to the older conventional one. He was pleased with the coincident weight reduction of the prosthesis-from 7 1/2 to 4 1/2 lb.</p> <h4>Case 25 (S.M.)</h4> <p>Case 25, a 42-year-old retailer weighing 195 lb. and standing 6 ft., suffered irreparable damage to his right leg in October 1944 when he stepped on a landmine. Amputation below the knee followed. Numerous metallic foreign bodies remain in the left leg and in both hands.</p> <p>The first prosthesis worn by this patient was of the conventional type-carved wood socket, side joints, and thigh corset. Subsequent prostheses had soft sockets instead of the carved-wood type. Patient was always fitted with, and wore, two wool stump socks, and he was a frequent visitor to the shop for socket modifications and limb repairs. The stump was in excellent condition, conical, and 6-3/4 in. long.</p> <p>In March 1960, when a PTB prosthesis was made, it was noted that, as usual, the patient wished to wear two stump socks. The patient was insistent that the socket be made accordingly. With the new PTB prosthesis, he was able to sit more comfortably because he could now flex his knee to 145 deg. as compared with 80 deg. with his old prosthesis. The PTB prosthesis also felt lighter than any of those previously worn.</p> <p>In a follow-up examination three months later, the patient claimed that the fit was still good even though he had lost some weight. Some stump irritation was evidently due to excessive perspiration.</p> <p>The patient was seen again in September 1960, at which time a new cuff suspension strap was provided and socket modification was required to relieve pressure in the antero-distal area. The perspiration problem was alleviated by a change during the day of one of the two stump socks he was wearing. The fresh, dry sock was worn next to the stump. There had been no stump breakdown since application of the PTB prosthesis, and at last report the patient was still wearing his appliance comfortably.</p> <h4>Case 26 (W.O.)</h4> <p>Case 26, a 30-year-old claims adjuster and part-time professional golfer weighing 150 lb. and standing 6 ft., had his right leg amputated below the knee in November 1952 as the result of a landmine explosion. A surgical revision of the stump was done later the same year. The stump was cylindrical and 6 1/2 in. long, skin type was classified as tough, there was minimum distal padding, the quadriceps muscle group was strong, and there was only slight atrophy of the thigh on the side of the amputation.</p> <p>The first prosthesis had a soft socket fitted in a laminated fiber shank with side joints and thigh corset, the foot and ankle being of the Navy type (<i>i.e.</i>, with a two-durometer rubber ankle block). The second and third prostheses were similar except that the shanks were made of wood. The Navy ankle assisted in providing the pivoting action necessary in playing golf. Gait was excellent.</p> <p>In April 1960, a PTB prosthesis with SACH foot was delivered to the patient, but he returned after a week and asked to have the SACH foot replaced with a Navy-type foot and ankle. The SACH foot, he claimed, did not give him the function he desired-primarily the pivoting action or rotation at the ankle. Replacement was made to the patient's satisfaction.</p> <p>After the prosthesis had been worn five months, the socket was modified to provide additional relief for the medial hamstring area. Perspiration was not a problem. The patient was well satisfied and more comfortable. At last report the prosthesis had been in use for nine months with an average wearing time of 12 to 16 hours per day. A spare PTB prosthesis was fabricated.</p> <h4>Case 27 (C. Q.)</h4> <p>Case 27, a 43-year-old sheetmetal worker weighing 175 lb. and standing 6 ft. 2 in., had his right leg amputated below the knee in June 1945. In November 1947, a right lumbar sympathectomy was performed in an attempt to relieve intractable pain. Several weeks later a revision of the stump was carried out. But the patient continued to complain of pain in the stump and was again admitted to the hospital in June 1948, when the sciatic and saphenous nerves were sectioned. Stump pain persisted, and in January 1956 further surgery was performed. The remnant of the fibula was removed; the distal portion of the right deep peroneal nerve was identified, resected out, and divided high; and the stump was injected with 50-percent alcohol. Final diagnosis on discharge in January 1956 was "abnormal amputation stump characterized by pain, right lower extremity below the knee."</p> <p>From 1946 to 1957, the patient had received six conventional carved-wood-socket below-knee prostheses, six new carved-wood sockets, and two major repair jobs, including the addition of ischial-bearing thigh corsets. In February 1957, a soft-socket plastic-laminate below-knee prosthesis was prescribed and delivered by VAPC. Numerous complaints of pain and irritation made it necessary to deliver another prosthesis in October 1957. In September 1958, the patient was hospitalized for removal of a foreign-body granuloma from the right knee.</p> <p>In January 1959, the patient was again hospitalized for possible revision of the 6 1/2-in. stump to a Gritti-Stokes type of amputation, but it was decided that conservative management should be continued before institution of any further surgical procedures.</p> <p>In February 1959, the patient reported to the VA Prosthetics Center for delivery of a PTB prosthesis. At the time, he was wearing a prosthesis with a slip socket and long thigh corset. The patient spent ten days at the Center to assure a satisfactory fitting and returned in March 1959 for socket modifications. Contrary to advice given him he had tried to walk with the prosthesis without using the cuff supension strap. The results were predictable: prosthesis slipped off, patient fell and damaged his stump. A modification of the socket corresponding to the area of the tibial tubercle was made, and a spare insert was fabricated.</p> <p>In December 1959, the patient again reported to the Center with complaints of an ill-fitting prosthesis. Arrangements were made to fit and fabricate a new PTB prosthesis. As a stopgap measure, an insert using thicker rubber was provided, and the new prosthesis was delivered later in the month. When the patient was seen again after 30 days (mid-January 1960), he was experiencing pressure on the distal end of the stump. Suitable relief was provided by building up the socket in the patellar-tendon area. Because of excessive perspiration, a spare insert was furnished at this time.</p> <p>The patient has not been seen at the Center since January 1960. Reports indicate that the litany of complaints is again being recited. Patient's stump seems to be in good condition and is as well fitted as possible, but the case remains a problem. The consensus is that past objective difficulties, perhaps complicated by emotional overtones, have resulted in an unusually strict standard for comfort.</p> <h4>Case 42 (E. B.)</h4> <p>Because of a landmine explosion in 1945, Case 42, a 37-year-old accountant weighing 170 lb. and standing 5 ft. 10 1/2 in., was subjected to amputation of the left leg below the knee. A revision performed later that year left deep folds and scars on the end of the stump. The right ankle had been fractured, and with increased activity it became swollen and painful.</p> <p>The first, second, and third prostheses worn by this patient were of the conventional type- carved wood socket, side joints, and thigh corset. The fourth prosthesis substituted a "muley" type of suspension for the side joints and thigh lacer. The fifth and sixth prostheses were suction-socket prostheses<a></a>, a type worn by the patient for almost two years. The patient claimed to be comfortable in the suction socket but was concerned about the increasing edema at the stump end.</p> <p>The 9-in. stump had an hourglass shape, and the distal end was edematous and discolored (<b>Fig. 2</b>). There was evidence of many old ulcerations on the distal end, and during weight-bearing the tissue overlapped the socket brim (<b>Fig. 3</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Case 42. Anterior (left) and posterior (right) views of stump showing discoloration and hourglass shape. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Case 42 wearing suction-socket prosthesis. Note overlap of tissue above socket brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A course of whirlpool therapy was instituted to reduce the edema as quickly as possible, and a PTB prosthesis with a functional ankle was prescribed and delivered in July 1960. When, after 30 days, the patient was seen again, the edema had been reduced and the skin color was lighter. Three months later, in November 1960, the patient again reported to the clinic. The prosthesis had been worn routinely since delivery, and the hourglass shape of the stump was not as prominent. Discoloration was still evident but greatly reduced. The patient claimed that perspiration had increased so that the liner had to be dried each evening. Accordingly, a spare insert was furnished.</p> <h4>Case 44 (T. MCA.)</h4> <p>In February 1960, Case 44, a 38-year-old sheetmetal worker weighing 185 lb. and standing 5 ft. 10 in., had his right leg amputated below the knee because of chronic osteomyelitis. At the distal end the stump was slightly edematous, a condition not unexpected at eight weeks postamputation. The 7 1/2-in. stump was slightly bulbous. There were no sensitive areas.</p> <p>The prescription for the PTB prosthesis, this patient's first artificial limb, contained instructions that the socket was to be mounted on an adjustable pylon as a shank (<b>Fig. 4</b>). Because the amputation was so recent, considerable stump shrinkage was anticipated, and it was felt that the use of the adjustable pylon would facilitate socket replacement and the necessary alignment changes as anticipated. A PTB prosthesis was delivered in April 1960, the pylon shank being concealed by a plastic-laminate cosmetic cover. After 30 days of wear, the socket needed modification in the areas of the patellar tendon, the flare of the medial tibial condyle, and the crest of the tibia. Several alignment changes were required, and the patient complained of excessive perspiration of the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Case 44. PTB socket mounted on an adjustable pylon. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The pylon-type prosthesis, with modified socket and alignment, was worn until June 1960, at which time a new "permanent type" PTB prosthesis was delivered. A spare socket insert was furnished to help alleviate the perspiration problem. The new limb, lighter by 1 1/2 lb. than the pylon-shank prosthesis, added to the patient's satisfaction. Subsequent follow-ups revealed no new problems.</p> <h4>Case 46 (R.R.)</h4> <p>Case 46, a 58-year-old assistant director of athletics weighing 192 lb. and standing 5 ft. 10 1/2 in., had his left leg amputated in 1945 as a result of severe leg wounds suffered in 1944. No further surgery was necessary. Prostheses had all been of the conventional type-carved wood socket, side joints, and thigh lacer.</p> <p>The stump was 9 in. long and bulbous. A nonadherent, longitudinal scar, 7 3/4 in. long, extended up the back of the stump from the anterodistal aspect to the mid-posterior aspect. There was some sensitivity of the stump end to palm pressure. Skin type was classified as delicate.</p> <p>A PTB prosthesis was delivered in June 1960, and the patient returned two months later for socket modifications. During this period, the patient had done some mountain climbing and stream fishing, activities which probably expedited stump shrinkage. The weight-bearing areas were restored by building up in the areas of the medial and lateral tibial condyles and of the patellar tendon. After another 30 days, the patient returned with the complaint that the posterior scar had been irritated and opened up. Playing baseball did little to help the situation. Whirlpool treatment expedited healing. The socket was relieved to prevent a recurrence of this irritation, and a spare socket insert was provided.</p> <p>As of last report, the patient continues to wear the PTB prosthesis satisfactorily and without discomfort. He has requested a spare prosthesis of the same type.</p> <h4>Case 47 (H.H.)</h4> <p>Case 47, a 44-year-old sales representative weighing 160 lb. and standing 5 ft. 10 in., had his right leg amputated below the knee in 1944 as the result of severe wounds. Two surgical revisions were performed in 1947. The stump was 6 1/2 in. long, cylindrical in shape, and classified as redundant. Because of discomfort, all of his prostheses, though otherwise conventional, had been made with a modified ischial-weight-bearing thigh lacer.</p> <p>A PTB prosthesis was delivered in August 1960. At follow-up examinations it was learned that no difficulty had been experienced as a result of going from one type of weight-bearing to a radically different type. The patient preferred the intimate fit, and he expressed the opinion that the prosthesis seemed more a part of him rather than an appendage.</p> <h4>Case 49 (V.M.)</h4> <p>Case 49, a 43-year-old, 185-lb. VA contact representative 5 ft. 10 in. tall, suffered severe injuries to his left leg from a shell explosion. Amputation of the leg below the knee was performed in July 1944. Two surgical revisions were done in 1950.</p> <p>This amputee had worn the conventional type of below-knee prosthesis with carved wood socket, side joints, and thigh lacer. When seen at the VAPC clinic early in 1960, he was wearing a Blevens-type prosthesis<a></a> that had been issued him in 1956. He was satisfied with the prosthesis, but it was badly in need of repair. The stump, cylindrical and 7 1/4 in. long, showed evidence of multiple skin ulcerations and numerous areas of infection. A PTB prosthesis was prescribed and delivered in July 1960.</p> <p>Follow-up examinations showed great improvement in the condition of the stump. The prosthesis was worn routinely for 14 to 16 hours a day.</p> <h4>Case 51 (J.W.)</h4> <p>Case 51, a 43-year-old editor weighing 165 lb. and standing 5 ft. 11 1/2 in. tall, lost his right leg below the knee as the result of a landmine explosion. Amputation was performed in October 1944, and a revision was effected early in 1945. The patient's stump was in excellent condition, conical, and 7 1/2 in. long. Musculature was active.</p> <p>The prosthesis that the patient was wearing was the first one issued to him, some 15 years earlier. It had a leather socket in a fiber shank, side joints, and thigh lacer (<b>Fig. 5</b>). A second prosthesis had been made in 1950, but it had never been worn because the original prosthesis had been so comfortable and generally satisfactory. As a result of the clinic team's examination and recommendation, the patient was willing to try the PTB prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Case 51 wearing 15-year-old conventional prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In July 1960 a PTB prosthesis was delivered. At a follow-up examination made after 30 days, the patient reported great satisfaction with the prosthesis. He wore it 14 to 16 hours a day and felt it was lighter, more comfortable, and "easier walking" than his old prosthesis. He also appreciated the freedom from sidebars and thigh corset. Subsequent follow-ups merely confirmed earlier impressions.</p> <h3>Summary</h3> <p>Details covering these 15 cases, and also some information on the 38 others, are summarized in <b>Table 1</b>,<b>Table 1 Cont.</b>. Although the study was concluded in November 1960, wear-experience data were carried to September 1961. Experience has shown that as stump changes occur certain modifications are more prevalent than others. In 27 cases, modifications (build-ups) were required in the area of the patellar tendon and in the popliteal region. The necessity for this type of modification was evidenced by pressure at or on the distal end of the stump, and the discomfort could be alleviated by restoring the stump to its proper position in the socket by building up on the socket shell.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1 Continued. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In 24 cases it was necessary to modify the socket in the area of the flare of the medial tibial condyle, a modification also of the buildup type. Since the medial flare has excellent weight-bearing ability, a good fit in this area is essential.</p> <p>The medial hamstring area of the socket had to be relieved or lowered in 15 instances. In general, the socket brim was made lower for proper accommodation of the medial hamstring than for the lateral hamstring.</p> <p>Seven cases experienced pressure on the crest of the tibia, a condition that was relieved by building up the socket shell on both sides of the tibial crest.</p> <p>In 14 cases, stump shrinkage after one to three months of wear made it necessary to fabricate new PTB sockets. These amputees all had either fleshy or bulbous stumps and in some cases both conditions prevailed.</p> <p>Perspiration had been anticipated as a major problem with the PTB socket, but only 16 cases complained of excessive perspiration. For these cases spare inserts were provided. The facility with which inserts can be changed makes such a measure practical.</p> <h3>Conclusions</h3> <p>Experience in the fitting of PTB prostheses has led to some general prescription criteria. The amputee should have a sound, stable knee. Instability of the knee that cannot be corrected by physical therapy is a contraindication to the use of a PTB prosthesis without thigh lacer.</p> <p>Caution should be exercised in prescribing a PTB prosthesis for heavy individuals. They often cannot tolerate, for long, full weight-bearing on the stump and will often require the additional support of a thigh lacer.</p> <p>The amputee with a long stump (<i>i.e.</i>, with an amputation in the lower third of the leg) can, and does, present many problems. Often there are circulatory complications. Achievement of the required intimate fit is much more difficult. Proper fit and alignment can be arrived at initially but are difficult to maintain over long periods of time.</p> <p>Similar comments can be made regarding sensitive stumps and those that are badly scarred. These should be treated with particular care.</p> <p>The bilateral below-knee amputee presents another special situation. It is often feasible to limit the use of the PTB prosthesis to one side only. After a period of successful, problem-free wear, a fitting can be attempted on the other side. In general, one may say that prescription for bilateral fitting should be limited to young, slender amputees of average weight.</p> <p>Another factor of prime importance is the skill and ability of the prosthetist. His talents must be brought into full play to achieve a good socket fit. Use of an adjustable alignment device is mandatory. The old cut-and-try methods have no place in the fitting and alignment of the PTB prosthesis.</p> <p>Finally, the amputee should be oriented, or indoctrinated, by the clinic team even before fitting of a PTB prosthesis is attempted. In general, initial PTB fittings are much less troublesome to the patient than are initial fittings with a conventional carved below-knee socket. In the PTB case, therefore, the amputee may be lulled into an overly optimistic belief that the initial level of comfort will always continue. To avoid any disappointment on the part of the wearer, the clinic team should make clear the substantial possibility that stump changes and other factors may later necessitate socket modifications. Because, indeed, the usual indications for a change in socket fit are not as sharply defined in the PTB socket as they are in the conventional wood socket, it is essential that the clinic team plan for periodic follow-up examinations over a relatively long period until the stump reaches a comparatively stable condition. Similarly, the patient himself should be prepared to give adequate time for the examinations (and, if need be, for socket modifications), and he should be encouraged to be constantly on the alert for subtle but progressive changes that might signal impending difficulties. Persistence on the part of the team, together with investment of the amputee's time and interest, leads eventually to a significant return in the form of a comfortable, well-fitting, and functional prosthesis without the restrictions of sidebars and thigh corset.</p> <p><b>References:</b></p> <ol> <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. Pp. 723-724.</li> <li>Murphy, Eugene F., <i>Lower-extremity components,</i> Chap. 5 in <i>Atlas of orthopaedic appliances, </i>Vol. 2, Edwards, Ann Arbor, Mich., 1960. P. 221.</li> <li>Murphy, Eugene F., <i>Lower-extremity components,</i> Chap. 5 in <i>Atlas of orthopaedic appliances, </i>Vol. 2, Edwards, Ann Arbor, Mich., 1960. P. 222.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Atlas of orthopaedic appliances, Vol. 2, Edwards, Ann Arbor, Mich., 1960. P. 221.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">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. Pp. 723-724.</td></tr><tr><td class="clsTextSmall"><b> 3.</b> </td><td class="clsTextSmall">Murphy, Eugene F., Lower-extremity components, Chap. 5 in Atlas of orthopaedic appliances, Vol. 2, Edwards, Ann Arbor, Mich., 1960. P. 222.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Frank A. Witteck, B.M.E. </b></td></tr><tr><td class="clsTextSmall">Assistant Chief, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1962_02_074/tmp62F-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1962_02_074/tmp62F-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1962_02_074/tmp62F-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1962_02_074/tmp62F-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1962_02_074/tmp62F-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1962_02_074/tmp62F-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1962_02_074/tmp62F-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 Some Experience with Patellar-Tedon-Bearing Below-Knee Prostheses Creator An entity primarily responsible for making the resource Frank A. Witteck, B.M.E. * https://staging.drfop.org/files/original/3bd373d7b71c5da2b6a9a46f7a8b1a61.pdf 0902badc0f53cd23ac3d290e99214489 https://staging.drfop.org/files/original/4a95db85b24a9753157d2091a3a2a5ec.jpg c7bc89ef10dd6110b7b5107695947e36 https://staging.drfop.org/files/original/873ca0c36463fdee471bc415f3db6a30.jpg fb11174d4492e099d8c5bf4ada23cb5a https://staging.drfop.org/files/original/cc5c394b9babc8c66452d969e0ec3360.jpg 6002758e2fce5cc2c9cb4a78a4673074 https://staging.drfop.org/files/original/f4d6246ae5163ec9fd33ac86c230a674.jpg 5efe317f898eb54a61e9af475e49b444 https://staging.drfop.org/files/original/80d686ca496322d9bab4e840a41d9ed5.jpg 90254103541c6ed9430f948a568504ee https://staging.drfop.org/files/original/7522225df64cd7f5a947c3ae9914c2eb.jpg f6a79e27bd830681dec524c398cdb24b https://staging.drfop.org/files/original/658e23dc8166ab586faa2bf8eace64e1.jpg b155747e7c2e83cd2fdd9ca2e2ed8fde DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1962_02_016.pdf Year 1962 Volume 6 Issue 2 Page Number(s) 16 - 24 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1962_02_016.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1962_02_016.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Biomechanics of Below-Knee Prostheses in Normal, Level, Bipedal Walking</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>Human locomotion involves the transformation of a series of controlled and coordinated angular motions occurring simultaneously at the various joints of the lower extremity into a smooth path of motion for the center of gravity of the body as a whole. Though largely taken for granted, it is an extremely complicated process, the complexity becoming evident when one considers that the path of motion is influenced by six major factors: knee-ankle interaction, knee flexion, hip flexion, pelvic rotation about a vertical axis, lateral tilting of the pelvis, and lateral displacement of the pelvis. A thorough study of walking in the orthograde attitude would therefore include not only the influence of each of these factors on the total displacement pattern but also a complete analysis of the action of major muscle groups of the lower extremity. The present discussion is limited to a consideration of the hip, knee, and ankle joints and of their interaction during level walking-first in the normal person and then in the case of the below-knee amputee wearing the patellar-tendon-bearing prosthesis with and without additional impedimenta in the form of thigh corset and sidebars.</p> <h4>Phases of the Walking Cycle</h4> <p>The upright, bipedal walking cycle may be divided into two phases-the stance (or weight-bearing) phase and the swing phase. The stance phase of any given leg begins at the instant the heel contacts the ground, ends at toe-off when ground contact is lost by the foot of the same leg. The swing phase begins at toe-off and ends at heel contact. The two feet are in simultaneous contact with the walking surface for approximately 25 percent of a complete two-step cycle, this part of the cycle being designated as the "double-support" phase.</p> <p><b>Fig. 1</b> gives a graphic account of the interaction between the knee and ankle joints and of the phasic action of major muscle groups during a typical walking cycle. The particular curves shown represent the average of actual measurements recorded during studies<a></a> of four male college students considered to be representative of a larger population sample. The sequence of events is arbitrarily started at heel contact and followed until the next heel contact of the same foot. The term "knee moment" refers to the action of the muscle groups about the knee which tends to change the knee angle, either in flexion or extension. Similarly, "ankle moment" refers to the muscular action about the ankle joint which may cause either plantar flexion or dorsiflexion. The mechanics of major muscle groups of the lower extremity is indicated in <b>Fig. 2</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Correlation between joint action and muscular activity in the lower extremity during normal, level walking. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Major muscle groups of the normal lower extremity (schematic), showing the major mechanics in the parasagittal plane. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Eevents Just Prior to Heel Contact</b></p> <p>In reference to <b>Fig. 1</b>, and particularly to the curves in the region corresponding to the end of the swing phase (about 95 percent of a complete cycle), it may be noted that the knee joint reaches its maximum extension just prior to heel contact and that a period of knee flexion then initiated continues on into the stance phase. As seen in the curves of muscle activity, this decrease in the rate of knee extension at the end of the swing phase, in preparation for the contact of the foot with the floor, is due primarily to the action of the hamstring muscle group, which is attached to the pelvis behind the hip joint and to the tibia and fibula below the knee joint. Tension in the hamstring group may cause either hip extension or knee flexion or the two simultaneously.</p> <p><b>Heel-Contact Phase</b></p> <p>As the heel makes contact, the hamstring action tends to bring it forcibly backward into contact with the floor, while the knee continues to flex rapidly. The activity in the hamstring group continues, but with decreasing magnitude, while the quadriceps action begins to build up quickly. The quadriceps group, acting anteriorly about the knee joint, and the pre-tibial group, acting about the ankle joint, serve to control the knee-ankle interaction and thus to effect a smooth motion of the forepart of the foot toward the floor. The major function of both knee and ankle during this phase is smooth absorption of the shock of heel contact and maintenance of a smooth path of the center of gravity of the whole body. Although the function of the knee as a shock absorber is often overlooked, energy studies<a></a> have shown that the knee and ankle contribute equally to shock absorption.</p> <p><b>Mid-Stance Phase</b></p> <p>The controlled knee flexion of the heel-contact phase continues into the mid-stance phase (between foot flat and heel-off), and the maximum angle of knee flexion, approximately 20 deg., occurs in the first part of the mid-stance phase. As the body rides over the stabilized knee, the upward thrust of the floor reaction moves forward on the sole of the foot, thus gradually increasing the dorsiflexion of the ankle and causing the knee to begin a period of extension. In this period, control of the leg is through ankle-knee interaction, there being only minimal muscular activity in the groups acting about the hip and knee. The knee reaches a position of maximum extension about the time the heel leaves the ground, the calf group providing the resistance to knee extension and ankle dorsiflexion. As the heel leaves the ground, the knee again begins a period of flexion, chiefly because of muscular action about the hip joint. This sequence of controlled flexion at heel contact, release to allow gradual extension in mid-stance, and controlled flexion preparatory to swing is important in accomplishing a smooth and energy-saving gait in normal persons.</p> <p><b>Push-off Phase</b></p> <p>During the push-off phase, a phase complex and often misunderstood, the knee is brought forward by action of the hip joint, and a sensitive balance is maintained by interaction of hip, knee, and ankle joints. The combined action has two purposes-to maintain the smooth forward progression of the body as a whole and to initiate the angular movements in the swing phase that follows. As the knee begins to flex (about the time the heel leaves the ground), the knee musculature must first resist the external effect of the force on the ball of the foot which passes through space on a line ahead of the knee joint. Then, as the knee is brought forward by hip-joint action, so as to pass through and then anterior to the line of the force acting upward on the foot, the knee must reverse its action to provide controlled resistance to flexion by increasing quadriceps activity. Some inconsistent hamstring activity is noted as an antagonist. The calf group continues to provide active plantar flexion during the entire push-off phase. At the time the toe leaves the floor, the knee has flexed 40 to 45 deg. of the maximum of 65 deg. it reaches during the swing phase. In normal persons, knee flexion in the swing phase is not due primarily to hamstring action, as might be supposed. Complete prosthetic restoration of normal function in the push-off phase is difficult, if not impossible. A proprioceptive sense of knee position by the amputee is necessary, as well as an active source of energy in the ankle. Because of lack of an active source of ankle energy, initiation of knee flexion in amputees wearing a prosthesis must come from active hip flexion.</p> <p><b>Swing Phase (Quadriceps Action)</b></p> <p>The over-all objective in the swing phase is to get the foot from one position to the next in a smooth manner while clearing the usual obstacles of terrain. At the start of the swing phase, the leg has just completed a period of rapid increase in kinetic energy caused by the active extension of the ankle and flexion of the hip during the push-off phase. The knee is flexing and continues to flex after toe-off. During rapid walking this would result in excessive knee flexion and heel rise were it not for the action of the quadriceps group in limiting the angle of knee flexion to approximately 65 deg. and then continuing to act to start knee extension. Knee extension continues as a result of a combination of pendulum effects owing both to muscle action and to the weight of the inclined shank and of the foot. Little quadriceps action is required, since other factors are of equal importance. For example, the iliopsoas muscle contributes by developing active hip flexion, which in turn accelerates the knee forward and upward.</p> <p><b>Mid-Swing</b></p> <p>During mid-swing there is a period of minimal muscular activity, and the leg accelerates downward and forward like a pendulum with forced motion of its pivot point.</p> <p><b>Terminal Deceleration (Hamstring Aaction)</b></p> <p>Near the end of the swing phase, the rate of knee extension must be reduced in order to decelerate the foot prior to heel contact. This "terminal deceleration" of the normal leg is due primarily to the extension resistance of the hamstring group.</p> <h4>Knee Action in Amputee Gait</h4> <p>In the past a common cause of difficulty in the use of the so-called "muley" below-knee prostheses<a></a> has been the "breakdown" of the stump, in particular of the knee joint on the amputated side. It has been due in part to overstraining of the ligamentous structures of the knee by excessive hyperextension under load. In order to protect these ligamentous structures on the amputated side, it is necessary to maintain within safe limits the forces and moments about the knee which tend to force it into hyperextension. In normal individuals a precise sense of knee position limits the hyperextension moment by maintaining the knee center close to the line of the force transmitted through the lower extremity. Since in many below-knee amputees the knee action is unaffected by amputation, it is reasonable to expect such an amputee to walk with a normal knee action. When this potential is anticipated and accounted for in the fitting and alignment procedure, a below-knee amputee of average-to-long slump length can make use of the controlled flexion-extension-flexion sequence of knee action required in absorbing shock and smoothing the path of motion of the center of gravity (<b>Fig. 1</b>). The socket must be fitted to accommodate the dynamic forces, and the amputee must contribute voluntary control of the knee by action of the musculature.</p> <h4>Analysis of Stump-Socket Forces</h4> <p>The contact pressures between the stump and socket of a below-knee amputee are influenced by a combination of factors. In the case of the patellar-tendon-bearing prosthesis (or of any other below-knee prosthesis without thigh corset and sidebars), the two major factors are the fit of the socket and the alignment of the prosthesis, <i>i.e., </i>the location of the foot with respect to the socket. When the thigh corset is used, there are certain modifying effects even when optimum alignment of sidebars and corset with respect to the socket is obtained. In discussing the relationship between fit and alignment, it is often helpful to discuss alignment factors first, since the method of fitting a socket to an amputee's stump is dictated largely by the manner in which he can be expected to perform while wearing his prosthesis. His performance, in turn, is influenced considerably by the structural relationship between the elements of his prosthesis, <i>i.e., </i>the alignment. The patellar-tendon-bearing cuff-suspension below-knee prosthesis, without side joints or corset, is here discussed first. Thereafter the modifying influences resulting from the addition of the side joints and corset are considered.</p> <p>The following analysis is based on the assumption that a below-knee amputee with a stump of at least average length can be expected to walk in a manner similar to that of a normal person. That is, if the prosthetic foot is properly designed to minimize the effects of the loss of normal ankle function, the amputee can compensate by hip and knee action so as to achieve a gait which closely approximates the normal. Accordingly, he should be expected to go through the following sequence of knee motions:</p> <ol> <li>Control of knee flexion from the time of heel contact until the foot reaches a stable position flat on the floor.</li><li>Control of knee flexion-extension during roll-over. The foot-shank serves as a firm base during this portion of the stance phase. The position of the knee relative to the force acting on the foot can be gauged accurately by properly trained amputees. The muscular moment about the knee required to maintain a particular knee position serves as an excellent source of proprioceptive sensation if the socket fit is intimate enough to reduce lost motion to a minimum.</li><li>Control of knee flexion during the push-off phase as an aid in accelerating the prosthesis forward in the swing phase.</li></ol> <p><b>Mediolateral Forces, Cuff-Suspension Below-Knee Prosthesis</b></p> <p><b>Fig. 3</b> is a front view of a below-knee amputee in a position corresponding to the mid-stance phase. Two force systems are shown. Figure <i>3A </i>shows the forces exerted on the amputee. These forces are of two types- the body weight due to the effect of the earth's gravitational pull and the forces applied through contact with the socket. <b>Fig. 3B</b>shows the forces acting on the prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Mediolateral force diagram for a below-knee amputee wearing the patellar-tendon-bearing prosthesis with supracondylar cuff only. <i>A, </i>Forces on the amputee; <i>B, </i>forces on the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If, as seen from the front, the prosthesis is considered as a means of supporting the body, it must be capable of providing both vertical support and mediolateral balance. It is apparent that vertical components of pressure are applied against the surfaces of many areas of the stump, but for purposes of simplified analysis the combined effect of all these forces is shown as the single support force <i>S.</i></p> <p>Considering the point of application of the support force <i>S</i> as a balance point, the lateral force <i>L </i>times the distance <i>b </i>equals the body weight <i>W </i>times the distance <i>a, </i>or, in equation form:</p> <p><i>Lb = Wa </i>and <i>L = Wa/b </i>  (1)</p> <p>Unfortunately, the effect of the horizontal acceleration of the center of gravity cannot be ignored in this case, and hence in neglecting the horizontal acceleration equation 1 is incorrect.</p> <p>As indicated in <b>Fig. 3</b>, the horizontal acceleration of the body in a medial direction, due to the medial inclination of the total floor reaction <i>R, </i>results in a lateral inertia force which tends to oppose the acceleration. This inertia force must be included when consideration is given to balancing moments about the point of support. The correct relationship is therefore <i>Lb </i>+ <i>Ic = Wa:</i></p> <p><i>L </i>= (<i>Wa</i> - <i>Ic</i>) / <i>b</i>   (2)</p> <p>Equation 2 shows that the magnitude of the required lateral stabilizing (balancing) force <i>L </i>can be reduced in one of two ways-by increasing the horizontal inertia force or by increasing the effective lever arm <i>b. </i>Increasing the horizontal inertia force requires that the horizontal acceleration be increased or, in other words, that the foot should be moved laterally so as to increase the medial inclination of the total floor reaction.</p> <p><b>Effect of Foot Iinset-Outset on Mediolateral Forces</b></p> <p>The effect of changing the inset or outset of the foot is shown in <b>Fig. 4</b>, where it is possible under special conditions, as shown in <b>Fig. 4B</b>, to eliminate the need for the lateral stabilization force <i>L, </i>since in this case the weight and inertia force are seen to be in balance:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Change in mediolateral force diagram owing to inset or outset of foot from optimum position, PTB prosthesis with cuff only, as in Figure 3. <i>A, </i>Inset; <i>B, </i>outset. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Wa </i>= <i>Ic </i>  (3)</p> <p>The force on the lateral aspect of the stump has shifted to the region of the head of the fibula.</p> <p>Complete elimination of the lateral stabilizing force <i>L </i>by outset of the foot is generally undesirable, for the resulting wide-based gait is abnormal and unnecessary. Actually, a narrow-based gait with a definite need for the lateral force <i>L </i>(and corresponding lack of pressure on the head of the fibula) is definitely indicated for stumps 4 in. or more in length, the wide-based alignment being then reserved for very short below-knee stumps. It must be remembered, however, that planning the fit and alignment of a below-knee prosthesis to accommodate a narrow-based gait requires that the need for a definite lateral stabilizing force be recognized and accounted for in the fitting of the socket.</p> <p><b>Effect of Thigh Corset and Sidebars on Mediolateral Forces</b></p> <p><b>Fig. 5</b> shows the modifying effect of the thigh corset and sidebars on the pressures between stump and socket. If the sidebars are stiff enough it is possible to develop against the medial thigh a force <i>T </i>which acts in cooperation with the lateral-distal socket contact force <i>L </i>in providing mediolateral stabilization. In fact, with judicious use of bending irons the lateral pressure can be greatly reduced. In the past, this has been done to compensate for uncomfortable lateral-distal stump pressure. With a good socket fit against the lateral aspect of average-length stumps, however, the need for lateral stabilization by the thigh corset is minimized. Use of a thigh corset is indicated only for amputees with very short stumps or those in whom other medical factors require reduction in stump-socket contact forces.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Effect of thigh corset and sidebars on medio-lateral stump-socket forces, PTB prosthesis. When the thigh corset applies a force against the medial side of the upper part of the thigh, the effect is similar to a force on the laterodistal side of the stump. Corset adjustment constitutes a possible means of modifying the magnitude and distribution of forces against the lateral side of the stump. This circumstance suggests that if the lateral sidebar is constructed with sufficient stiffness it may be of assistance in relieving excessive pressure on the laterodistal end of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Anterposterior Forces, Cuff-Suspension Below-Knee Prosthesis</b></p> <p><b>Fig. 6</b> shows a side view of a below-knee amputee and the cuff-suspension prosthesis under three conditions-at heel contact, during the shock-absorption portion of the mid-stance phase, and during push-off. At the instant of heel contact, and for a short time corresponding to about 5 percent of the walking cycle, knee stability is maintained primarily by active extension of the hip joint. The tendency of the external load on the prosthesis to extend the knee is resisted by hamstring action. During this phase, forces are acting as shown in <b>Fig. 6A</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anteroposterior force diagrams for a below-knee amputee wearing the patellar-tendon-bearing prothesis -with supracondylar cuff only. <i>A, </i>At heel contact; <i>B, </i>during shock absorption (foot flat in midstance); <i>C, </i>during push-off. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Analysis of the forces acting during the shock-absorption portion of the mid-stance phase shows that it is typical for the floor-reaction force <i>R </i>to be acting along a line which passes posterior to the knee center. Under such circumstances, a completely relaxed knee would buckle, but the amputee is able to resist this tendency by active knee extension. The resulting force pattern on the stump (disregarding end-bearing) is as shown in <b>Fig. 6B</b>,where the forces are concentrated in three areas-around the patellar tendon, on the anterodistal portion of the tibia, and in the popliteal area. The socket fit must be designed to accommodate the resulting functional pressures.</p> <p>During the push-off phase, the floor reaction continues to pass behind the knee, and the anteroposterior forces are concentrated in the same three areas, as shown in <b>Fig. 6C</b></p> <p><b>Effect of Thigh Corset and Sidebars on Anteroposterior Forces</b></p> <p>If a below-knee amputee is fitted with a thigh corset and back-check so that he relies on the mechanical action of the back-check to resist knee extension, the force pattern is altered considerably. <b>Fig. 7</b> shows the effect. The floor reaction <i>R </i>must now be assumed to pass anterior to the knee, since otherwise the knee would not be extended against the back-check. If the knee joint is considered as a moment center, the effect of the force <i>R </i>is resisted by the back-check moment <i>Mo </i>and the two forces <i>A </i>and <i>P </i>exerted by the stump within the socket. Under the proper conditions, it is possible for the mechanical back-check to provide the total resistance to the floor reaction, the stump being suspended freely in the socket. This would indicate that, by proper adjustment of thigh corset, sidebars, and back-check, it is possible to modify the pattern of anteroposterior stump-socket contact pressures.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Effect of thigh corset, sidebars, and back-check on anteroposterior stump-socket forces, PTB prosthesis. Shear force, <i>Sh, </i>is absorbed by mechanical side joint. Moment reaction forces on the stump are reduced through absorption of moment by knee stop. Without a knee stop, the stump would have to resist moment due to floor reaction passing ahead of knee joint. The resulting high pressure on the patellar tendon can be eliminated if the knee is allowed to flex (Fig. 6) instead of being forced into full extension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Summary</h4> <p>Thus it may be seen that, while normal skeletal and neuromuscular structure of the lower extremity is so organized as to accommodate the complex and precisely phased performance needed for erect, bipedal locomotion, the below-knee amputee, even though provided with a well-fitting prosthesis of the patellar-tendon-bearing cuff-suspension type, is unavoidably destined to experience in walking a continually changing set of stump-socket forces in both the anteroposterior and the medio-lateral directions. Successful fitting of the below-knee amputee means, therefore, the resolution of stump-socket forces in such a way as to provide both comfortable support and adequate stabilization throughout the walking cycle. Whenever addition of thigh corset and sidebars is required, there occurs a change in the pattern of motion, and hence a change in stump-socket forces to be anticipated, and accordingly suitable modifications are required. Allowance for such factors calls in every case for the sound judgment of the prosthetist if fully satisfactory results are to be obtained.</p> <p><b>References:</b></p> <ol> <li>Bresler, B., and F. R. Berry, <i>Energy and power in the leg during normal level walking, </i>Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 15, May 1951.</li> <li>Murphy, Eugene F., <i>The fitting of below-knee prostheses, </i>Chapter 22 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The fitting of below-knee prostheses, Chapter 22 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bresler, B., and F. R. Berry, Energy and power in the leg during normal level walking, Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 15, May 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Mechanical Engineering, University of California, Berkeley.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1962_02_016/tmp624-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Biomechanics of Below-Knee Prostheses in Normal, Level, Bipedal Walking Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * https://staging.drfop.org/files/original/6a14887dccb6af6e9e26ce87123196dd.pdf 9c0426c05e766c9fea1f2d8fdf087e6b https://staging.drfop.org/files/original/842bf0cf5047f21bfbb1f5b67b405d57.jpg c5929c69483ba3a3674295e9c05e2798 https://staging.drfop.org/files/original/b69258705c1c1029fea89e959a20461f.jpg 8d3adecc23bb719325e7f3b757b2bbfb https://staging.drfop.org/files/original/44354ad5672e786cb22286eed8615f9a.jpg 4be40ceee37e10c8210384107aa5a06c https://staging.drfop.org/files/original/ee5d5da90ccb3fbaba84f056609ca61a.jpg 2d5d7cd8183cb4aefac4c723e16fd1d7 https://staging.drfop.org/files/original/840cc38fe69fc89973c3ca0430b6b333.jpg de4df5209df76fb80f081dc30f4a582d https://staging.drfop.org/files/original/ec31e35fa05e26ac2dc2d20061e34567.jpg 0643a7a42d9b832e42cb92f8de360af7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_076.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 76 - 85 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1961_01_076.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_076.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Biomechanics of the Syme Prosthesis</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br /></h5> <blockquote><p>*A contribution from the Biomechanics Laboratory, University of California, San Francisco and Berkeley, aided by U. S. Veterans Administration Research Contract VAm-23110.</p> </blockquote> <p>The purpose of any limb prosthesis is to replace, to the reasonable satisfaction of the wearer, as much as possible of the normal form and function lost through amputation. To provide a suitable prosthesis in any particular case, therefore, the several cooperating professional persons-physicians, prosthetists, therapists, others as appropriate-must have an intimate knowledge of just what losses have been incurred and just what new circumstances, if any, have accrued as a result of the losses. Among these are the losses of structural elements, of joint motion, and of muscle function; the decrease in proprioceptive sense as well as in sensory perception; the development of persistent or recurrent pain in one form or another; the impairment of circulation; and the losses of what in the normal would be the weight-bearing areas; not to mention numerous other matters purely medical and not necessarily associated with the amputation. Any one of these factors, or any combination of them, may influence the way in which an amputee will use a given type of limb prosthesis-that is, a device intended as a limb substitute.</p> <p>In the case of the Syme amputee, where the patient has suffered loss of the foot and ankle while retaining essentially the full length of the shank and more or less of the typical weight-bearing characteristics of the normal heel, the obvious problem is to restore foot and ankle function (or to supply the equivalent of foot-ankle function), to extend the stump so as to accommodate the loss of the tarsus and of the calcaneus, to furnish adequate support for the body during standing and during the stance phase of walking, to provide suitable suspension for the prosthesis during the swing phase, and to do all these things in such a way that the final result is acceptable to the wearer under both static and dynamic conditions. As with prostheses for other levels of amputation in the lower extremity, determination of the requirements of the Syme prosthesis takes its departure from a review of the normal pattern of locomotion and proceeds toward assessment of the means through which such a pattern may best be reproduced by application of inanimate devices. Discussion is here limited to the pertinent features of straight and level walking in the normal person and to the corresponding circumstances in a Syme amputee enjoying good general health, using a prosthesis, and having a stump itself free from any inherent medical complications such as excessive scar tissue, or neuromas, or skin disorders, or sensitive joints, or other conditions ordinarily beyond control of the limb designer.</p> <h3>LOCOMOTION PATTERNS</h3> <p>In any analysis of bipedal locomotion such as that of man, it is common practice to divide the walking cycle into the two obvious phases through which the lower limbs pass alternately-the stance phase and the swing phase. <b>Fig. 1.</b> and <b>Fig. 2.</b>, based on averages from tests on four normal young males during straight and level walking,<a></a> show five different kinds of data-angular motion at the knee and ankle joints, moments about the knee and ankle joints as a result of muscle activity, muscle activity as measured by electromyographic techniques, energy level at the knee and ankle joints at a given instant, and change in energy level. Correlation of the energy data <b>Fig. 2.</b> with motions of the joints <b>Fig. 1.</b> provides an insight into knee-ankle interaction in normal human locomotion and is useful in determining the compensation required to make up for the losses incurred by Syme's amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Correlation between joint action and muscular activity in normal locomotion in man. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Energy levels and work done at knee joint and ankle joint during normal, level walking. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The terms "work done on/' "work done by," "input," and "output" used in describing energy requirements can best be defined by citing examples. In the simplified sketch of musculoskeletal joint action <b>Fig. 3.</b>, the musculature exerts an internal moment <i>M </i>which resists the load <i>W. </i>If the load <i>W </i>is sufficient to overcome the moment <i>M </i>and thus to cause the joint to rotate in opposition to the muscle action, then work is done <i>on </i>the joint, <i>i.e., </i>the joint absorbs energy. If the moment <i>M </i>is sufficient to cause the joint to rotate in the same direction as the muscle action and thus to move the load <i>W </i>in a direction opposite to its sense, then work is done <i>by </i>the joint, <i>i.e., </i>the joint provides an energy output.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Energy input and output at a typical joint. Left, equilibrium; center, energy in at knee joint, i.e., work done <i>on </i>the joint; right, energy out at knee joint, <i>i.e., </i>work done <i>by </i>the joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>THE STANCE PHASE</h4> <p>Comparison of the stance phase of the normal with that of the Syme amputee wearing a prosthesis reveals an excellent example of compensation by one joint (the knee) for loss of a second joint (the ankle) in the same extremity.</p> <h4><i>Shock Absorption</i></h4> <p>During the subphase designated "shock absorption" (<b>Fig. 1.</b> and <b>Fig. 2.</b>), the ankle in the normal subject undergoes plantar flexion while the knee flexes, both under load. Thus, an energy input results at both knee and ankle (work is done <i>on </i>both joints during the first part of the stance phase). As summarized in the bar graph of <b>Fig. 2.</b>, the work done on one joint is approximately equal to that done on the other. It could therefore be stated that in bipedal walking the knee and ankle contribute equally to the cushioning of the shock transmitted to the body at the beginning of the stance phase when the leg first assumes its function of support.</p> <p>In the Syme amputee, ankle function has-been lost and some way of compensating for it must be found. Because of the inherent space limitations in conventional Syme prostheses,. use of articulated ankle joints and elastic compression members has been for the most part unsuccessful. It is known that, in order to keep stresses in elastic bumpers within reasonable limits, the bumpers must contain a certain minimum volume of material. Otherwise the energy-absorption requirements per unit volume are excessive, and overheating and fatigue occur rapidly. The alternatives are to increase the volume of shock-absorbing material so as to reduce the unit stresses, or to transfer shock absorption to some other area, or both.</p> <p>The volume of shock-absorbing material can be increased by eliminating the articulated ankle joint and using in the heel the greatest possible volume of suitable sponge-rubber cushion-as in the SACH foot.<a></a> In general, function may be improved over that supplied by an articulated joint, but owing to the space limitations the Syme amputee cannot be given the same degree of shock absorption as can be afforded the above-knee or below-knee amputee wearing a SACH foot.</p> <p>To compensate for the lack of adequate function in the artificial foot, the knee joint on the side of the amputation must assume a greater proportion of shock absorption by increasing the amount of knee flexion under load just after heel contact. If the knee does not assume this function, the amputee must tolerate a definite impact force from prosthesis to stump and must also accept the deviation from normal gait that might be expected to accompany such a circumstance.</p> <h4><i>Roll-Over</i></h4> <p>The roll-over portion of the stance phase in normals may in turn be subdivided into three parts corresponding to the direction of knee motion. During the first part, the knee continues to flex under load and thus prolongs the period of its function as a shock absorber for the initial support of the body weight. The ankle, acting as a controller, is required to supply energy during this time, as indicated by the rising curve of energy level and the positive bar for the ankle <b>Fig. 2.</b>. In the Syme amputee, the heel cushion of the modified SACH foot contributes some of its energy of compression and thereby simulates normal ankle action, but again the knee joint must compensate for the shortcomings of the prosthetic foot-ankle unit. Because of the lack of active plantar flexion in Syme amputees, maximum knee flexion during this subphase is in general less in persons wearing a Syme prosthesis than it is in normal persons.</p> <p>While in normal locomotion the body continues to roll over the foot, which for the time being continues in full contact with the floor, the knee begins a second period of active extension, a circumstance that results in work being done on the body as a whole (<i>i.e., </i>the knee exhibits energy output). Meanwhile, the ankle absorbs about half the energy output of the knee. In a typical Syme amputee wearing a prosthesis, the foot-ankle unit is neither absorbing nor supplying energy during this period, and the energy requirement of the knee during this interval is thus reduced as compared with that of the normal person.</p> <p>During the third part of normal roll-over, the knee is forced into full extension and maintained there by the external forces acting upward on the ball of the foot. The ankle continues to absorb energy as the tibia rotates forward over the stationary foot. To compensate for the inability of the prosthetic ankle to absorb energy during the last part of rollover, the prosthetic foot must be designed so that the forward point of support corresponds to the ball of the foot, an arrangement which maintains the knee along a path corresponding to that of the normal. In other words, the knee should move forward smoothly, and no sensation of vaulting over the fore part of the foot should be experienced. In the amputee wearing a Syme prosthesis with a properly aligned SACH foot, knee action at the end of roll-over should be almost the same as it is in a normal person.</p> <h4><i>Push-Off</i></h4> <p>The push-off portion of the stance phase begins when the heel is lifted from the floor. During the first part of this subphase in normal persons, both knee and ankle contribute energy-the knee by virtue of energy that has been stored by passive stretching of the hamstring ligaments and the ankle by virtue of active plantar flexion which continues throughout the push-off phase. In the Syme amputee, the ankle substitute cannot contribute energy by active plantar flexion, and accordingly other means must be found to maintain a smooth path of the center of gravity of the body. In the SACH foot, a comparatively simple keel contour, with a cylindrical or spherical surface on a 2-in. radius at the end of the keel, has been found practical for most adults. Under these circumstances, the hip and knee joints serve as the active elements in the kinematic chain which controls the pathway of the center of gravity.</p> <p>In the second part of push-off, the normal knee absorbs about half as much energy as is supplied by the normal ankle joint, energy absorption by the knee being associated with the maintenance of a smooth path for the center of gravity of the body as a whole. At toe-off, for example, the knee in normal persons has flexed 40 deg. of the total of 65 deg. achieved at the point of maximum knee flexion. Energy absorption by the normal knee continues at about the same rate after active plantar flexion of the ankle has started to slow down. Since the foot-ankle unit in the Syme prosthesis must maintain the pathway of the knee by proper keel contour rather than by active plantar flexion of the ankle, the amount of energy absorption required of the knee is less in the Syme than it is in the normal. The need to initiate knee flexion before the end of the stance phase remains, however, and the socket must therefore be designed to permit maximum control of knee motion by the stump in preparation for the swing phase.</p> <h4>THE SWING PHASE</h4> <p>Since in the patient with Syme's amputation the knee and hip joints are usually undisturbed, it might be assumed that the swing phase of the Syme amputee would always appear relatively normal. But the role of the ankle joint at the end of the stance phase must be considered. In normal locomotion, the knee starts to flex before the foot leaves the ground, and the controlled knee-ankle interaction provides a major source of energy for the forward propulsion of the knee. If this motion is smooth and precisely controlled, the thigh-shank-foot combination enters the swing phase normally. Anything that tends to disturb this smooth transition from stance to swing has a noticeable effect throughout the swing phase.</p> <p>For the patient who has undergone Syme's amputation, poor function in the prosthetic foot and pain in the weight-bearing areas of the stump are the two most common sources of unstable or erratic action during transition from stance to swing phase. When, however, the prosthetic foot has been properly designed, aligned, and adjusted to allow the knee and hip to provide normal-appearing control of knee motion at the end of the stance phase, the amputee should, in general, have the ability to exercise complete control of his prosthesis during swing phase.</p> <h3>SOCKET DESIGN</h3> <h4>ANALYSIS OF STUMP-SOCKET FORCES DURING THE STANCE PHASE</h4> <p>Analysis of the distribution of contact pressures between stump and socket at various times during the stance phase is useful in the design of a socket that will be comfortable for the amputee. Since pressure distribution varies during each of the three subphases-shock absorption, roll-over, and push-off-each must be analyzed separately.</p> <h4><i>Shock Absorption</i></h4> <p>If it be assumed that body weight is supported at the distal end of the stump, it can be seen clearly from <b>Fig. 4.</b>A that during the shock-absorption subphase the major functional forces between stump and socket occur in the anterodistal and posteroproximal areas. During roll-over, the need for posteroproximal pressure decreases, and the contact pressure at the end of the stump shifts toward the center of that area. If the force system is to be in equilibrium, the paths of the forces <i>P, D,</i>and <i>F </i>must intersect at <i>M </i>and their vectors must form a closed polygon. Use of this principle makes it possible to estimate the relative magnitudes of the three forces.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Stump-socket forces during the stance phase. A, Shock absorption; B, push-off. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4><i>Push-Off</i></h4> <p><b>Fig. 4.</b>B shows the force system that develops as the Syme amputee rolls over the ball of the foot in the push-off subphase. At the instant shown, the hip joint is being used to help flex the knee against the force acting upward on the ball of the foot. Again, the principle of force equilibrium can be applied to estimate the magnitude of the forces. A posterodistal and an anteroproximal contact force between stump and socket are seen to be necessary to resist the floor reaction against the ball of the foot. It is essential that the anteroproximal force against the tibia be kept at as high a level as possible. Shortening of the distance <i>a </i>results in increased inclination of the line of the posterodistal contact force and in a transfer of the force away from areas surgically prepared for end-bearing.</p> <p>Since some change in the inclination of the distal stump-socket force is unavoidable, it must be anticipated during the fitting procedure. If the line of the floor reaction is kept in a particular position relative to the knee, the amputee can use some voluntary control in shifting the distal contact point. Moreover, the anteroproximal force at push-off will be several times the posteroproximal force at heel contact. For this reason, the prosthesis must be strong enough to resist the large bending moment in the ankle region during push-off. Suppose that in a 180-lb. man there is an increase of 30 percent (as compared with body weight) in the dynamic force against the ball of the foot during push-off and that dimension <i>b </i>is 4 in. Then the structure must resist a bending moment of 1.30 X 180 X 4 = 936 lb.-in.</p> <h3>SOCKET MATERIALS</h3> <p>Because of the bulbous form of the typical Syme stump, any prosthesis devised for it will be bulky in appearance. To provide the least bulky socket requires that the thickness of the wall be kept to a minimum commensurate with structural demands. Plastic laminates with high strength-weight ratios that can be molded easily over a plaster model seem ideally suited for construction of sockets for the Syme prosthesis.</p> <p>Since a snug fit throughout the length of the stump is necessary if proper function is to be expected, a cutout must be provided in the narrow section of the socket to permit entry of the bulbous end of the stump. The question arises as to where to locate a cutout, which in any case obviously should not interfere with the functional characteristics of the prosthesis nor affect its structural properties unduly. Several possibilities have been suggested. Among others are the posterior cutout used at Sunnybrook Hospital in Toronto and the medial cutout proposed at the Veterans Administration Prosthetics Center (page 57). Some predictions as to the relative structural strengths to be had from the several approaches may be arrived at through the techniques of engineering stress analysis.</p> <p>From a review of data on normal human locomotion it has been determined that in level walking maximum forces are brought to bear on the shank at the time of push-off. At this point in the walking cycle the center of pressure is eccentric with respect to the shank. Obviously the highest unit stress will occur at the level of the shank where the cross-sectional area is smallest. The relationship at push-off between the center of pressure acting upward on the ball of the foot and the minimum cross-section at the ankle is indicated in <b>Fig. 5.</b>, where the ankle is approximated by a circle of radius <i>R </i>and where all dimensions are expressed in terms of <i>R. </i>If the same loading conditions be assumed to be present when a Syme prosthesis is worn, the result is a combination of three different types of stresses in the structure of the prosthesis: compression stresses resulting from the direct thrust load carried by the structure, bending stresses resulting from a tendency for the structure to bow laterally, and bending stresses resulting from a tendency for the structure to bow posteriorly. If the loading conditions and the dimensions of the cross-section are known, the magnitudes of the stresses can be calculated, as indicated in <b>Fig. 6.</b>A. In such calculations, a plus sign indicates that a fiber of the material would be in tension at the point being investigated. A minus sign shows that the fiber would be compressed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Center of pressure as related to minimum cross-section of the ankle. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Summary of stress calculations for various socket cutouts. <i>A</i>, Sample stress analysis for Canadian-type posterior cutout, ø = 210 deg. <i>B, </i>Comparison of stresses at edge of cutout for varying degrees of cutout at three locations about the circumference; <i>P, R, </i>and <i>t</i> constant. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Summarized in <b>Fig. 6.</b>B are the results of a number of calculations based on stresses in a hypothetical Syme prosthesis with a circular cross-section of radius <i>R, </i>with a material thickness <i>t, </i>carrying a load P, and with a constant eccentricity. An interesting feature is that, even when the values for direct compression as a result of proximal weight-bearing are included, in general the posterior cutout results in tensile stresses at critical points whereas the medial cutout results in compressive stresses at critical points. The posterior cutout with <i>ø = </i>210 deg. and the medial cutout with <i>øT = </i>270 deg. are perhaps most nearly representative of actual conditions.</p> <p>These results would indicate that, when Syme prostheses are constructed with a posterior opening in the socket (tensile stresses at critical points), a material with the highest possible tensile strength should be used. A laminate of Fiberglas cloth with epoxy resin, such as is used by Canadian makers of Syme prostheses, would be an efficient material, particularly when reinforced with roving along the edge of the cutout. A laminate of Fiberglas cloth and polyester resin would also be satisfactory if fabricated carefully. Either material would provide great strength and minimum thickness with more than sufficient tensile strength. Nylon stockinet with polyester-resin laminates has lower tensile strength, and the lamination would have to be thicker.</p> <p>When the stresses at critical points are compressive, such as in the case of medial opening, a material with the greatest compressive strength should be used. In situations involving compressive loading of thin-walled columns (as in a proximally loaded Syme prosthesis), failure may be due either to failure of the laminate at the area of direct compression or to buckling of the material in a localized area, such as near a free edge carrying a compression stress. The sides of the cutout in the Syme socket with medial opening would constitute free edges of this type. To increase resistance to local buckling, the wall thickness of the laminate should be increased. Doing so will also increase resistance to direct compression because the area of the cross-section will be increased proportionally.</p> <p>Since in practice it is more convenient to use nylon stockinet as a laminating material, and since the thickness must be increased to overcome the effects of buckling, nylon stockinet is probably the material of choice for the medial opening. Although theoretically Fiber-glas laminates would have sufficient direct compressive strength even with thin walls, resistance to local buckling would be lower than in the case of a thicker nylon laminate. Moreover the compressive strength of a structure made of thin-walled Fiberglas laminate depends mainly on the quality of the laminating technique.</p> <p>It should be pointed out that in Syme prostheses direct end-bearing has been used more often in Canada than in the United States. Since end-bearing tends to increase the critical tensile stress in the posterior-opening socket by eliminating the direct compressive stresses due to proximal loading, the need for an extremely strong laminate such as one of Fiberglas cloth, Fiberglas roving, and epoxy resin is obvious. When direct end-bearing is used with the medial opening, the critical compression stress is reduced, sometimes to the extent that it is converted into tension of some low value. Nylon stockinet and polyester resin should be an adequate material for the medial-opening socket, although such a socket is more bulky in appearance.</p> <h3>CONCLUSIONS</h3> <p>To ensure a satisfactory period of use, the ankle of any prosthesis must be so designed that the elastic members resisting dorsiand plantar flexion have adequate volume to provide sufficient fatigue strength. Furthermore, the foot must be designed to permit the knee and hip joints to move smoothly through space during the roll-over and push-off phases. The SACH-type foot, with its sponge-rubber heel wedge and a keel of proper proportions, has proved useful in meeting most of the requirements for use in a Syme prosthesis, but, like all other known foot-ankle units, its inability to provide energy at push-off requires that the remaining musculoskeletal system compensate for functions lost in amputation.</p> <p>To satisfy the requirements of a comfortable transmission of functional stump-socket contact forces, the socket must provide the following features:</p> <ol> <li>Comfortable support of the body weight on the distal end of the stump or on the proximal part of the socket brim or both.</li><li>Firm support against the anteroproximal surface of the leg at the time of push-off. Careful fitting against the wedgelike medial and lateral surfaces of the tibia can satisfy this requirement.</li><li>Similar support against the posterior surface of the leg at the time of heel contact. This requirement can be satisfied by pressure in the region of the gastrocnemius. Here the main interest is to prevent lost motion between socket and stump as the reaction point shifts from the posterior to the anterior surface of the leg.</li><li>Provision for shifting of the center of pressure against the distal end of the stump, as indicated by the force analysis. If a cuplike receptacle is provided for the stump end, it must extend around and up the sides of the bulbous stump far enough to prevent relative motion between stump and socket in the anteroposterior direction. It is particularly important to provide for the horizontal component of the force against the posterodistal region of the stump during push-off.</li><li>Adequate stabilization against the torques about the long axis of the leg. A three-point stabilization against the medial and lateral flares at the anteroproximal margin of the tibia and a flattening of the postero-proximal contour can be highly effective in providing the necessary torque resistance. If the needed stabilization is not provided, torques acting on the distal end of the stump will result in skin abrasion and other associated difficulties in more proximal areas.</li></ol> <p>Either the posterior cutout of the socket favored by the Canadian workers or the medial cutout proposed by the VA Prosthetics Center will result in a socket of adequate strength if a laminate of the correct type is used. When a posterior cutout is incorporated, the laminate must be capable of resisting high tension stresses. Fiberglass-epoxy laminates are therefore indicated. When a medial cutout is used, particularly in those cases where a large proportion of proximal weight-bearing is provided, the critical stresses are compressive. When compression stresses are involved, the thicker nylon-polyester laminate may have advantages.</p> <p><b>References:</b></p> <ol> <li>Bresler, B., and F. R. Berry, <i>Energy and power in the leg during normal level walking, </i>Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 15, May 1951.</li> <li>New York University, Prosthetic Devices Study, Research Division, College of Engineering, <i>Evaluation of the solid ankle cushion heel foot (SACH foot)</i>, May 1957</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, Research Division, College of Engineering, Evaluation of the solid ankle cushion heel foot (SACH foot), May 1957</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bresler, B., and F. R. Berry, Energy and power in the leg during normal level walking, Prosthetic Devices Research Project, University of California (Berkeley), [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Series 11, Issue 15, May 1951.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Mechanical Engineering, University of California, Berkeley.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1961_01_076/d001.jpg Figure 2 http://www.oandplibrary.org/al/images/1961_01_076/d002.jpg Figure 3 http://www.oandplibrary.org/al/images/1961_01_076/d003.jpg Figure 4 http://www.oandplibrary.org/al/images/1961_01_076/d004.jpg Figure 5 http://www.oandplibrary.org/al/images/1961_01_076/d005.jpg Figure 6 http://www.oandplibrary.org/al/images/1961_01_076/d006.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Biomechanics of the Syme Prosthesis Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * https://staging.drfop.org/files/original/3448d7dd1f3b869e445982db2d59f981.pdf 56435bb25ac8133541df9f7615933fde https://staging.drfop.org/files/original/b92e747ec2d4c7fcbfb142f3b21fe188.jpg 15743c372ab5f5bfd9b131b52786f267 https://staging.drfop.org/files/original/162bfd1cff0200013041316cd03e4205.jpg 503fcd8d3eb91b82ee443d8c094e848d https://staging.drfop.org/files/original/649c45f292a3e6abbcfd67f3e7cad646.jpg bc5d177879ac5d8d63ba74148f139e50 https://staging.drfop.org/files/original/f8c103b59e1186b3debc06b41e7fa8da.jpg ff5d40912d24dc4437c5e3e86637ad0f https://staging.drfop.org/files/original/5bd55cdc8130e022cb74e9ef9310851c.jpg 877f6a2bef161af85baa70b0a7e0fc56 https://staging.drfop.org/files/original/5a13f50435edc580bd20bc0b92e39199.jpg f36ffbe912c1327a31adc0871b9584a2 https://staging.drfop.org/files/original/09f2f692fb4fb8baed50b8c404c39ff4.jpg 95dc00e192231965d2df32a4557237c3 https://staging.drfop.org/files/original/98186d2e80f51ab2c05b8e921e8b4a7c.jpg 6a7d4c0dc2f96f891e8d6f648eccb65a https://staging.drfop.org/files/original/cfb1f9e83cd52dba6e8367990403d0e7.jpg cb6459e8aa8f964867d06e310b8fb963 https://staging.drfop.org/files/original/a7526ae779090df35051bf5f19108e0f.jpg 157c3ae9edb18f10067093236eef0ecd https://staging.drfop.org/files/original/6000d92905f47758878821ee2247dd59.jpg 97191c9616d9b52f95fe7c1f3d48d26d https://staging.drfop.org/files/original/05be51461b9c231a36fab727850aafb9.jpg d2ac320312732a0ac60358b403acf8c6 https://staging.drfop.org/files/original/3d81a73baf2da2320112f7beab21a3f5.jpg 79eaca67e92aeaf4a3255846ed2f5c2d https://staging.drfop.org/files/original/3d6a53a092ad8f47d3ba47cba434cce8.jpg 0b274fe90d766da8a3eca6a1f8cbb030 https://staging.drfop.org/files/original/645ce73fcf7da4e641a02f0187a49867.jpg 7ce207a9c89481e48d4da20607137601 https://staging.drfop.org/files/original/e1898cc9379d33c5f9b2be176e2cdc18.jpg 674e6e6f3c9cfc86f882142cd90c70ad https://staging.drfop.org/files/original/1706a0b2db516be5330eec15cb82cf18.jpg 87ba92355dc1039809f33e711d681192 https://staging.drfop.org/files/original/1078a3e62aee9846acde9c3a5e792575.jpg b6a854f1571ededd167b2be93409c9d2 https://staging.drfop.org/files/original/90c35927fcd50eee702738338ce53b66.jpg da617dcbd9573aa9f0636c23afc99e41 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_052.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 52 - 75 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1961_01_052.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_052.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>Prostheses for Syme's Amputation</h2> <h5>A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>Whereas detailed information on Syme prostheses prior to the turn of the 20th century is not readily to be had, the catalogs issued by limb manufacturers in the early 1900's seem invariably to include a description of a prosthesis for the Syme stump. Of many different designs offered, some used articulated ankles (if space were available below the stump and socket), some used rubber feet without ankle joint. Wood sockets, steel-reinforced leather sockets, and even cast aluminum sockets were available. Though most manufacturers showed prostheses with a full-length anterior opening for entry of the stump, there also were designs employing a partial anterior opening, and at least one used a full-length posterior opening.</p> <p>The descriptions accompanying the catalog presentation of these devices indicate that the originators were themselves aware of most of the problems involved in designing a prosthesis for the Syme stump. One design of the Winkley Artificial Limb Co.<a></a> had no ankle joint because, according to the designer, in many cases no known ankle unit small enough to fit into the available space could withstand the high stresses involved. When ankle joints were provided (<b>Fig. 1.</b>, left), a steel-reinforced leather socket was used; when space limitations precluded use of an ankle joint (<b>Fig. 1.</b>, right), use was made of a willow wood socket, presumably to provide a base for attaching the felt or sponge-rubber feet available at the time.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Two types of Syme prostheses offered by the Winkley Artificial Limb Company, Minneapolis, <i>circa </i>1910. Design at left incorporates an articulated ankle, that at right a foot without ankle joint, presumably of rubber. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Gaines-Erb<a></a> used a wood socket with a full below-knee socket at the top and only a partial opening on the anterior aspect so that it was possible to make any desired distribution of weight-bearing between distal and proximal areas of the stump <b>Fig. 2.</b>. Marks<a></a> was aware of the need for distributing uniformly along each side of the tibia the loads developed on the stump during roll-over and, realizing that this requirement was rarely met with an anterior opening and lacing, attempted to solve the problem by using a cast aluminum socket with appropriate relief for the tibial crest and other sensitive areas <b>Fig. 3.</b>. A leather cuff closing the posterior opening encircled the shank to an anterior lacing, and the Marks rubber foot must have permitted a good cosmetic effect. An earlier version of the Marks foot, one of wood, illustrates the extent to which the inventor went to achieve resistance to the high forces developed in the area of the ankle <b>Fig. 4.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Syme prosthesis offered by the Gaines - Erb Company, Denver, <i>circa </i>1915. Note provision for weight-bearing about the proximal portion of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Syme prosthesis offered by A. A. Marks, Inc., New York, early in the 20th century. The shank-socket, cast from aluminum, contained a posterior opening. A rubber foot was used routinely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. An early version (<i>circa</i> 1889) of a Syme prosthesis manufactured by A. A. Marks, Inc. Socket and keel were formed from a single piece of wood so selected that the grain afforded maximum strength. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In a 1919 design by Bowler,<a></a> dorsiflexion bumpers were replaced by a strap between the posterior surfaces of the socket and the foot <b>Fig. 5.</b>, a feature also suggesting an appreciation of the high stresses involved in the ankle-joint mechanism. Not only were the unit stresses in the resisting material thus reduced but during dorsiflexion the forces on the ankle joint itself remained compressive instead of becoming tensile, a condition favoring longer life. Instead of being in the usual medial and lateral positions, the metal straps reinforcing the leather socket were anterior and posterior, where they were least bulky and most effective structurally. A Syme prso-thesis available from the Columbus Artificial Limb Company<a></a> employed the posterior strap patented by Bowler and added an anterior elastic strap, presumably to maintain compressive forces on the ankle joint during plantar flexion <b>Fig. 6.</b>, but the idea of anterior and posterior reinforcing straps, as proposed by Bowler, was discarded.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Syme prosthesis patented by Bowler<a></a> in 1919. First known attempt to improve appearance by use of an opening on the side of the socket, reinforcing straps on the anterior and posterior surfaces. A flexible cable, another novel feature, provided resistance to dorsiflexion without placing the ankle parts in a state of tension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Syme prosthesis offered by the Columbus Artificial Limb Company, Columbus, Ohio, <i>circa </i>1925. Some of the features of the Bowler patent<a></a> are incorporated. Cf. Fig. 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In almost all cases, lack of materials easily molded and with adequate strength but light in weight resulted in a certain bulkiness and heaviness that tended to produce a certain amount of discomfort for the wearer even if the fit itself were comfortable. In an effort to decrease weight and size, some prosthetists fabricated devices with marginal strength characteristics, devices which seldom lasted as long as comparable ones intended for leg amputations at other levels. The prosthesis that by 1940 seems to have been fitted almost routinely in both the United States and Canada consisted of a leather socket, reinforced with steel straps along the medial and lateral sides and made with a lacer and soft leather tongue along its anterior aspect <b>Fig. 7.</b>. Feet were generally of the so-called "conventional" type employing a single-axis ankle joint (often placed lower than usual) and incorporating foreshortened rubber bumpers. It was often uncomfortable, usually bulky because the sidebars projected beyond the bulbous end of the stump, and highly subject to mechanical failure of the sidebars.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Syme prosthesis typical of the era before introduction of plastic laminates into the fabrication of Syme prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the introduction of plastic laminates<a></a> into the practice of prosthetics, research workers at the Prosthetic Services Centre of the Department of Veterans Affairs, Toronto, were quick to realize that the use of plastic laminates might well result in the development of a Syme prosthesis to a great extent free from the shortcomings of Syme prostheses previously used. Prior attempts to use laminated wood-veneer sockets had failed to produce practical prostheses owing to the difficulty of molding about the bulbous end, but the results encouraged the investigators to proceed with the then newly developed fabric-plastic laminates. The first model that showed promise<a></a> consisted of a socket molded of a polyester-Fiberglas laminate with a neoprene-crepe foot reinforced by a polyester-Fiberglas keel extending from the distal end of the socket <b>Fig. 8.</b>. To provide more comfort along the anterior aspect of the stump, the opening for entry of the stump was cut out of the rear section of the socket, stability being obtained by replacing the cutout section and holding it in place by a metal fitting at the bottom and a strap and buckle at the top.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. An early version of the Canadian-type plastic prosthesis for Syme's amputation. The nonarticulated foot was in this instance constructed of a neoprene crepe of uniform density. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although use of plastic laminate materially reduced bulkiness, and although the nonartic-ulated foot eliminated many of the problems associated with the so-called "conventional" unit, mechanical failure in the socket where the cutout was largest occurred too frequently for the new prosthesis to be adopted as a standard item.<a></a> Fiberglas roving (loosely spun cords of Fiberglas molded in place along the edges of the cutout) increased the strength of the socket, but it was necessary to substitute epoxy resins (much better adhesion to the glass fibers) for the polyesters before fully adequate strength could be obtained. With a few refinements, this prosthesis <b>Fig. 9.</b> is in use routinely today by the Canadian Department of Veterans Affairs.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The Syme prosthesis now adopted as standard by the Canadian Department of Veterans Affairs. The plastic laminate consists of Fiberglas cloth and roving impregnated with an epoxy resin, and the posterior opening extends the length of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Attempts by workers in the Artificial Limb Program in the United States to employ the Canadian technique using polyester-Fiberglas laminates led to the same kinds of mechanical failures experienced by the Canadians.<a></a> In addition, a good proportion<a></a> of the Syme cases fitted could not continue to assume full end-bearing comfortably throughout the entire day. This experience, coupled with a reluctance to employ Fiberglas if the more convenient nylon stockinet<a></a> could be used, or to use the first-available epoxy resins because of the inherent toxicity of the wet, uncured resin when mixed with the hardener, [*The recent introduction of polyamide hardeners has since greatly reduced the risk of the fabricator's contracting dermatitis.] led to the development of the "Medial-Opening Plastic Syme Prosthesis" <b>Fig. 10.</b> at the Veterans Administration Prosthetics Center.<a></a> To reduce the unit stresses along the periphery of the cutout necessary for entry of the stump, the cutout was made in the medial wall of the socket (page 68). Unlike the posterior cutout in the Canadian version, the medial opening does not extend upward to the brim of the socket but resembles a door, an arrangement which permits the Syme case to be so fitted that all or any part of the weight may be carried along the brim of the socket. The foot is a commercially available version of the SACH foot.<a></a>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Syme prosthesis developed by the Veterans Administration Prosthetics Center, New York. The nylon-dacron-polyester socket is provided with an opening in the medial wall. Weight-bearing may be divided, in any proportion, between the proximal rim and the distal portion of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Concurrent with the development of the medial-opening plastic Syme prosthesis at the Veterans Administration Prosthetics Center, the Prosthetics Research Center of Northwestern University introduced into the Canadian technique a number of refinements which might also be applied in fabricating and fitting the medial-opening type of prosthesis. Of especial interest are a new method of obtaining casts of Syme stumps and a method of attaching a SACH foot to permit greater latitude in alignment of the foot with respect to the socket, including also a method of reinforcing the keel of a SACH foot should that be necessary in individual cases.</p> <p>Manuals<a></a> containing detailed, step-by-step procedures for fabricating, fitting, and aligning the Canadian and the medial-opening Syme prostheses are available, and details of the Northwestern techniques have been published.<a></a> An outline of all of these procedures is given here so that any might be adopted singly or in combination to meet the requirements of individual patients.</p> <h3>THE CANADIAN-TYPE PLASTIC SYME PROSTHESIS</h3> <h4>TAKING THE MEASUREMENTS AND MAKING THE MODEL</h4> <p>All anatomical measurements necessary for constructing the Canadian-type plastic Syme prosthesis are taken while the patient bears his body weight on the end of the stump. Placed under the stump is a block of wood of such thickness as to maintain the pelvis in a horizontal position, and the anteroposterior dimension, the width, and the circumference of the stump are recorded, all at the level of the largest part.[*A special device, consisting of two wedges that can be moved with respect to each other so as to provide for rapid adjustment <b>Fig. 11.</b>, has been found to be a useful improvement over the single wood block.] For use later on in the alignment procedure, a line perpendicular to the floor and passing through the mediolateral center of the patella <b>Fig. 12.</b> is marked on the stump with indelible pencil for eventual transfer to the plaster model.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Special device used in taking measurements of the Syme stump while the stump is bearing weight. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Stump measurements required for fabrication of socket for the Canadian-type plastic Syme prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After all sensitive areas and bony prominences, including the tibial crest throughout its length, have been similarly marked with indelible pencil, a cast is made using plaster-impregnated bandage, a longitudinal cut being made along the posterior mid-line to permit removal of the cast. Thereafter, a model of the stump is made by filling the cast with liquid plaster of Paris, a bar or pipe being inserted in the soft plaster at the proximal end to provide an extension to be used later in holding and handling the model.</p> <h4>MODIFICATION OF THE MODEL</h4> <p>Upon removal of the cast, a finishing nail <b>Fig. 13.</b> is driven all but 1/4 in. into the bottom of the model at the intersection of an anteroposterior extension of the vertical reference line and a medio-lateral line bisecting the area on the bottom of the model. The bulbous end is now built up by adding plaster until the dimensions conform to those recorded while the stump was bearing weight. At the same time, in order to allow space for a sponge-rubber pad in the finished socket, a layer of plaster 1/8 in. thick is added to the bottom portion and faired in, leaving the nail protruding 1/8 in. So that a recess to receive a foot nut will be formed in the finished socket, a piece of leather or other suitable material 1/8 in. thick and 1 1/4 in. in diameter is pierced at its center and positioned on the protruding nail. To provide relief for the sensitive areas and bony prominences, skived leather patches are added to the model as appropriate.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Plaster model of stump just before application of Fiberglas. It is easier to modify the model before the plaster has hardened completely. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The path of the sawline to be used in forming the cutout for stump entry is marked on the model, and metal wedges <b>Fig. 14.</b> are inserted to facilitate the later re-establishment of the sawline on the exterior of the socket. The saw-line itself is located by establishing on each side of the model a point 3/8 in. behind the anteroposterior mid-line of the model at the top and another point 1/4 in. behind the same mid-line at the level where the stump begins to bulge <b>Fig. 13.</b>. Two metal wedges are inserted well apart on each of these lines, 1/4 in. being left to protrude. After the model has dried thoroughly and three coats of cellulose-acetate lacquer have been applied, it is ready for use in fabricating the prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Steel wedge used to outline cutout, shown twice actual size. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>LAMINATION</h4> <p>In the lamination of Fiberglas with epoxy resins, rapid work is essential to obtain the best structural results, and accordingly it is desirable here that this operation be performed by two persons working together. The model is held vertically in a vise, a brush coat of epoxy resin is applied, and a length of 10-strand Fiberglas roving is laid along the anterior side of each of the vertical portions of the sawline and fanned out over the end of the bulbous portion of the model <b>Fig. 15.</b>. The multiple-strand roving is held in place by encircling the model and roving with a piece of single-strand roving.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. First layup of Fiberglas roving and cloth. Note that roving is fanned out over ball of model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A piece of Fiberglas cloth 4 in. longer than the length of the model and 2 in. wider than its circumference at the largest part is laid up over the model so that the surplus length is placed distal to the bulbous end, and the whole is tied in place with single-strand roving <b>Fig. 15.</b>. The surplus length is then slit vertically every 2 in. along the periphery and laid over the bulbous end of the model, and the entire piece of cloth is saturated with the resin. Three additional pieces of Fiberglas cloth of the same size are applied in the same manner but are so placed that none of the vertical overlaps coincide.</p> <p>To complete the lamination, four pieces of Fiberglas cloth 2 in. wide and about 2 in. longer than twice the length of the model are applied, one at a time, with the transverse centers of the strips located over the bulbous end and positioned approximately 45 deg. apart <b>Fig. 16.</b>. The entire assembly is held in place by a spiral wrapping of single-strand roving, and after application of a final brush coat of resin a snugly fitting sleeve of polyvinyl alcohol film (PVA) is pulled over the layup, the lower end being tied snugly to the holding rod, the top end model. To compress the laminate and to re-trimmed to a point 5 in. from the end of the move air and excess resin, the layup is wrapped tightly in spiral fashion with a strip of PVA 2 in. wide, the wrap starting from the holding end of the model <b>Fig. 17.</b>. To the excess resin thus forced upward into the top end of the sleeve there is now added as much chopped roving as possible so as to form an extension around which the foot may be fabricated.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Layup of longitudinal strips of Fiberglas cloth just before application of PVA bag. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Lamination for socket, ready for curing. Note extension for keel, formed by introducing resin and chopped Fiberglas roving into end of PVA bag. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After curing for 30 min. at room temperature (or 45 min. at 250° F. if time is important),[*In an alternate, and preferable, procedure, the layup is allowed to gel at room temperature overnight and then, after the cutout has been made, replaced over the model, fastened in place by suitable straps, and cured for 30 min. at 225° F.] the laminate is cut, with a cast cutter or other suitable device, along the lines defined by the protruding wedges. At the lower portion of the cutout, large radii are used, and the lowest point reached is just proximal to the point of maximum anteroposterior socket diameter.</p> <h4>MAKING THE FOOT</h4> <p>After the laminated parts, socket and cutout, have been removed from the model, the extension is so shaped by grinding that the foot may be built around it. By means of a standard foot nut and a bolt 1 1/4 in. in diameter <b>Fig. 18.</b>, the keel <b>Fig. 19</b>, formed from a strip of aluminum alloy (7075-T6) 1 1/4 in. wide and 0.128 in. thick, is fastened to the extension at the point indicated by the recess formed in the bottom of the socket. For most adults, two thirds of the length of the keel is placed ahead of the center of the socket, but the proportion may be varied to suit individual cases. To provide reinforcement during the fitting procedure, a piece of wood is bonded temporarily to the keel and socket extension by use of epoxy paste.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Standard steel foot nut used by the Canadian Department of Veterans Affairs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Cross-section of foot and lower end of Canadian-type plastic Syme prosthesis. Before final assembly, the wood block is replaced by epoxy resin and chopped Fiberglas roving. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A 4-ply rubber-fabric belting 4 in. wide and four pieces of 18-iron neoprene sponge are now laminated (with Barge's cement) to the configuration shown in <b>Fig. 19</b>, the neoprene layers being slotted to receive the keel. A wood block 4 in. wide and shaped to conform to curve A-A in <b>Fig. 19</b> should be used to assist in holding the layers in place while bonding is effected.</p> <p>When the initial bonding of the neoprene and belting is fully set, a layer of 9-iron neoprene sponge is bonded to the underside of the belting, and a wedge of some resilient material is added to form the heel. Material for the heel, selected to meet the particular requirements of the individual patient, may be neoprene sponge, rubber sponge, solid rubber, or some other elastomer. Finally, the foot is cut and ground to the shape necessary to fit the shoe.</p> <h4>ALIGNMENT AND ASSEMBLY</h4> <p>Temporary attachment of the foot to the keel <b>Fig. 20</b> is effected by driving a 1/8-in. steel pin transversely through the heel section just ahead of the end of the keel <b>Fig. 19</b>. The corset, the portion of the socket that has been cut out, is now provided with the means for holding it in place-a tongue-and-slot arrangement at the bottom <b>Fig. 21.</b> and an encircling leather strap in the calf area <b>Fig. 9.</b>. Details of the parts required are shown in <b>Fig. 22.</b>, <b>Fig. 23.</b>, and <b>Fig. 24.</b>. The metal pieces are bonded and riveted to the laminated parts. Two buckles are recommended as a precaution against the possible loss of use of a particular eye in the strap <b>Fig. 9.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Insertion of keel into neoprene portion of foot. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Tongue-and-slot method of holding corset in place. Tongue and slot are held in place temporarily by the bolts and wing nuts. Epoxy resin and rivets are used for permanent attachment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Slot, shown actual size. Aluminum 0.040 in. thick. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Tongue, shown actual size. Aluminum 0.125 in. thick. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Double-buckle assembly used to secure corset in place. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After a pad of felt or neoprene sponge, carved to fit the bottom of the socket and the end of the stump, has been placed in position, the prosthesis is ready for final alignment. The relationship between the keel and the socket may be changed by removing the attaching bolt and keel and changing the configuration of the socket extension, either by grinding or by adding shims. When the desired alignment has been obtained, a 1/8-in. hole is drilled through the aluminum keel into the socket extension, and a 1/8-in. dowel of cold-rolled steel <b>Fig. 19</b> is driven into the hole. The established alignment may thus be reproduced upon reassembly during the finishing process. To achieve maximum rigidity of the keel, the temporary wood block is removed, two steel rods each 1/8 in. diameter are inserted into holes drilled in the anterior surface of the socket extension and allowed to extend into the cavity, and the cavity is filled with a mixture of epoxy resin and chopped Fiberglas roving.</p> <p>The aluminum surfaces must be clean to ensure an adequate bond. All gaps between keel and neoprene are filled with epoxy resin, and a fairing between the foot and socket is fashioned from a mixture of epoxy resin and fine sawdust, which after curing can be ground and sanded to shape. If desired, small holes may be drilled through the socket wall to furnish ventilation. When, after sanding, the outside of the socket and corset have received a coat of enamel, and when the neoprene parts of the foot have been sealed with two light coats of cellulose-acetate lacquer, the prosthesis is ready for use <b>Fig. 25.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Completed Canadian-type plastic Syme prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>THE MEDIAL-OPENING PLASTIC SYME PROSTHESIS</h3> <h4>TAKING THE MEASUREMENTS</h4> <p>The anatomical data considered necessary for fabrication of the medial-opening socket are somewhat more extensive than are those suggested as being needed in the Canadian technique. In addition to determining the distance from the end of the stump to the floor while the stump is bearing half of body weight,[*Because a neoprene sponge-rubber pad will be used later in the end of the socket, it is recommended by VAPC that a sponge-rubber pad 1/4 in. thick be used between the stump and the supporting block <b>Fig. 26.</b>.] circumferential measurements of the stump are made at 1-in. intervals in the first 5 in. of the stump while it is in the weight-bearing condition. Besides this, circumferences at these five levels and also circumferences at 2-in. intervals from a point 5 in. from the end of the stump to the medial tibial plateau are read while the stump is free of weight-bearing. At each level measured, marks are made with indelible pencil. A form for recording the required information is shown in <b>Fig. 26.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Form for recording measurements and other information necessary for fabrication and fitting of a Syme prosthesis (VAPC type). From Iuliucc.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>MAKING THE CAST AND THE MODEL</h4> <p>To protect the stump from the plaster of Paris used in making the cast, a length of cotton stockinet, sewed at one end, is pulled over the stump and secured by an elastic band above the knee. Outlines of sensitive areas and bony prominences are made on the stockinet with an indelible pencil so that they will be transferred to the cast and in turn to the model for guidance in making appropriate modifications.</p> <p>Although the particular method of obtaining a cast is not critical provided a faithful model of the stump can be obtained ultimately, the Veterans Administration Prosthetics Center suggests a method wherein the cast is made in two pieces, so as to eliminate the need for cutting the plaster to remove the stump.[*The same technique can, of course, be applied in obtaining any cast that requires separation for removal of the stump.] To obtain the two-piece mold, the end of the stump is first wrapped with 3-in. plaster bandage to the level of greatest circumference <b>Fig. 27.</b>. A slab of five layers of plaster bandage 6 in. wide is then molded against the entire anterior half of the stump and secured in place by a few turns of 3-in. plaster bandage at the narrow part of the shank and again at the area just below the patella <b>Fig. 28.</b>. So that the cast, and hence the model, will approach the configuration of the stump in the weight-bearing condition, the plaster is allowed to harden while the patient bears weight through the distal end <b>Fig. 29.</b>, a sponge-rubber pad being placed between the bottom of the cast and the supporting block. As the plaster hardens, the edges should be faired to the stump. Lateral and medial centerlines are now drawn on the anterior portion of the cast for guidance in forming the parting line, petrolatum is applied to the exposed stockinet, and a similar slab of plaster bandages is molded to the posterior portion of the stump up to the lateral and medial centerlines <b>Fig. 30.</b>. Lines drawn transversely across the seams at several levels serve at reference points for proper reassembly of the cast after removal from the stump. Before pouring of the model is started, the indelible marks on the interior of the cast should be retraced to ensure a satisfactory transfer. For the pouring operation, the two halves may be held together by a wrapping of plaster bandage.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. First step in obtaining a plaster impression of a Syme stump. A plaster bandage 3 in. wide is applied over the end of the stump to the level of greatest circumference. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Application of a slab of plaster bandage to anterior surface of stump to provide one half of a two-piece casting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Stump under weight-bearing conditions while anterior and distal portions of plaster impression are allowed to harden. The posterior portion of the impression is applied later. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Application of plaster-bandage slabs to form posterior portion of two-piece casting. Note parting line drawn on anterior casting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>MODIFICATION OF THE MODEL</h4> <p>So that the finished socket will fit snugly along the sides of the tibia and yet not press unduly on its crest, plaster is removed from the model along each side of the area representing the tibial crest <b>Fig. 31.</b>, and a long leather patch, skived in the usual manner, is glued in place on the plaster. Skived leather patches also are attached at the points representing the malleoli, over areas corresponding to the flare of the condyles, and at any other points that will require relief in the finished socket <b>Fig. 32.</b>. Then the posteroproximal end of the model is flattened somewhat to provide for stability between socket and stump about the longitudinal axis. Finally, to make certain that the distal end of the socket will be of the proper volume to accommodate a sponge-rubber pad for cushioning the end of the stump, a circular piece of sponge rubber 1/4 in. thick is skived and glued to the distal end of the model (<b>Fig. 33.</b>) All modifications of the model are made with reference to the circumferential measurements taken earlier, <i>i.e., </i>the measurements over the distal 5 in. of the stump during weight-bearing and those above during relaxation are maintained.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Model showing where plaster should be removed so that in finished socket forces may be taken along each side of the tibial crest. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Model with skived leather patches applied to provide in finished socket relief for sensitive areas. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Model with socket liner and sponge-rubber pad applied. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>THE SOFT SOCKET LINER</h4> <p>To provide more comfort for those patients expected to take some or all weight-bearing along the proximal end of the socket, a liner of neoprene sponge rubber covered with horse-hide is provided. When a liner is to be used, a horsehide sleeve is molded around the model upward from a point 5 in. below the medial tibial plateau. Sponge-rubber sheet 1/8 in. thick is formed over the horsehide, 3/4 in. of the distal end of the leather being left exposed <b>Fig. 33.</b>. The distal end of both the horsehide and neoprene are skived.</p> <h4>LAMINATION</h4> <p>Unlike the procedure described for fabrication of the Canadian-type plastic Syme prosthesis, wherein the corset (or cover for the cutout) consists of the laminate that was cut from the socket, in the VAPC prosthesis the socket and the cover for the cutout may be laminated separately. Thus, it is here possible to begin with a socket cutout a little too small, trim away only as much material as necessary to permit easy entry of the stump, and still have available a piece of laminate large enough for a cover.</p> <p>To prevent adherence of laminate to the sponge-rubber pad (and to the soft socket liner if one is used), a snugly fitting sleeve of polyvinyl alcohol is pulled over the model and tied neatly at each end. The recommended laminate filler consists of two layers of dacron felt inside and ten layers of nylon stockinet outside. Like the PVA, the dacron felt must also be tailored into snugly fitting sleeves. If the nylon stockinet is cut into lengths slightly more than twice the length of the model, and if each length is then sewed transversely at the middle, a very neat layup can be obtained by successively pulling one half of a length over the model as far as possible and then pulling the other half over while turning it inside out. Instead of coinciding with one another, the individual transverse stitchings should be spaced equally as spokes in a wheel, the second being 36 deg. away from the first, the third 36 deg. away from the second, and so on <b>Fig. 34.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Application of stockinet over model in preparation for laminating. Two layers of dacron felt have already been applied. Note seam sewed across stockinet to form neat layup at distal end of socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A sleeve of PVA film is now drawn over the layup, and a polyester resin is introduced. To date, best strength characteristics have been obtained from a mixture of 70 percent of the "rigid" type of resin and 30 percent of the "flexible" type.<a></a></p> <p>Material for the medial cover is made by laminating three layers of nylon stockinet over the socket layup after it has been allowed to stand for one hour at room temperature. Resin is introduced on the medial side only (or only in that area selected for the cutout). After an additional hour of curing at room temperature, the entire assembly is subjected to a temperature of 180-190° F. for 25 min. The outer shell can now be cut and removed and the impregnated portion saved for use later <b>Fig. 35.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Removal of laminate to be used later in fabrication of cover for opening in socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>MAKING THE OPENING</h4> <p>The socket opening can best be cut out while the laminate is still warm. In order that the opening shall be the minimum needed for introduction of the stump, the initial aperture is deliberately made undersize, later enlarged by trimming the edges little by little until the patient can insert the stump without experiencing discomfort. The outline of the initial opening is determined by a horizontal line 1 in. above the point of maximum circumference of the bulbous portion of the socket, two lines parallel to and medial to the line of the tibial crest (one being 3/4 in. medial, the other medial by 3/4 in. plus 1/4 of the circumference of the bulbous portion 1 in. above its maximum circumference), and a horizontal line at that point on the socket where the circumference is the same as that 1/4 in. above the point of maximum circumference at the bulbous end <b>Fig. 36.</b>. Because further trimming will be necessary, the dimensions of the radii at the corners are not critical at this stage.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Outline of initial cutout in socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the initial cutout has been made, the excess material trimmed away, the plaster removed, and the proximal border of the socket trimmed, the cutout is enlarged enough that the patient can introduce his stump <b>Fig. 37.</b>. The radii of the corners should now be kept as large as possible, and the edges of the cutout should be smooth so as to contribute to the strength of the finished product by eliminating the high-stress areas commonly associated with mechanical nicks and notches.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Introduction of stump in socket to determine trim lines of cutout and, later, of proximal border. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>ALIGNMENT AND ASSEMBLY</h4> <p>In most instances, satisfactory use can be made of one of the commercially available SACH feet constructed especially for Syme prostheses. If not, a suitable SACH foot can be fabricated in accordance with the instructions given in the Canadian manual<a></a> or in the University of report, or use can be made of the reinforcement technique introduced by Northwestern University.<a></a> <!-- (page 71) --></p> <p>When the commercial version is used, it is first shaped to fit the shoe, and a guide hole 1 1/4 in. in diameter is drilled in the keel to a height above the heel sole equal to the height of the block used while the anatomical measurements were taken <b>Fig. 38.</b>. The keel and neo-prene crepe are then hollowed out to receive the bulbous end of the socket. Because of the tendency of Syme stumps to bow toward the cen-terline of the body, usually both guide hole and hollow should be offset medially. Moreover, the foot should be placed as far forward as possible with respect to the socket and be set in a small amount of dorsiflexion <b>Fig. 39.</b>, and care should be taken to ensure that the bottom surface of the heel is parallel to the floor <b>Fig. 40</b>. Such alignment should be effected by actually having the patient don the socket, place the distal end into the recess in the SACH foot, and assume a position of normal standing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Simplified cross-section of SACH foot showing certain modifications needed for use in Syme prosthesis. A hole 1 1/4 in. in diameter is drilled in keel to a depth corresponding to the height of the block used when measurements were taken [link26]. The hole is used as a guide in removing material at top of foot to accommodate socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Alignment of foot and socket in lateral view. Usually a slight amount of dorsiflexion results in best performance. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Alignment of foot and socket in posterior view. The foot must be so located that the sole is parallel to the floor when the wearer stands in his own habitual position with hips level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When initial, or static, alignment has been achieved, reference marks are made on the socket and foot to be used as a guide in reassembly, and masking tape <b>Fig. 41.</b> is applied around the juncture of the two units to hold them in place while a 3/8-in. hole is drilled through the keel and socket to receive the attaching bolt. The hole in the socket is now enlarged to 5/8 in., and the hole in the keel is provided at the bottom with a 5/8-in. countersink to accommodate the nut <b>Fig. 42.</b>, both operations best being done with the prosthesis disassembled. A cover that will overlap the socket opening 3/4 in. around the periphery is cut from the section of laminate made for the purpose. After two single-buckle straps have been riveted to the cover, a felt pad exactly fitting the opening is glued to the concave side, and the entire inner surface of the closure is lined with thin horsehide, care being taken to effect a rabbetlike contour along the periphery of the felt <b>Fig. 43.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Application of masking tape to secure foot to socket for drilling alignment hole through socket. Note reference marks used to ensure same alignment upon reassembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Simplified cross section of foot and lower end of VAPC prosthesis showing attachment of foot to socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Final step in fabrication of cover for opening in side of socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the prosthesis has been assembled, dynamic alignment is effected under conditions of actual walking. Inserted into the socket in the form of contoured discs of sponge rubber is enough distal padding to distribute the forces as desired between the proximal end of the socket and the end of the stump. Slight changes in alignment can be brought about by enlarging the hole in the end of the socket.</p> <p>Final finishing of the prosthesis includes bonding the foot to the socket, building up a smooth transition between foot and socket by use of a mixture of epoxy resin and chopped Fiberglas, and gluing the soft liner in place in the proximal area of the socket.</p> <h3>DEVELOPMENTS AT NORTHWESTERN UNIVERSITY</h3> <h4>TAKING THE CAST</h4> <p>Plaster of Paris in one form or another has been used for nearly a century in making impressions of limb stumps, and especially with the relatively new, quick-setting formulations it has proved to be fairly satisfactory. There are nevertheless certain disadvantages inherent in the use of plaster. Unless a separating medium is used, plaster will adhere to the skin. Cured plaster of Paris is extremely rigid, so that when plaster is used to take a cast of a stump like the Syme it is necessary either to cut the cast or to form it in two pieces. Furthermore, plaster is very dense and therefore heavy and comparatively hard to manage.</p> <p>In an effort to overcome some of the difficulties associated with plaster, the Prosthetics Research Center at Northwestern University's Medical School has developed a procedure for taking a cast of a Syme stump with alginate, a material used by dentists in taking impressions of the gums and teeth. Because when mixed with water alginate gels rather rapidly into a rubbery solid, it seems especially useful in taking casts of bulbous stumps and of those intended to take end-bearing. To enable the gelled material to yield when the stump is withdrawn, the impression is made in a rigid, tapered cylinder lined with an oversize canvas bag which can be withdrawn so that the rubbery alginate is left free to be displaced as the bulbous portion is pulled through the narrow section of the impression <b>Fig. 44.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Removal of stump, alginate mold, and canvas bag from canister. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since alginate solidifies so rapidly, and since so many factors (such as temperature and various impurities in the water used[*In certain areas best results can be obtained only with distilled water.]) affect the rate of gelling, it is important always to check the gelling time on a small sample before actually taking an impression. The correct mixture should gel in about six minutes. A tapered can about 20 in. long, 5 1/2 in. in diameter at the bottom, and 6 1/4 in. in diameter at the top has been found satisfactory for taking impressions in adults. The impression is taken while half of the body weight is borne by the stump, <i>i.e.,</i> while the pelvis is level and the patient is standing with feet together.</p> <p>After the stump has been removed, the bag and alginate are replaced in the conical can for pouring of the model, which should take place as soon as possible because the alginate has a tendency to shrink rather rapidly after gelling.</p> <h4>INSTALLATION OF THE SACH FOOT</h4> <p>To provide for wider degree of alignment adjustment than has been the case heretofore between the socket and the commercially available SACH foot, there has been developed a method of attachment employing a bolt with a spherical head <b>Fig. 45.</b>. Combined with an oversize hole in the socket, it permits some swivelling action between socket and foot. Adequate bearing area for the spherical bolt head is provided by laminating into the end of the socket a spherical washer <b>Fig. 45.</b> having the same spherical radius as the head of the bolt.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Spherical-head bolt (top) and spherical washer used in attaching SACH foot to plastic socket to permit relatively wide range of adjustment. Spherical washer and spherical part of bolt head can be made using plastic-laminating techniques. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Both washer and bolt head can be fabricated easily by use of plastic-laminating techniques. A mold suitable for forming both pieces can be made by immersing in wet plaster of Paris a PVA-covered rubber ball, or other spherical object of suitable size, to a depth equal to about a third of its diameter <b>Fig. 46.</b>. The washer is formed by placing in the mold about eight layers of Fiberglas cloth saturated with epoxy resin, then placing the ball in the cavity and weighting it, and then curing the resin. Trimming the periphery of the washer and drilling a 1-in. hole in the center completes the job. The spherical bolt head is constructed by placing under the head of a standard 3/8-in. machine bolt 10 discs of Fiberglas cloth drilled with 3/8-in. holes, screwing the bolt into a hole drilled into the plaster mold, filling the cavity to the top of the bolt head with epoxy resin, and curing the plastic. When curing is complete, the top may be finished by sanding.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Mold used in fabricating spherical washer and spherical bolt head. Convex portion consists of a rubber ball covered with PVA film. Concave portion is formed from wet plaster of Paris by pressing the ball in to a depth equal to approximately one third its diameter. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>So that the spherical washer may be laminated into the socket, it is attached to the plaster model of the stump with beeswax <b>Fig. 47.</b>, care being taken at this point because the location of the washer with respect to the model determines the location of the foot with respect to the socket in a horizontal plane.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Placing the spherical washer on the plaster model of the stump so that it may be laminated into the socket. Beeswax is used both to support it in the proper position and to fasten it to the model. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To enable the socket to be attached to the foot, a bandsaw is used to make in the keel of the foot a cutout conforming to the radius of the bulbous portion of the socket <b>Fig. 48.</b>. When the length of the stump dictates that the keel be so cut away as to weaken it significantly, the keel must be reinforced. In such a case, a wood screw is used to fasten the socket to the remaining portion of the keel <b>Fig. 49.</b>. The heel wedge and balata belting are peeled back, some nine layers of Fiberglas cloth, tailored to fit the keel and the end of the socket (which is covered with PVA film to prevent adherence), are laid up and saturated with epoxy resin, and the balata belting is screwed back in place <b>Fig. 50.</b>. After curing of the resin has been effected, a 3/8-in. hole is drilled through the keel reinforcement and the socket at the center of the spherical washer, the foot is removed, and that part of the hole which is in the socket is enlarged to 1 in. so as to match the hole in the spherical washer <b>Fig. 51.</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. View showing the type of cut made in the top portion of a SACH foot to accommodate a Syme socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Fastening the socket to the keel of the SACH foot with a wood screw. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Fiberglas cloth, used to reinforce keel of SACH foot, being tailored to fit bottom of keel and socket. Note PVA film placed over socket to prevent adherence to Fiberglas during laminating process. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Cross-section of completed prosthesis showing spherical head bolt, spherical washer, modified keel, and laminated Fiberglas reinforcement. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Finally, a hole 1 1/4 in. in diameter is formed in the heel wedge and sole in such a way as to receive the wrench needed to tighten the attachment nut <b>Fig. 51.</b>. The heel wedge having been modified to fit the contours of the reinforced keel and then cemented in place, the socket and foot can be assembled for walking trials. When all necessary adjustments have been made, the socket is bonded to the foot with epoxy resin and the space around the socket is filled with a mixture of resin and sawdust which, when cured, is ground and sanded to provide a suitable contour.</p> <h3>CONCLUSION</h3> <p>The several methods presented here for fabrication of a prosthesis for Syme's amputation have all been found to be useful. It seems reasonable to believe that some of the features of each method may be combined in order to suit the equipment of the individual prosthetist as well as to meet most effectively the requirements of the individual patient. For example, the technique offered by VAPC for fabrication of a cover for the cutout might well be applied to fabrication of a prosthesis with a full-length posterior cutout as used by the Prosthetic Services Centre. The use of alginate as an impression material may be the method of choice for some prosthetists, while others may find the two-piece mold best for their use, especially if the local water supply contains certain minerals. The measurement-and-modification techniques described might be combined advantageously. Thus most of the individual methods are interchangeable between the basic prostheses described.</p> <h3>ACKNOWLEDGMENT</h3> <p>Any reliable article on the recommended methods of construction of a limb prosthesis must necessarily be based on the cumulative experience and the collective judgment of many workers in many places. Most of the material for this article was drawn from three pre-existing publications-<i>Construction of the Plastic Symes Appliance </i>(Technical Bulletin No. 32, Prosthetic Services Centre, Canadian Department of Veterans Affairs, Toronto, August 1959), <i>VAPC Technique for Fabricating a Plastic Syme Prosthesis with Medial Opening </i>(U. S. Veterans Administration, New York, September 1959), and <i>Recent Developments in the Fitting and Fabrication of the Syme Prosthesis (Orthopedic and Prosthetic Appliance Journal,</i> March 1960). Much valuable advice and counsel was forthcoming from a number of highly accomplished persons, among them R. M. Turner, of the Canadian Department of Veterans Affairs, Ottawa, and C. S. Boccius, of the Prosthetic Services Centre, Toronto; Colin A. McLaurin and Fred Hampton, of the Prosthetics Research Centre of Northwestern University in Chicago; and Anthony Staros and Louis Iuliucci, of the U. S. Veterans Administration Prosthetics Center, New York City. Of the 51 illustrations, the drawings not credited to original publications are the work of Annette Kissel, illustrator for the Veterans Administration Prosthetics Center in New York City, and of George Rybczynski, freelance artist of Washington, D. C. Miss Kissel executed Figures 26 through 43. Mr. Rybczynski prepared Figures 11, 12, 13, 14, 15, 16, 17, 19, 22, 23 and 24. The cooperative efforts of all these individuals are gratefully acknowledged and duly appreciated.</p> <p><b>References:</b></p> <ol> <li>Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</li> <li>Columbus Artificial Limb Company, catalog, Columbus, Ohio, ca. 1925.</li> <li>Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, <i>Syme's amputation and prosthesis, </i>January 1, 1954.</li> <li>Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, <i>Construction of the plastic Symes appliance, </i>Technical Bulletin No. 32, August 1959.</li> <li>Foort, J., <i>The Canadian type Syme prosthesis</i>(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 1956.</li> <li>Gaines-Erb Company, catalog, Denver and Pueblo, Colo., ca. 1915.</li> <li>Gardner, Henry F., <i>A report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual. </i>Veterans Administration Prosthetics Center, New York, January 31, 1958.</li> <li>Gardner, Henry F., <i>First addendum to the January 31, 1958, report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual, </i>Veterans Administration Prosthetics Center, New York, May 1, 1958.</li> <li>Hampton, Fred, <i>Recent developments in the fitting and fabrication of the Symes prosthesis, </i>Orthopedic and Prosthetic Appliance Journal, March 1960, p 45.</li> <li>Iuliucci, Louis, <i>VAPC technique for fabricating a plastic Syme prosthesis with medial opening, </i>Veterans Administration Prosthetics Center, New York, September 1959.</li> <li>Kay, H. W., and A. Staros, <i>Plastic laminate. Syme prosthesis, </i>Prosthetic Devices Study, New York University, and Veterans Administration Prosthetics Center, New York, January 1960.</li> <li>Marks, A. A., Inc., <i>Manual of artificial limbs, </i>New York, 1889.</li> <li>Marks, A. A., Inc., <i>Manual of artificial limbs, </i>New York, 1931.</li> <li>New York University, Prosthetic Devices Studies, College of Engineering, <i>Progress report, test of the Canadian type plastic Syme prosthesis (modified)</i>, New York, December 1958.</li> <li>University of (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>2nd ed., William R. Santschi, ed., 1958.</li> <li>Winkley Artificial Limb Company, <i>Artificial legs with the patent adjustable double slip socket, </i>descriptive catalog, Minneapolis, Minn., ca. 1910.</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">Foort, J., The Canadian type Syme prosthesis(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, Construction of the plastic Symes appliance, Technical Bulletin No. 32, August 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>11.</b> </td><td class="clsTextSmall">Kay, H. W., and A. Staros, Plastic laminate. Syme prosthesis, Prosthetic Devices Study, New York University, and Veterans Administration Prosthetics Center, New York, January 1960.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">University of (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed., 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>10.</b> </td><td class="clsTextSmall">Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, 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">Hampton, Fred, Recent developments in the fitting and fabrication of the Symes prosthesis, Orthopedic and Prosthetic Appliance Journal, March 1960, p 45.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, Construction of the plastic Symes appliance, Technical Bulletin No. 32, August 1959.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, 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>5.</b> </td><td class="clsTextSmall">Foort, J., The Canadian type Syme prosthesis(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 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>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Kay, H. W., and A. Staros, Plastic laminate. Syme prosthesis, Prosthetic Devices Study, New York University, and Veterans Administration Prosthetics Center, New York, January 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">University of (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed., 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>14.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Studies, College of Engineering, Progress report, test of the Canadian type plastic Syme prosthesis (modified), New York, December 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>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Foort, J., The Canadian type Syme prosthesis(Series 11, Issue 30), Lower-Extremity Amputee Research Project, Institute of Engineering Research, University of , Berkeley, December 1956.</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Gardner, Henry F., A report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual. Veterans Administration Prosthetics Center, New York, January 31, 1958.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Gardner, Henry F., First addendum to the January 31, 1958, report of the checkout of the UC-Berkeley Syme prosthesis and fabrication manual, Veterans Administration Prosthetics Center, New York, May 1, 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>4.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services Centre, Toronto, Canada, Construction of the plastic Symes appliance, Technical Bulletin No. 32, August 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">Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, Syme's amputation and prosthesis, January 1, 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>15.</b> </td><td class="clsTextSmall">University of (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., William R. Santschi, ed., 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>1.</b> </td><td class="clsTextSmall">Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Columbus Artificial Limb Company, catalog, Columbus, Ohio, ca. 1925.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bowler, Bartholomew, U. S. Patent 1,323,444, Dec. 2, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Marks, A. A., Inc., Manual of artificial limbs, New York, 1889.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Marks, A. A., Inc., Manual of artificial limbs, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Gaines-Erb Company, catalog, Denver and Pueblo, Colo., ca. 1915.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Winkley Artificial Limb Company, Artificial legs with the patent adjustable double slip socket, descriptive catalog, Minneapolis, Minn., ca. 1910.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 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/1961_01_052/c001.jpg Figure 2 http://www.oandplibrary.org/al/images/1961_01_052/c002.jpg Figure 3 http://www.oandplibrary.org/al/images/1961_01_052/c003.jpg Figure 4 http://www.oandplibrary.org/al/images/1961_01_052/c004.jpg Figure 5 http://www.oandplibrary.org/al/images/1961_01_052/c005.jpg Figure 6 http://www.oandplibrary.org/al/images/1961_01_052/c006.jpg Figure 7 http://www.oandplibrary.org/al/images/1961_01_052/c007.jpg Figure 8 http://www.oandplibrary.org/al/images/1961_01_052/c008.jpg Figure 9 http://www.oandplibrary.org/al/images/1961_01_052/c009.jpg Figure 10 http://www.oandplibrary.org/al/images/1961_01_052/c010.jpg Figure 11 http://www.oandplibrary.org/al/images/1961_01_052/c011.jpg Figure 12 http://www.oandplibrary.org/al/images/1961_01_052/c012.jpg Figure 13 http://www.oandplibrary.org/al/images/1961_01_052/c013.jpg Figure 14 http://www.oandplibrary.org/al/images/1961_01_052/c014.jpg Figure 15 http://www.oandplibrary.org/al/images/1961_01_052/c015.jpg Figure 16 http://www.oandplibrary.org/al/images/1961_01_052/c016.jpg Figure 17 http://www.oandplibrary.org/al/images/1961_01_052/c017.jpg Figure 18 http://www.oandplibrary.org/al/images/1961_01_052/c018.jpg Figure 19 http://www.oandplibrary.org/al/images/1961_01_052/c019.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 Prostheses for Syme's Amputation Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/25d7008c03dbf5520812970f5e24a3b8.pdf 5e4f5d62d004e9714dae9287001a5288 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_088.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 88 - 116 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/1958_02_088.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_088.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>Studies of the Upper-Extremity Amputee, VII. Psychological Factors</h2> <h5>Jerome Siller, Ph.D. <a style="text-decoration:none;">*</a><br />Sydelle Silverman, M.A. <a style="text-decoration:none;">*</a><br /></h5> <p> With the possible exception of the introductory Section I (Artificial Limbs, Spring 1958; Vol. 5, No. 1), the foregoing presentations in this series have in general been concerned with the biomechanical aspects of the man-machine entity in prosthetic restoration. If, however, our understanding of amputee needs and limitations is to be comprehensive, we must inquire also into the mental and emotional characteristics of the man served by the machine. Consideration of the psychological factors in amputee rehabilitation was therefore an important aspect of the Upper-Extremity Field Studies, and the results of these investigations are summarized in this three-part article. The first part, <i>Personality Dynamics of Amputees,</i> discusses a number of the psychological variables that are relevant to amputation. The second deals with <i>Social and Functional Factors in Prosthetic Wear.</i> And the final one, <i>Attitudes Toward Prosthetic Wear, Before and After Fitting,</i> describes the attitudes shown toward arm prostheses by amputees who had never before worn an artificial arm. The rationale of the study, and the data-collecting instruments here referred to as "appendices," are all to be found in Section I (Artificial Limbs, Spring 1958; Vol. 5, No. 1; pp. 46 through 56). </p> <h3>Personality Dynamics of Amputees</h3> <p>At present no single theory, or combination of theories, encompasses all the central problems arising in man from the loss of a limb. One reason for this circumstance is that the special problems and needs of the amputee have never been defined adequately. What does an amputation mean to the amputee? What does it mean to his family, friends, and co-workers? What reaction does the amputee have to his loss? How is he affected socially, vocationally, emotionally? Does his amputation cause basic psychological changes? What major needs are frustrated? What new needs arise? Does prosthetic restoration affect personality restoration? These are but some of the questions that seem pertinent and to which answers were sought during the NYU Upper-Extremity Field Studies.</p> <p>A probing of specific amputee problems was considered to be the most fruitful approach, and accordingly a set of questions was designed to elicit information about areas in which the amputee might be expected to have significant problems. By means of a 57-item, multiple-choice questionnaire (Appendix IIIE), supplemented by a 9-item instrument calling for narrative answers (Appendix IIIF), nine personality variables (acceptance of loss, identification with the disabled, functional adequacy, independence, sensitivity, appraisal of acceptance by others, sociability, frustration, and optimism) were identified and defined. Of 359 adult male amputees who responded in this phase of the investigation, all but 55 were currently wearing prostheses or had worn one in the past.</p> <p>Each of the nine personality variables has many ramifications, and it was possible to investigate a limited number only. Moreover, a preliminary analysis indicated that the data did not differ significantly for different levels of amputation, and accordingly the responses of the three groups (below-elbow, above-elbow, and shoulder-disarticulation) were combined. The results therefore represent only an early exploration of the field with two principal purposes-first, to stimulate further inquiry, and, second, to build a more general awareness of the psychological aspects of treating and dealing with amputees. While the central concept of each variable is discussed here, emphasis has been placed on principles of theoretical and practical interest to those concerned with the management of amputees. Whenever possible, the interrelationships between a particular concept and other variables are examined, and an effort is made to bring out implications for research and practice. Vocational attitudes provided an additional area of interest, as did also the shifts in the valuation of prosthetic service.</p> <p>The data presented are chiefly those gathered after the period of treatment and fitting. Although the treatment procedure produced few measurable changes of any consequence, where such changes were observed they are also discussed.</p> <h4>Acceptance of Loss</h4> <p>"Acceptance of loss" refers to the amputee's ability to accept the physical limitations that result from his injury, to avoid depreciating or pitying himself, and to recognize the social implications of his loss without exaggerating or denying them. This matter was explored by means of questions relating to the amputee's adaptation to his loss, his wishful thinking about the lost limb, and his reaction to the artificial one.</p> <p>When the treatment period was over, most of the subjects claimed to be adapted to their loss:</p> <table> <tbody><tr> <td> <p><b> To what extent do you feel that you have become adapted to the loss of your limb?</b> </p> </td> </tr> <tr> <td> <p>Completely</p> </td> <td> <p>42%</p> </td> </tr> <tr> <td> <p>Almost completely</p> </td> <td> <p>32</p> </td> </tr> <tr> <td> <p>Considerably</p> </td> <td> <p>16</p> </td> </tr> <tr> <td> <p>Somewhat</p> </td> <td> <p>5</p> </td> </tr> <tr> <td> <p>Slightly</p> </td> <td> <p>5</p> </td> </tr> </tbody></table> <p>Before the treatment period, only 35 percent of the amputees said that they felt completely adapted to their loss. The increase to 42 percent after completion of the treatment program would seem to indicate that the fitting of the artificial limb had a strong positive effect upon the adaptation of at least a small number of amputees.</p> <p>Although 90 percent of the amputees claimed either complete, almost complete, or considerable adaptation to their respective losses, it is doubtful that so many had really achieved it. While some may truly have accepted their physical loss and its implications, there were surely many who were trying to maintain feelings of bodily integrity and adequacy by denying the personal and social concomitants of amputation. Clearly, they preferred to de-emphasize regret and any hint of abnormality and difference. In keeping with this feeling, 86 percent of the amputees said that they rarely, very rarely, or never felt sorry about their loss:</p> <table> <tbody><tr> <td> <p><b> Do you feel sorry that you're an amputee?</b> </p> </td> </tr> <tr> <td> <p>Most of the time</p> </td> <td> <p>1%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>13</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>12</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>33</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>41</p> </td> </tr> </tbody></table> <p> But it should be noted that many amputees <i>do</i> admit that they have fantasies about the matter: </p> <table> <tbody><tr> <td> <p><b> Do you find yourself wishing you were a two-handed person?</b> </p> </td> </tr> <tr> <td> <p>Much of the time</p> </td> <td> <p>8%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>45</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>28</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>10</p> </td> </tr> </tbody></table> <p>A second question also explored this phenomenon :</p> <table> <tbody><tr> <td> <p><b> Do you ever think of how much better off you would be if you had not lost an arm?</b> </p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>6%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>32</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>16</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>32</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>14</p> </td> </tr> </tbody></table> <p> Thus it appears that, although most amputees try to avoid thinking about themselves as amputees, regrets over their loss <i>do</i> come out in fantasy. Other indications of this subconscious process can be seen in the contradictory data resulting from different avenues of questioning. About half of the amputees indicated that they frequently tried to perform with their prostheses tasks which they knew would be difficult, and approximately the same number said that what bothered them most was "the inability to perform as I used to." Both of these reactions, which persisted throughout the entire period of participation in the program, seem to represent the amputee's attempt to retain his status as an active, competent, and self-sufficient person. But an amputee who frequently tries to use his artificial arm for a task that he knows will be difficult must have an unrealistic attitude toward his physical limitation. He is evidently demonstrating an unwillingness to accept the full implications of his loss. </p> <p>Among the many considerations involved in the loss of an arm, the most obvious is the inability to perform at one's previous level. Others are the loss of normal appearance and the thought of not being like other people. Although 57 percent of the amputees said that performance was their most bothersome problem, while only 15 percent mentioned the other two considerations, it is difficult to accept such a response at face value. It is likely that the loss of normal appearance and the thought of not being like other people bother amputees far more than they are willing to admit.</p> <p>Two factors lead us to this belief. First, we are convinced that people (and men in particular) hesitate to admit that they are concerned over their appearance or over the thought of not being like other people. An amputee probably finds it much more acceptable, both personally and socially, to seize upon the very real functional and vocational problems caused by his amputation and to use them as the "real" causes of his distress. Secondly, an amputee who admits to being bothered by his inability to perform is really also saying that he is concerned about being different from others, since performance difficulties as well as altered appearance make one "different."</p> <p>Amputation has also other, less obvious aspects that are even more difficult for the amputee to accept. These involve the subconscious effects of the loss, such as the thwarting of life goals, threats to masculinity-femininity identifications, and the arousal of latent fears of castration. Although the reality and importance of these problems have repeatedly been demonstrated clinically, controlled investigation designed to explore them is exceptionally difficult and has not yet been undertaken. Hence most of the subconscious effects of amputation cannot yet be evaluated systematically, even though it seems clear that they exert a great influence upon the amputee's acceptance or nonacceptance of his loss.</p> <p> In general, it may be concluded that an amputee's acceptance of loss depends upon many factors, the most important usually being beyond his own control. His ability to accept depends upon his conscious and subconscious interpretation of his status. If he feels that his amputation has relegated him to an inferior social and vocational status, that he can no longer achieve his principal goals, that he is inferior, and that he has been reduced in functional and sexual potency, he will naturally attempt to reject the implications of his loss. If he looks upon his amputation as a means of escaping from the competition of everyday life, he may accept his loss. If it justifies catering to his need to feel dependent, he may even derive satisfaction from it. But when the amputee is able to look upon his experience as primarily a major frustration that must be overcome-and that <i>can</i> be overcome by his own efforts, in cooperation with family, friends, and rehabilitation personnel-then the stage is set for a real acceptance of loss. </p> <p> Although it seems clear that when first seen many of the participating amputees had not achieved full acceptance of their loss, experience shows that, after the early postamputa-tion period of readjustment, and after satisfactory prosthetic fitting, most amputees <i>do</i> accept their loss to a significant degree. </p> <h4>Identification with the Disabled</h4> <p>"Identification with the disabled" refers to the degree to which the amputee considers his abilities, general appearance, and personality similar to those of other persons physically impaired. To a great extent this factor serves as the basis for his interaction with others.</p> <p>The basic question exploring this matter was:</p> <table> <tbody><tr> <td> <p><b> I think of myself as a:</b> </p> </td> </tr> <tr> <td> <p>physically abnormal person....</p> </td> <td> <p>1%</p> </td> </tr> <tr> <td> <p>normal person except for a major physical defect....</p> </td> <td> <p>18</p> </td> </tr> <tr> <td> <p>normal person except for a slight physical defect....</p> </td> <td> <p>29</p> </td> </tr> <tr> <td> <p>normal person except for a very slight physical defect....</p> </td> <td> <p>24</p> </td> </tr> <tr> <td> <p>completely normal person...</p> </td> <td> <p>28</p> </td> </tr> </tbody></table> <p>Obviously the subjects tended to describe themselves as normal persons and to de-emphasize their physical defects. Of particular interest are the 28 percent who described themselves as completely normal, not even conceding a "very slight" defect.</p> <p>Few of the subjects admit that amputation is of considerable consequence:</p> <table> <tbody><tr> <td> <p><b> Do you think being an amputee makes:</b> </p> </td> </tr> <tr> <td> <p>a considerable difference?</p> </td> <td> <p>7%</p> </td> </tr> <tr> <td> <p>some difference?</p> </td> <td> <p>31</p> </td> </tr> <tr> <td> <p>a slight difference?</p> </td> <td> <p>19</p> </td> </tr> <tr> <td> <p>a very slight difference?</p> </td> <td> <p>26</p> </td> </tr> <tr> <td> <p>no difference at all?</p> </td> <td> <p>17</p> </td> </tr> </tbody></table> <p>In keeping with their expressed tendency to place the fact of amputation in the background, and to consider themselves physically normal persons, most claimed that they often forgot about their amputations:</p> <table> <tbody><tr> <td> <p><b> I forget that I am an amputee:</b> </p> </td> </tr> <tr> <td> <p>never.</p> </td> <td> <p>7%</p> </td> </tr> <tr> <td> <p>rarely.</p> </td> <td> <p>4</p> </td> </tr> <tr> <td> <p>sometimes.</p> </td> <td> <p>21</p> </td> </tr> <tr> <td> <p>most of the time.</p> </td> <td> <p>61</p> </td> </tr> <tr> <td> <p>all of the time.</p> </td> <td> <p>7</p> </td> </tr> </tbody></table> <p>Still tending to play down any differences, 67 percent of the subjects said that they thought amputees had about the same number of personal problems as did nonamputees. At the start of the treatment program, only 57 percent of the amputees felt that way. But even then a sizable minority (30 percent) believed that amputees did have more personal problems than nonamputees. In any case, it is noteworthy that, in an area where one might reasonably expect some expression of difference, so large a percentage of the subjects denied any difference at all. A strong tendency to reject any hint of abnormality or "difference" appears throughout the study.</p> <p>In setting goals and evaluating achievements, most of the amputees would like to be considered as nondisabled persons:</p> <table> <tbody><tr> <td> <p><b> In deciding what you should be physically able to do, do you compare yourself with:</b> </p> </td> </tr> <tr> <td> <p>very active nonamputees?</p> </td> <td> <p>16%</p> </td> </tr> <tr> <td> <p>active nonamputees?</p> </td> <td> <p>53</p> </td> </tr> <tr> <td> <p>inactive nonamputees?</p> </td> <td> <p>2</p> </td> </tr> <tr> <td> <p>active amputees?.</p> </td> <td> <p>28</p> </td> </tr> <tr> <td> <p>inactive amputees?</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <p>Over two thirds seem to feel that their physical abilities should be comparable to those of active or very active nonamputees. In short, amputees want to be considered normal and would like to discount their physical defects. Since most arm amputees can function in society without serious disadvantage, they would seem to have a sound basis for de-emphasizing their handicaps.</p> <p> There is, of course, a stigma attached to those who are "different," and this circumstance also gives the amputee a strong reason for rejecting identification with the disabled. Thus he tends to maintain that being an amputee does not really "make a difference," although what is certainly implied is that he feels it <i>should not</i> make a difference. It is difficult to believe that so many can forget a fact of such consequence as amputation. But obviously they would <i>like</i> to forget it, and many <i>do</i> forget it, at least intermittently. For them to repress the amputation completely would be to deny the loss rather than to accept it, and this would be an equally unrealistic type of adjustment. From clinical observation, we have the impression that few amputees wear their loss as a badge, but the fact of amputation does seem to underlie a good part of their behavior. Whether this results in a neurotic fixation or is viewed as one more of life's frustrations to be overcome depends upon the individual. </p> <p>The fact that 30 percent of the amputees seem to feel that they have more personal problems than do nonamputees should not be taken as showing that amputees are more poorly adjusted than nonamputees. Other studies on physical handicap and amputation have indicated that, although particular problems of adjustment differ, there is generally no marked difference in adjustment between those who are handicapped and those who are not.<a></a></p> <p>An amputee has mixed conscious and subconscious identifications both with disabled and with nondisabled groups. Whichever group he primarily identifies with provides the basis for his concept of himself, the goals he sets, the aspirations he has, and the way he interacts with others. The amputees in the NYU Field Studies overwhelmingly elected a non-amputee, nondisabled frame of reference. In such a course lie dangers for them-dangers of self-deception, of denial and distortion of reality. Yet advantages follow too. Identifying with the nondisabled provides stimulation and drive to actualize the potential that each amputee has. It helps to combat defeatist attitudes and withdrawal into lethargy and invalidism. The amputee who is able to recognize and accept his identifications with both the disabled and the nondisabled groups maintains the soundest approach to personal adjustment.</p> <h4>Functional Adequacy</h4> <p>"Functional adequacy" refers to the amputee's estimate of his level of competence in performing physical activities. Questions were asked exploring the amputee's evaluation of his physical abilities. As has already been seen, over two thirds of the amputees seemed to feel that their physical abilities should be comparable to those of active or very active nonamputees. How well did they think that they met this exacting standard? Generally speaking, they said that they were able to achieve their high goals:</p> <table> <tbody><tr> <td> <p><b> As compared to nonamputees, I am generally able to do:</b> </p> </td> </tr> <tr> <td> <p>much less.</p> </td> <td> <p>2%</p> </td> </tr> <tr> <td> <p>somewhat less.</p> </td> <td> <p>35</p> </td> </tr> <tr> <td> <p>as much.</p> </td> <td> <p>49</p> </td> </tr> <tr> <td> <p>somewhat more.</p> </td> <td> <p>14</p> </td> </tr> <tr> <td> <p>much more.</p> </td> <td> <p>0</p> </td> </tr> </tbody></table> <p> Only about one third conceded that they could not do as much as nonamputees. Furthermore, 68 percent of the amputees said that "very little effort" or "a little extra effort" was required to keep up with nonamputees. Ten percent even claimed that <i>no</i> extra effort was required. But 21 percent did admit that "a lot of extra effort" was necessary to keep up with others. </p> <p>In response to other questions, 92 percent said that they believed their work to be as good as or better than that of their nonamputee co-workers, and 66 percent said they felt they could be employed in jobs requiring "almost as much use of the prosthesis as of the normal hand."</p> <p>Comparing their present abilities with those had before amputation, 83 percent said they found doing things only "slightly more difficult now." Speaking of the things they could do before their loss, 96 percent said that they could still do "many," "almost all," or "all" of them. Only 8 percent said that being an amputee restricted their capacities "considerably." But 97 percent believed that they could do as much as, or more than, most other amputees.</p> <p>Here again the optimistic responses show some increase after the treatment period, and there are still other indications that the amputee's feelings of competence are related to the use of the new type of prosthesis. After treatment, 81 percent of the amputees said that they were "very much; or ;completely" satisfied with their prostheses, whereas at the beginning of the treatment program only 58 percent said so. Improved prosthetic equipment and better management procedures seem largely responsible for the favorable results.</p> <p>Generally speaking, we may describe the picture as follows. The amputee sets high limits to his physical accomplishments, most often aiming to equal the nonamputee. He will sometimes concede that he can do less than a nonamputee, but more often than not he will claim that he can do as much or more. While he almost never admits to a substantial inferiority, he will acknowledge that it takes a little extra effort to keep up with nonamputees. He feels competent to handle the daily routine of living, and he expresses no deprivation associated with his functional limitations. Finally, his estimate of his own abilities increased as a result of participation in the research program.</p> <p>Taken at face value, this self-picture by the amputee seems a blissful one. But experience indicates that, while some amputees do approach the ideal state, the average patient is far more concerned about his functional adequacy than the responses show. Some of the amputee's description of his high level of competence must certainly be the result of wishful thinking. Concerned with maintaining his self-esteem and confidence, he surely must often distort reality so as to diminish the gap between what he imagines he can do and what he actually can do. And his feelings of great competence may also reflect certain changes in his habits since his amputation-changes that have brought his activities more into line with his new physical abilities.</p> <p>Complete analysis of functional adequacy requires both objective and subjective estimates of competence and a study of the effect that the difference between the two has upon the amputee's adjustment. In the absence of such an investigation, the data presented are best considered as the responses of people who are concerned with maintaining their self-esteem, their feelings of confidence, and their sense of adequacy. The responses show what the amputee subconsciously desires in the way of treatment from nonamputees. In effect, what we have here is the collective mask that amputees present to the public-and often to themselves. The extent to which we can accept this mask, or how we need to modify it, is a clinical problem that can be resolved only when the amputee's real and fancied achievements are considered in the light of his basic needs.</p> <h4>Independence</h4> <p>"Independence" refers to the extent to which the amputee can make a reasonable effort to be self-sufficient while still feeling free to call for assistance or to use help that is offered. It has been seen that the amputees in this study tend to characterize themselves as self-sufficient. When the amputee knows himself to be capable of handling a situation, he usually declines offers of help:</p> <table> <tbody><tr> <td> <p><b> When I know that I am capable of handling a task, I:</b> </p> </td> </tr> <tr> <td> <p>never accept help.</p> </td> <td> <p>28%</p> </td> </tr> <tr> <td> <p>very rarely accept help.</p> </td> <td> <p>34</p> </td> </tr> <tr> <td> <p>rarely accept help.</p> </td> <td> <p>12</p> </td> </tr> <tr> <td> <p>sometimes accept help.</p> </td> <td> <p>22</p> </td> </tr> <tr> <td> <p>frequently accept help.</p> </td> <td> <p>4</p> </td> </tr> </tbody></table> <p>In keeping with this desire for self-sufficiency, almost three quarters of the amputees said that they rarely or very rarely solicit help:</p> <table> <tbody><tr> <td> <p><b> How often do you call for help from others?</b> </p> </td> </tr> <tr> <td> <p>Never.</p> </td> <td> <p>5%</p> </td> </tr> <tr> <td> <p>Very rarely.</p> </td> <td> <p>57</p> </td> </tr> <tr> <td> <p>Rarely.</p> </td> <td> <p>14</p> </td> </tr> <tr> <td> <p>Occasionally.</p> </td> <td> <p>23</p> </td> </tr> <tr> <td> <p>Frequentrly.</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <p>Two facts are of particular interest here. First, the course of treatment provided by the program increased from 49 percent to 57 percent the proportion of those who claimed they very rarely called for help. Secondly, none of the most physically disabled patients (bilateral and shoulder-disarticulation cases) reported frequent calls for help. In answer to other questions, only 1 percent of the amputees said that they refuse help under any circumstances. More than half said that they accept help only when it means the difference between success or failure. About one quarter said they accept help if it makes the task easier. And 14 percent said they accept help even if it does not make the task easier.</p> <p>It is clear that the amputee is vitally concerned about his sense of independence. He tends to depict himself as a self-sufficient individual who rejects offers of help whenever he can and who asks for help only occasionally. Despite the stress he places on self-sufficiency, however, the amputee almost always accepts the fact that complete independence is impossible. But he will be practically certain to reject any suggestion of serious dependence.</p> <p> Why does the amputee value his independence so highly? The answer seems to lie with our society, which places a high premium on personal competence and achievement. The dependent person often finds himself assigned an inferior status in his group. The amputee, constantly faced with this prospect, feels a strong need to prove that he is self-sufficient and that he does not differ from other people. In any case, a handicapped, dependent person is seriously restricted in his ability to reach simple goals that are easily achieved by others.<a></a> </p> <p> Before the amputee can judge the extent of his handicap, he must go through an extensive trial-and-error period, particularly in the early stages of his loss. Depending on how realistically he views his limitations, dependency will or will not become a critical problem. At this point, three kinds of reactions are possible: he may appraise realistically his functional capacities and limitations; he may partly deny his limitations, at the same time often attempting to compensate for them; he may deny his limitations completely. <a style="text-decoration:none;">*</a> Underlying all three of these reactions is the basic need of all persons to maintain feelings of self-sufficiency-if necessary, by distorting reality. Thus an amputee may distort the extent of his dependence on others and exaggerate his abilities to fulfill society's demands for independence. Conversely, some amputees may distort reality in the other direction, emphasizing their loss in order to help them think of themselves as dependent, affection-seeking persons. In general, however, the amputee's ability to make a realistic appraisal of his capacities, to recognize a certain amount of dependency where it is inevitable, and to ask for help when necessary will depend above all on his feelings of basic security. The amputee who is insecure will be more likely to seek help indiscriminately or to reject it unreason-ably.<a></a> </p> <p> To avoid overdrawing the negative effects of reality distortion, a distinction must be made between extreme distortion of reality and its temperate shaping. We tend to admit into our perceptions things in line with positive self-feelings and to eliminate or modify those which might cause anxiety. This is a form of adaptive, nonpathological distortion involving control of situations so that, when reality must be faced, it may be done despite the temporary pain associated with the process. Some avoidance of harsh reality is sometimes necessary in order to preserve equanimity in the face of many daily frustrations. In some cases, however, the amputee displays an extreme form of dependence that has been called "invalidism."<a></a> When this happens, the amputee exploits those about him by harping on his incapacities more than his injury warrants. He uses his handicap to avoid responsibilities. While it is true that anyone might be tempted to plead illness to avoid an unpleasant experience, in invalidism the individual employs his loss as a constant way out. Invalidism can also be an attention-getting device as well as an attempt to obtain love that the amputee is not sure of having otherwise. It is used to threaten and control other persons and sometimes provides the disabled person with the means of taking revenge upon others by limiting their freedom of action and making them anxious and guilty. </p> <p> Whatever the reaction, the family plays an important role in the amputee's attempts to achieve self-sufficiency and yet to fulfill his needs for dependency. The attitude of the family is often thought to be at least as important as the physical injury itself in determining the amputee's reaction to his disability.<a></a> The amputee's attitude toward his family is a combination of a drive for independence and a plea for aid, explicit or implicit. In the ideal family relationship, both needs will be satisfied. But the stress should be upon helping the amputee to take his place in society as a self-respecting, adequate person. </p> <h4>Sensitivity</h4> <p>"Sensitivity" refers to the amputee's subjective appraisal of the effect of his physical condition on others and to the feelings of self-consciousness he experiences as a result of this appraisal. Sensitivity about disability may therefore be related to two sources: perception of the negative appraisals of others, and the individual's own self-rejection. These two factors are of course not entirely independent, since an amputee's notions of what others think of him may largely determine what he thinks of himself.</p> <p>The majority of the amputees in the study readily admitted concern about the opinion of others, but it is noteworthy that almost a fourth of the group refused to admit anything more than a "little" sensitivity:</p> <table> <tbody><tr> <td> <p><b> How much do you care about what others think of you?</b> </p> </td> </tr> <tr> <td> <p>Considerably.</p> </td> <td> <p>53%</p> </td> </tr> <tr> <td> <p>Somewhat.</p> </td> <td> <p>23</p> </td> </tr> <tr> <td> <p>Little.</p> </td> <td> <p>8</p> </td> </tr> <tr> <td> <p>Very little.</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>Not at all.</p> </td> <td> <p>7</p> </td> </tr> </tbody></table> <p>The clinical treatment program had the effect of reducing the self-consciousness admitted. Amputees who said that they never, rarely, or only sometimes felt self-conscious about their personal appearance went from 59 percent before treatment to 72 percent afterward. But 28 percent still said they felt self-conscious most of the time or almost always.</p> <p>Twenty-one percent of the amputees said that they felt they looked "the same as most people," and 62 percent answered "almost the same as most people." In keeping with this attitude, most of the amputees claimed that they did not feel themselves to be conspicuous. But a significant 22 percent confessed that the idea occurred to them with some frequency:</p> <table> <tbody><tr> <td> <p><b> The idea that people are looking at me:</b> </p> </td> </tr> <tr> <td> <p>is almost always on my mind.</p> </td> <td> <p>2%</p> </td> </tr> <tr> <td> <p>sometimes occurs to me.</p> </td> <td> <p>20</p> </td> </tr> <tr> <td> <p>rarely occurs to me.</p> </td> <td> <p>17</p> </td> </tr> <tr> <td> <p>very rarely occurs to me.</p> </td> <td> <p>38</p> </td> </tr> <tr> <td> <p>never occurs to me.</p> </td> <td> <p>23</p> </td> </tr> </tbody></table> <p>The majority of the amputees said that they expected other people to discuss the disability. Only a few believed this occurred frequently, and even fewer denied its existence:</p> <table> <tbody><tr> <td> <p><b> Do you think that people talk about your disability?</b> </p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>3%</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>30</p> </td> </tr> <tr> <td> <p>Occasionally</p> </td> <td> <p>57</p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>Always</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <p> Most amputees (67 percent) denied that they felt any resentment over the curiosity of other people. The rest maintained a ratio of three positive reactions <i>(e.g.,</i> pride in demonstrating the prosthesis, appreciation of interest) for every negative reaction <i>(e.g.,</i> self-consciousness, resentment, nervousness). In all, reactions of annoyance caused by people's curiosity decreased significantly by the end of the treatment period. </p> <p>Although 99 percent of the amputees said that they seldom or never tried to hide the fact of their amputation, the overwhelming majority said they would not tell a new acquaintance about it unless asked.</p> <p>The question of whether to fit a hook or a hand is often decided on the basis of the amputee's sensitivity. Those particularly sensitive about their amputation might be expected to reject a hook because of its appearance. The majority of the amputees in this study (61 percent) said that they believed hooks to be mechanical-looking but not unsightly, while a significant additional number (25 percent) expressed a more negative attitude concerning their appearance. But only 1 percent said they would not use one under any condition:</p> <table> <tbody><tr> <td> <p><b> I think that a hook is :</b> </p> </td> </tr> <tr> <td> <p>so ugly I would never wear one...............................</p> </td> <td> <p>1%</p> </td> </tr> <tr> <td> <p>so ugly I would never wear one when I'm with other people...</p> </td> <td> <p>2%</p> </td> </tr> <tr> <td> <p>unsightly but not enough to prevent me from wearing one...</p> </td> <td> <p>23%</p> </td> </tr> <tr> <td> <p>mechanical looking but not unsightly..............................</p> </td> <td> <p>61%</p> </td> </tr> <tr> <td> <p>as natural looking as any artificial hand........................</p> </td> <td> <p>13%</p> </td> </tr> </tbody></table> <p>The composite data indicate that, although the amputees showed considerable awareness of their appearance, they did not brood about it. When asked directly, they were much more likely to deny being sensitive than to admit being preoccupied with their condition. They were well aware that amputations and prostheses arouse curiosity, but they maintained that they (the amputees) were "normal" and so did not feel resentful toward these attentions. Amputees who do acknowledge self-consciousness are most likely to do so in situations where there is no social pressure against displaying sensitivity.</p> <p>On the basis of other evidence, there seems to be considerably more indication of sensitivity and of hostility toward the curious person than is revealed by the questionnaire. This is to be expected, for clinical situations induce greater rapport and permit the amputee to express hostile feelings with less fear of social criticism. Thus, it is quite likely that the amputee's sensitivity is much greater than he is willing to admit.</p> <p> The universal unwillingness of amputees to admit that they differ from others rests in part on the fact that in many respects they are indeed no different from other people. But it also may represent a "whistling-in-the-dark" attitude, an attempt to deny something that the amputee really believes to be true <i>(e.g.,</i> that he <i>is</i> handicapped or inferior), and may reflect the amputee's resistance against the social consequences of being "different." </p> <p>As has already been mentioned, amputees are likely to incorporate the negative attitudes of others into their own self-concept. Most amputees recognize that nonamputees are more comfortable when the fact of amputation is not conspicuous, and they will attempt by various means to "spare the feelings" of others by trying to reduce the visual "shock" for the nonamputee. Many of the subjects are not, however, merely responding appropriately to social cues but rather are using this explanation as a rationalization for their own self-rejecting thoughts. The same self-rejection may be responsible for the denial of sensitivity, which the questionnaire data show to be characteristic of a sizable minority of the sample.</p> <h4>Appraisal of Acceptance by Others</h4> <p>Appraisal of acceptance by others" refers to the amputee's evaluation of the effect his disability has on the approval others may give him. Less than 5 percent of the amputees said that they felt they were being treated any way different from that in which they had been treated before amputation. Almost all of the subjects claimed that their amputation had had little or no effect upon their acceptance by others. They rejected overwhelmingly the suggestion that their amputation merited them either special treatment or discrimination in their job, family, or social relationships. Most of them said they did not feel that people paid them undue attention. In general, the data indicate that amputees feel they receive sufficient but not excessive attention in social situations. A small percentage admit that some sympathetic behavior is displayed consistently in their job and family relationships.</p> <p>The amputee claims to be accepted by others on the same basis as anyone else, and he rejects strongly the suggestion of "different" treatment. But he will more readily admit to being favored than to being rejected. The treatment program seemed to bring a slight increase in the number of those who felt they were accepted on the same basis as other people. But little change was noted among those who claimed to be the recipients of either favoritism or antagonism. The data suggest that the treatment program was psychologically beneficial to those who were "uncommitted" on the first testing but that it had no effect on those who were convinced of their "different" status.</p> <p> The cumulative evidence about the social position of the disabled person strongly suggests that the results of the survey again represent the amputees' <i>wishes</i> rather than the actual situation, a finding supported by the fact that, when asked indirectly how they thought amputees should be treated, the majority revealed that they preferred to have little made of their physical handicap: </p> <table> <tbody><tr> <td> <p><b> If you were a nonamputee, how would you react to an amputee?</b> </p> </td> </tr> <tr> <td> <p>I would ignore the fact that the person is an amputee</p> </td> <td> <p>16%</p> </td> </tr> <tr> <td> <p>I would treat him as a normal person who just happens to have lost an arm or hand</p> </td> <td> <p>72</p> </td> </tr> <tr> <td> <p>I would expect less from him physically</p> </td> <td> <p>6</p> </td> </tr> <tr> <td> <p>I would be more kind and thoughtful of his feelings</p> </td> <td> <p>5</p> </td> </tr> <tr> <td> <p>I would know that, as an amputee, he requires special treatment</p> </td> <td> <p>1</p> </td> </tr> </tbody></table> <h4>Sociability</h4> <p>"Sociability" refers to the extent to which the amputee seeks, and derives pleasure from, social relationships. In this connection, the subjects said that they looked forward to social functions and enjoyed them. The treatment program had the effect of increasing by about one fourth the number of amputees who said that they "always" enjoyed these functions. All but a very few of the subjects said that they had greater social confidence with their new prostheses. Neither before the treatment period nor after, however, did more than S percent confess to any lack of social confidence. Over three quarters of the amputees said that neither their amputations nor their prosthesis-wearing had caused any change in their social relationships. Those who did report changes were almost unanimous in claiming that the changes were toward greater sociability.</p> <p>These results reaffirm the earlier observations that the amputee tends to deny he has any major problems of acceptance. He usually claims that he engages in social activities eagerly and freely and experiences no prejudice because of his disability. But here again it is possible to read these results as expressing not so much the real facts as the wishes of the amputee to be accepted fully into the nonamputee world. Nevertheless, the indications are clear that the amputee tends to have more social confidence after suitable prosthetic fitting and treatment, the implications being that superior prosthetic equipment provides the basis for the ability to meet others with less trepidation and with greater feelings of personal adequacy. It also confirms indirectly the significance of feelings of functional adequacy and of ability to be independent.</p> <h4>Frustration</h4> <p>"Frustration" refers to the amputee's experience resulting from his inability to achieve personal, social, and vocational goals because of his amputation. The term refers both to whatever blocks or interferes with the amputee's strivings and to his subjective feelings of annoyance, confusion, or anger when he is thwarted. While 58 percent of the amputees said they rarely or never were prevented from achieving their goals, the other 42 percent claimed to feel frustrated from time to time as a result of amputation:</p> <table> <tbody><tr> <td> <p><b> Does being an amputee prevent you from doing things you really want to do?</b> </p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>20%</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>27</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>11</p> </td> </tr> <tr> <td> <p>Someties</p> </td> <td> <p>37</p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>5</p> </td> </tr> </tbody></table> <p>When, however, absence of a limb prevented performance of a task, a considerable proportion of the amputees (86 percent) felt annoyed. They almost unanimously (98 percent) said that they did not give up trying to do something because it was difficult, or that they gave up only after repeated failures.</p> <p>As for vocational goals, a majority of the amputees refused to admit more than slight difficulties. Some 40 percent indicated that there was some substantial interference:</p> <table> <tbody><tr> <td> <p><b> Do you feel that your amputation interferes with your getting a job?</b> </p> </td> </tr> <tr> <td> <p>Not at all</p> </td> <td> <p>27%</p> </td> </tr> <tr> <td> <p>Very slightly</p> </td> <td> <p>15</p> </td> </tr> <tr> <td> <p>Slightly</p> </td> <td> <p>18</p> </td> </tr> <tr> <td> <p>Somewhat</p> </td> <td> <p>29</p> </td> </tr> <tr> <td> <p>Seriously</p> </td> <td> <p>11</p> </td> </tr> </tbody></table> <p>Here the fact that the more seriously disabled (bilateral and shoulder-disarticulation cases) responded as did the other amputees seems to suggest that the results do not accurately reflect the real situation.</p> <p>The relatively small degree of frustration the amputees reported is surprising in view of the many frustrating situations they encountered. It suggests that many of the responses were given because they seemed socially desirable and because the test situation did not encourage the amputee to express freely his aggressive or negative feelings. But it is also possible that repeated experiences of frustration, together with the strong motivation to be "like anyone else," which is so characteristic of the subjects studied, can produce in many amputees a truly high level of frustration tolerance. To this must be added the active efforts to avoid situations potentially frustrating.</p> <p>Any interference with goal-directed activity constitutes a frustration. But interpreting frustration in others has certain dangers because what frustrates one individual may not frustrate another. The nonamputee who fails to consider this circumstance is likely to make toward the disabled person unnecessary offers of help. The amputee may take such overtures as indicating that people believe him to be incompetent and may, consequently, feel downgraded in his status as a functioning person. In a sense, the real frustration in this particular situation is the nonamputee's lack of awareness of the amputee's competence.</p> <p>The intensity of an amputee's frustration depends upon how important his thwarted goals are to him. And while he may not feel seriously deprived if he cannot accomplish some trivial task, his frustration may be great if the particular failure happens to symbolize his inability to reach some more important goal. A minor frustration may assume importance if it symbolizes a general downgrading of status. Furthermore, when frustration is chronic the setting is ripe for the development of neurotic symptoms that represent the amputee's attempt to escape from an intolerable situation. It is considerably easier for anyone to deal with a short-term frustration than to adapt to a long-term one. Amputation is permanent and hence can lead easily to chronic frustrations and to neurotic solutions for the frustrations.</p> <p>The amputees in question showed two general types of reaction to frustration. One was concerned with overcoming the obstacles that interfere with the attainment of goals. In the other, the concern had more to do with preserving self-esteem and warding off anxiety than with achieving thwarted objectives. The first, or goal-directed, reaction to frustration is characterized by the amputee's ability to accept the reality of his amputation with a minimum of self-deception. In this type of reaction, the amputee seeks goals that are in line with his reduced capabilities and takes whatever steps he must to overcome the barriers imposed by his amputation. When questioned, he admits to being frustrated sometimes, but he shows a high toleration for frustration and tends to give up only when a task is clearly beyond his abilities, at which time he is willing to accept appropriate help. Besides, he will probably accept himself as a person and neither brood over nor resent his situation.</p> <p> In the second, or "ego-protective," reaction to frustration, the amputee refuses to accept reality. Instead, he distorts it and tries to create situations in which he can be at ease and relatively free of anxiety. If necessary, he will go so far as to deny his disability. He tends to set such low limits for achievement that he can avoid frustration, and he often sharply restricts his involvement in life as he seeks to eliminate opportunities for frustration. Such protective action is likely to lead to neurotic symptoms-to hypersensitivity, invalidism, defeatism, somatic complaints, anxiety, social withdrawal, and so on. In an earlier publication, Siller <a></a> observed that amputees who achieved good adjustment were often strongly oriented toward compensating for their loss. They were, in other words, showing a goal-directed reaction to frustration. It was also observed that amputees who adjusted poorly often directed their efforts toward avoiding the implications of their loss, thus showing an ego-protective reaction to frustration. </p> <p>As a result of the treatment program in the NYU Field Studies, there was a small increase in the number of amputees who reported a moderate degree of frustration tolerance combined with the ability to recognize their limitations clearly. While in answering the test questions the amputees undoubtedly had a tendency to deny unfavorable feelings and behavior, the subjects as a whole still showed a rather high tolerance for frustration.</p> <h4>Optimism</h4> <p>"Optimism" refers to those feelings of adequacy, of self-confidence, and of positive future outlook that the amputee experiences. The negative aspects of this personality variable are pessimism, depression, and feelings of inadequacy and inferiority. While the subjects in the study tended to stress their positive feelings of optimism and to de-emphasize their pessimistic feelings, few denied that they experienced depression at times:</p> <table> <tbody><tr> <td> <p><b> How often do you feel "down in the dumps" or "blue"?</b> </p> </td> </tr> <tr> <td> <p>Frequently</p> </td> <td> <p>3%</p> </td> </tr> <tr> <td> <p>Sometimes</p> </td> <td> <p>29</p> </td> </tr> <tr> <td> <p>Rarely</p> </td> <td> <p>21</p> </td> </tr> <tr> <td> <p>Very rarely</p> </td> <td> <p>39</p> </td> </tr> <tr> <td> <p>Never</p> </td> <td> <p>8</p> </td> </tr> </tbody></table> <p>The treatment period had the effect of increasing from 33 percent to 39 percent those amputees who answered "very rarely," and in general the fitting of new prostheses increased slightly the claims of optimism. Most of the amputees professed to be very optimistic about their future prospects, and none at all said that they expected to be unsuccessful:</p> <table> <tbody><tr> <td> <p><b> Does your future promise to be:</b> </p> </td> </tr> <tr> <td> <p>extremely successful?</p> </td> <td> <p>14%</p> </td> </tr> <tr> <td> <p>moderately successful?</p> </td> <td> <p>66</p> </td> </tr> <tr> <td> <p>slightly successful?</p> </td> <td> <p>11</p> </td> </tr> <tr> <td> <p>neither successful nor unsuccessful?</p> </td> <td> <p>9</p> </td> </tr> <tr> <td> <p>unsuccessful?</p> </td> <td> <p>0</p> </td> </tr> </tbody></table> <p>Throughout the questionnaire, the subjects tried to avoid responses indicating pessimism, depression, and feelings of inadequacy or inferiority. They were more likely to admit feelings of superiority than of inferiority, but in general they avoided admitting extreme feelings in either direction:</p> <table> <tbody><tr> <td> <p><b> Do you ever have feelings of:</b> </p> </td> </tr> <tr> <td> <p>Inferiority?</p> </td> <td> <p></p> </td> <td> <p>Superiority?</p> </td> </tr> <tr> <td> <p>38%</p> </td> <td> <p>Never</p> </td> <td> <p>29%</p> </td> </tr> <tr> <td> <p>28</p> </td> <td> <p>Very rarely</p> </td> <td> <p>22</p> </td> </tr> <tr> <td> <p>12</p> </td> <td> <p>Rarely</p> </td> <td> <p>15</p> </td> </tr> <tr> <td> <p>20</p> </td> <td> <p>Sometimes</p> </td> <td> <p>30</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>Frequently</p> </td> <td> <p>4</p> </td> </tr> </tbody></table> <p>The amputees tried of course in their answers to place themselves in a socially favorable light-to shun answers with negative implications. But we may still estimate the feelings of the average amputee. He resists, rejects, and resents any suggestion that as a person he differs from anyone else; at the same time he acknowledges some (but not too much) physical difference and handicap. If he senses that the nondisabled people about him consider him "different" because of his loss, he may often go to extremes to deny pessimistic feelings which in a more relaxed environment he might well acknowledge.</p> <p>Amputees are not alone in their desire to be placed in a favorable light. The tendency to respond in a socially desirable manner seems to be characteristic of all groups when tested under conditions similar to those of the present study. Nevertheless, when we consider the very real handicaps amputees must face, we may conclude that those studied here are for the most part maintaining an optimistic outlook.</p> <h3>Social and Functional Factors in Prosthetic Wear</h3> <p>The attitudes of amputees toward prostheses have in the past received little systematic study. The amputee's preferences in artificial limbs, and his habits in using them, are evidently not based entirely upon his objective assessment of his functional and social needs. They are influenced also by emotional factors arising from the meanings he attaches to the wearing of artificial limbs. Little organized information is available about these attitudes, whether rational or irrational, and we know little as yet about the specific effects that an amputee attributes to his prosthesis once he has accepted and worn it. What difference does he think it makes in his daily life?</p> <p> The prosthetic-reaction test (Appendix IIIG), designed to explore in a systematic way some of the attitudes and reactions underlying prosthetic wear, attempted to gauge, in various situations, the amputee's response, both when he is considered to be <i>wearing</i> an artificial arm and when he is considered <i>not</i> to be wearing one. In a series of nine different pictures, a fictitious amputee, "John," was shown in some everyday situations-some in which his sensitivities as an amputee might be expected to be aroused. Below each picture were from five to nine statements indicating possible responses that John, the amputee in the picture, might make to the situation depicted. The subjects under test were asked to select the statement most nearly describing what John might say, feel, or do in each case. The assumption, of course, was that the amputees would attribute to the imaginary John some of their own feelings and reactions. It was thought that, as the amputees thus responded to specific life situations through the medium of this other person, their attitudes might be expressed more freely than they would be through direct questioning. </p> <p> The test was administered to each of the amputees three times, once at the beginning of the research program (Evaluation I) and twice at the end of the studies (Evaluation II). In Evaluation I, and at the first administration during Evaluation II, the subjects were asked to select John's response <i>"if he were wearing a prosthesis as he usually does."</i> Immediately after the amputees had completed the test for the first time during Evaluation II, they took it again but now were asked to select John's response <i>"if he never wears a prosthesis."</i> For convenience, we shall refer to these three administrations of the test as El, E2a, and E2b. Together, the three provide data for the study of three major questions: </p> <ol> <li>In the difficult social situations that an amputee faces daily, what are his most frequent responses and his most commonly held attitudes?</li><li>What changes, if any, in his attitudes and reactions came as a result of his being fitted with a new prosthesis and taking part in the research program?</li><li>In these difficult social situations, how does the wearing of a prosthesis affect the amputee's responses?</li></ol> <p>Each of these problems shall be taken up in turn.</p> <p>The prosthetic-reaction test touches upon a number of aspects of an amputee's performance. Foremost is the general area of "security," which involves the amputee's basic acceptance of himself and others, particularly his personal adjustment to the loss of his arm. Included within the concept of security were such constructs as self-acceptance (the ability to view the loss without self-pity, exaggeration, or denial, and without resorting to maladaptive means of defending self-esteem) and reality-facing (the ability to appraise environmental situations as they are). In addition, there was evidence that several of the cartoons strongly measured a second variable, "independence," which describes the amputee's motivation to be self-sufficient and to function adequately with a minimum of assistance.</p> <p> Psychologically, strivings for independence are likely to stem from the individual's feelings of security, and as such the two must be considered related phenomena. But since the need to be independent is a major concern of amputees, separate analyses of the data concerning independence were made whenever appropriate. Each statement in the test was therefore rated first for "security" and, when indicated, for "independence." Four psychologists ranked from 1 to 5 all possible responses according to the extent that the individual variables were reflected therein. <a style="text-decoration:none;">*</a> Personal differences in ranking were resolved through mutual discussion among the four. </p> <p>Responses rated 1 or 2 were considered "high." A rating of 3 was considered "intermediate," a rating of 4 or 5 as "low," and the terms "high," "intermediate," and "low" were used as relative terms to describe the individual's position along the "security" and the "independence" scales. For example, Picture VI (Appendix IIIG) showed an amputee in a restaurant with a steak that seemed too tough for him to cut. The seven statements given beneath the picture were ranked and judged as shown in the following tabulation:</p> <p>The prosthetic-reaction test, then, tells us how amputees appraise various social situations and what they think about the worth of artificial arms in these situations. It also gives us some indication of their feelings of independence and security, both when they are wearing prostheses and when they are not. What light does this information shed upon the three major problems already mentioned?</p> <h4>Amputee Responses to Everyday Social Situations</h4> <p> The most outstanding finding of this study was that the amputees overwhelmingly-in fact, almost invariably-selected the most positive responses to the situations depicted in the cartoons, particularly when the amputee was assumed to be wearing an artificial arm. For almost every situation of the series, the statement most frequently chosen was one extremely high in both independence and security. Moreover, for most of the pictures well over half the sample responded with statements that were judged "positive" <i>(i.e.,</i> high in security or independence). Even in E2b, where positive responses were considerably fewer, they still accounted for a large segment of the sample. Typical percentages of amputees showing high, intermediate, and low "security" and "independence" responses to each cartoon are shown in <b>Table 1</b> , where the data are derived from E2a (post-treatment) and refer to circumstances in which John was supposed to be wearing a prosthesis. For the sample as a whole, there were negligible differences between the El (pretreatment) and the E2a (post-treatment) data. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 1</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> For every situation, more than 60 percent of the sample chose positive responses, and in only one instance did more than a negligible proportion choose a statement reflecting definite insecurity. As for that item, many of the respondents had not correctly interpreted the other person to be the amputee's wife. Even more striking is the fact that from a fourth to a half gave as their response the single most positive statement. It is clear, then, that the majority of the amputees wished to be viewed as functionally independent, having confidence in their ability, with a desire to demonstrate their functional achievements, and willing to accept some aid if it is found to be needed. The vast majority of the responses expressed an acceptance of the loss of the limb, a willingness to discuss the amputation with others, and a general self-assurance in social situations. ( <b>Fig. 1</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In general, the most popular responses were those which emphasize functional effectiveness, self-confidence, and lack of sensitivity about amputation. Reactions suggesting any admission that the amputee considered himself at all "different" from anyone else were extremely rare. It seems clear that the subjects readily recognized the socially desirable responses and favored them overwhelmingly. To what extent this eventuality represents the true feelings and behavior of the group, and to what extent it represents wishful thinking, cannot be determined from these data-a situation that reflects a weakness in the prosthetic-reaction test as currently conceived. Evidence indicates that amputees are very much concerned with conforming to the important cultural values of self-reliance and self-confidence and that they abhor any suggestion of a departure from complete normality. <b>Table 1</b> </p> <h4>Changes in Responses as a Result of Fitting</h4> <p>For the group as a whole, there were virtually no significant differences between El and E2a, even though the latter was administered after a considerable period of time had elapsed. This result would suggest that the treatment program had little or no effect on the expressed attitudes of the group. But when we consider separately those amputees who were being fitted for the first time and those who had worn prostheses before, some changes can be detected among the new wearers. Since the number of amputees being fitted for the first time was small (only 55), no extensive quantitative analysis can be made. Nevertheless, a few general conclusions can be drawn.</p> <p>First of all, the responses after fitting indicated that new wearers were slightly disappointed in the functional efficacy of their artificial arms. While initially (on El) a large number of these amputees revealed expectations that the prosthesis would enable them to do "almost everything," particularly in their occupational roles, the E2a responses indicated more modest attitudes. But these changes were not toward more negative responses. Rather, they reflected the fact that the amputees concerned had indulged in unrealistic expectations for the prostheses and then had adjusted to a more realistic view after some experience with their new arms. There were, moreover, indications of a greater degree of security in social situations. After fitting, some of the new wearers indicated an increased acceptance of their amputation-a greater ability to talk about it, less tendency to withdraw from situations revealing the disability, and less expectation of pity from others. Besides this, they expressed a greater readiness to ask for help without apology or embarrassment.</p> <h4>Effects of Fitting Upon Responses to Everyday Situations</h4> <p> As has already been indicated, the primary aim of the prosthetic-reaction test was to evaluate the amputee's feelings about the part that an artificial arm plays in the common difficult situations of his life. The statements the subjects chose as describing John's behavior may therefore be taken as reflecting aspects of their own behavior. Consequently, if we compare the results of E2a (in which John is considered to be <i>wearing</i> a prosthesis) with those of E2b (in which he is considered <i>not</i> to be wearing one), both tests having been administered at the end of the studies, we discover some of the effects that wearing an artificial arm has on the daily life of an amputee. Toward this end, the two personality variables, independence and security, were considered. In separate analyses of the data from the "nonprevious prosthesis wearers" (referred to as NPPW's) and the "previous prosthesis wearers" (PPW's), it was found that the two groups did not differ in their responses except as discussed specifically hereafter. <a style="text-decoration:none;">*</a> </p> <p> A review of the E2a (prosthesis worn) and E2b (prosthesis not worn) responses follows: <b>Fig. 2</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Greater tolerance of curious strangers is exhibited when a prosthesis is worn. In E2a the amputees appear better able to view the situation without misinterpretation, to be more sure of themselves and less likely to pity themselves or to expect pity from others. The PPW's are somewhat more secure in the E2a situation than are NPPW's, even though both groups were wearing prostheses at the time of the tests. The most reasonable explanation for this difference would seem to he in the fact that the period of prosthetic wear for the NPPW group was insufficient for feelings of conspic-uousness to disappear.</p> <p> <b>Fig. 3</b> , <b>Fig. 4</b> , <b>Fig. 5</b> , <b>Fig. 6</b> , <b>Fig. 7</b> , <b>Fig. 8</b> , <b>Fig. 9</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 7</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Differences between the E2a (with prosthesis) and E2b (without prosthesis) responses were considerable throughout the entire test, both for amputees who were being fitted for the first time and for those who had previously worn prostheses. We may thus conclude that the positive acceptance of prostheses reflects not merely the enthusiasm of new wearers but rather the genuine value of prosthetic wear in its own right.</p> <p>The indications are clear that amputees regard a prosthesis as a definite asset in functionally demanding situations and that they think of it as something enabling them to be more independent, more secure, and more willing to accept their condition. In the potentially threatening situations that an amputee must face from time to time, a prosthesis contributes to his ability to handle himself easily and self-confidently, even in cases where the prosthesis does not have immediate functional value.</p> <p>The data for "emotional" situations indicate that the amputees' positive expressions of security were definitely greater when the protagonist was wearing a prosthesis than when he was not. An artificial arm apparently gives many amputees an increased confidence in their functional adequacy. This in turn helps them to achieve a greater self-acceptance, enables them to face their disability more realistically, and lets them view the reactions of others without feeling quite so threatened.</p> <p>Of the two personality variables considered, independence and security, independence appears to be the more strikingly affected by prosthetic restoration. The subjects tend to expect that the amputee who wears a prosthesis will be more effective functionally, more self-sufficient, and generally more adaptive than the nonwearer. When the matter of security is concerned, the role of the prosthesis is less pronounced. Still, most of the amputees think of prosthesis wearers as more self-accepting, less shy, and less easily embarrassed than non-wearers.</p> <p>The responses to the prosthetic-reaction test strongly indicate that amputees feel there is both functional and psychological advantage in the wearing of a prosthesis. They consistently attribute more positive responses to the amputee wearing an artificial arm than they do to the nonwearer in the same situation. But of course all of these findings are merely projections upon a fictitious amputee pictured in a cartoon; we do not yet know the precise extent to which these projections reflect the actual responses amputees make in life situations. Nevertheless, it is clear that the wearing of a prosthesis has a positive effect upon the way an amputee perceives and reacts to many social situations in his daily life.</p> <h3>Attitudes Toward Prosthetic Wear, Before and After Fitting</h3> <p> The discussion thus far indicates that the amputee believes strongly in the importance of wearing an artificial arm. He tends to feel that a prosthesis increases his functional capabilities and helps him to cope with social situations. He retains these beliefs, even reinforces them, after participating in the research program. To analyze still further amputee attitudes toward the wear and use of a prosthesis, additional studies were designed to seek answers to the questions <i>Are the expectations of nonprosthesis wearers fulfilled by a prosthesis?</i> and <i>Can the postfitting attitudes of amputees toward their prostheses be predicted on the basis of their prefitting expectations?</i> </p> <p>As for the first of these queries, the amputee who does not wear a prosthesis holds certain preconceived opinions about the value of an artificial limb before he ever undertakes to wear and use one. If these expectations are fairly realistic, his experience with his prosthesis may be gratifying. But unrealistic expectations can interfere with the successful wearing of a prosthesis. For this reason, a study was made of the alterations in attitudes of nonwearers after they had used a new prosthesis. As for the second question, it is reasonable to expect that the opinion an amputee holds about prostheses before he receives one will be related to his opinion after he has been fitted. If these relationships are stable enough to be predicted, potential problems may be anticipated and perhaps avoided. It is well known that a negative attitude on the part of an amputee interferes with his wholehearted participation in the rehabilitation process and thus reduces the probability of success. Identifying such a situation is the first step toward correcting it.</p> <h4>Are the Expectations of Nonprosthesis Wearers Fulfilled by a Prosthesis?</h4> <p>Among the subjects for whom data were available in this aspect of the study were 45 amputees who had never worn prostheses before their participation in the research program. About half of them were relatively "new" amputees who at the time may not yet have had an opportunity for fitting. The other half consisted of persons who had been amputees for from one to 27 years and who were therefore considered to have had ample opportunity to obtain prostheses had they wanted to. Although it is possible that some in the latter group may have been discouraged long ago by the lack of adequate prostheses for shoulder disarticulation and for certain other types of amputation, some had stumps relatively easy to fit, and accordingly factors other than lack of prosthetic equipment seem to have been present.</p> <p>Because this study was only one phase in a more general investigation of the conditions underlying the wear or nonwear of a prosthesis, use was made of a broad approach in which was collected information generally related to amputation and to prosthetic restoration. Gathered by means of a questionnaire probing prior beliefs and attitudes on a variety of matters relating to prostheses (Appendix IIIH), the data sought included sources of prosthetic knowledge and an estimate of its extent, functional expectations, opinions of the appearance of prostheses, opinions of the comfort of prostheses, attitudes toward prosthetic training, attitudes toward the general value of artificial arms, and anticipated difficulties with prostheses. Approximately six months after the fitting of a prosthesis to these patients, the questionnaire was given again to obtain post-fitting attitudes.</p> <h5> <i>Sources of Prosthetic Knowledge and Estimate of Its Extent</i> </h5> <p> The extent of prosthetic knowledge claimed by the subjects increased only slightly after they had participated in the program. Before fitting, 95 percent said they knew little or nothing about artificial arms; after fitting 85 percent still said so. Even after some six months of having worn prostheses, only 14 percent said they knew "much" about the subject. These findings may of course only reflect restraint and modesty. If they reflect the situation accurately, the amputees are indeed poorly informed. To determine whether the sources of information had any bearing on the state of amputee enlightenment, the subjects were asked to name their principal source of information, As can be seen in <b>Table 2</b> , the answers were rather diverse. Mentioned were five major sources of information before fitting. Three of these (other amputees, friends, self) are generally unreliable in matters of prosthetics. Friends and one's own self are hardly qualified without special training, and other amputees, as has been indicated already, are not necessarily well informed. Medical personnel, including physical therapists, occupational therapists, and nurses, were cited by only one amputee as a source of information. But after the amputees had participated in the program, the picture changed sharply. Then most of them mentioned medical personnel as the main source of information, while "other amputees" were not mentioned at all. <b>Table 2</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 2</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the extensive list of pretreatment sources of information may indicate that the amputees were alert, receptive, and inquisitive, seeking information from all quarters, it may on the contrary mean that they used all these sources because they were not given information by those most competent to provide it. The general impression is that adequate information about prosthetics is not readily available to the average amputee and that there is therefore a real need for a more thorough prosthetics education of medical personnel. We might even suggest that more attention be given to improving knowledge of prosthetics among new amputees. One approach would be to furnish literature portraying different types of prostheses-along with a sober appraisal of the utility, as well as of the disadvantages, of current prosthetic equipment. Doing so would help the patient to acquire more realistic expectations, to eliminate some of his trepidation, and to fill his individual needs more successfully.</p> <h5> <i>Functional Expectations</i> </h5> <p> Experience tends to modify any overly ambitious ideas the amputee may have about the value of the prosthesis. Most of the amputees in the study had more realistic expectations after they had been fitted with their artificial limbs than before: ( <b>Fig. 10</b> ).The 73 percent who before fitting said they believed prostheses were essential included 21 percent who said they thought artificial arms were "as good as normal limbs." Among those who after fitting said they believed prostheses to be very important, there were still 10 percent who said they thought their prostheses were as good as normal limbs. Apparently the fitting of the prosthesis reduces the number of amputees who deny reality but does not eliminate that group completely.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Before they were fitted, the amputees tended to expect that artificial limbs would take a considerable expenditure of energy for effective operation, but experience showed them that these estimates had been too pessimistic: ( <b>Fig. 11</b> ), ( <b>Fig. 12</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Those who deal with prospective wearers should make use of the general tendency among amputees to believe that prostheses are helpful. But unless the limitations as well as the advantages of artificial arms are explained, false hopes and unreasonable expectations will result.</p> <h5> <i>Opinions on the Appearance of Prostheses</i> </h5> <p>Judgment of appearance is a complex and subjective process. The phrase "acceptable appearance" means many things to many people because the component factors are not often defined. In this study, three factors were identified. The first relates to the appearance of the prosthesis itself-to the degree to which it resembles the natural limb. The second relates to the readiness with which the artificial limb is recognized by observers. And finally the third relates to the appearance of the prosthesis when it is actually in use by the amputee.</p> <p>Roughly 75 percent of the subjects said they believed that their prosthetic arms and hands closely resembled normal limbs. Although the remainder said they found no strong resemblance, it was clear that in general the amputees accepted the appearance of their prostheses. One patient alone gave "unfavorable appearance" as the reason for not wearing a prosthesis.</p> <p>At this point it is perhaps worth noting that medical personnel who see many varieties of prosthetic equipment tend to develop, out of their own experience, personal sets of standards about the appearance of prostheses and sometimes impose these standards upon an amputee. But the patient, having had very little experience with prostheses, bases his opinions on quite personal factors, and these may be at great variance with those which influence the judgment of the clinic team. We must therefore strive to fulfill the actual needs of the individual amputee rather than to satisfy our own honest but at times inappropriate standards.</p> <p> Initially, most of the amputees said they expected to be recognized as amputees even when wearing prostheses, an expectation apparently confirmed by experience: ( <b>Fig. 13</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These findings are especially interesting when we recall that about 75 percent of the amputees said they thought their prostheses closely resembled natural arms and hands. Yet only a few of the subjects, either before or after fitting, said that they believed they could be taken for nonamputees. It seems apparent, therefore, that more than just the physical appearance of the artificial arm was involved. A strong similarity may be thought to exist, but generally the amputee does not believe similarity alone will enable him to pass as a nonamputee.</p> <p> Data from studies by Dembo and Tane-Baskin <a></a> on the noticeability of a cosmetic glove indicate that noticeability depends upon the "intensity" of the situation, that is, upon the closeness of the amputee's social and physical contact with others at any particular time. In view of this observation, it is clear that the inability to discriminate between situations of varying intensity keeps us from interpreting the present data any further. The amputees' responses in the study came from their experiences in both casual and intense situations, and we cannot distinguish between the two. </p> <p>Ease and smoothness of operation constitute another important factor in the general appearance of the amputee. The well-trained, smoothly functioning amputee contrasts strongly with a less-trained, uncoordinated, and awkward one. Full evaluation of appearance must, therefore, also take into account the dynamic factor, the impression given by smooth, normal-appearing movement as contrasted with that given by halting, uncoordinated motions.</p> <p>We see, then, that there are at least three important considerations involved in any judgment of an amputee's appearance-the actual appearance of the prosthesis apart from its functioning (the "static factor"), the naturalness with which the prosthesis is used (the "dynamic factor"), and the intensity of the amputee's situation (the "situational factor"). Treatment personnel usually place greatest emphasis on the appearance of the limb itself; the amputee may base his impression more upon the other two considerations.</p> <h5> <i>Opinions on the Comfort of Prostheses</i> </h5> <p> The amputees' statements about the comfort of artificial limbs did not change very much with experience. Both before fitting and after some period of wear, about 25 percent of the subjects claimed considerable discomfort, while 50 percent or better had no complaints on this score: ( <b>Fig. 14</b> ). For three quarters of the prosthesis users, comfort does not appear to be an important problem, and expectations of comfort seem to be borne out by actual experience. But the 25 percent who complained about discomfort <i>do</i> represent a very significant problem because discomfort is a common cause for rejection or infrequent use of artificial limbs. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>At present, research aimed at eliminating discomfort focuses on prosthetic and physiological factors, an emphasis that seems appropriate in view of the fact that the principal objective causes of amputee discomfort are related to fit of the socket and harness and to weight of the prosthesis. But the problem has several other aspects, and these might also be explored profitably. There is for example the question of education-of how to prepare the amputee to expect at least some degree of initial discomfort. Another possible factor relates to the early use of the new prosthesis unwisely and too well. The mere statement, "At first this may be uncomfortable," may be insufficient warning for the new user. This phase of orientation needs more emphasis. Otherwise there is always the danger that amputees not fully aware of the difficulty of initial adjustment may give up with the feeling that prostheses are not for them.</p> <p>In addition to all these matters, there are psychological problems related to the amputee's pain tolerance. The way the amputee reacts to pain is influenced by such psychological factors as his acceptance of the amputation and his unrealistic hopes for the prosthesis. Finally, there is a need to recognize the special social attitudes that an amputee elicits when he expresses discomfort.</p> <h5> <i>Attitudes Toward Prosthetic Training</i> </h5> <p> Training to operate a prosthesis effectively requires a period of time ranging from a few hours to many hours, as correctly anticipated by all but three percent of the subjects: ( <b>Fig. 15</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig.15</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As we have seen, the subjects of study generally knew little about the potentials of prosthetic restoration. When, on top of the amputee's functional disability, there is superimposed the unavoidably new and ambiguous situation, anxiety and feelings of dependency are created. Since at a number of points in the rehabilitation process the physical and occupational therapist is in closest contact with the patient and is offering direct functional assistance, he is one of the natural recipients of these negative reactions. It should be possible during training for the therapist to use these dependency feelings and other factors to instill in the patient an attitude of realistic independence. Moreover, the training situation offers the amputee opportunity to develop and to demonstrate his functional competence under professional guidance. Regulated training routines have many advantages. Learning is quicker and more efficient, and the number of successful experiences can be maximized while failures are held to a minimum. For the amputee, the training experience should result not only in proficiency with the artificial limb but also in a realistic functional independence and a general sense of adequacy and personal competence.</p> <h5> <i>Attitudes Toward the General Value of Artificial Arms</i> </h5> <p>In an effort to determine the significance that artificial arms had for the amputees, the subjects were asked to express their opinions in terms of three frames of reference the advantages of using a prosthesis, the general functional help of a prosthesis, and the importance of the artificial arm.</p> <p> <i>Advantages.</i> The overwhelming opinion among the amputees, both before and after fitting, was that artificial arms have more advantages than disadvantages: ( <b>Fig. 16</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 16</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>General Help.</i> The prosthesis enabled the amputees to get along better. Most of them maintained that they could get along <i>much</i> better. A few said that it hindered them slightly. No one said that it really interfered. But among the amputees who had expected to find extreme advantages, there were indications of marked changes of opinion. That the group with the highest expectations dropped from 78 percent to 59 percent illustrates the development of more realistic values through experience. The same kind of change is illustrated by the increase in the number of amputees who said they thought a prosthesis could help them to get along "about the same" or "slightly worse": ( <b>Fig. 17</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 17</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Importance.</i> Despite a drop of 9 percent in the two most favorable categories of response, over 70 percent of the amputees said after fitting that they still believed it "very important" or "extremely important" for them to wear artificial arms. There was, however, an increase from 4 percent to 12 percent in the number of amputees who said they thought their prostheses "not at all" or only "slightly" important: ( <b>Fig. 17</b> ) </p> <p>It seems clear that the amputees retain favorable attitudes toward their prostheses after a period of wear. They appear to consider prostheses generally helpful, to believe that the advantages far outweigh the disadvantages, and to be convinced of the importance of artificial arms.</p> <p>If these findings are accepted as showing the general feelings of the amputees, the next step is to relate these attitudes to the amputees' actual use of their prostheses. The relevant factors here are the amount and type of use, the situations in which prostheses are worn and employed, and the amputee's reasons for discarding a prosthesis.</p> <h5> <i>Anticipated Difficulties With Prostheses</i> </h5> <p>As regards the wearing of an artificial arm, the amputees foresaw certain difficulties. They anticipated problems in becoming accustomed to wearing the arm, in learning to operate it, in dealing with fatigue, and in avoiding awkwardness. With the exception of the second difficulty, learning to operate the arm, all of these turned out to be real problems, and some additional ones, such as mechanical failure of the prosthesis, stump pain, and excessive heat, developed.</p> <p>The difficulties that amputees experience with their artificial arms range from relatively trivial annoyances to serious complications. Most of them may be placed in either of two categories-problems related directly to mechanical, functional, or medical disorders, and problems related to emotionally based preoccupation with conditions otherwise insignificant. Those in the first category disappear when the relevant conditions are corrected. Those in the second category reflect personality variations. In the interests of clarity and emphasis, these emotion-laden complaints have been classified in accordance with six hypothetical kinds of personality. Although having no value in themselves the stereotypes thus created are not intended as "pigeon-holes," they serve nevertheless as organizing aids for identifying the problems.</p> <p> <i>The Unmotivated.</i> The unmotivated amputee does not expend the effort necessary to overcome obstacles in using a prosthesis. The person without drive wears and uses his prosthesis so long as everything operates smoothly, but when even slight difficulties arise he lacks the motivation to continue with the limb and to expend any extra effort needed to operate it. Wear and use are thus limited. In justification of his action in discarding the prosthesis, the amputee may present many rationalizations in the form of spurious complaints about comfort and effectiveness. </p> <p> <i>The Ghost Story.</i> Complaints derived from phantom sensation are likely to occur among amputees who are unaware of the common phenomenon and who consequently do not anticipate it. Still others, on experiencing the phantom, fall prey to misconceptions about it and fail to acknowledge the experience for fear of implying that they are disoriented or are suffering from mental disturbances. Through ignorance, such patients may attribute their phantom sensation or phantom pain to poorly fitting sockets or harnesses. Complaints usually disappear when the amputee has been well informed. </p> <p> <i>Mind Over Matter.</i> People vary in the amount of discomfort they can accept. Since it is probably impossible to eliminate discomfort entirely, some dissatisfaction is inevitable. But this common difficulty may be reduced to some extent if, before fitting, the amputee develops realistic attitudes toward whatever discomfort he cannot escape. Forewarning the amputee may help him to avoid disappointment and exaggeration of his discomfort. </p> <p> <i>The Exaggerators.</i> Some amputees tend to elaborate upon their complaints and to distort the situation out of all proportion to its real significance. They develop fixations about relatively unimportant details or symptoms, and they are not open to persuasion or logical argument. Most often such a complaint is based upon a personal need, as for sympathy or attention, perhaps only remotely related to the actual prosthetic condition. But until this personal need is satisfied, little success can be expected in handling the related prosthetic or medical conditions. </p> <p> <i>Motor Trouble.</i> Difficulties associated with the actual operation of a prosthesis result from two conditions-from poor neuromuscular endowment, or from tensions and anxieties producing awkwardness and lack of coordination. In the first condition, the amputee possesses in balance and coordination basic deficiencies which together operate to reduce his functional potential. Owing to the effects of banging and twisting in awkward and erratic movements, the prospects of prosthetic maintenance tend to increase. In such a case, faults that are apparently prosthetic are really human faults. </p> <p>The second condition typifies the anxious person who always anticipates something bad. He looks upon every squeak, every irritation, and every temporary malfunction as a sign that the prosthesis is falling apart or at least is in need of adjustment. He differs from the exaggerator in that his reactions are much more diffuse and not nearly so emphatic. Anxiety induces characteristic muscular tension, which interferes with function in much the same way as does an innate psychomotor inferiority. Since the latter condition offers a poorer prognosis and dictates a different course of care, it is necessary to make a distinction based upon etiology.</p> <p> <i>The Comparison Shopper.</i> Every prosthetist knows of amputees who are always looking for something better. Sometimes such persons channel their needs constructively and make a contribution by entering the field of prosthetics development. More often, however, they dissipate their energies going from limbshop to limbshop looking for satisfaction they probably cannot get. These amputees are apt to become a matter of professional concern, for they often tend to depreciate the efforts, skill, and integrity of the art. </p> <p> <i>Recapitulation.</i> It is likely that a single explanation runs through several of the foregoing categories, for the amputee's subconscious nonacceptance of his amputation may underlie lack of motivation, phantom sensation, over-reaction, and inability to be satisfied. The problems of phantom sensation and of low discomfort tolerance may be accounted for physiologically, and the conditions of over-reaction and constant apprehension may be traced to personality factors more general than refusal to accept amputation. In any event, the categories can be made more useful, or at least revised constructively, if conceptual and experimental analysis is undertaken to establish the extent of each category, the etiological backgrounds, and the best manner of treatment in each case. </p> <p>Two general considerations should govern the follow-up of complaints-improvement of undesirable conditions, and the identification and description of the "complainers." The first is limited only by the present state of technical knowledge and skill in the field of limb prosthetics. The second has received only casual attention in the past. Further work in this area of psychology could prove to be fruitful.</p> <h4>Can the Postfitting Attitudes of Amputees Toward their Prostheses be Predicted on the Basis of their Prefitting Expectations?</h4> <p> As we have seen, the attitudes held by the amputees before they had participated in the program were modified by their subsequent experience with prostheses. The shift was generally toward a more realistic opinion of the results that could be obtained with prostheses. In addition to these changes, however, the attitudes of the amputees both before and after fitting showed that they placed a great deal of importance on the desirability of wearing a prosthesis. The next step, then, was to study the relationship between an amputee's attitude before fitting and his attitude afterwards. Our aim was to determine whether or not it is possible to predict an amputee's postfitting adjustment from a knowledge of his expectations before he is fitted. To this end, the question was asked: <i>Are the prefitting attitudes of amputees toward prosthetic restoration related to the attitudes they hold after fitting and a period of usef</i> Or, to put the question more specifically, will the amputee who approaches the fitting with a positive attitude about prostheses tend to maintain that attitude after he has worn and used an artificial arm, and, conversely, will the amputee who starts with a less positive, ambivalent, or negative attitude toward prostheses persist in that attitude after wear and use? </p> <p> Appendix IIIH, used previously to determine the degree of satisfaction of amputee expectations, was now applied to test whether or not postfitting attitudes could be predicted from the corresponding prefitting attitudes. <a style="text-decoration:none;">*</a> Selected for this analysis were 42 amputees, none of whom had worn a prosthesis before participating in the program. They included 18 below-elbow, 18 above-elbow, and 6 shoulder-disarticulation cases ranging in age from 17 to 54 years, in education from none to postgraduate school, and in the year of amputation from 1916 to 1955. The group was, in short, highly diverse. According to their combined expectancy scores, the subjects were placed on a continuum ranging from high to low in prosthetic expectation and were then divided into three equal groups representing high, intermediate, and low prosthetic expectancy. For comparative purposes, only the upper third, representing high expectancy, and the lower third, representing low expectancy, are used in the following analyses. </p> <h5> <i>Combined Expectancy Score of High Group Compared With That of Low Group</i> </h5> <p>The first step was to determine whether the initial attitudes of the high-expectancy and low-expectancy groups were maintained after prosthetic experience or were modified by it.</p> <p> Accordingly, the attitudes of the high and low groups were compared before and after fitting, <a style="text-decoration:none;">*</a> as indicated in <b>Table 3</b> ]. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 3</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In both instances, the difference between the average combined expectancy scores of the high-expectancy group and of the low-expectancy group was found to be statistically significant (P 0.05). Moreover, the mean score for each group did not change significantly after fitting (P 0.05). Thus in general positive or negative attitudes within the group were maintained after fitting.</p> <p>The individual items of the questionnaire were studied in an effort to determine why within each group there was only insignificant change in the combined expectancy scores from before fitting to after fitting. Was this result owing to lack of systematic differences between evaluations? Or were gains in positive feelings toward some items canceled out by loss of positive feelings toward other items?</p> <h5> <i>High and Low Group Comparisons for Individual Items</i> </h5> <p> Within each group an analysis was made of the way in which the responses to individual questionnaire items changed after fitting. The opinions expressed by the high-expectancy group and by the low-expectancy group about each item before and after fitting are listed in <b>Table 4</b> , where it may be seen that the nine items originally used to differentiate high prosthetic expectancy from low continued to differentiate the two groups, the "high's" in every instance remaining more favorably disposed than the "low's." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 4</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Inspection of the data indicates that the lack of change from prefitting to postfitting evaluations, as measured by the combined expectancy score, does not result from the cancellation of negative changes by positive ones. The average score of both the high-expectancy and the low-expectancy groups increased (became less positive) on most items. The conclusion may thus be drawn that experience with prostheses led both groups to expect less in the way of functioning (items 1 and 2), to expect less resemblance between prostheses and natural arms (item 3), and to expect artificial arms to be more uncomfortable (item 5). On the other items, the average score either decreased or remained about the same. Both groups said that the artificial hand more closely resembled the normal hand than they had expected (item 4). The "low's" apparently found (more so than the "high's") that they had not sufficiently appreciated the advantages of wearing prostheses (item 8). Of considerable interest were the group differences in response to item 6 (the importance of wearing an arm). The "high" group showed a lessening of positive opinions, and this decrease corresponded to a decline in negative attitudes among the "low's."</p> <h5> <i>Certainty of Response</i> </h5> <p> Throughout the questionnaire, the amputees had been asked to indicate by code the degree of certainty they felt about each of their responses. After the initial investigation, a study was made of the certainty with which any particular response had been expressed. In the code <i>AS</i> (absolutely sure), <i>VS</i> (very sure), <i>FS</i> (fairly sure), <i>SU</i> (somewhat unsure), <i>VU</i> (very unsure), <i>AS</i> was arbitarily assigned a weight of 1; <i>VS</i> a weight of 2; <i>FS,</i> 3; <i>SU,</i> 4; and <i>VU,</i> 5. Thus was obtained an average certainty score for each person in each group. The mean certainty scores for each group, prefitting and postfitting, are shown in <b>Table 5</b> . </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Table 5</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Amputees with high expectancy express themselves as being a good deal more certain of their responses than do the low-expectancy amputees, although both are generally quite affirmative. Since in general the amputees admit to very little prosthetic knowledge, one may wonder about the basis for such certainty. After they had acquired experience with their prostheses, both groups became even more certain in their responses, as might have been expected. But the increase in certainty among the "low's" was considerably less than the increase expressed by the "high's." There would seem to be much value in further analysis of the relationship between attitude toward prostheses and certainty of response.</p> <h5> <i>Relationships Between Expectancy and Other Factors Related to Amputation</i> </h5> <p> In order to learn whether or not there were systematic relationships between prosthetic-expectation level and certain other factors, the "high" and the "low" groups were compared with regard to amputation type, hand dominance, marital status, age, educational level, and age at time of amputation. Analysis indicated no statistically significant differences<a></a> between the group with high expectancy and the group with low expectancy. <a style="text-decoration:none;">*</a> It would appear that, for this sample, the amputees who expect considerable returns from prosthetic service and those who do not expect very much are not greatly different in the factors of amputation type, handedness, marital status, age, education, and time since amputation. The suspicion that "attitudes held by amputees about prosthetic restoration before fitting are related to the attitudes they hold after fitting and a period of use" is therefore confirmed by the data. The findings also substantiate the more specific hypothesis: <i>The amputee who approaches the fitting with a positive attitude about prostheses will tend to maintain that altitude after he has worn and used one; the amputee who starts with a less positive, ambivalent, or negative attitude toward prostheses will persist in that attitude after wear and use.</i> </p> <p>It must be emphasized that these findings relate to the amputees' general attitudes toward prosthetic restoration. Any particular reaction will be a function of the general prosthetic attitude and also of the specific factor involved, whether it be that of appearance, of function, or of something else.</p> <h5> <i>Relationships Between High and Low Expectancy and Other Attitudes of Amputees</i> </h5> <p>In the course of the studies, information also was gathered describing the attitudes, experience, and expectancies of the subjects. Not all of these data were thought to be directly related to the question of what the amputees expected from prosthetic restoration. But in continuation of the study of amputee attitudes toward prosthetic service, they were examined anyway. A nonstatistical comparison, made between high-expectancy and low-expectancy groups to detect differences with respect to other reactions, uncovered the following distinctions:</p> <ol> <li>On the whole, the group with the high expectations reported a great deal of improvement in performance. But the low-expectation group said that performance of a number of activities was impaired after prosthetic treatment. The degree of negative change reported by the "low's" was not as great as the degree of improvement reported by the "high's." Activities showing the greatest amount of change were eating, dressing, driving, and participating in sports. The "low" group expressed the most disappointment about eating, dressing, and sports activities. The "high" group reported its greatest improvements in the areas of dressing and driving.</li><li>The "low's" expected more difficulties than did the "high's" (18 to 12), and in the evaluations after fitting they continued to report more difficulties (19 to 14).</li><li>More "high's" than "low's" reported having had favorable comments made to them about the appearance of their prostheses.</li><li>More "low's" than "high's" admitted to negative changes in feelings since amputation.</li><li>Before wearing a prosthesis, four "low's" felt resentful when new acquaintances asked about the amputation; none of the "high's" expressed any negative feelings. After wear, the "high's" still did not express resentment, although three "low's" did.</li><li> The most outstanding difference between the "high" and "low" groups was manifest in response to the question, <i>If you don't consider appearance, do you think that you could get along as well without a prosthesis as with one?</i> Before fitting, none of the 28 subjects responded in the negative (perhaps because they were getting a free prosthesis). Three of the "high's," however, gave extremely positive responses ("The prosthesis is like a part of my body; I cannot do without it."), while the rest of the "high's" and all of the "low's" answered more temperately ("It facilitates things, increases independence."). In the postfitting evaluation, one of the "high's" said that he could do without a prosthesis, as his was not too helpful; two of the "high's" gave extremely positive replies; and the rest were more moderately positive. The "low's" presented a much more negative picture in the postfitting evaluation. Four said that they felt they could do without a prosthesis, and only one expressed himself as being oriented very positively. </li></ol> <p>The validity of the group division appears to be supported by the sample findings from the rest of the psychological data. Although we are concerned at present with establishing points of difference between the "high" and the "low" groups, it is well to add that in many other variables, such as social sensitivity and reactions to frustration, use of these measuring instruments revealed no differences.</p> <p>In conclusion, then, the hypothesis was confirmed that the attitudes of nonwearers toward prosthetic restoration are related to their attitudes after they have worn prostheses. Through the use of a set of questions, it was found possible to differentiate between favorable and unfavorable attitudes. The division of the amputees on the basis of their general attitudes toward the usefulness of prostheses gave some indication of being related to other than prosthetic factors. But judging from the results, the establishment of predictive indicators of attitude toward prosthetic restoration appears to be feasible. It should be possible to develop a predictive scale which will have clinical and research utility and which at the same time can be administered and interpreted in a relatively simple way.</p> <h3>Summary</h3> <p> Throughout this section a number of recurrent themes have been encountered. Chief among these has been the amputees' need for unprejudiced recognition by nonamputees. In order to gain this recognition, the amputees consistently present themselves in a manner which only partially represents their true feelings. The interpretation of the data has therefore been that the amputees utilized the questionnaires more to express their feelings about how an amputee <i>should</i> be regarded than to state how he actually <i>is</i> treated. From this point of departure the information has been handled at two levels-the first involving the assumption that the data are valid and meaningful in themselves, the second based on the premise that the responses reflect the conscious and subconscious wishes of the subjects. </p> <h4>Personality Dynamics of Amputees</h4> <p>Although 90 percent of the amputees said that they were adapted to their loss, it is doubtful that so many had really achieved this result. Evidence seemed to indicate that many of the amputees were trying to maintain feelings of bodily integrity and adequacy by denying the personal and social concomitants of amputation. Any implication of abnormality was overwhelmingly rejected. Their physical defect was consistently de-emphasized, and their goals and values were those of the normal, nondisabled person.</p> <p>In almost all instances, amputees portray themselves as being as able an nonamputees. While almost never admitting to being substantially inferior to nonamputees, they do acknowledge that some extra effort is necessary to keep up with them. Other evidence confirms that amputees are, in the main, correct in stressing their ability. But their consistent refusal to acknowledge limitations reflects their own self-concern. Apparently they must exaggerate to maintain a social and vocational status equal to that of nonamputees.</p> <p>Considerable stress is placed upon self-sufficiency. Amputees say they resist accepting help because it is generally unnecessary. Unexpressed, but no less important, is the feeling that to accept help makes one dependent and lowers one's status.</p> <p>Sensitivity about physical prowess and appearance is one of the crucial influences in the psychological functioning of the amputee. The subjects in this study readily admitted their concern about the opinions of others, but few were ready to admit any considerable amount of sensitivity. They claimed not to resent curiosity about their appearance and to expect people to look at them. Clinical experience, however, indicates that amputees are much more sensitive and hostile toward the curious person than was indicated by the data. Not infrequently such sensitivity is denied not only to others but also to themselves.</p> <p>Amputees claim to be accepted by others on the same basis as anyone else, and they reject strongly the suggestion of "different" treatment. Mostly, the subjects did not feel that amputation had been a serious source of frustration. They felt they usually could do the things they wanted. When they were unable to perform because of the amputation, their usual reaction was to try all the harder.</p> <p>Finally, the general tone of the amputees is to give the impression of being optimistic about their abilities, acceptance by others, and future goals.</p> <p>The positive effect of the experimental treatment program on many of these variables was demonstrated. Although no radical personality changes were observed, there were consistent indications that some decrease in sensitivity and frustration resulted from the improved management procedures and from the improved prostheses. In addition, some degree of greater acceptance of loss, increased feelings of functional adequacy, and greater ease in social situations were noted.</p> <h4>Social and Functional Factors in Prosthetic Wear</h4> <p>The prosthetic-reaction test resoundingly confirmed the data from the questionnaires. It was clear that participation in the treatment program resulted in an increase in those responses indicating greater independence and increased feelings of security. The amputees believed there was both functional and psychological advantage in the wearing of a prosthesis. They viewed prostheses as providing the wherewithal for independent functioning. Increased confidence in their functional adequacy helped them to achieve greater self-acceptance, enabled them to face their disability more realistically, and let them view the reactions of others without feeling quite so threatened. They expected nonwearers to be more shy, more easily embarrassed, and less adaptive.</p> <h4>Attitudes Toward Prosthetic Wear, Before and After Fitting</h4> <p> In the final phase of the investigation two questions were asked: <i>Are the expectations of nonprosthesis wearers fulfilled by wearing a prosthesis?</i> and <i>Can the postfitting altitudes of amputees toward their prostheses be predicted on the basis of their prefitting expectations?</i> </p> <p>A number of avenues of approach were utilized to answer the first question. It was found that the extent of prosthetic knowledge claimed by the amputees was very small. The implications of the lack of information were discussed, with stress upon the opportunity ignorance presents for the development of unrealistic expectations (which may influence negatively future attitudes toward prostheses). Overly ambitious ideas as to the value of prostheses were modified with experience, and after being fitted most of the amputees had more realistic expectations of the advantages to be derived from prosthetic wear.</p> <p>General acceptance of the appearance of the prosthetic components was clear. There was little change in opinion regarding the extent to which prosthetic arms and hands resembled normal members. Three important constituents to the final judgment of amputee appearance were identified-the static factor of the cosmetic value of the prosthesis irrespective of function, the dynamic factor of natural appearance in use, and the situational factor of the intensity of the contact.</p> <p>Preconceptions regarding comfort did not change markedly with experience. Although comfort appears to be no important problem for three fourths of the amputees, the remaining one fourth found their prostheses to be uncomfortable.</p> <p>The amputees retained favorable attitudes toward the prostheses after a period of wear. Prostheses were considered to be generally helpful and very important to the amputees, the advantages far outweighing the disadvantages.</p> <p>With the exception of "learning to operate," most of the difficulties anticipated in wearing an arm actually developed. In addition, other problems evolved, such as mechanical failure, stump pain, and excessive heat. A number of hypothetical personality types were described to help identify complaints based upon emotional factors as contrasted with those directly related to prosthetic or medical problems. The second question was directed toward the idea that attitudes held before prosthetic fitting may influence the valuation of prosthetic usefulness regardless of experience. Tested and confirmed was the hypothesis that attitudes held by amputees about prosthetic restoration before fitting are related to the attitudes held after fitting and a period of use. Amputees holding favorable attitudes before using prostheses tended to maintain those attitudes after wear and use; subjects negatively disposed continued to be less favorably inclined.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li> Barker, R. G., B. A. Wright, L. Meyerson, and M. R. Gonick, <i>Adjustment to physical handicap and illness: a survey of the social psychology of physique and disability,</i> Social Science Research Council, New York, Revised 1953. </li> <li> Cameron, N, and A. Magaret, <i>Behavior pathology,</i> Houghton-Mifflin, Boston, 1951. </li> <li> Dembo, Tamara, and Esther Tane-Baskin, <i>The noticeability of the cosmetic glove,</i> Artificial Limbs, 2(2) :47 (May 1955). </li> <li> Dembo, Tamara, Gloria Ladieu Leviton, and Beatrice A. Wright, <i>Adjustment to misfortune - a problem of social-psychological rehabilitation,</i> Artificial Limbs, 3(2) :4 (Autumn 1956). </li> <li> Ladieu, G., E. Hanfmann, and T. Dembo, <i>Studies in adjustment to visible injuries: evaluation of help by the injured,</i> J. Abnorm. and Soc. Psychol., 42:169 (1947). </li> <li> Meyerson, L., <i>Physical disability as a social psychological problem,</i> J. Soc. Issues, IV(4):2 (Fall 1948). </li> <li> New York University, Prosthetic Devices Study, Report No. 115.07 [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Social usefulness of the cosmetic glove: its notice-ability and appearance,</i> October 1949. </li> <li> New York University, College of Engineering, Research Division, Prosthetic Devices Study, Report No. 115.21, <i>Surveys of child amputees at the Mary Free Bed Hospital, Grand Rapids, Michigan,</i> Prepared for the Prosthetics Research Board, National Research Council, May 1957. </li> <li> Siegel, S., <i>Nonparametric statistics for the behavioral sciences,</i> McGraw-Hill, New York, 1956. </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">Kolmogorov-Smirnov and Fisher Exact Probability Tests (Siegel) indicated P&gt;0.05 in all instances.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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"> Siegel, S., Nonparametric statistics for the behavioral sciences, McGraw-Hill, New York, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be remembered that expectancy scores approaching 1 indicate favorable prosthetic attitudes, those approaching 5 indicate unfavorable attitudes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">A measurement of prosthetic expectancy was obtained by a system of scores and ratings similar to that used in the analysis of the results obtained with Appendix IIIG. Each question in Appendix IIIH had five possible answers ranging from one that expressed very positive feelings to one expressing very negative feelings. The response reflecting the most favorable attitude was given a score of 1, that reflecting the least favorable attitude a score of 5. There was thus obtained a score for each item as well as an average score for the questionnaire as a whole (combined expectancy score). Each amputee was then assigned a rating which represented the direction and intensity of his feelings about prosthetic restoration and which was therefore a measurement of his prosthetic expectancy.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall"> Dembo, Tamara, and Esther Tane-Baskin, The noticeability of the cosmetic glove, Artificial Limbs, 2(2) :47 (May 1955). </td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall"> New York University, Prosthetic Devices Study, Report No. 115.07 [to the] Advisory Committee on Artificial Limbs, National Research Council, Social usefulness of the cosmetic glove: its notice-ability and appearance, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be remembered that on the average E2 was administered about six months after fitting. It is probable that, had this test been administered to the NPPWs before they received and used artificial arms, considerably greater differences between PPWs and NPPWs would have been found.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Six of the nine cartoons portrayed situations not relevant to independence and were therefore rated for security only. See Table 1, page 102.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall"> New York University, College of Engineering, Research Division, Prosthetic Devices Study, Report No. 115.21, Surveys of child amputees at the Mary Free Bed Hospital, Grand Rapids, Michigan, Prepared for the Prosthetics Research Board, National Research Council, May 1957. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall"> Barker, R. G., B. A. Wright, L. Meyerson, and M. R. Gonick, Adjustment to physical handicap and illness: a survey of the social psychology of physique and disability, Social Science Research Council, New York, Revised 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>2.</b> </td><td class="clsTextSmall"> Cameron, N, and A. Magaret, Behavior pathology, Houghton-Mifflin, Boston, 1951. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall"> Dembo, Tamara, Gloria Ladieu Leviton, and Beatrice A. Wright, Adjustment to misfortune - a problem of social-psychological rehabilitation, Artificial Limbs, 3(2) :4 (Autumn 1956). </td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall"> Ladieu, G., E. Hanfmann, and T. Dembo, Studies in adjustment to visible injuries: evaluation of help by the injured, J. Abnorm. and Soc. Psychol., 42:169 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The third reaction represents an extremely poor adjustment, for it leads to withdrawal from any situation that might point out the true extent of dependency. Typically, such amputees are characterized by sharply restricted behavior and a limited involvement in life.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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"> Meyerson, L., Physical disability as a social psychological problem, J. Soc. Issues, IV(4):2 (Fall 1948). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall"> Barker, R. G., B. A. Wright, L. Meyerson, and M. R. Gonick, Adjustment to physical handicap and illness: a survey of the social psychology of physique and disability, Social Science Research Council, New York, Revised 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>Sydelle Silverman, M.A. </b></td></tr><tr><td class="clsTextSmall">Assistant Research Scientist, Prosthetic Devices Study, Research Division, College of Engineering, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Jerome Siller, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Associate Research Scientist, Prosthetic Devices Study, Research Division, College of Engineering, New York University, New York City.</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 Studies of the Upper-Extremity Amputee, VII. Psychological Factors Creator An entity primarily responsible for making the resource Jerome Siller, Ph.D. * Sydelle Silverman, M.A. * https://staging.drfop.org/files/original/c0d0eca6feaf1da610d7cb20b544cd80.pdf 4ab0cc41972a01f65f7db078a1de828c https://staging.drfop.org/files/original/b6d2f7ed0ba556ec7090952c752fbbc5.jpg 41c792470fa9bf7060831ecdd6c6bebc https://staging.drfop.org/files/original/a3f76296fb4dd3889147b7e76d279fd1.jpg 7fdba66f3090467035423319664668ed DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_117.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 117 - 127 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/1958_02_117.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_117.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>Studies of the Upper-Extremity Amputee VIII. Research Implications</h2> <h5>Sidney Fishman, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>It was the purpose of the NYU Field Studies to explore the matter of the upper-extremity amputee in a broad and comprehensive way. To this end there was devised a research program consisting of three phases-survey studies, clinical studies, and evaluation studies. The first of these consisted of the single examination of each of 1630 upper-extremity amputees for the purpose of developing normative, descriptive data concerning the status of the upper-extremity-amputee population at the beginning of the research program. Through the vehicle of an organized program of prosthetic management, 769 of the 1630 amputees surveyed were provided in the clinical studies with what at the time was a new type of upper-extremity prosthesis, the purpose being to study the varieties of prostheses provided, the prescription procedures used, the preprosthetic treatment employed, the adequacy of prosthetic fabrication and fitting, the effects of training, and the results of initial and final checkouts. Finally, in the evaluation studies, the prior status, mental and physical, of 359 individuals selected from the clinical study was compared with their corresponding status after participation and treatment. The procedures used in each of these studies, and the objectives sought in the work, have all been discussed in detail in Section I of this series (Artificial Limbs, Spring 1958, p. 4).</p> <p>While the variety, scope, and degree of completeness of the resulting data all increased as work progressed from the survey studies through the clinical studies and on to the evaluation studies, the size of the experimental sample decreased. The survey studies were limited to the normative data that could reasonably be gathered by means of a onetime interview and examination of the largest possible sample of upper-extremity amputees. The clinical studies supplemented the normative data with observational information concerning 769 amputees receiving prosthetic treatment. The evaluation studies included normative, observational, and research procedures. Only in the last series of studies did control of any research variables become possible. The major focus of the evaluation studies was, then, to obtain information on possible changes in the individual resulting from the application of new and experimental procedures in the management of the upper-extremity amputee.</p> <p>The types of information sought in each of the three phases fell into one or more of five broad categories:</p> <ol> <li><i>The physical and personal characteristics of the amputees.</i>Included identifying data (age, height, weight, residence, marital status); educational level; vocational, avocational, and recreational pursuits; amputation etiology; amputation type; and the strength, ranges of motion, and general characteristics of the stump.</li><li><i>The prosthetic components and fabrication techniques utilized.</i>Included information concerning the functional and mechanical characteristics as well as the advantages and disadvantages of each component of the artificial arm.</li><li><i>The treatment factors.</i>Included data concerning the frequency of prescription of various components, pre-prosthetic therapy, prosthetic training, and checkout.</li><li><i>Amputee performance.</i>Concerned with testing the individual's proficiency in accomplishing the basic activities of prehension, positioning, and release of objects from grasp and with amputee reports concerning the usefulness and importance of the prosthesis in various practical activities of daily living.</li><li><i>Psychological considerations.</i>Involved an assessment of amputee attitudes and personality factors as they affect reactions to prosthetic restoration as well as the social consequences of living with a disability.</li></ol> <p>While data within these five areas of interest were gathered in all three phases of the investigation, the comprehensiveness and sophistication of the measurement techniques varied from phase to phase. In view of the wide range of matters investigated, it is clear that the problems involved in their accurate measurement were considerable. Some factors <i>(e.g.,</i>mechanical characteristics of prosthetic components, results of checkout, certain personal identifying data, etc.) lent themselves rather conveniently to so-called "objective measurement," while in the light of presently available techniques other factors could be appraised only through subjective observation and rating by trained observers <i>(e.g.,</i>amputee performance, quality of prosthetic training, quality of prosthetic fabrication, etc.). Still other factors <i>(e.g.,</i>attitudes, personality factors, opinions concerning prosthetic components and treatment methods, etc.) could only be inferred from the verbal reports of the amputees themselves. As a consequence, the resulting data are of three kinds-objective measurements, observations and ratings, and amputee verbalizations. It should, however, be pointed out that no relationship necessarily exists between the significance and value of various data and their objectivity. Quite often the most objective data are the easiest to obtain but are also the least revealing. Yet certain data obviously subjective and barely capable of meeting any standards of precision provide the greatest insights and understanding.</p> <p>With several relatively minor exceptions, all five subject areas have individually been the topic for separate analyses and discussions and have culminated in five corresponding articles (Sections II, III, V, VI, and VII) in this series. Section II (Artificial Limbs, Spring 1958, p. 57) dealt with the descriptive characteristics of the sample. Section III (Artificial Limbs, Spring 1958, p. 73) was concerned with the evaluation of the treatment process. Section V (page 4) reviews the specific components and fabrication techniques that go to make up a prosthesis. Section VI (page 31) describes the performance or functional capabilities of the amputee subjects, while Section VII (page 88) analyzes the psychological attributes of the amputee group.</p> <h3>Studies Completed</h3> <h4>The Sample (Section II)</h4> <p>The initial point of interest is that there were in the nationwide, somewhat urban sample almost as many above-elbow as there were below-elbow amputees (41 percent as compared with 51 percent). The remaining cases consisted of shoulder-disarticulation amputees (5 percent) and bilateral arm cases (3 percent). Within each of these four basic amputee types, a further detailed breakdown is presented. For example, the below-elbow cases are classified and discussed as very short, short, medium, and long, and as wrist disarticulations. A similar breakdown is offered for the above-elbow and shoulder-disarticulation groups.</p> <p>It is important to emphasize that 73 percent of the participating subjects were veterans of military service who had lost limbs in World War II, a matter having a strong influence on the characteristics of the sample- on age, height, weight, educational level, and vocational status as well as on other physical characteristics.</p> <p>Although certain amputees continued to pursue agricultural and mechanically oriented occupations, amputation generally resulted in a shift away from agricultural, manual, and mechanical occupations toward clerical, sales, and managerial activities, and there was in addition a very significant increase in the extent of unemployment (from 1 percent to 19 percent). Such a finding raises the question whether these shifts are caused chiefly by the physical inability to perform and compete in certain activities or primarily by socioeconomic factors.</p> <p>An overwhelming majority of the subjects were found to have in their residual anatomy sufficient strength and sufficient range of motion to use an upper-extremity prosthesis. Despite this physical potential, 25 percent of the below-elbow, 39 percent of the above-elbow, and 65 percent of the shoulder-dis-articulation amputees were not wearing arm prostheses at the time of the survey studies. Typically, those who did wear prostheses used Dorrance hooks, Miracle or APRL hands, and friction-type wrist units. The below-elbow prostheses typically consisted of a leather socket, rigid metal elbow hinges, and a figure-eight harness. The above-elbow and shoulder-disarticulation prostheses had in general plastic or leather sockets, manually operated or harness-controlled elbows (in about equal proportions), and chest-strap harnesses with shoulder saddles.</p> <h4>The Treatment Process (Section III)</h4> <p>Before the advent of the Upper-Extremity Field Studies, only some 17 percent of the group had had arms prescribed for them by a clinic team consisting of a physician, a therapist, and a prosthetist. In the NYU program, where prescriptions were written and filled in this manner routinely, all the professional groups concerned and 94 percent of the amputee subjects heartily approved of the multidisciplinary, clinical approach.</p> <p>With respect to prosthetic components utilized there were several very significant shifts, such as the tendency toward the use of the APRL hook (from 12 percent to 61 percent of the sample) and toward the APRL hand (from 11 percent to 80 percent of the sample). There was also a marked increase in the use of positive-locking wrist units as compared with friction types, a strong shift toward the use of flexible hinges instead of rigid hinges for the below-elbow amputees, and an increase from 46 percent to 100 percent in the proportion of above-elbow amputees wearing harness-operated elbows. Plastic laminates were used exclusively for fabrication of the nonoperating parts of the prostheses, and the harness patterns tended to be of the figure-eight type. In point of fact, it may be said that the whole pattern of prosthetic prescription for the upper-extremity amputee was revolutionized in the course of the Upper-Extremity Field Studies.</p> <p>Introduction of the checkout procedures met with considerable success. Clinic personnel considered checkout a valuable management tool, and more than 90 percent of the amputees thought it useful. Whether initial checkout or final checkout, almost 70 percent of the arms passed on the first trial. The remaining cases required two or more visits to resolve all problems, the major deficiencies uncovered being in the areas of socket fit, harnessing, and alignment of control systems.</p> <p>Application of the training procedures was not nearly so successful. Some 40 percent of the group thought that the results of training could be improved by extending the instruction over a longer period and by including more and varied practice in the regimen. The finding that during the training period 54 percent of the sample needed adjustments or corrections in the prosthesis suggests the great value of supervised training-that is, of training in a situation so controlled that specific difficulties can be uncovered and resolved with a minimum of difficulty. Although the length of the training period was greater for bilateral cases than for shoulder disarticulations, greater for shoulder disarticulations than for above-elbow amputees, and so on, the time allotted for shoulder disarticulations and for above-elbow cases over that allowed below-elbow cases did not seem to be in keeping with the increase in operating difficulty known to accompany loss of the natural elbow.</p> <p>All in all, the system of amputee management introduced as part of the Field Study was accorded a high degree of acceptance both by the amputees and by the professional personnel charged with their care. Perhaps the strongest recommendation for the management procedures lies in the fact that, with appropriate revisions and variations, they are now in widespread use in amputee clinics throughout the country.</p> <h4>The Armamentarium (Section V)</h4> <p>The data concerning the prosthetic armamentarium tend to be encyclopedic and documentary. Each component of the upper-extremity prosthesis has been considered in terms of appearance, usefulness, ease of operation, and weight, and this information has been supplemented by data on the ranges within which the components functioned and on the magnitudes of the activating and resulting forces. The adequacy of the fabrication techniques utilized in making the upper-extremity prosthesis was also reviewed. These data provide the biomechanical basis upon which to revise a number of the checkout standards.</p> <p>Lastly, the new components that go to make up the present armamentarium (terminal devices, wrist units, elbow hinges for below-elbow arms, elbow joints for above-elbow arms, control systems, and harnessing equipment) have been compared with corresponding components in the prior art. Amputee reactions toward the conventional preprogram arms have been compared with the reactions toward the new program prostheses. The amputees felt that the program prostheses are characterized by:</p> <ol> <li>Higher, better-fitting, and better-appearing sockets.</li><li>More useful and easier-operating elbows.</li><li>Improved efficiency of force transmission reflecting better cable alignment and more stable materials.</li><li>Lighter, freer, and more comfortable harnessing.</li><li>A marked increase in terminal devices offering improved control of grasp force.</li></ol> <p>Of the 290 amputees who had an opportunity to wear both types of arms, 261 preferred the new, 25 the old, while 4 expressed no preference.</p> <h4>Amputee Performance (Section VI)</h4> <p>Section VI has been concerned with the functional value of arm prostheses, the uses to which they are put, and the skill and efficiency with which arm amputees can utilize them. From interrogation of the subjects, it became apparent that the usefulness of an arm prosthesis varied considerably from activity to activity in the five broad areas of daily living (work, home, recreation, dressing, and eating). In the numerous activities that go to make up work, recreation, and home life, prostheses tended to have wide applicability and to be most helpful to the wearer. As a matter of fact, use of the prosthesis in a variety of jobs and hobbies was much more extensive than is usually recognized, and we must therefore conclude that the functional potential of the upper-extremity amputee is also a good deal greater than commonly thought. But in the activities of dressing and eating, which for the most part involve a limited number of relatively difficult operations performed close to the body, prostheses tended to be considerably less useful. An interesting note is that, as regards the performance of any one given task, prosthetic usage tends to be on an all-or-none basis. Either the amputee uses his prosthesis every time he is confronted with a given task, or else he never uses it for that task. "Sometimes" usage is reported infrequently.</p> <p>To shed further light on the comparative values of below-elbow, above-elbow, and shoulder-disarticulation prostheses, 20 selected bimanual activities, considered both by the examiners and by the amputees to be significant in terms of frequency of occurrence and of importance, were used in an attempt to determine how widely prostheses were used. In summary, the results showed that:</p> <ul> <li>Over 50 percent of the below-elbow amputees always used their prostheses for 19 of the 20 tasks.</li> <li>Over 50 percent of the above-elbow amputees always used their prostheses for 13 of the 20 tasks.</li> <li>Over 50 percent of the shoulder-disarticulation subjects always used their prostheses for 8 of the 20 tasks.</li> <li>Over 50 percent of the bilateral arm amputees always used their prostheses to accomplish 15 of 18 tasks (two tasks not applicable).</li> </ul> <p>These and other data show clearly that the higher the level of amputation for which an arm prosthesis is intended the less the utility of the prosthesis. The sharp distinction between the usefulness of prostheses for below-elbow amputees and that of prostheses for above-elbow and shoulder-disarticulation amputees can be explained readily in terms of the limited function to be had from the mechanical elbow and the concomitant need for a comparatively high order of skill in order to use it properly. The difference in apparent usefulness is clearly due to the loss of the normal anatomical elbow. This circumstance re-emphasizes the need for more practically oriented and more extended training for above-elbow and shoulder-dis-articulation amputees.</p> <p>While contemporary below-elbow prostheses appear to be more useful than are the corresponding prostheses for above-elbow amputations and for shoulder disarticulations, arms for the higher levels of limb loss still offer a significant measure of utility. It should also be noted that not all amputees of a given type use their prostheses to the same extent or for the same activities. Obviously, then, the prosthesis varies in value and convenience for the individual wearer, and this factor also helps to determine the amount of use made of the limb by the individual wearer.</p> <p>Through a series of tests of abstract function (prehension and positioning viewed as ends in themselves) and of the performance of practical activities of daily living, a systematic, observational method of rating amputee performance was developed. Although the tests are not as precise as might be desired, an initial step in the measurement of amputee function has been taken. One direct result has been the establishment, for the upper extremity, of a set of norms which may be used as a point of comparison in evaluating amputee performance and in setting reasonable goals for prosthetic training.</p> <p>The data from these tests clearly indicate that, in general, more could be accomplished with the new arms than with the old and that more skillful and more natural performance with the new prostheses was usually obtained without any increase in performance time.</p> <p>The advantages of the experimental arms over the older, conventional arms were most noticeable in above-elbow and shoulder-disarticulation prostheses, less so in below-elbow prostheses. In the below-elbow case, apparently, prosthetic function is very much less dependent upon the quality or precision of arm fabrication, or on the specific components included in the prostheses, or both.</p> <p>While in general the results point up the inadequacies of even our most advanced devices and techniques and thus emphasize the continued existence of much room for improvement, they also show that present-day upper-extremity prostheses are quite useful devices despite the inadequacies, especially for those types of amputees heretofore thought incapable of deriving much benefit from any prosthesis. Since we seem now to have exploited the existing concepts of upper-extremity prosthetics, there would seem to be little more to be gained by continued redesign of current prosthetic equipment. Instead, there is now a need for dramatic, if not drastic, new concepts in approaching the problem of rehabilitating the upper-extremity amputee.</p> <h4>Amputee Attitudes And Reactions (Section VII)</h4> <p>Section VII attacked the problem of prosthetic restoration from the point of view of the psychological characteristics of the amputee and tried to evaluate the subjects on the basis of nine personality variables, to explore a number of factors influencing prosthetic wear and function in social situations, and to study the amputees' attitudes toward prosthetic wear before and aftei fitting with a prosthesis The predominant finding as regards the personality functioning of the amputees was that, no matter which aspect was studied, the subjects appeared to try consistently to maintain feelings of bodily integrity and adequacy by denying many of the personal, vocational, and social consequences of amputation. They consistently de-emphasized their physical difficulty, rejected notions of abnormality, and set their cosmetic and functional desires in line with those of normal people. Superimposed on this general positive tone of the amputees' statements concerning adjustment was the additional positive effect of the treatment program on many of the personality variables, as evidenced by consistent indications of some decrease in expressed feelings of sensitivity and frustration, increased feelings of functional and social adequacy, and greater acceptance of their disability.</p> <p>One problem associated with this aspect of the study was that, because of the limitations of the experimental design, the data were based entirely upon the voluntary expressions of the subjects themselves, who consistently tended to color their responses by hiding any attitudes which might be viewed as "negative." Aware of this difficulty in the measurement of the social and functional factors affecting prosthetic wear, the experimenters attempted a somewhat more indirect approach in the form of cartoons depicting a series of ambiguous, potentially sensitive, situations. The amputees were asked to respond to these situations, the expectation being that they would "project" their attitudes in a less inhibited form. Probably the major finding of this line of inquiry developed from the answers given when the amputees were requested to react to the cartoons as prosthesis wearers and then as nonwearers. The data show consistently positive attitudes toward prosthetic wear, the feeling being expressed that the prosthesis makes the amputee more effective and independent functionally, more self-reliant, more secure, more self-accepting, less shy, less easily embarrassed, and more adaptable. One may, of course, ask whether the amputees held these attitudes fundamentally or whether they were merely expounding an expected "cultural norm." On the basis of the available data it is not possible to answer the question.</p> <p>In a comparison of the preprosthetic expectations of amputees with the actual degree to which these expectations were fulfilled after fitting, it was concluded that:</p> <ol> <li>Normally, little prosthetic information is available to the new amputee, and this deficiency encourages the development of unrealistic expectations concerning prosthetic wear.</li><li>Anticipations which tended to be overly optimistic were in most cases modified downward (with considerable personal disappointment and regret) after the individual had an opportunity to wear a prosthesis.</li></ol> <p>The last question studied had to do with whether or not the postfitting behavior of the amputee toward his prosthesis is related to, and whether or not it can be predicted on the basis of, his prefitting attitudes, a matter that would seem to have significant practical implications. Should preprosthetic attitudes turn out to exercise a determining or controlling influence over later prosthetic acceptance, performance, and use, it would be desirable to attempt to influence early attitudes so as to obtain the best possible rehabilitation results. Investigation did indeed show that those amputees holding favorable attitudes before ever having had a prosthesis tended to maintain favorable attitudes after wear and use; those at first negatively disposed continued to react negatively after receiving a prosthesis.</p> <h3>Future Studies</h3> <p>Although the amputees in the NYU Field Study have thus far been assessed rather thoroughly in terms of five broad areas (physical and personal characteristics, prosthetic components and fabrication techniques, treatment procedures, prosthetic performance, and psychological orientation), little has yet been done toward exploring the relationships that may exist either within or between the several categories of data. As a matter of fact, the data reported and discussed here constitute a phenomenological picture of observed events and are therefore basically descriptive in nature. While data of this type are valuable in that they focus attention on significant occurrences and reveal what is taking place and what is changing during the period of observation, the reasons why the events occur, and the nature of the causal train producing them, can be learned only by more detailed and more definitive study.</p> <p>The only studies of this more detailed variety which have been performed thus far are as follows:</p> <ol> <li>A substantial segment of the findings concerning the unilateral amputees have been analyzed and presented in terms of the three basic amputee types- below-elbow, above-elbow, and shoulder-disarticulation amputees. But there is still a need for further analyses of this variety using finer categories in the amputee-type classification system (such as wrist disarticulation, long below-elbow, medium below-elbow, short below-elbow, very short below-elbow, etc.).</li><li>A number of attitudes toward prosthetic wear held by the amputees prior to prosthetic fitting have been studied and presented in relation to postfitting attitudes and psychological adjustment.</li></ol> <p>Whatever cross-correlations are attempted, however, it must be remembered that the subject matter deals with the complex interactions between a human being, the patient, and an involved environmental process, the treatment procedure. Man is not composed of a series of discrete traits and attributes, nor does he represent the simple sum of such features Taken as a whole, the configuration is more exponential that additive. Similarly, the treatment procedures at any given level of observation may represent a series of obvious events simply measured and simply described, or they may be seen more subtly as sets of behavior of professional people- physicians, prosthetists, therapists, others- directed toward another individual, the amputee. In this light, distinctions and comparisons drawn between the patient, the treatment process, and the restorative result are unavoidably arbitrary to the extent that they tend to be abstractions from the intricate network of human behavior. Since in practice, however, analyses must be performed at some level not fully reflecting the human interactions at work, attempts at further study require some kind of conceptual framework within which to consider the data.</p> <h4>A Conceptual Framework</h4> <p>When the mass of available data is reviewed,<a style="text-decoration:none;">*</a> the individual elements fall naturally into two groups-those which describe the factors contributing to the over-all result of prosthetic restoration and those which describe the result itself. The data in the first category, those dealing with the causal factors, seem in turn to constitute two separate subcategories-the individual characteristics, which the patient brings to the restoration regimen, and the treatment process, which describes the management procedures applied. Together the interaction of these two contributing factors (variables) produces the over-all result of prosthetic restoration. Thus:</p> <p>Amputee Characteristics + Treatment Process = Over-All Result of Prosthetic Restoration</p> <p>But each of these three broad factors consists, again in turn, of a number of more specific considerations that were the subject of investigation in the NYU Field Studies. It is therefore possible to recast the formula into somewhat more specific terms, whereupon the three factors in the original relationship are found to consist of seven different types of data. Thus: <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Further expansion of such a breakdown leads to <b>Table 1</b>, which reflects in greater detail the kinds of information available. All told there are some 60 variables on which data have been collected.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The data having been thus classified, it is now necessary to find the means with which to develop whatever significant interrelationships may exist within and between the various categories. Analyses may be performed at any of the three levels of complexity, but those best undertaken first would tend to consider the segmented types of data listed in the lower portion of <b>Table 1</b>. Contrary to first impression, they are in reality by far the simplest to investigate. To study the earlier, more general, and apparently less complex relationships shown in the first two formulae will require the development of suitable means for consolidating individual sets of data in some meaningful way to describe the composite concepts utilized. Accordingly, analyses of the data will vary in complexity depending on whether we wish to study the relationships between discrete variables or those between increasingly composite, and therefore complex, conceptualizations. As the chosen formulation becomes clinically more meaningful, the complexity of the statistical analysis increases. Conversely, the simple selection of a pair of variables and the study of their interrelationship is easiest to effect statistically.</p> <h4>Two-Variable Analyses</h4> <p>When the available data are considered, the area of primary interest that comes at once to mind concerns the question of what factors in the amputee and/or in the treatment process tend to influence the over-all restoration result in a significant way, positively or negatively. Since the final level of prosthetic restoration is a composite measure made up of two different types of data, we can study various individual factors, one at a time, as they influence one segment of the rehabilitation result (use of the prosthesis by the amputee) or the other segment (the amputee's postfitting patterns of psychological adjustment). In the study of these relationships, the data concerning prosthetic performance (or those concerning amputee adjustment, one or the other) are organized and then compared systematically with data describing a variety of possible causal factors.</p> <p>Since any of some 40 individual factors may influence either segment of the final result of prosthetic restoration, it becomes a matter of judgment as to which of the many possible relationships are worth checking. On the basis of previous experience, the prefitting considerations which seem to have the greatest potential significance, and which would seem to be most worth while exploring in relation to each part of the prosthetic restoration result, are as follows:</p> <p>I. Personal characteristics: age, residence, education, marital status, vocation, hobbies, recreational activities.</p> <p>II. Psychological characteristics: acceptance of loss, identification with the disabled, functional adequacy, independence, sensitivity, acceptance by others, sociability, frustration, optimism, security, prosthetic expectations.</p> <p>III. Physical characteristics: etiology, dominant or subdominant loss, amputation level, stump strength, stump motion.</p> <p>IV. Prosthetic-component characteristics: voluntary-opening <i>vs.</i>voluntary-closing terminal devices, canted <i>vs.</i>lyre-shaped fingers, range of pinch forces, friction <i>vs.</i>locking-type wrist units, step-up <i>vs.</i>nonstep-up elbow hinges, single-axis <i>vs.</i>polycentric hinges, figure-eight <i>vs.</i>shoulder-saddle harnesses, quality of prosthetic fabrication (as revealed by checkout).</p> <p>V. Management procedures: extent of training, time lapse before training, extent of preprosthetic therapy, behavior and attitudes of clinic personnel (physician, therapist, prosthetist).</p> <p>In this analysis, the factors included under headings I through V may be considered "predictor" variables, while the data listed under headings VI and VII may be looked upon as "criterion" information. If firm relationships can be established between the data in the first group of categories (I-V) and those in the second group (VI-VII), the former information may be used as a basis for predicting the outcomes of the prosthetic restoration process. The choice of predictor variables to be studied depends, of course, upon the segment of the prosthetic restorative result (prosthetic use or psychological adjustment) selected for study. It is, for example, quite enlightening to relate stump factors to prostehtic usage, but there would be less reason to select stump factors when we are interested in predicting psychological adjustment. Whatever variables are ultimately selected for study, however, the basic analytic approach remains unchanged.</p> <p>A second important type of two-variable analysis can very well involve a study of what relationships exist between the two aspects of the post-treatment result itself (prosthetic use <i>vs.</i>psychological adjustment). Is there, for example, any relationship between an amputee's sense of independence and the extent to which he uses his prosthesis? Is the quality of prosthetic performance related to the individual's social sensitivity? Any number of relationships of this variety could be the subject of study, and the results would contribute to the solution of one of the problems of amputee rehabilitation. Does extensive prosthetic usage of high quality imply good general adjustment, or does good adjustment give rise to efficient prosthetic use? Or is there in fact no significant relationship between these two important aspects of successful amputee rehabilitation?</p> <p>A third variety of two-variable analysis stems from the fact that even within the individual areas of prosthetic usage and of amputee behavior there are important relations to be studied. How, for example, does the amputee's performance with a prosthesis relate to the importance which he attributes to a given activity? What is the relationship between the efficiency of prosthetic use as reflected by tests (actual usage) and the efficiency as reported verbally by amputees (reported usage)? In the psychological area, what is the relationship between an amputee's feelings of sensitivity and his sense of identification with the disabled? To what extent do feelings of frustration affect the amputee's sense of functional adequacy? All these are examples of significant relationships which may exist within the given segments of the prosthetic restoration result and which may very well be amenable to study.</p> <p>In addition to all these possibilities, there remains a fourth type of two-variable analysis, one concerned with the relationships between the various amputee characteristics and data concerning the treatment process. Do amputees with similar occupations, hobbies, and/or recreational pursuits receive similar prosthetic prescriptions, or is the prescribed prosthesis unrelated to these matters and more dependent upon the personal attitudes of the clinic personnel? Are the variations in prescription, training, and checkout procedures based on geographic factors, age of patient, etc.? Relationships such as these are also worth exploring.</p> <p>There is no question but that a considerable amount of knowledge is to be gained from the segmented type of analytic approach described. But a major limitation and a fundamental weakness is inherent in these techniques. When correlations are limited to no more than two factors at a time, the variables concerned are unavoidably isolated out of the large complex of continuously interacting forces known to exercise control over the final result of prosthetic restoration in any given case. In separating, out of the entire data, pairs of variables that may happen to interest us, we ignore the well-known clinical observation that the whole result of prosthetic rehabilitation is the consequence of a number of simultaneous, interdependent influences. In effect the other factors are treated as "constants" at any given time, an expedient admittedly not in keeping with the facts. Were the data made up of a large number of independent variables (factors independent of other influences in a situation), the difficulty would be less critical. But we find in fact that only comparatively few of the items are truly independent of one another.</p> <p>Although this limited analytical approach will not provide the ultimate in understanding of the prosthetic restoration process, it will provide information concerning the more salient relationships existing within the data. The technique of two-variable analysis can be carried one last step by combining selected distributions of data in order to develop indices of more general factors in the prosthetic-restoration complex. Data concerning performance on prehension tests, positioning tests, practical-activity tests, and reported use of the prosthesis may, for example, be combined to provide a composite measure of amputee performance. This combination factor may then be studied in relation to other discrete variables or other composite factors. But before one goes very far along this path he comes face to face with the desirability of attempting a "global analysis."</p> <h4>Global Analysis</h4> <p>In view of the weaknesses in the two-variable approach, it would seem desirable to be able to explore the interaction of all the various factors, each with the others. That is to say, it would be helpful to be able to gauge the extent to which each factor in the prosthetic-restoration complex affects the others and to determine to what extent the total pattern of interdependence affects the final result. In any such study of interactions of variables, we are of necessity drawn to relatively sophisticated methods in statistics, such as multiple correlation, analysis of variance, and possibly factorial analysis. That analysis by these methods would be completely fruitful is by no means assured. For unless the relationships within the data are reasonably clear-cut, the statistical procedure may not be discriminating enough to bring them to light. Deficiencies in the sampling, weaknesses in the measuring instruments, and other technical shortcomings would also tend to obscure the results.</p> <p>This known risk notwithstanding, such an effort is clearly worth while and will be undertaken in view of the <i>possibility</i>of approximating the significance to be afforded various considerations involved in the prosthetic-restoration potential of an individual. Success in this more ambitious approach would shed light on the relative influence that various factors, within the amputee and within the treatment process, have on the final result. Although it is well understood clinically that not all patient characteristics or all treatment methods influence the final outcome equally, no scientifically validated picture of the relative significance of the causal factors exists to date. From further studies, one might hope to learn what combinations of amputee characteristics and treatment procedures make for the best prosthetic-restoration results and, by the same token, what combinations dictate poor results. An understanding of these matters would permit reasonable predictions as to the probable success of the restorative effort, suggest modifications of the treatment process the better to fit the needs of the individual patient, and make it possible to identify and to grade "optimum" restoration results in any given case.</p> <h3>Conclusion</h3> <p>It is clear then that this presentation constitutes an overview of the information evolving from the NYU Field Studies and suggests that a considerable amount of additional data analysis will be required before the available material will have made its final contribution to the field of upper-extremity prosthetics. Many of the remaining analyses are already in process, and it is planned to publish these results as the work is completed. It must, however, be recalled that the NYU Field Study was essentially research "in breadth" and that this approach should not be expected to answer all questions relating to the upper-extremity amputee. For many of the issues needing resolution, research embracing the study of individual cases "in depth" will be required. Meantime, it is in order to express appreciation for the singular opportunity of studying such a large group of upper-extremity amputees. Because of the nature of the disability associated with arm loss, it usually is very difficult to gather large numbers of arm amputees in any one location, and it is almost impossible to be able to subject such a group to a systematic pattern of treatment. Although it would be gratifying if it could be said that the most had been made of the unusual opportunity afforded, afterthought and hindsight tell otherwise. Unfortunately the problems of research into the unknown do not cast their shadows before, and the path to discovery remains exceedingly narrow. Until better methods of dealing with the complicated manifestations of the human being become available, we must be content with studies and analyses that can shed even small light on the challenging problems of prosthetic restoration.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Almost all of the data developed during the NYU Field Studies have been codified and punched on IBM (International Business Machines Corp.) cards, and all of the major analyses presented in this (Vol. 5, No. 2) and the preceding (Vol. 5, No. 1) issue of Artificial Limbs have been performed through the use of IBM electromechanical data-sorting techniques. Any future analyses may be accomplished conveniently through the same means.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Sidney Fishman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetic Devices Study, Research Division, College of Engineering, New York University; Director, Prosthetics Education, NYU Post-Graduate Medical School; Adjunct Professor of Psychology, Fairleigh-Dickinson University, Rutherford, N. J.; member, Committee on Prosthetics Research and Development and Committee on Child Prosthetics Problems, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_02_117/aut1958-117-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_02_117/aut1958-117-2.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 Studies of the Upper-Extremity Amputee VIII. Research Implications Creator An entity primarily responsible for making the resource Sidney Fishman, Ph.D. * https://staging.drfop.org/files/original/35801aa99143213c24197cf394e4d956.pdf 5639c70b68cbd0e4326be89301a23af7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_044.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 44 - 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/1961_01_044.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_044.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>Syme's Amputation for Gangrene from Peripheral Vascular Disease</h2> <h5>Gordon M. Dale, M.B. <a style="text-decoration:none;">*</a><br /></h5> <p>Peripheral vascular disease as a cause of amputation was first forcefully brought out in Canada by the many cases of acute thromboangiitis obliterans occurring in young men after World War I. In the early days of the 20's, amputation for this disorder was carried out at knee level (Gritti-Stokes), an operation itself considered a daring innovation at the time, the site of election in such cases then being viewed as the junction of the upper and middle thirds of the thigh. In the present series, the first Syme amputation for gangrene of the foot was performed in 1925 in a case of thromboangiitis obliterans. Since that time, the Syme amputation has been used in Canada in such cases whenever it seemed warranted.</p> <p>By 1940, Syme's amputation had been used successfully for many and varied conditions, including infected and perforating ulcers in unrecovered sciatic-nerve and cauda-equina lesions, septic and tuberculous arthritis of the ankle joint, frostbite, arterial occlusion, and gangrene owing to peripheral arterial disease. When, after the beginning of World War II, the question of amputations once again became prominent, we were able to refute the views expressed by the British Ministry of Pensions in regard to Syme's and other end-bearing amputations generally.<a style="text-decoration:none;">*</a> We showed, by demonstration of actual cases, the great value and durability of these amputations in active life. We were fortunate in having an excellent prosthetic service started during World War I and concentrated in February 1919 at the Dominion Orthopaedic Hospital (later Christie Street Hospital). It had constantly been improving our prostheses, and to that group we owe much of our success.</p> <p>During the period 1920-1956, many new factors modified our views and methods of treatment. In 1930, lumbar ganglionectomy was adopted in vascular disease, and it is thought that doing so saved or postponed many major amputations. Embolectomy and anticoagulants saved some limbs. Sulfa drugs, penicillin, and later antibiotics bolstered our courage. Although the incidence of infection was no lower after than before the use of such agents, there were operated upon during World War II cases that in World War I would not even have been considered for surgery. Now arterial grafting promises well in selected cases. Advances in anesthesia and in medicine generally have of course helped a great deal. Of the problems facing the Department of Veterans Affairs today, one is senile gangrene owing to the advancing age of veterans.</p> <h3>CASE HISTORIES</h3> <p>The case histories that follow represent most of the Syme amputations performed for gangrene owing to thromboangiitis obliterans, diabetic gangrene where there was also peripheral vascular disease, and senile gangrene from arteriosclerosis <i>per se. </i>Omitted are those cases whose files were destroyed after death, but all failures are recorded. Included are 23 Syme amputations and one mid-tarsal amputation, all for vascular disease and all with gangrene. Six have undergone reamputation.</p> <p>Cases 3, 6, and 7, listed under thromboangiitis obliterans, each underwent reamputation within six months and must therefore be classified as failures. Two cases (17 and 22) listed under arteriosclerotic gangrene are doubtful operative failures. The first underwent reamputation after his stump had healed and he had walked quite well. The reason for reamputation apparently was not breakdown of the stump. The stump of the second healed <i>per primam. </i>Fitted at an early date, the patient bore his weight chiefly on the stump for 18 months. Case 9, discussed under diabetic and arteriosclerotic gangrene, is considered a success. Not only did he wear his limb for nine years but his stump breakdown was occasioned by neglect and later circulatory failure from myocardial infarction. Cases 16 and 19 (arteriosclerotic gangrene) had well-healed stumps and were fitted but never wore their limbs to any useful extent. They are therefore recorded as failures.</p> <p>There are thus seven failures in 23 cases (roughly 30%). So marked is the prevalence of myocardial infarction in thromboangiitis obliterans at all ages that an electrocardiogram and cardiovascular examination are now part of our routine examination.</p> <h4>CASES OF THROMBOANGIITIS OBLITERANS</h4> <p>CASE 1. (W. E.)</p> <blockquote><p>Male, born 1891. Served in the Imperial Army, 1914-19. Wounded and had trench feet in service. On discharge, complained of painful feet and occasional cramp in right calf. Had two attacks of phlebitis. Was doing heavy work.</p> <p>Admitted to Christie Street Hospital 1924 with localized gangrene, dorsum of right foot, arising from infection between second and third toes. Severe pain. No pulse below the femoral on the right side, weak pulsation in dorsalis pedis and posterior tibial arteries on the left.</p> <p>Right Syme amputation 1925, healed <i>per primam. </i>Case followed until 1947, when patient returned to England. No trouble with stump. Increasing disability in left leg had forced change to light work. Arterial pulsation below the femoral had disappeared. Left radial pulse absent. Patient had not smoked since 1924.</p> <p>Patient failed to communicate further as promised.</p> </blockquote> <p>CASE 2. (R. G.)</p> <blockquote><p>Male, born 1900. Served in Army, 1915-19. V.D.S. on service. Subsequently worked as teamster in the bush. Had frequent mild attacks of frostbite. Patient's feet were cold in winter, scalded in summer. Had claudication of left leg 1934. In the winter of 1934-35, left foot was frozen, and gangrene of the left great toe developed. Amputation of toe was performed at local hospital. Wound did not heal for nine months.</p> <p>In February 1936, right foot was frozen, right fifth toe amputated. Wound failed to heal and gangrene extended. Patient was referred to a city hospital, where thromboangiitis obliterans was diagnosed and a right lumbar ganglionectomy was done in March 1937. In May and November, same year, toes were amputated. Gangrene extended slightly.</p> <p>In November 1937, patient was admitted to Christie Street Hospital with gangrene involving the distal third of the right foot. Marked equinus deformity. No palpable pulsation in arteries below the femoral on either side. Vein filling on the right, two minutes. Patient had suffered great pain and was practically a morphine addict.</p> <p>Right Syme amputation in December 1937. Slight necrosis at center of wound, but stump healed well. Patient fitted and walking in March 1938.</p> <p>Patient readmitted in April 1939 for disabling claudication of left leg. Findings as before, except that vein filling was 90 seconds. Left lumbar ganglionectomy done with excellent result. Patient seen February 1940, March 1943, April 1945, December 1946, and January 1947, all for minor infections, left foot, due to lack of cleanliness, a carbolic-acid burn, and an artefact. Left Syme amputation, performed July 1947, healed <i>per primam.</i></p> <p>Review in June 1948 showed excellent stumps. Patient walking well and working at woodcutting. Doing well 1953, when photograph of stumps (<b>Fig. 1.</b>) was taken. Death for coronary thrombosis in 1954.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Case 2 (R. G.). Anterior view of bilateral Syme stumps. Right (viewer's left), 16 years after amputation; left (viewer's right), six years. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>CASE 3. (T. A.)</p> <blockquote><p>Male, born 1886. Served in Army 1914-19. V.D.S. on service. Alcoholic. Onset vague pains in feet 1915. Nothing definite noted on discharge. Subsequent attacks of phlebitis, diagnosed as thromboangiitis obliterans 1928. Patient then had absence of pulsation both arteries right foot and in the left dorsalis pedis. Erythromelia was marked. Vein filling, 30 seconds. Admitted to Christie Street Hospital 1936. Right lumbar ganglionectomy in November 1936. Much improved. Admitted Christie Street in February 1937. Sudden onset gangrene right foot and leg. Right Gritti-Stokes amputation performed in March 1937. Healed well. Fitted with limb and walking, June 1937.</p> <p>Admitted Christie Street Hospital in February 1938. Gangrene of toes, left foot. No pulse below femoral. Left lumbar ganglionectomy, performed in March 1938, produced some improvement, but patient complained greatly of pain. Left Syme amputation, May 1939. Heel flap did not slough, but wound healed slowly. Well healed in November. Patient refused to bear weight on Syme stump and complained so bitterly of pain that a left Gritti-Stokes was carried out.</p> <p>Patient thereafter made no attempt at walking. Remained an invalid until death from coronary thrombosis.</p> </blockquote> <p>CASE 4. (R. E. C.)</p> <blockquote><p>Male, born 1909. In 1947, patient was admitted to a city hospital for a nonhealing infection, right great toe nail. Thromboangiitis obliterans diagnosed and bilateral lumbar ganglionectomy performed. Right great toe was later amputated, and wound healed slowly. In 1949 and 1950, two other toes, right foot, were amputated. Right below-knee amputation, done later in 1950, healed fairly rapidly with some sloughing of the flaps. Four months after amputation, patient was fitted with a prosthesis and walked well. Shortly thereafter stump broke down.</p> <p>Admitted to Sunnybrook Hospital, March 1951, with complete breakdown of end of below-knee stump. No pulsation below the femoral on either side. Left foot blanched sharply on elevation. Vein filling, 25 seconds.</p> <p>Right Gritti-Stokes amputation in May 1951. Healed <i>per primam. </i>Fitted with prosthesis August 1951, and walked well. Readmitted in 1952 with minor infection of left foot requiring only few days to heal.</p> <p>Working steadily as engineer, March 15, 1953. Sudden, severe pain in left foot, which rapidly changed color. Admitted to Sunnybrook Hospital. Purple discoloration, distal half of left foot, which did not change on application of pressure or on elevation. Discolored area insensitive. Vein filling, 25 seconds. Weak femoral pulse. Pain very severe in left leg and foot.</p> <p>Treated by rest, heat, dry dressing, Buerger's exercise, whiskey, and papaverine. Pain not controlled and gangrene extended. Left Syme amputation in April 1953. Healed well with slight necrosis in small area around scar. Patient fitted in June 1953. In September 1953, developed stump abscess, which was opened widely and packed open. Secondary suture, done one month later, healed well.</p> <p>Patient was walking well in June 1954. Returned to full-time work. Died suddenly in October 1954 from acute coronary thrombosis.</p> </blockquote> <p>CASE 5. (W. S.)</p> <blockquote><p>Male, born 1914. While in Army, developed phlebitis in right foot, and claudication ensued. Symptoms increased, and thromboangiitis obliterans was diagnosed. Right lumbar ganglionectomy done and patient discharged.</p> <p>Admitted to Christie Street Hospital in September 1947 with gangrene of left great toe and whole right foot extending to the leg. Condition grave. Had had steadily increasing doses of morphine but obtained little relief. No pulsation below the femoral, either side. Right guillotine amputation at level of tibial tuberosity, October 1947. Patient's condition improved rapidly and pain was largely relieved.</p> <p>Left lumbar ganglionectomy six days later with good result. Disarticulation of the left great toe in November, flaps left open. Right Gritti-Stokes and left Syme December 1. Gritti-Stokes healed <i>per primam, </i>Syme showed slight necrosis at suture line but was well healed in seven weeks.</p> <p>Patient was walking well in August 1948 (<b>Fig. 2.</b>). Has worked as limbfitter ever since. No trouble, either stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Case 5 (W. S.). Anterior and lateral views of left Syme stump 11 years after amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>CASE 6. (H. T. O.)</p> <blockquote><p>Male, born 1910. Sprained right ankle while in Army, pain and phlebitis in right leg subsequently. Thromboangiitis obliterans diagnosed and right lumbar ganglionectomy performed in 1943. Twice admitted to Sunnybrook Hospital in 1946, first with gangrene of fourth toe (amputated and healed), second with gangrene of great toe (amputated but did not heal). Right Syme amputation in January 1947. Heel flap did not slough, but wound did not heal. Right Gritti-Stokes, May 1947, healed promptly.</p> <p>In 1951, patient underwent left lumbar ganglionectomy and amputation of a gangrenous great toe, then passed into other hands. Subsequent history includes left mid-tarsal amputation, 1952; left Syme, 1953; left below-knee, 1954; left Gritti-Stokes, 1956.</p> </blockquote> <p>CASE 7. (W. P.)</p> <blockquote><p>Male, born 1899. Discharged from Army in 1919 with history of painful feet. In September 1939, developed phlebitis of right leg with rapidly increasing claudication. Three weeks after onset, patient could walk only a dozen yards.</p> <p>Admitted to Christie Street Hospital in November 1939 with ulceration and gangrene of fourth and fifth toes, right foot. Acute phlebitis at calf and at dorsum of foot. No pulsation in arteries below femoral, either side. On elevation of limb, color faded in two minutes. Vein filling, one minute.</p> <p>Old thrombosed veins on dorsum of left foot and in left calf. On elevation of limb, purplish color remained for three minutes. Vein filling, 30 seconds. Right lumbar ganglionectomy November 17, 1939. Right Gritti-Stokes December 19, 1939. Left lumbar ganglionectomy April 5, 1940.</p> <p>After the last operation, patient returned to work as repair man. No trouble until October 1949, when he had acute onset of pain in left foot and leg. Able to walk only a few steps. Left great toe was gangrenous, left foot livid, cold, and insensitive. Left Syme amputation performed April 1, 1950, at patient's request and against professional advice. Flap remained viable but never regained natural color; wound did not heal completely. Left Gritti-Stokes, performed June 1, 1950, healed <i>per primam.</i></p> <p>Walking on two Gritti-Stokes prostheses, patient was discharged in December 1950. Died August 1957, acute coronary thrombosis.</p> </blockquote> <p>CASE 8. (B. P. H.)</p> <blockquote><p>Male, born 1923. While in Army in 1944, sustained superficial wound of left leg. Healed, but scar frequently broke down. Patient was in Christie Street Hospital on another service in 1948 because of phlebitis and breaking down of wound scar. X-rays showed no retained foreign bodies. Femoral vein was ligated.</p> <p>In a 1949 diagnostic, examination was negative except for erythromelia. Diagnosis of thromboangiitis obliterans was indefinite but patient was advised to stop smoking.</p> <p>Admitted to Sunnybrook Hospital 1952. Two months previously had infection of the left great toe nail. Claudication appeared shortly thereafter. No pulse below femoral on left side. On elevation of limb, color faded slowly. Vein filling, 40 seconds. Marked erythromelia. All pulses palpable on right side. Vein filling, 15 seconds. Left lumbar ganglionectomy done with good result. Three weeks later guillotine amputation of the great toe was effected, and a month after that the stump of the great toe was disarticulated and flaps sutured. Wound healed in three weeks, and patient returned to work.</p> <p>Sudden onset of pain in right leg in December 1953 following infection and gangrene of right great, second, and third toes. Admitted to Medical Service and put on anticoagulants, Priscoline, and heavy doses of morphine. Medication discontinued upon transfer to Orthopaedic Services and papaverine and whiskey substituted. When blood coagulation was again normal, right lumbar ganglionectomy was performed. Eight days later, guillotine amputation of the distal half of foot was done. Right Syme amputation, three weeks after that. Good healing. Patient was walking well on prosthesis in May 1954. Has worked steadily since and has had no trouble.</p> </blockquote> <h4>CASES OF DIABETIC GANGRENE WITH ARTERIOSCLEROSIS</h4> <p>CASE 9. (R. G.)</p> <blockquote><p>Male, born 1901. When patient enlisted in 1940, it was noted that the left third toe had been amputated. Subsequently, it was found that he had had diabetes prior to enlistment. Lues evident. Admitted to Christie Street Hospital in October 1940 with osteomyelitis of the tarsus and gangrene of toes. Many sinuses. Dorsalis pedis pulse absent. Weak posterior tibial. Marked neurotrophic changes. Patient emotionally unstable.</p> <p>Left Syme amputation, 1941, healed well. Patient, fitted with prosthesis and able to walk well, neglected diabetic treatment and was readmitted in 1950 with ulceration in the amputation scar. Ulcer excised, stump healed. While still in hospital, patient had severe myocardial infarct and wound broke down. Gritti-Stokes was carried out.</p> <p>Patient never was active, although he walked fairly well. Died in August 1954 from acute coronary thrombosis. Autopsy showed marked aortic degeneration with mural thrombus. Peripheral vascular endarteritis.</p> </blockquote> <p>CASE 10. (A. E.)</p> <blockquote><p>Male, born 1893. Truck driver. Diabetes discovered in 1948 and patient put on diet. While in local hospital for fractured right tibia, was put on insulin. Admitted to local hospital in 1952 with ulcer on sole of right foot. With incomplete healing, patient returned to Iwork. Perforating ulcer developed, and patient was admitted to Sunnybrook Hospital in January 1955.</p> <p>Examination showed extensive soft-tissue infection about a perforating ulcer. No dorsalis pedis pulse. Weak posterior tibial. X-rays showed extensive osteomyelitis (neurotrophic foot). Marked calcification of vessels. Culture showed organisms resistant to all antibiotics except terramycin.</p> <p>Right Syme amputation January 31, 1955. Healed <i>per primam. </i>Fitted and walked well. Returned to work in November 1955. No trouble since.</p> </blockquote> <p>CASE 11. (W. W.)</p> <blockquote><p>Male, born 1900. Diabetes recognized in 1932. In 1949, following lapse in diet, developed gangrene and osteomyelitis of right foot. Much neurotrophic change. Pulses in feet weak. Right Syme 1949. Wound healed well. Patient worked as caretaker until December 1951, when he developed infection in a callus on the left foot. Ten days later was admitted moribund to Sunnybrook Hospital. Discharging sinuses on sole of left foot, lymphagitis, and femoral adenitis. No sensation in foot. Abscess in sole drained. Patient put on antibiotics, and carbohydrate metabolism improved.</p> <p>Guillotine amputation of left foot January 10, 1952, followed by marked improvement. Left Syme January 22, 1952. Some wound infection, but healed well in six weeks.</p> <p>Patient is still walking on two prostheses. Is not now working, but can walk to bathroom on stumps alone (<b>Fig. 3.</b>). Sectioned arteries in both stumps show marked endarteritis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Case 11 (W. W.). Front and side views of bilateral Syme stumps. Right stump (viewer's left), after nine years; left stump (viewer's right), after six yeais. Corresponding x-rays show bony proliferation from subperiosteal dissection of the flaps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>CASE 12. (W. C.)</p> <blockquote><p>Male, born 1886. Diabetes diagnosed in 1948. Admitted to Sunnybrook Hospital in 1951 on Medical Service. Diagnosis: "Arteriosclerotic heart disease; peripheral vascular disease; diabetes with peripheral neuritis; lues; gangrene of right foot." No arterial pulsations below the femorals. Gangrene in distal half of foot. Right Syme done and well healed. Fitted with artificial limb on which patient walked well.</p> <p>Admitted 1953 with congestive heart failure and ulcer of left foot. Healed with bed rest.</p> <p>In 1954, dyspnoea, swelling of limbs, nephritis, ulceration (hot-water-bottle burn) on dorsum of foot.</p> <p>Admitted February 10, 1956. Died. Autopsy showed marked peripheral vascular disease, arteriosclerotic heart disease, and myocardial infarction.</p> </blockquote> <p>CASE 13. (A. J.)</p> <blockquote><p>Male, born 1886. Admitted to Sunnybrook Hospital in September 1949. One month previously had developed ulcer in bunion on left foot. Two weeks later great toe "became black." Patient was found to have severe diabetes, had recently lost much weight. Femoral pulse present, no pulse below. X-ray showed osteomyelitis of first and second metatarsals.</p> <p>Treated by bed rest, antibiotics, and dry heat. Fever continued, and pain increased. Great toe disarticulated October 5, 1949, and wound left open. Temperature normal 10 days later, patient much better.</p> <p>Left Syme amputation April 18. 1950. Arteries sectioned showed marked endarteritis obliterans. Stump healed well. Patient fitted in June 1950, discharged in September walking well.</p> <p>Patient admitted February 1951 with uncontrolled diabetes and jaundice. Had discontinued his insulin three months previously. Died June 10, 1951</p> </blockquote> <p>CASE 14. (W. R.)</p> <blockquote><p>Male, born 1872. Medical graduate. Diabetes diagnosed 1941, symptoms of polyuria and foot drop. Patient was put on diet and insulin. Did not follow diet strictly and stopped insulin in 1944.</p> <p>In September 1954, patient pared corn on right great toe. Infection spread over foot. Treated self. Healed in nine months.</p> <p>Infection, right great toe, December 1955. Hospitalized. Healed January 1956.</p> <p>Admitted to Sunnybrook Hospital February 26, 1956, with gangrene of great and second toes, right. Systolic blood pressure, 210; diastolic, 90. No pulsations other than femorals in right and left lower extremities. Treated by rest and antibiotics.</p> <p>Right lumbar ganglionectomy April 13, 1956. Right Syme May 3, 1956. Healed <i>per primam. </i>Fitted in August 1956. Patient gets about well on limb and states he is still (December 1958) fairly active.</p> </blockquote> <p>CASE 15. (R. C.)</p> <blockquote><p>Male, born 1896. Discharged from Army 1919. Diabetes diagnosed 1927. Did well on diet alone for three years. Then noticed numbness and coldness of feet. Health was poor. In 1941, patient developed septic arthritis of left knee and, later same year, of right ankle. Drained at local hospital.</p> <p>Admitted to Christie Street Hospital in February 1942, very ill. Sedimentation rate, 147 mm. X-rays showed destruction of outer condyle of left tibia and erosion of lower end of right tibia and upper margin of right astragalus. Ankle joint drained and knee drainage improved. <i>Staph, aureus </i>cultured from both.</p> <p>Condition improved, and carbohydrate metabolism was balanced in July 1942. Right Syme then performed, but destruction of lower end of tibia required section somewhat higher than usual. Stump healed in three weeks.</p> <p>In September 1942, left knee was excised. Patient fitted with prosthesis and walking well by January 1944. Continued to wear leg until sudden death in 1947, cause unknown.</p> </blockquote> <h4>CASES OF ARTERIOSCLEROTIC GANGRENE</h4> <p>CASE 16. (J. E. N.)</p> <blockquote><p>Male, born 1896. Was in good health until 1945, when intermittent claudication in left calf was noted on walking half a block. In June 1950, patient was put on Priscoline. In July, developed gangrene of fourth and fifth toes. Admitted to local hospital in August 1950 for left lumbar ganglionectomy. Fifth toe amputated, but wound failed to heal. In January 1951, patient underwent transmetatarsal amputation.</p> <p>Admitted to Sunnybrook Hospital September 20, 1951, in poor condition and in great pain. Stump foul with protruding bones. No arterial pulsations below femoral. Patient given choice of gamble with a Syme or almost certainty with a Gritti-Stokes. Left Syme performed September 24, 1951. Stump healed slowly but well. Patient discharged November 5, 1951, returned for fitting. Died of coronary thrombosis before limb could be issued.</p> </blockquote> <p>CASE 17. (L. G.)</p> <blockquote><p>Male, born 1880. Admitted to Sunnybrook Hospital in May 1954. Two years earlier had noticed claudication of left leg. Left inguinal herniotomy performed at local hospital in January 1954. Six weeks later, patient developed infection and gangrene of left third toe. Upon amputation of toe, gangrene spread rapidly involving distal third of foot.</p> <p>Weak femoral pulses. No pulsation in arteries, either foot. Left lumbar ganglionectomy May 12, 1954. Left Syme amputation May 26, 1954. Stump healed slowly but with little necrosis. Patient developed moderate flexion deformity at knee despite all efforts but was walking quite well in March 1955. Patient refused Veterans' care but did not wish to be discharged. Finally discharged walking well, September 1955.</p> <p>Patient returned to home town, where for reasons unknown leg was amputated at mid-thigh level. Syme stump had not broken down. Referred back to Sunnybrook in March 1956, patient had a 45-deg. flexion deformity of the hip and could not be fitted.</p> </blockquote> <p>CASE 18. (F. E.)</p> <blockquote><p>Male, born 1885. Worked as stableman. In summer of 1949, patient noticed fissure in skin on medial side of first tarsometatarsal joint, right. Consulted physicians and chiropodists, but an ulcer formed and increased until, when patient was admitted to a city hospital, it measured 1 in. x 1 1/2 in.. Given bed rest and antiluetic treatment, patient did not improve. Right lumbar ganglionectomy was performed with poor result.</p> <p>Admitted to Sunnybrook Hospital February 3, 1950. No pulsation below the femorals. Ulcer was inflamed and had become larger. Very severe pain. After treatment of a flexion deformity of the knee, a right Syme amputation was done in March 1950. Healing was complete by May. Slight marginal skin necrosis along suture line.</p> <p>Discharged September 1950 walking well on a prosthesis, patient has had no further trouble.</p> </blockquote> <p>CASE 19. (R. E.)</p> <blockquote><p>Male, born 1887. In 1939, had claudication in right leg. Right lumbar ganglionectomy done at a city hospital in 1940. Considerable improvement. In 1950, a left lumbar ganglionectomy was done for similar symptoms on the left side. In January 1951, left great toe nail became infected and was removed. Toe became red and swollen. Redness spread over whole foot, and toe became black. Large doses of morphine gave no relief for the severe pain.</p> <p>Admitted to Sunnybrook Hospital in March 1951 with gangrene affecting toes and distal third of foot. No pulsation below femoral, either limb. Left Syme amputation April 3, 1951. Completely healed May 13. Patient returned for fitting November 1951, died 1952 of coronary thrombosis.</p> </blockquote> <p>CASE 20. (G. E. O.)</p> <blockquote><p>Male, born 1881. Admitted to General Surgical Service, Sunnybrook Hospital, November 1950, intoxicated. Shotgun wounds both feet-superficial on left side, marked bony destruction on right. X-ray showed bony defect in right os calcis, numerous lead pellets in region of right heel. Wound debrided and plaster cast applied. Despite antibiotics, wound became infected and foot gangrenous.</p> <p>When, in February 1951, patient came under care of Orthopaedic Services, distal portion of right foot was gangrenous, and marked edema and cellulitis extended to ankle. No pulsation below femoral artery. Patient very ill. Abscess drained February 19, 1951. Eusol dressings. Right Syme February 28, 1951. Standard operation, except that no section was made of lower end of tibia or of malleoli. Wound left open. Pathological report on sectioned vessels: endarteritis obliterans. Patient improved rapidly.</p> <p>Right Syme completed March 14, 1951. Malleoli removed, but tibia not sectioned. Healing good, although a small sinus persisted until May 1951. Fitted in June, patient walked well.</p> <p>Hospitalized June 4, 1953, for infection about residual shot pellet. Discharged. Readmitted November 30, 1955, for bronchopneumonia and empyema. Discharged. No further trouble with stump, though health is poor.</p> </blockquote> <p>CASE 21. (J. A. S. J.)</p> <blockquote><p>Male, born 1876. A blind vagrant who had slept in an open boxcar while intoxicated, patient was admitted to Sunnybrook Hospital December 27, 1951, in moderate state of shock. Toes of right foot mottled but fairly warm. Distal third of left foot purple and showing no color change on application of pressure or on elevation of the limb. Left toes livid. No sensation in distal third of left foot. Edema in left leg up to knee. No arterial pulsation below the femorals.</p> <p>X-ray showed marked arterial calcification. Patient treated expectantly by antibiotics, rest and dry heat. Well-marked line of demarcation, left foot, by February 16, 1952. No loss of tissue of note, right foot. Left mid-tarsal amputation proximal to line of demarcation, March 4, 1952. Wound healed well. Stump was good, but patient walked poorly. Died February 1954.</p> </blockquote> <p>CASE 22. (W. R.)</p> <blockquote><p>Male, born 1890. Complained in 1953 of coldness and pain in feet, left being most affected. Admitted to a city hospital, where left lumbar ganglionectomy was performed. In 1954, following myocardial infarction. developed gangrene in the second and third toes on the left.</p> <p>Patient admitted to Sunnybrook Hospital in April 1955 on the Medical Service. Weak pulsation in arteries, right foot. Posterior tibial absent; weak dorsalis pedis, left foot. Gangrene extended and caused great pain.</p> <p>Left Syme amputation, March 1, 1956, healed <i>per primam. </i>Fitted with a prosthesis, patient had no trouble with stump. Right foot broke down, and weight was borne mainly on the amputation stump. By October 1957, patient walked with crutches and took weight on the stump only.</p> <p>By January 1958, stump showed bluish discoloration and was cold. Deep fluctuation appeared and was aspirated. Two c.c. of serosanguinous fluid were obtained. Skin was intact. Disarticulation at the left knee was carried out January 29, 1958. Wound healed <i>per primam, </i>but patient has not walked since.</p> </blockquote> <h3>SUMMARY</h3> <p>Between October 1920 and May 1956, I personally conducted or else supervised all Syme amputations performed in the DVA Hospitals at Christie Street and Sunnybrook. Uniformly satisfactory, they resulted in durable and stable stumps. In the cases owing to vascular disease with gangrene, the amputations were equally satisfactory. Six cases (2, 6, 7, 9, 17, and 22) required reamputation. Only two were subjected to amputation for failure of healing. One (Case 9) is considered a success. Two cases (16 and 19), while healed and fitted, died before use of their prostheses and are considered failures. Stumps were in active use for periods of 22, 17, 7, 12, 4, 9, 10, 7, 5, and 5 years, others for shorter periods.</p> <p>From my experience, I would venture to suggest:</p> <ol> <li>Lumbar ganglionectomy at an early date in all cases of thromboangiitis obliterans and, should gangrene develop, Syme's amputation.</li><li>In diabetic gangrene where carbohydrate balance can be maintained and where minor amputations have failed, Syme's amputation.</li><li>In selected arteriosclerotic (senile) gangrene where ganglionectomy and arterial resection and graft have failed to arrest gangrene, Syme's amputation. These patients should understand the great risk of failure.</li><li>In all cases of gangrene with infection, and in diabetics with infection where carbohydrate-metabolism disturbance is not yielding to treatment, a preliminary guillotine amputation.</li><li>Success in the Syme, or other type of tarsal amputation, gives a degree of activity otherwise impossible. Such cases may expect trouble in the other limb.</li><li>Amputation between the knee and ankle (below-knee) is not advisable in cases of severe vascular disease.</li><li>Amputations through the knee (Gritti-Stokes) are almost always successful in healing and give good walking comfort where the patient's condition warrants. Such patients frequently have severe cardiac and cardiovascular lesions, and activity may result in sudden death.</li></ol> <p>-G. M. D.</p> <p><b>References:</b></p> <ol> <li><i>Artificial Limbs and Their Relation to Amputations, </i>British Ministry of Pensions, His Majesty's Stationery Office. London. 1939.</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">Artificial Limbs and Their Relation to Amputations,British Ministry of Pensions, His Majestys Stationery Office. London. 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Gordon M. Dale, M.B. </b></td></tr><tr><td class="clsTextSmall">Present address: 84 Woodlawn Ave., E, Toronto, Ontario, Canada. Until his retirement in May 1956 as Chief of the Orthopaedic Service at Sunnybrook Hospital, Toronto, Dr. Dale had for more than 35 years (since October 1920) been in charge of all amputations for the Canadian Department of Veterans Affairs at Christie Street Hospital and at Sunnybrook. His patients have been drawn not only from World Wars I and II, the Korean War, the Boer War, and the Northwest Rebellion but also from many lesser campaigns in many parts of the world, from the Canadian Mounted Police, from the Canadian Department of Indian Affairs, and, until recently, from Canada's active Army. The cases here reported upon are of interest for at least two reasons-first because a goodly number were followed for periods ranging from five to 22 years (or until death from other causes), second because Dr. Dale either has performed the operation himself or else has served as the supervisor.-Ed.</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 Syme's Amputation for Gangrene from Peripheral Vascular Disease Creator An entity primarily responsible for making the resource Gordon M. Dale, M.B. * https://staging.drfop.org/files/original/79a235e1d4c4ac4171b6ad7c96f90851.pdf 7d14943ca2f5c25f952db617169ffdde https://staging.drfop.org/files/original/d93a7f5e6bfbb40a83f52c51fc6a67a0.jpg db9f1ea0b3a5c0dae6916c1ef66fda44 https://staging.drfop.org/files/original/7cfe500718aa89f77b72e9954ceaa92a.jpg bc918fbb4fd53f2e78ad4605c3abc065 https://staging.drfop.org/files/original/f998e66b14d6b1f834d759185e8e31cc.jpg 690db42406a21e4599e9835f0033c37a https://staging.drfop.org/files/original/559362f3b4c65498619fab8d04b2e42d.jpg f404f1ed2a48fcbad91850fac32efb17 https://staging.drfop.org/files/original/7af014f5d48267ea4832e4f0ba735e65.jpg 609b9bfd8cf0cad72c5cf2fd2ea68995 https://staging.drfop.org/files/original/6da85b1d4d85e1ce07a103930d4575b1.jpg c18a528ba271b6327ebd72aa14550653 https://staging.drfop.org/files/original/1c2e54190c5087e85a7fbc06ef5d358c.jpg 475202f1811c126dfb0443740358cd5a https://staging.drfop.org/files/original/77afa88f7126e3389bfeddccc24b5a2f.jpg 96215102b821993251b391e9acb6d3f2 https://staging.drfop.org/files/original/2371fc89399f73ef4387072b2b40d799.jpg 18b9d437398b6a98ea408c303b0a1ee2 https://staging.drfop.org/files/original/d8cedb74083df4c71c32c360d03b67b8.jpg 5808de98d275b210021d7c661d2ff3d9 https://staging.drfop.org/files/original/163c3b8f65e454aba7ec0bfafdbca66a.jpg 0cb901d66c2c9cdede16bf37b1b551a7 https://staging.drfop.org/files/original/345ce876e71543363ff3c14412c219fb.jpg 8d1848456d7991653f7e3dcad092df20 https://staging.drfop.org/files/original/24ae1765809e82da9084f33c1af4ad5d.jpg 45f56fde2581a9b627c3e7b20f49bae8 https://staging.drfop.org/files/original/684aa5896d82c06bec7a0f958890cadb.jpg b8ce7048f8e79c9339b98b24877b4692 https://staging.drfop.org/files/original/c0e25772039790e312707e0a3e972640.jpg 74351e8b3732f843b1e09d0acc3a1e30 https://staging.drfop.org/files/original/fa307185379e510f725ef82250490487.jpg 90909e24310f83b7ade0e3c07b5cd24b https://staging.drfop.org/files/original/339a789db42e3eea242dd8c322350790.jpg 50a04b08971e95aabb20ffd944f2163c DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1962_02_004.pdf Year 1962 Volume 6 Issue 2 Page Number(s) 4 - 15 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1962_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1962_02_004.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>Anatomical and Physiological Considerations in Below-Knee Prosthetics</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br />A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>One of the most difficult problems in the design of prostheses is the development of the best means of attaching the prosthesis to the wearer. In lower-extremity cases, transmission of forces between stump and prosthesis is of primary importance. To effect efficient transmission of forces, a stable connection between stump and prosthesis is necessary. At the same time comfort and freedom of motion must be maintained to as high a degree as possible. All of these goals are affected by anatomical and physiological characteristics of the stump and the next proximal joint, and often of the joint above that.</p> <p>Stability is provided most often by encasing the stump in a socket to a point near the first proximal joint. The soft tissues of the stump are not especially ideal for providing resistance to the torques and moments imposed on them by a socket during use of a prosthesis. If the tissues are compressed in an attempt to provide maximum stability, circulation will be impaired; if the socket is too loose, a false-joint effect is produced resulting in abnormally high unit pressures at proximal and distal points, chafing, and a reduction in ability to control the prosthesis. Thus, extreme care must be exercised in socket design and fabrication if the optimum condition is to be obtained.</p> <p>When weight-bearing can be achieved through the long bones, as in the case of many disarticulations and certain special types of amputation, the socket is designed to permit loads to be carried through the end of the bone in the stump. If most of the weight-bearing needed cannot be achieved through the end, some other areas must be found to provide the transmission of forces necessary during standing. For all of these reasons, then, it is extremely important that prosthetists and others responsible for the design of sockets take into consideration certain anatomical and physiological factors in the management of the amputee. In no other case is it more important than in that of the below-knee amputee.</p> <h3>Function of the Below-Knee Stump</h3> <p>Because most of the insertions of the muscles and ligaments that control the knee are located on the tibia and fibula at points close to the knee joint (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>), amputation below the knee rarely affects the function of the knee joint. An exception is the gastrocnemius which originates from the posterior portion of each of the femoral condyles and has for its insertion the Achilles tendon, thus acting as a flexor. Upon amputation, however, the distal end of the gastrocnemius often becomes reattached to the tibia, and the remaining musculature is thus available to assist the flexors and perhaps to aid in preventing dislocation of the fibula with respect to the tibia. Thus the moment that can be generated about the knee in the parasagittal plane by a typical below-knee amputee is approximately the same as that before amputation. Because, in general, the ligaments are left untouched, mediolateral stability of the below-knee amputee usually is not affected.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Posterior view of left knee joint, showing anterior ligaments. Redrawn from Gray's <i>Anatomy.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The major muscles that flex and extend the knee joint. From <i>The Patellar-Tendon-Bearing Below-Knee Prosthesis (4).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. X-rays of a typical below-knee slump <i>. A,</i> Anterior view; <i>B,</i> medial view. Courtesy <i>Veterans Admlnistration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Those muscles which have origins on the tibia and fibula, and which control ankle and foot motion, have been severed and consequently atrophy, resulting generally in a bony, conical-shaped stump (<b>Fig. 4</b>). The amount and type of atrophy that takes place depend of course upon surgical technique and postoperative care.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Lateral and anterior views of a typical well formed, right below knee stump Courtesy <i>Veterans Ad-ministration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In very short below-knee stumps, removal of the fibula (<b>Fig. 5</b>) is sometimes performed to prevent lateral and posterior deviation with uncomfortable protrusion at the distal end. Such deviation is generally thought to be caused by frictional engagement on the socket wall (with inadequate relief) or by action of the biceps femoris. In any below-knee amputee, the distal ligamentous attachment near the ankle is missing, and in short stumps the interosseus membrane (<b>Fig. 6</b>) between the remnants of the tibia and the fibula is presumably inadequate, partly because the proximal opening for the vessels leaves only a small amount of the membrane, and particularly because atrophy of intervening muscles leaves some slack in the membrane. Removal of the fibular head, though, implies that the tendon of the biceps femoris, as well as the fibular collateral ligament, should be reattached with appropriate lengths and at suitable centers on the tibia. A bone bridge from fibula to tibia that would restore stability between tibia and fibula as well as increase the possibilities for bearing weight on the end of the stump would seem to be preferable to removal of the fibula.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Roentgenogram of a short below-knee stump in which lateral deviation and rotation of the fibula have taken place. <i>Courtesy University of California Medical School.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6. Anterior ligamentous structure of the right knee.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Knee Joint</h3> <p> The knee joint formed by the condyles of the femur and tibia (<b>Fig. 3</b>, <b>Fig. 7</b>) allows about 160 dcg. of flexion. It is classified as a synovial joint, or one that is provided with synovial Quid, and the friction developed between the moving surfaces of an unimpaired joint is of an unusually low magnitude as compared with moving joints in machinery.<a></a> It is not a simple hinge joint with a single axis of rotation. Because movement of the tibia with respect to the femur is a combination of gliding and rolling actions, and because of the shape of the contacting surfaces, the instantaneous center of rotation of the knee varies with each degree of flexion. Though the exact course of the instantaneous centers for different individuals cannot be described with present knowledge, a general idea of the typical area through which they move can be had (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Major structures that form the knee joint. From <i>The Patellar-Tendon-Bearing Below-Knee Prosthesis (4).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8. Section through the medial condyle of the femur and through the tibia. The center of curvature is shown for three parts of the articular surface. As gliding occurs in the joint, the instantaneous center moves along the curve connecting these centers of curvature. From Elftman (2).</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For many years it has been common practice to divide the responsibility of weight-bearing between the below-knee stump and the thigh by use of simple hinge joints (located along the medial and lateral aspects of the knee) connecting a thigh corset to the socket and shank (<b>Fig. 9</b>). But, because the center of rotation of the knee moves constantly while flexion or extension takes place, any artificial joint attached on the outside of the leg and thigh that does not follow the complex pattern of the human joint will cause relative motion between the body parts and the prosthesis. Since there is not available an artificial joint that simulates normal movement, it appears highly desirable to provide the below-knee amputee with a prosthesis that does not require side joints, even though the tissues in the stump and thigh are capable of absorbing the effects of some relative motion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9. Some examples of the so-called "conventional" below-knee prosthesis offered by prosthetists for more than a century. Note the sidebars, corset, relatively low brim, and free space at distal end of socket.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Weight-Bearing</h3> <p>If sidebars are to be avoided, obviously all of the weight-bearing loads must be transmitted through the stump to the skeletal system. Some areas on the stump are better suited to assume these loads than others. In the light of present knowledge and technology it is necessary to design and construct the socket so that the pressures imposed on specific areas, whether by normal repeated loads encountered during walking or whether by single emergency loads, are not of values that exceed the varying tolerances of the different tissues of the stump. And just as obviously some means other than sidebars and thigh corset must be found to maintain the limb on the stump. If, however, the necessary mediolateral stability is not present, there is no known recourse except to use at least one sidebar and generally two.</p> <h4>The Patellar Ligament</h4> <p>Extension of the knee is effected by the contraction of the quadriceps muscle, so named because it has four distinct components. However, they merge into a single tendon which inserts on the anterior portion of the tibia just below its head (<b>Fig. 6</b>). Embedded in this tendon is the patella (<b>Fig. 7</b>), which is therefore a sesamoid bone, the largest in the body. Its function is twofold. While acting as a guide for the quadriceps tendon by following the vertical groove between the femoral condyles, it also tends to increase the lever arm of the quadriceps acting about the knee axis. Its cartilaginous underbody tends to produce very little friction as it slides over the anterior surface of the femur. That part of the quadriceps tendon between the patella and the insertion, frequently referred to as the patellar ligament (<b>Fig. 10</b>), is composed of extremely tough fibers which stretch insignificantly under normal tensile loads along the long axis and is particularly suited to take compressive loads anteroposteriorly. Because of the inextensible quality of the quadriceps tendon, there can be little or no relative motion between the patella and the tibia when the quadriceps develops tension, a condition which permits compressive loads over the quadriceps tendon, perpendicular to the fibers, up to the proximal edge of the patella. The sharp lower edge of the patella, though, is relatively unsuited for weight-bearing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Schematic drawing showing the nearly complete lack of relative motion between patella and tibia during flexion of the knee. The inextensibility of the patellar ligament prevents the patella from moving proximally with respect to the tibia. From Marks <i>(3).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Branching out from the quadriceps tendon on each side above the patella are the lateral and medial retinacula (<b>Fig. 6</b>), which insert on the flares of the tibia. Like the patellar ligament, these tendons are capable of weight-bearing.</p> <p>If the socket wall contains an indentation (<b>Fig. 11</b>) between the lower edge of the patella and the tendinous insertion, some initial tension is placed on the tendon. The upper surface of the indentation also permits the tendon to assume a load with a larger vertical component than would be the case if the indentation were not present (<b>Fig. 12</b>). Moreover, when the socket is aligned so that a slight amount of initial flexion is present when the wearer is in the standing position, both initial tension in the quadriceps tendon and the vertical components of load-bearing are enhanced.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11. Vertical cross-section of anterior portion of socket designed to take maximum advantage of patellar ligament for transmission of weight-bearing loads. Compare with Figure 12.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12. Vertical cross-section of anterior portion of socket with little provision for use of the patellar ligament for transmission of weight-bearing loads. Note the small vertical component of the force between socket and stump in this area as compared to the condition shown in Figure 11.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Flares of the Tibial Condyles</h4> <p>By virtue of its wedgelike shape and the nature of its thin, tough, overlying tissues, the upper portion of the tibia can assume part of the weight-bearing load by distribution of pressure over the medial and lateral flares of the condyles. Because part of the lateral flare of the tibial condyle is obscured by the head of the fibula, the medial flare offers most of the weight-bearing area.</p> <p><b>Fig. 13</b> shows horizontal cross sections of the tibia below the condyles superimposed on each other. Thus it can be seen that there is available potentially a considerable difference in horizontal area over which to distribute vertical forces to balance body weight. If the socket is aligned so that the stump is forced into a slightly flexed position when the wearer is standing erect, the horizontal components are reduced, the requirements for counter-pressure over the posterior wall are less, and therefore the risk of pressure over the major vessels and nerves in the rear is reduced. Proximity to relatively sensitive zones like the head of the fibula (typically present under the lateral flare), the sharp tibial crest, and the rough tibial tubercle greatly reduces the useful area on the anterolateral portion. The medial flare, though seemingly smaller than the lateral, is quite effective in providing support.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Horizontal cross-sections of leg at four different levels. View below leg shows level <i>A</i> superimposed on level <i>D</i> to illustrate the horizontal area potentially available for vertical support along the sloping areas of the tibia. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Tibial Crest</h4> <p>The shaft of the tibia is roughly triangular in horizontal section, one apex, the tibial crest, lying in the anterior portion of the leg (<b>Fig. 13</b>). The anteromedial wall of the tibia is covered with a thin layer of tissues and is admirably suited to assume some of the weight-bearing stresses. In the normal limb, the anterolateral wall of the tibia is covered by the tibialis anterior, which inserts in the region of the foot. Upon amputation, the tibialis atrophies but can still transmit, without discomfort, considerable load to the anterolateral wall. But the tibial crest itself cannot assume a weight-bearing load because of the high unit pressures that would necessarily develop over the knifelike ridge. For the same reason, compressive stresses cannot be tolerated either at the lateral aspect of the distal end of the fibula or at the anterior aspect of the distal end of the tibia.</p> <h4>The Head of the Fibula</h4> <p>Because the common peroneal nerve passes on the lateral side below the head of the fibula, only very low pressure can be tolerated in that area. Also, for bony stumps it is sometimes necessary to provide a groove proximally from the region of the head of the fibula in order to permit entry of the stump into the socket. <b>Fig. 14</b> shows in a somewhat exaggerated way how a socket is shaped to preclude the application of pressure in tender areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14. Cross-section showing typical method of avoiding pressure between socket and tender areas on stump, in this case the area about the head of the fibula.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Distal End of the Stump</h4> <p>Few below-knee stumps will tolerate very much pressure on the distal end, presumably because of the shearing stresses developed between soft tissues and the cut end of bone. Short stumps, where amputation was made through cancellous bone, and those cases where a bridge of bone has formed between the distal ends of the tibia and fibula, accidentally or surgically, are exceptions to the rule.</p> <h3>Stability</h3> <p> Vertical pressures on the areas projected on the horizontal plane, and hence total vertical forces, unhappily can be obtained only as <i>components</i> of the larger unit pressures and total forces exerted at right angles to the obiquely sloping surfaces of the stump, the thin but tough underlying tissues, and ultimately the bone (<b>Fig. 15</b>). Because these surfaces slope, there must be forces <i>in</i> the horizontal plane. Because the slowly curving surfaces slope generally <i>inward</i> toward the longitudinal axis of the tibia, in the frontal plane that fraction of the horizontal components of the sloping forces from the socket acting on the broad medial aspect of the condyles must oppose the corresponding components of the force acting on the more limited lateral aspect, resulting in over-all compression or constriction of the stump. Any net imbalance near the condyles may be counteracted by a distal horizontal force to yield in the frontal plane a moment balanced elsewhere. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 15. Schematic drawing showing the approximate direction of forces acting on the flares of the tibial condyles. The vector representing the force on the lateral side is shown in true view in the lower sketch. Note the components developed in the horizontal plane. The components shown must of course be balanced by other forces in the horizontal plane.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Because both the medial and lateral condyles slope generally <i>backward,</i> the horizontal components in parasagittal planes would tend to force the stump backward and hence allow it to slip downward off the sloping shelves matching the tissues overlying the condyles. Similarly, forces on the patellar ligament and retinacula have components directed rearwardly. Obviously, counterpressures from the rear wall must be so distributed over the stump as to develop adequate counter-forces without pressure sufficient to cause pain at any point, restrict return circulation, or interfere with adequate knee flexion during sitting. Superimposed on these forces acting in the horizontal plane as a result of vertical weight-bearing there generally are other forces, high on one aspect of the stump and low on the opposite, forming couples related to mediolateral stability, forcible knee extension, and so on. </p> <p>The optimum level for the rear brim of the socket is the popliteal crease. Though as high a brim as feasible is desirable to provide greater area for horizontal counterpressure, a rigid socket brim above this level on the posterior aspect will seriously restrict knee flexion; one below results in bulging of the tissues over the brim during flexion.</p> <p>The medial and lateral aspects of the socket wall should be carried to about the level of the proximal edge of the patella to enhance mediolateral stability.</p> <h3>The Hamstrings</h3> <p>The most important flexors of the knee are the hamstrings, which have two areas of insertions-one on the posterior aspect of the medial tibial condyle, the other on the posterolateral aspect of the head of the fibula (<b>Fig. 2</b>). As flexion occurs and the tibia and fibula rotate with respect to the femur, the hamstrings move away from the center of the femur. To prevent bunching of the tissues in the popliteal space during substantial knee flexion, especially during sitting, the brim of the socket should be brought precisely to the level of the popliteal crease. Because the two insertions of the hamstrings are below this level, interference between the hamstring tendons and the brim of the socket would occur when the knee is flexed were appropriate grooves, or cutouts, not provided in the rear portion of the brim. The medial groove is generally deeper than the lateral because the insertion of the semi-tendinosus is more distal on the tibia than the insertion of the biceps femoris is on the fibula.</p> <h3>Edema</h3> <p> One of the causes of edema is an unbalanced condition in the interchange of materials between blood and body cells by way of the capillary and lymphatic systems, <i>i.e.,</i> more fluid is pumped temporarily into the exchange system than is pumped out. An imbalance can be the result of either mechanical or biochemical factors. The wearing of a limb is not likely to lead to the formation of chemicals that produce edema, but it can produce mechanical factors that do. The action of voluntary muscle working within the normally intact fascial envelope is responsible in part for the return of the blood to the venous system via the capillary and lymphatic systems, and hence factors that alter normal muscle activity can contribute to the formation of edema. Further, concentrated pressures in one area can cause edema in a distal area either by inhibiting muscle action or by restricting the low-pressure venous or lymphatic return systems and thus are to be avoided. For this reason, when relief is required for bony prominences or tender areas, the indentation in the socket wall should be flared gently. Relief should never be provided by a hole or window which removes external counterpressure from a localized area while maintaining support or even constriction elsewhere. </p> <p>Also to be avoided is a combination of a tight fit in the proximal portion of the socket and a loose fit distally. Under such circumstances the venous and lymphatic systems can be constricted to the point that edema is produced.</p> <p>Gentle external pressure on soft tissues offers a mechanical aid to the return of blood to the venous system. The equivalent can be obtained by encasing the entire stump with the socket in such a manner that at least a slight amount of pressure is brought to bear over the soft tissues as the prosthesis is used.</p> <h3>The Composite Socket</h3> <p>The shape of the socket in which the anatomical and physiological factors discussed above are taken into account is shown in <b>Fig. 16</b> and <b>Fig. 17</b>. The anterior brim is brought to the level of the center of the patella; a horizontal indentation is provided at the midpoint of the patellar ligament to induce tension in the ligament and at the same time to afford a more horizontal weight-bearing surface; the lateral and medial aspects of the brim are brought about level with the proximal edge of the patella to assist in providing mediolateral stability; grooves are incorporated into the posterior brim of the socket to accommodate the hamstring tendons during flexion; the entire stump is encased; and areas for relief of bony prominences are flared gently to avoid radical changes in pressure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 16. Cutaway view of the patellar-tendon-bearing socket incorporated in a thin-walled plastic shank. Note especially cuff-suspension strap, high lateral and medial walls, and the total-contact feature.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 17. Posterior view of brim of PTB socket for a right stump. Note that the medial wall is slightly lower than the lateral. Not shown is the soft inner liner commonly used.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The socket shown was developed by the Biomechanics Laboratory of the University of California<a></a> after a thorough study of previous practices and after an analysis of the anatomical, physiological, and biomechanical factors involved. The socket is installed in the prosthesis so that the knee is in some 5 to 8 deg. of flexion when the patient is standing erect. This slight degree of initial flexion not only places the weight-bearing loads on the stump in a direction that reduces the unit stresses and shearing forces but also relieves the popliteal area of some pressure as well. In addition, use of the quadriceps is encouraged, and the risk of overloading ligaments as a result of excessive hyperextension is reduced. </p> <p> Because of the difficulty in achieving a truly intimate fit, and for lack of an accurate method of measuring forces between the stump and the socket, use of a soft liner is recommended. The liner, usually of sponge rubber 1/8 in. thick on the sides, slightly thicker on the end, and covered with leather, reduces the chances of abrupt changes in stress. </p> <p>Suspension usually can be effected by a simple cuff above the femoral condyles attached to the shank by flexible straps, but a waist belt or sidebars and corset may be used if necessary.</p> <p>The entire prosthesis has come to be known as the "patellar-tendon-bearing leg," or simply the "PTB leg," perhaps useful as a code name but an unfortunate nomenclature if taken literally, not only because it describes only a part of one functional aspect offered by the prosthesis but also because even that portion would more rightly be termed "patellar-liga-ment-bearing" or "quadriceps-tendon-bearing."</p> <p>Sidebars and corset may be indicated in cases where rather extreme mediolateral instability of the knee is present or where muscles which control the knee have been impaired to the extent that exercise will not strengthen them. Sidebars and corset with ischial support may be indicated either for cases where bone or joint impairments prevent any of the long bones from assuming weight-bearing loads or for those where the skin is of such nature that the imposition of the required loading is simply out of the question. In addition, certain occupations might be carried out more readily if sidebars were used. Except for such limitations, virtually all below-knee amputees with healthy stumps can derive benefit from the PTB prosthesis with cuff suspension, provided the clinic team fully understands the underlying principles in the design and provided also that the prosthetist has the skill necessary to incorporate the essential features into the finished prosthesis.</p> <h3>Acknowledgment</h3> <p>The authors wish to acknowledge the gracious assistance and guidance afforded by Herbert Elftman and Gabriel Rosenkranz in the preparation of this article.</p> <p><b>References:</b></p> <ol> <li> Charnley, John, <i>The lubrication of animal joints,</i> in <i>Symposium on Biomechanics,</i> The Institution of Mechanical Engineers, London, 1959, pp. 12-22. </li> <li> Elftman, Herbert, <i>The functional structure of the lower limb,</i> Chapter 14 in Klopsteg and Wilson's <i>Human limbs and their substitutes,</i> McGraw-Hill, 1954. </li> <li> Marks, George E., <i>Treatise on artificial limbs,</i> A. A. Marks Co., New York, 1899. </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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall"> University of California, Biomechanics Laboratory (Berkeley and San Francisco), The patellar-tendon-bearing below-knee prosthesis, 1961. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall"> Charnley, John, The lubrication of animal joints, in Symposium on Biomechanics, The Institution of Mechanical Engineers, London, 1959, pp. 12-22. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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, Committee on Prosthetics Research and Development, National Academy of Sciences - National Research Council, 2101 Constitution Avenue, 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>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Avenue, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-17.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 Anatomical and Physiological Considerations in Below-Knee Prosthetics Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/76945f6516dcc0545d2b91cfc6caeb8b.pdf c7a89a78b48b8aa9065dc973197081da https://staging.drfop.org/files/original/8272f870d623593975109366a1d714b7.jpg b08648bc765812c399bac1c19cce2712 https://staging.drfop.org/files/original/4b7fd07801fb1d9d0ea15226722773a1.jpg 31e1b3419fb5675d97f4c3ca9ddaef2b https://staging.drfop.org/files/original/648d969a13a9bfcbf9776e7f897bb027.jpg e6e25a69ad3a0eecb8b14f7d3cc6e198 https://staging.drfop.org/files/original/b2768987a6f827aa82820f33774881c2.jpg 3263b9f8e8039406c257c4297c706577 https://staging.drfop.org/files/original/565d4cdb0cb7c3928f0cc609eecabbad.jpg 23623942433011b5212537b43ff50a42 https://staging.drfop.org/files/original/bf659b0d50d8c30b699e980c1f46cfc3.jpg 2a10c2a368eda3fd3271e2c3d0b654bf https://staging.drfop.org/files/original/9ce4a3a221bb7e80fe9d0ac6e9038998.jpg a5593d13ccca338b6ac13c4fa60b0c30 https://staging.drfop.org/files/original/35f43c3f17c550391dc44c8477510bc7.jpg ee2788f57195e89a29eb725640ddf569 https://staging.drfop.org/files/original/1da9a7a00eb343939657082c12fdb22c.jpg 909ebcfb948c3e308eeea4c9c6129fca https://staging.drfop.org/files/original/107f8865b76201e760a87b25a700925f.jpg ac9a63d4f56b0bfe2d3d809c5be4b62a https://staging.drfop.org/files/original/da057c8bdbf8ceb1905f88c4011035d6.jpg 1364e32658239dc95d96ff1f793bc60e https://staging.drfop.org/files/original/142e0aebc5734f02b98738402171591a.jpg 23e4623a64eb2c8d4be159bc6b0f03ac https://staging.drfop.org/files/original/60c955ee13d73d7d06dd7a1ca0a291f1.jpg f9b06353c26a48c7556434f08d6d1a30 https://staging.drfop.org/files/original/d5169c0556a5fc30c968ca2e1bee5b6d.jpg 6222c5563bd9f4c29aa01964ed644fcd https://staging.drfop.org/files/original/21aa54f2cc58f1d7bbbf371460f09293.jpg 91d6c232ce2547fd4a92b2da4bdfa3ce https://staging.drfop.org/files/original/43a8e159de0c26aa574ccfee54b66866.jpg d697bc4196132af4b6a33226ea167054 https://staging.drfop.org/files/original/bbd717fc89481bf516d899e84e674930.jpg fa7da43c15df8f4730367e7d1a28d083 https://staging.drfop.org/files/original/095050e87ef41d2f053cf7fdb2d3f9d8.jpg 8d867d08333393bb2170844cf6d76586 https://staging.drfop.org/files/original/5fd0bdf92a32a8d7b20419407e0a6e07.jpg 0d975f91d4cbfda7367c753e55bfbd73 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_031.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 31 - 87 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/1958_02_031.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_031.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Studies of the Upper-Extremity Amputee VI. Prosthetic Usefulness and Wearer Performance</h2> <h5>Hector W. Kay, M.Ed. <a style="text-decoration:none;">*</a><br />Edward Peizer, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Systematic research in limb prosthetics has, during the past decade, produced not only better prostheses but also improved techniques for their application. Similarly, programs of prosthetics education have provided a new generation of physicians, prosthetists, therapists, and associated professional personnel with a greater appreciation of the amputee's physical and emotional needs and a greater understanding of how best to meet them. But ultimately research and education in the fitting of artificial limbs have real worth only to the extent that the individual amputee can accept and utilize the prosthesis provided him.</p> <p>The degree of acceptance and utilization is governed ultimately by the single consideration : <i>Of what value is the prosthesis to the amputee?</i> While the wearer himself must provide the essential elements of this valuation, his feelings and attitudes about other matters can significantly affect his opinions and judgments about the worth of his prosthesis. Accordingly, data which included both subjective amputee reactions and more objective ratings and judgments of independent observers were collected. Properly analyzed, these data provide a firm assessment of recent achievements in arm prostheses as well as some measure of the effectiveness of the techniques now recommended for the management of arm amputees.</p> <p>The classification, analysis, and interpretation of the more subjective portions of the data (those collected by interrogation of amputee subjects) make up Part 1 of this two-part discussion. Presentation and support of the more objective material (that obtained by tests and observation) constitute Part 2. All of the data reported were recorded on the special forms illustrated in Appendices IIIB and IIIC of Section I of this series (Artificial Limbs, Spring 1958, pp. 32 through 39).</p> <p>The opinions and statements reported in Part 1 and the test results and observations presented in Part 2 relate to the meaning and the value of program prostheses in various tasks normally encountered in everyday life. As a perceptive reader will note, the term "activities of daily living" is used throughout this article to denote that specific context and is not meant to be synonymous with the term "ADL," which through increasing currency has become part of the professional jargon of physical and occupational therapy. As used here, it encompasses a broader range of activities than it does when generally used in the treatment of human disability. Generally ADL is limited to tasks relating to personal independence and self-care in the home; in our context, recreational and vocational activities are included.</p> <h3>Part 1. Amputee Opinions Concerning Utility of Arm Prostheses in Activities of Daily Living</h3> <p>In general, the prosthesis that will be most valuable to the arm amputee will be the one with which he can perform, most efficiently and with the least effort and discomfort, the greatest number of useful activities ordinarily performed with the normal upper extremity. Thus an evaluation of an arm prosthesis can be based upon the usefulness of a prosthesis to the patient as indicated by his need for it in performing daily activities, the activity level of the patient with respect to the number of activities which he performs with his arm, the ease with which he uses the prosthesis, and the frequency with which he uses it for the performance of activities which are important to him.</p> <p>To obtain amputee reactions concerning the general utility of arm prostheses, the participating subjects were intensively interviewed, and the essential data were recorded on two sets of questionnaires. One set was used to record amputees' opinions of the usefulness of their arms in activities of daily living, the activity level as regards the number of different activities they performed, and the degree of ease or difficulty with which they were able to use their prostheses. The second set of questionnaires was used to collect data concerning the use of prostheses in 20 selected bimanual activities, specifically the frequency with which these activities were performed and the importance to the amputee of being able to perform these activities. With certain minor exceptions, the interrogation was conducted with respect both to the old prosthesis (Evaluation I) and to the new (Evaluation II). The time lapse between the two interviews varied for individual amputees; it was never less than six months for any, as much as 18 months for a few, and approximately 12 months for the average case.</p> <h3>Usefulness, Activity Level, and Ease of Use in Activities of Daily Living</h3> <p>In view of the complexities of everyday human activities, almost any attempt to study the circumstances affecting prosthetic utilization is difficult. As a practical approach to the problem, however, the subjects were queried in a pattern designed to elicit their opinions concerning the value of both their old and new prostheses in the key activity areas of eating, dressing, work, social and recreational functions, and home tasks.<a style="text-decoration:none;">*</a> To determine general usefulness, the amputees were asked to rate their prostheses (first the old and then the new) as essential, very useful, of limited use, of no use, or as a hindrance, the purpose being to establish the amputees' own valuations of their prostheses in performing activities in the five activity areas. Secondly, the subjects rendered their own estimates as to the relative number of activities performed with old and with new prostheses, again with respect to the five key areas of activity. Finally, the subjects were asked to estimate the relative ease with which their old and new prostheses could be used in each of the same five areas.</p> <p>The questionnaires regarding usefulness, number of activities performed, and ease of performance with both old and new prostheses were applied to all available types of upper-extremity amputees, unilateral and bilateral. Because the problems of the bilateral arm amputee differ from those of the unilateral, and because the number of available bilateral cases was too small to have statistical significance, the results for 349 unilateral subjects are treated first, those for the 10 bilaterals in a separate section.</p> <h4>Unilateral Subjects</h4> <p>Among unilateral arm amputees especially, the level of use to which an arm prosthesis is put is determined to a considerable extent by the ease and convenience of performance with the prosthesis as compared with the ease and convenience of performance without it or as compared with the ease and convenience of not performing at all. If a particular activity is too difficult or too time-consuming for a given unilateral arm amputee to perform with his prosthesis, he will either avoid it completely or else find some other way of getting it done. If he elects to accomplish the activity without using the prosthesis, he may do so in any of several ways:</p> <ol> <li>He may use the remaining sound hand, with or without assistance from other parts of the residual anatomy or from external objects. Unilateral arm amputees commonly perform with one hand many activities which under normal circumstances would be bimanual (e.g., tying necktie or shoelaces).</li><li>He may use special devices and techniques (e.g., various tools intended for one-handed performance of tasks ordinarily bimanual), again with or without assistance from some other available source.</li><li>He may prevail upon another person either to provide assistance or to perform the task for him more or less completely.</li></ol> <p>Although any one of these alternatives may serve the purpose of accomplishing essential activities, none of them suggests adequate restoration of loss, either in terms of true personal independence or in the sense of normal appearance. In addition, factors such as temperament, disposition, motivation, and habit patterns further influence the simple "ease-difficulty" premise of prosthetic utilization. Though the true state of affairs in any particular case is a highly complicated one, there can be little doubt that the inherent "usefulness" of the prosthesis is one of the prime factors in determining the number and kinds of purposes to which an artificial arm will be put. This first series of studies was therefore designed to discover the activities for which prostheses are used by amputees with unilateral arm loss at various levels and to delineate any changes in use patterns properly attributable to the new types of prostheses fitted during the NYU Field Studies.</p> <h5><i>Eating</i></h5> <p><i>Usefulness</i>. As regards eating, unilateral below-elbow amputees generally thought well of their old prostheses, above-elbow subjects had a considerably lower opinion of their arms, and shoulder-disarticulation amputees viewed their prostheses as being of relatively little value. In almost all cases, the amputee rated the new prosthesis more useful than the old in eating. For all types of amputees, there were fewer opinions that the prosthesis was of "no use" or "a hindrance" and a greater number of opinions that it was "very useful" or "essential." While this shift in opinion was characterized primarily by a considerable decrease in the proportion of unilateral amputees (of all types) who considered their prostheses of "no use" or "a hindrance," there was also an increase in the number of those considering the prosthesis "very useful" or "essential."</p> <p>Of major significance is the fact that even with the newer arms the majority of unilateral amputees (58 percent of the below-elbow amputees, 83 percent of the above-elbow amputees, and 96 percent of the shoulder-disarticulation subjects) felt that the prosthesis was of limited use or no use in eating. Since only 41 percent of the below-elbow amputees, 15 percent of the above-elbow amputees, and 4 percent of the shoulder-disarticulation subjects considered their new prostheses essential or very useful in eating activities, it must be concluded that, although there was some increase in usefulness in the "program" prostheses, considerably greater improvement is necessary if the artificial arm is to have a significant influence upon the eating activities of the majority of unilateral arm amputees. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Activity Level</i>. Reports from all unilateral amputee groups indicated that the number of eating activities increased for a significant number of amputees while very few subjects experienced a decrease. The increase in usage was greatest for shoulder-disarticulation amputees (45 percent), less marked for the below-elbow group (34 percent), and least for above-elbow amputees (28 percent). <b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ease of Use</i>. As might be expected from the foregoing, a significant number of amputees of all types reported that eating activities were easier with the new prosthesis than with the old, although the increase in facility for the below-elbow and above-elbow groups was less marked than for the shoulder-disarticulation amputees. <b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Specific Activities Performed</i>. <b>Table 1</b>, based on responses from 168 below-elbow, 158 above-elbow, and 23 shoulder-disarticulation ampu- tees, presents a composite picture of the specific eating activities for which unilateral amputees of various amputation levels said they used their prostheses. Since the list of activities was compiled from amputees' responses to the unstructured request <i>List activities for which you use your [new] prosthesis</i>, and since in the experience of the authors arm amputees commonly use their prostheses more extensively than they can recall, it may be assumed to be minimal both with respect to number of activities and to incidence of performance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The prime significance of these responses lies in their indication of use potential of the prosthesis. For example, the fact that in opening a soda bottle some below-elbow, above-elbow, and shoulder-disarticulation amputees can and do hold the bottle with their terminal device suggests that this activity is not particularly difficult and that it could be performed by most amputees. Why, then, do some amputees prefer to use one hand only or to hold the bottle between the knees to take off the cap? Such questions are worthy of more intensive investigation than was possible in the NYU Field Studies.</p> <h5><i>Dressing</i></h5> <p><i>Usefulness</i>. Amputees' opinions concerning the usefulness of the prosthesis in dressing show a pattern somewhat similar to that found in eating. There is a general shift of opinion toward the positive end of the scale, but the extent of the change varies with amputee type. It is slight in the below-elbow group, somewhat greater in the above-elbow group, and most marked among shoulder-disarticu-lation amputees. When the percentage of amputees who considered the prosthesis essential or very useful is employed as the basis of comparison, the data for new vs. old arm were: below-elbow, 63 percent vs. 59 percent; above-elbow, 24 percent vs. 14 percent; shoulder disarticulation, 17 percent vs. zero. Although because of the small number of subjects involved the data on the shoulder-disarticulation group must be interpreted cautiously, there are definite indications that a significant number of amputees considered the new prosthesis more useful than the one worn previously. It is also apparent that most groups consider a prosthesis <i>more useful for dressing than for eating</i>. The comparative percentages of amputees who considered the new prosthesis either essential or very useful were—below-elbow: dressing, 63 percent, eating 41 percent; above-elbow: dressing, 24 percent, eating 15 percent; shoulder disarticulation: dressing, 17 percent, eating 4 percent. These differences may be attributable to the larger number of discrete tasks involved in dressing as compared with eating. Despite the improved sentiment toward the usefulness of the program arms, however, a considerable proportion of unilateral amputees of all types (below-elbow, 37 percent; above-elbow, 76 percent; shoulder disarticulation, 83 percent) still considered these prostheses of limited use, no use, or a hindrance. Again it is obvious that much room for improvement still exists, particularly for the more severely handicapped above-elbow and shoulder-disarticulation groups. <b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Activity Level</i>. An increase in the number of dressing activities performed with the prosthesis was reported by all amputee groups. The proportion of amputees indicating increased use of the prosthesis ranged from 28 percent of the below-elbow category to 38 percent of the shoulder-disarticulation sample. An insignificant number reported decreased usage. <b>Fig. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ease of Use</i>. Since extent of use is undoubtedly related to ease of use, it is not surprising to find that a high proportion of the amputees considered dressing activities easier to perform with their new prostheses than with their old. Easier operation was reported by 52 percent of the below-elbow, 42 percent of the above-elbow, and 55 percent of the shoulder-disarticulation subjects. Very few subjects at any amputation level reported greater difficulty of operation with the program prosthesis, although almost one in twelve below-elbow amputees fell into this category. The use of more complex terminal devices and the change from soft (leather) to hard (plastic) sockets may in some cases have contributed to this minority opinion. <b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Specific Activities Performed</i>. <b>Table 2</b> presents a tabulation of specific dressing activities in which unilateral arm amputees reported performance with their prostheses. Since this listing is based upon the responses of the subjects to open-end questions, it should be considered minimal and indicative rather than comprehensive.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The major significance of the data in <b>Table 2</b> lies in their indication of the use potential in existing prostheses. Equally important, however, is the corollary question, <i>Why is this potential not fully utilized by amputees? </i>For example, 88 below-elbow, 51 above-elbow, and 5 shoulder-disarticulation amputees claimed that they held one end of a necktie with the prosthesis while they tied the knot with their "good" hand. This circumstance would suggest that the activity is perfectly feasible for all three amputee types and that it might almost be considered a "typical" or "normal" prosthetic activity. Nevertheless, the fact remains that a considerable number of amputees tie their neckties using the "good" hand alone. Presumably it is "easier" or more convenient for them to employ the one-handed method, but whether the reason is related to prosthetic difficulty, lack of motivation to use the prosthesis, or prior habit pattern is not readily apparent. More intensive study in this area might be extremely fruitful in gaining deeper insight into the problems of prosthetic utilization.</p> <h5><i>Work</i></h5> <p><i>Usefulness</i>. As a result of the research program, all amputee types except the below-elbow showed an increase in positive attitude toward the usefulness of prostheses in their work. The shift in opinion was quite marked in the shoulder-disarticulation group but less apparent with the above-elbow subjects. Although the below-elbow amputees as a whole indicated little change in usefulness between the old and the new prostheses, their opinions of both prostheses were generally high.</p> <p>In spite of apparent improvement with the new prostheses, many of the amputees (below-elbow, 24 percent; above-elbow, 40 percent; shoulder disarticulation, 55 percent) felt that their prostheses were of little or no value to them on the job. Since, however, these percentages are much lower than the corresponding ones for the two activities previously discussed, it would appear that amputees consider their prostheses more useful for work than for either eating or dressing. The reason may be that eating and dressing involve a relatively small number of activities, many difficult to perform with a prosthesis, while vocational activities present a much broader variety of tasks of which perhaps many can be performed better with a prosthesis than without one. <b>Fig. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Activity Level</i>. Sixty-eight percent of the shoulder- disarticulation subjects reported that they performed more work activities with the new prosthesis. So did 41 percent of the above-elbow and 29 percent of the below-elbow participants. <b>Fig. 8</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ease of Use</i>. A major proportion of the amputees believed that the new arm made work activities easier. Holding this opinion were 63 percent of the be-low-elbow subjects, 75 percent of the above-elbow amputees, and 76 percent of those with shoulder disarticulations. Although this result represents a more uniform and significant "positive shift" than that found for either eating or dressing, one in eight of the below-elbow amputees felt that work activities were harder to perform with the program prosthesis. The basis for this minority opinion was not apparent from the data. <b>Fig. 9</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Specific Activities Performed</i>. The specific work activities that amputees can perform with their prostheses, and the kinds of jobs they can hold successfully, are of considerable interest from the viewpoint of vocational re- habilitation. <b>Table 3</b> presents a listing of vocational activities reported by the 168 below-elbow, 158 above-elbow, and 23 shoulder-disarticulation amputees involved in the study. Activities reported by the subjects have been classified arbitrarily as light work {i.e., activities typical of white-collar workers), medium work {i.e., activities typical of artisans and mechanics), heavy work {i.e., farming and other heavy manual occupations), and miscellaneous. Although this listing does not reveal the full story of the employability of unilateral arm amputees, it does indicate trends. While a detailed analysis of the subject is not possible at this time, it is apparent that unilateral arm amputees are capable of a wide variety of work activities and are employable in a wide range of occupations.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An additional interesting aspect of the relationship between vocation and amputation was provided by amputee responses to two questions asked at the conclusion of the study. These questions and the answers provided by 349 subjects in the study were: <b>Fig. 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>From these data it is evident that, while one in five amputees changed jobs during the course of the study, few of the changes were attributed to the new prosthesis. Of the total number of subjects in the study, therefore, very few felt that the new prosthesis affected their employment. Consideration of the type of job change made by the amputees also fails to reveal any significant trend. None of the changes reported (student to farm hand, post-office clerk to wholesale manager, hospital attendant to repairman, unemployed to guard, janitor to stock clerk) indicated any marked shift in vocational status, either positive or negative. It must be concluded, therefore, that the prostheses provided in the study had little apparent effect on the employment status of the participants.</p> <h5><i>Recreational and Social Activities</i></h5> <p><i>Usefulness</i>. All amputee groups reported that in recreational and social activities the program prosthesis was an improvement over the old prosthesis. As with the activity areas previously discussed, improvement was least marked in the below-elbow subjects, but even this group showed a change for the better. For example, 72 percent of the below-elbow sample considered that their new prosthesis was either essential or very useful as against 60 percent for the old prosthesis. Shoulder-disarticulation amputees reflected a greater degree of improvement, 33 percent reporting essential or very useful for the new prosthesis as compared with 19 percent for the old. Above-elbow amputees appeared to obtain the most benefit from their new prostheses, the proportions rating their prostheses in the upper two categories of the scale being: new arm, 69 percent; old arm, 33 percent. The proportion of amputees reporting that the prosthesis was of little or no use or was a hindrance in leisure-time activities (below-elbow, 28 percent; above-elbow, 31 percent; and shoulder disarticulation, 67 percent) was greater than for vocational activities but less than for eating and dressing. <b>Fig. 11</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Activity Level</i>. A significant number of amputees used their new prostheses for additional leisure-time activities. One third of the above-elbow and shoulder-disarticulation subjects and one fourth of the below-elbow subjects had found new uses. A very small proportion of above-elbow and below-elbow amputees reported decreased usefulness (3 percent and 5 percent respectively). <b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ease of Use</i>. More than 50 percent of all the amputees felt that the performance of social and recreational activities was easier with the new arm. A small number of below-elbow (7 percent) and above-elbow (3 percent) subjects felt that activities in this area were harder to do. <b>Fig. 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Specific Activities Performed</i>. <b>Table 4</b> presents a listing of leisure-time activities performed by unilateral arm amputees using a prosthesis. Some of the pursuits listed are performed vocationally also, but the subjects in the study mentioned them more frequently as a hobby than as a vocation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>While an amputee's social or hobby interests are perhaps not of the same level of importance as eating, dressing, and working, they are nevertheless quite significant in his total pattern of living. It is apparent that to many arm amputees a major value of the prosthesis in leisure-time activities resides in its cosmetic contribution, this factor being mentioned most frequently by all types. In addition, many found their prostheses useful in a variety of sports and hobbies, including such relatively active endeavors as hunting, fishing, golf, and baseball.</p> <h5><i>Home Tasks</i></h5> <p><i>Usefulness</i>. Use of a prosthesis at home encompasses a wide variety of tasks, from washing dishes and sweeping floors to gardening, painting, and electrical and plumbing repairs. Some of these activities are, of course, basically of a vocational nature but are performed as avocations on a part-time or intermittent basis. As for improvement in the usefulness of the prosthesis in home tasks, the shift in opinion was relatively small in below-elbow subjects but quite pronounced in above-elbow and shoulder-disarticulation amputees. In home tasks, as in other activity areas discussed previously, a high percentage of below-elbow subjects (70 percent) considered their old prostheses either essentia] or very useful, and this opinion was maintained for the new prosthesis (73 percent). It would appear that for this type of amputee there was less margin for improvement and hence less was achieved, or, the other way round, the old arms available for below-elbow amputees were relatively more satisfactory than were those available for other amputee types. <b>Fig. 14</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Activity Level</i>. Nearly 45 percent of the above-elbow and shoulder-disarticulation cases and a smaller proportion of the below-elbow amputees (28 percent) found new uses in the home for their program prostheses. A small minority of the below-elbow group (6 percent) found fewer uses for their new prostheses. <b>Fig. 15</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ease of Use</i>. The proportion of amputees reporting greater ease in performance of home tasks with the program prostheses ranged between 64 and 75 percent. Shoulder-disarticulation amputees (75 percent) were most favorably impressed, followed by above-elbow (66 percent) and below-elbow (64 percent). A few below-elbow (9 percent) and above-elbow (3 percent) subjects found home tasks more difficult than before. <b>Fig. 16</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Specific Activities Performed</i>. <b>Table 5</b> indicates the types of home activity for which unilateral amputees used their prostheses. From the scope of activities listed, it is apparent that unilateral amputees find a wide range of uses for their prostheses in the home. While the rate or quality of performance is not indicated by the data, several of the tasks performed imply a high degree of dexterity. For example, a number of amputees undertook automobile and electrical repairs and various types of carpentry, and they made use of a wide range of tools, including power equip- ment. Since, as mentioned earlier, many tasks performed in the home by choice or necessity are vocational in nature, a more intensive investigation of this performance pattern would throw further light on the employment potential of arm amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Bilateral Subjects</h4> <p>In the performance of bimanual activities by unilateral arm amputees, the prosthesis serves primarily, as has been seen, to assist the remaining good hand. Similarly, and for various reasons, unilateral arm amputees not infrequently perform with the one remaining hand activities ordinarily bimanual. Bilateral arm amputees quite obviously are faced with an entirely different situation. Since more or less of both upper extremities is lacking, at least one prosthesis must assume more than an assistive role, and one-handed performance of tasks normally two-handed cannot be substituted for use of a prosthesis. Manual activities required of bilateral arm amputees must therefore be done prosthetically if done at all. In a very real sense, then, the performance problems and the adaptations of bilateral arm amputees are quite unlike those of any type of unilateral amputee, and they therefore warrant separate discussion.</p> <p>In the Upper-Extremity Field Studies, data were collected on 10 bilateral arm amputees (7 bilateral below-elbow, 3 bilateral above-elbow/below-elbow). Five of these subjects (4 bilateral below-elbow, 1 bilateral above-elbow/below-elbow) were wearing prostheses bilaterally when admitted. The other five had either one prosthesis only or none at all. Thus, although information as regards program prostheses was obtained on all 10 subjects, comparative data on new vs. old arms are available on only five subjects.</p> <h5><i>Experienced Wearers</i></h5> <p>Although the five amputees who had worn prostheses bilaterally prior to the NYU Field Studies rated their old arms quite useful in all five of the activity areas, they considered the new prostheses equally useful or slightly better than the old ones (<b>Table 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As shown in <b>Table 7</b>, four of the five experienced wearers of bilateral prostheses indicated equivalent or increased use of their new prostheses as compared to the old, while one reported decreased use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As might have been anticipated, the pattern of amputee responses concerning ease of use (<b>Table 8</b>) of the new prostheses as compared with the old was quite similar to that concerning extent of use (<b>Table 7</b>). In general, the evidence indicated somewhat easier operation of the program prostheses, although the improvement was by no means universal.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Those bilateral arm amputees who reported easier operation and more extensive use of their new prostheses attributed the improve- ments primarily to the more secure grasp permitted by the terminal devices prescribed in the Field Studies. Neoprene-lined hook fingers and the heavy-load feature of the Northrop-Sierra two-load hook contributed greatly to this improved grasp security. Other favorable aspects of the new arms, mentioned by different subjects, were lighter weight and better control (faster operation and lower force requirement). The one subject fitted with an above-elbow arm indicated that operation of his new elbow lock was simpler and more efficient.</p> <h5><i>New Wearers</i></h5> <p>The five amputees who had not worn prostheses bilaterally prior to the Field Studies rated their program prostheses quite useful (<b>Table 9</b>). For some reason, however, their ratings showed less enthusiasm than did those of the patients who had previously worn prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Specific Activities Performed</i></h5> <p>At Evaluation II (new prostheses), information on the specific uses to which bilateral arm amputees put their prostheses was obtained from all 10 subjects for each of the activity areas under study. The activities reported by the individual amputees were given as "free responses" (i.e., unprompted and unstructured), and hence the listings may be considered more representative than complete.</p> <p>The available data on the 10 bilateral subjects indicate that they used their prostheses extensively in eating and attained a relatively high level of independence. Two mentioned specifically that they performed all eating activities with their new prostheses (i.e., were completely independent). <b>Table 10</b> presents specific eating activities reported to be performed by the bilateral subjects.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Only one of the 10 bilateral amputees claimed complete independence in dressing, although two other subjects reported the performance of all dressing activities except buttoning shirt sleeves. Two more persons performed all activities except fastening buttons, lacing shoes, and tying neckties. <b>Table 11</b> lists specific dressing activities reported as performed by the bilateral subjects.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The employability or vocational-placement possibilities of bilateral arm amputees always hold considerable interest. Although the sample was in this instance exceedingly small, it may be worth noting that five of the 10 bilateral amputees were self-employed, that four worked for others, and that only one was unemployed. Of the nine employed subjects, one was a lawyer, one an engineer, one a forester, and one a quality-control inspector. Two were filling-station attendants, and three were farmers. The quality-control inspector, unemployed at the beginning of the program, obtained his position after receiving his new prostheses, and he credited the functional qualities of the limbs for his new employment.</p> <p><b>Table 12</b> lists specific activities reported by the nine employed subjects as being performed with their program prostheses at work.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A listing of recreational activities performed by the bilateral amputees revealed that with their new arms most were able to drive a car independently and that most engaged in some form of active or passive recreational endeavor. <b>Table 13</b> lists specific activities mentioned by the subjects as being performed with their prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The pattern of home activities performed by bilateral amputees (<b>Table 14</b>) does not differ greatly from that of unilateral except that among bilaterals there is a lesser tendency to undertake tasks requiring fine manipulation. Even allowing for the smaller number of subjects involved, it is apparent that the home activities of bilaterals run more to gross tasks, such as pushing a lawnmower or handling a broom, than to precision activities, such as electrical or radio repairing. Since the absence of "at least one good hand" would be a major handicap in work requiring manipulation of small parts, such a situation is quite understandable.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In summary, the comparative data on five bilateral arm amputees whose preprogram prostheses were replaced by program arms appeared to indicate that:</p> <ol> <li>The five subjects thought well of their old prostheses and used them extensively.</li><li>In four of the five cases there was slight but definite evidence of functional improvement over that provided by the old prostheses. Contributing largely to this improvement appeared to be the better grasp furnished by the Dorrance 5X and Northrop-Sierra two-load hooks, partly because of the neoprene-lined hook fingers and partly because of the heavy-load feature of the Northrop-Sierra device. Other favorable features mentioned by some of the subjects were lightness and ease of operation. The one amputee fitted with an above-elbow prosthesis felt that his new elbow was much more dependable and much easier to operate than the one previously worn. One subject in the group apparently had a left prosthesis very poorly fitted and functionally inadequate, a deficiency which, in view of the rigorous checkout procedures and the close control of fittings by the clinic teams, is hard to explain. Nevertheless, that particular patient was obviously fitted unsatisfactorily, and this circumstance affected his whole reaction to the prostheses provided.</li></ol> <h4>Discussion</h4> <p>An outstanding characteristic of the data thus far presented is general consistency. For all categories of daily-living activities considered (eating, dressing, work, recreational and social life, and home tasks), and for all criteria applied (general usefulness, level of usage, and ease of use), the evidence strongly indicates that the prostheses provided in the program were more useful than those previ- ously worn. But the material also raises a number of interesting questions of which only some can be answered satisfactorily by the available data. For example, the extent of improvement provided by the new prostheses varied considerably from amputee type to amputee type. It was least for the below-elbow subjects, and some few members of this group even expressed a preference for the old prosthesis. For the unilateral above-elbow and shoulder-disarticulation subjects, the increased usefulness of the new prosthesis was considerably more marked and dramatic.</p> <p>When one speculates on the reasons for these differences, it must be borne in mind that the so-called "old" prostheses exhibited a wide range of quality from very poor to excellent. A number of the preprogram arms, particularly those for below-elbow amputees, were probably as good as, in some few cases even better than, those provided in the study. Moreover, some of the below-elbow subjects whose old leather-socket arms had some of the comfort qualities of old shoes or slippers reacted unfavorably to the new plastic sockets. Whatever the reasons, it was evident that some of the old arms provided below-elbow amputees with a relatively high degree of usefulness and that the impact of the research program on these subjects was relatively small. The reverse appears to have been true of above-elbow and shoulder-disarticulation prostheses. Taken as a whole, the old arms for these cases were of comparatively limited usefulness, and hence considerable improvement was effected by the new prostheses. Thus it may be said that the prostheses provided in the field program made the greatest contribution where improvement was most needed.</p> <p>Another thought-provoking finding of the study was that the usefulness of the prostheses obviously varied from one activity area to another, sometimes quite significantly. All three unilateral groups rated their prostheses as being about equally useful in home, work, and social activities but considerably less useful in dressing and of least use in eating. An explanation of these differences may lie in the fact that eating and dressing involve a limited number of specific activities, particularly those which require bimanual effort, and that the majority of these are quite difficult to perform with an arm prosthesis. It may also be conjectured that, in the sometimes quite lengthy time lapse between amputation and receipt of an arm prosthesis, patients build strong habit patterns of one-handed eating and dressing and that these habits carry over after the prosthesis has been supplied. Work, leisure, and home tasks present a much wider and more varied range of activities. Presumably more of these require bimanual performance in which the prosthesis is of definite assistance. Bilateral arm amputees gave uniformly high ratings to their prostheses in all activity groups, but their performance problems are quite different from those of unilateral arm amputees.</p> <p>A third area of interest involves the matter of basic reasons for use or nonuse of the prosthesis. In numerous instances, a particular activity was performed with the prosthesis by a considerable number of amputees of a given type. Why, then, do not all amputees of that type perform that activity with the prosthesis? Here is a question with many implications. It has been suggested that of the factors determining prosthetic usage-such as ease and convenience of performance, motivation, habit patterns-the first named is of basic importance. If, for example, we consider some specific activity such as tying shoelaces, which with prosthetic help apparently can be performed by some amputees of all types, even including a few with shoulder disarticulations, we may assume that this activity presents a certain level of difficulty and inconvenience. For below-elbow subjects the level may be low enough not to discourage more than a few from performing the task with their prostheses. But it must also be high enough so that others, by reason of habit or lack of motivation or some other influence, will tie the laces one-handed, wear loafers or buckle shoes, or in some other fashion avoid use of the prosthesis. For above-elbow and shoulder-disarticu-lation amputees, of course, the difficulty in performing the activity rises progressively and markedly, so that even though the performance potential be available with the prosthesis fewer amputees would be inclined to avail themselves of it. Obviously, then, further study of the factors affecting prosthetic utilization is highly desirable.</p> <p>A fourth area of interest has to do with the vocational potential of arm amputees. The number and variety of tasks that amputees can perform with the aid of an artificial arm is quite surprising. Extensive use of the prosthesis on the job, in activities around the house, and in hobbies suggests for arm amputees a much wider employment potential than is generally recognized. This subject too is worthy of further investigation on a more intensive basis than was possible in the NYU Field Studies.</p> <p>In general, the relation between the pre-treatment (Evaluation I) and post-treatment (Evaluation II) conditions of the five bilateral amputees was quite similar to the corresponding relation for the unilateral below-elbow amputees discussed previously. Since the bilateral sample included predominantly below-elbow fittings (4 bilateral below-elbow, 1 bilateral below-elbow/above-elbow), the similarity is not surprising. The over-all performance patterns of the 10 bilateral subjects would indicate that as a whole these patients achieved a high level of performance in a wide range of tasks. To a very considerable degree they appeared able to operate their prostheses effectively and to meet independently a substantial number of the requirements of daily living.</p> <h3>Extent of Use of Arm Prostheses in Twenty Selected Bimanual Activities</h3> <p>In the preceding section, the evaluation of the utility of prostheses provided arm amputees was based upon an analysis of their usefulness in five key activity areas, changes in activity level, and ease of use. To gain further insight in this matter, additional study was made of how amputees use their prostheses in 20 selected activities which were considered significant on the basis of four criteria:</p> <ol> <li>The activities should be important ones drawn from all five of the areas of daily living previously discussed (i.e., eating, dressing, work, social life and recreation, and home tasks)</li><li>The activities should call for a range of work levels from floor to head.</li><li>The normal performance of the activities should be bimanual.</li><li>Prosthetic performance of the activities should be possible for all unilateral amputee types.</li></ol> <p>The tasks selected were:</p> <ol> <li>Cut food with knife and fork</li><li>Sharpen pencil</li><li>Sweep up dirt with brush and dustpan</li><li>File and clean fingernails</li><li>Tie necktie</li><li>Use telephone (particularly when taking notes)</li><li>Assist someone with coat</li><li>Take bills out of wallet</li><li>Unbutton shirt sleeve</li><li>Carry several packages</li><li>Use "Flit" gun</li><li>Open bottles, jars, and tubes</li><li>Put on glove</li><li>Use paper clip</li><li>Carry cafeteria tray</li><li>Use can or bottle opener</li><li>Tie shoelaces</li><li>Play cards</li><li>Rewire electric plug</li><li>Use hammer and nails</li></ol> <p>With regard both to preprogram and to program prostheses, the subjects were asked concerning each of the selected activities five questions:</p> <ol> <li>How often in your routine of living does the occasion arise for you to perform the activity? (Daily, weekly, monthly, other)</li><li>How important is the activity in your particular pattern of living? (Very important, important, of little or no importance)</li><li>How often do you perform the activity with your prosthesis? (Daily, weekly, monthly, other)</li><li>If you do not perform the activity with your prosthesis every time the occasion arises, why not? (Write-in)</li><li>If you never use the prosthesis to perform the activity, how do you perform it? (Write-in)</li></ol> <p>The material that follows presents amputee responses to these questions and from these responses seeks to determine the extent to which prostheses were meeting amputee needs. In the main, attention is directed toward the new prostheses provided in the study, that particular data being considered as indicative of present status and hence more meaningful. Only in regard to Question 3, and then with respect to unilateral cases only, is a comparison made between old and new prostheses.</p> <p>The subjects in this study were the same as those making up the sample for the previous series of questions. Again, the data on the three unilateral amputee groups are presented first, with those for the bilateral subjects in a separate section following.</p> <h4>Unilateral Subjects</h4> <p>As we have seen, the problem of restoring function to unilateral arm amputees varies from amputee type to amputee type, the extent of restoration generally being related inversely to the degree of anatomical loss. But all three types of unilateral arm amputees usually have left one normal arm and hand, and accordingly the prosthesis needs for the most part only to assist the remaining natural member.</p> <h5><i>Frequency of Occasion to Perform Activities</i></h5> <p>The purpose of the question "How frequently does the occasion arise to perform the activity?" was to ascertain how often amputees were called upon, or had the opportunity, to perform each of the 20 selected activities, regardless of whether they used the prosthesis in the performance of the activity or whether they even performed it at all. For instance, the question "How often do you have occasion to cut food with a knife and fork?" was interpreted as "How often do you have food which requires cutting with a knife?" Responses relative to each of the 20 activities were tabulated in four categories-at least once daily; at least once weekly; at least once monthly; and less than once monthly, or never. Separate tabulations were prepared for below-elbow, above-elbow, and shoulder-disarticulation amputees. On the basis of these tabulations, there was calculated the percentage of amputees (of each type) who reported once daily or oftener as the frequency of occurrence of a particular activity. The percentage figures were then used to arrange the 20 activities in order from those occurring most frequently to those occurring least frequently. It should be emphasized that "most frequently," as used here, means occurring on a daily basis to the largest proportion of amputees.</p> <p><b>Table 15</b> presents the results for the three groups of unilateral amputees. Since these data are based on unverifiable amputee statements concerning their activities, the information in <b>Table 15</b> cannot be considered as presenting any absolute answer. Nevertheless, the data are quite consistent. Percentages for the first nine activities are of the same order for all groups, and that for the tenth shows a slight variation for the shoulder-disarticula-tion subjects only. The 10 tasks on the lower end of the table were performed daily by the least number of amputees. These data showed similar patterns of occurrence for each of the three types of amputees. Thus it would appear that some of the activities on the "selected" list confront a large proportion of all types of amputees on a daily basis. Other activities affect relatively few amputees as often as this.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>How often an activity should occur, or how many people it should affect to be considered "significant" in the lives of amputees, is a philosophical question. On an arbitrary basis we might say that the first nine activities in <b>Table 15</b>, which occur daily in the lives of more than about half of the amputee population, are "significant" activities. Yet who can say that tying a necktie (occurring to one third of the group daily) or even using a hammer and nails (less than one fifth of the population affected daily) are "insignificant" activities? Obviously such tasks could be highly significant to the particular amputees involved.</p> <h5><i>Relative Importance of the Activities</i></h5> <p>In addition to the frequency of occurrence, the degree of importance subjectively attached to being able to perform a specific activity is a second significant factor in determining the usefulness of a prosthesis to its wearer. Accordingly, the ten subjects were also asked to rate each of the 20 selected activities as "very important," "important," or "of little or no importance" to them in their regular activity pattern.</p> <p><b>Table 16</b> presents the percentages of amputees rating the respective activities as either "very important" or "important," the activities being arranged in the approximate order of importance on the basis of these percentages. For example, "cut food with knife and fork" was rated "very important" or "important" by more amputees within each of the three unilateral amputee groups than was any other of the 20 selected activities. Tying a necktie was second in importance to above-elbow and shoulder-disarticulation amputees but fifth in importance to the below-elbow subjects. Thus the ranking of activities in <b>Table 16</b> may be thought of as indicating the general level of importance attached to the activities by the unilateral amputee population as a whole.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In these terms the 20 activities fall rather obviously into three levels of significance. The first 10 tasks are rated as important by two thirds or more of the sample, cutting food being by far the most significant activity (about 9 out of 10 subjects). The next three activities may also be considered quite significant, almost one in two amputees designating them as important. The final seven tasks may be regarded as having lower general significance, no more than one in three amputees rating them as important. With the possible exception of using a "Flit" gun, however, even these low-ranking activities cannot be considered as completely insignificant. For example, rewiring an electric plug, nineteenth in order on the list, is rated as an important activity by one in five unilateral amputees of all types, a fairly substantial number of people. We may conclude therefore that, while according to the criteria used in this study the 20 selected activities vary widely in importance, all, or almost all, have value to some significant proportion of unilateral arm amputees.</p> <p>It is of interest to compare the data on the importance of activities with those on the frequency of occurrence discussed earlier. <b>Table 17</b> presents the 20 activities in approximate order of frequency of occurrence (from <b>Table 15</b>) and also lists the approximate order of importance for the 20 tasks (from <b>Table 16</b>). A fairly consistent relationship between frequency and importance is apparent at once. Seven of the nine most important activities occur very frequently.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It can be inferred therefore that, in general, activities which occur most frequently are likely to be regarded as being the most important, but the instances where this principle does not hold are also of interest. Two out of three shoulder-disarticulation amputees said they had occasion to use a paper clip daily, but only one out of three considered the activity important. Less than one in six below-elbow amputees reported that they had occasion to use a hammer and nails on a daily basis, yet two out of three considered the activity important. While only one in three of the below-elbow subjects reported tying a necktie daily, about three in four considered it important to be able to do so. Thus, some activities that occur frequently may be relatively unimportant; others may occur only infrequently but still have great personal significance.</p> <h5><i>Performance of Activities with the Prosthesis</i></h5> <p>Having considered the frequency of occurrence of the 20 selected activities and the relative importance of these activities in the lives of amputees, we come now to the frequency of use of the prosthesis in the performance of the tasks, the point being to evaluate both the extent of prosthetic use and the relationship between this utilization and the two factors previously presented (i.e., frequency of occurrence and importance).</p> <p>Data on use of the prosthesis in the 20 selected activities, obtained from all amputees in the study, were organized to show the percentage of amputees who always, regardless of frequency, used the prosthesis in the performance of a particular activity, the percentage who sometimes used the prosthesis, and the percentage who never used it, a small number of amputees who claimed that they never had occasion to perform a particular activity being excluded. <b>Table 18</b> presents the incidence of use of the program prostheses as reported by the unilateral subjects.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Analysis of <b>Table 18</b> shows that the prosthesis is used extensively by below-elbow sub- jecls in performing the 20 selected activities, all tasks save one being performed by more than 50 percent of the group every time the opportunity arose. With rare exceptions (e.g., carrying packages), the utilization of the prosthesis in performing activities dropped off sharply and progressively from the below-elbow to the above-elbow to the shoulder-disarticulation groups. An intriguing and somewhat unexpected finding is the relatively small percentage of amputees reporting occasional use of the prosthesis. It would appear that amputee use of the prosthesis tends to be on an all-or-none basis. If an amputee uses his prosthesis to perform an activity at all, he tends always to use it for that activity. Even when this general tendency is violated, there are interesting areas for speculation. For example, cutting food with knife and fork has a relatively high incidence of "sometimes" responses. Since we know that cutting food is relatively difficult at all amputation levels, it seems probable that some amputees ignore the prosthesis under some circumstances (e.g., eating at home) but use it on other occasions (e.g., eating out or when they have company) in spite of the difficulty. The fairly general always-or-never use of the prosthesis in the performance of specific activities reinforces a conclusion presented earlier-that there is for each activity a certain threshold, or tolerance, level of difficulty associated with prosthetic performance, that this threshold varies from amputee to amputee and from activity to activity, that if the performance difficulty is within the individual's tolerance limits he will tend to use the prosthesis consistently, and that if the level of difficulty is above his limit he will tend not to use the prosthesis at all.</p> <p>The data in <b>Table 15</b>, <b>Table 16</b>, <b>Table 17</b>, and <b>Table 18</b> may also be viewed as an index of the relative usefulness of the prosthesis in the performance of the 20 selected tasks and, conversely, as a measure of the relative difficulty of the several activities from the standpoint of accomplishment by means of a prosthesis. For instance, the activity "sharpen pencil" appears to be performed (with help from the prosthesis) by 90 percent of below-elbow, 76 percent of above-elbow, and 62 percent of shoulder-disarticula- tion amputees every time the occasion arises. It would appear, therefore, that sharpening a pencil is not too difficult an operation for any type of unilateral arm amputee. The corollary conclusion is that, in pencil-sharpening, the prosthesis is a highly useful assistive device. On the contrary, activities such as cutting food or holding a telephone with the prosthesis appear to be quite difficult for arm amputees at all levels, and the prosthesis is then obviously of less value.</p> <p>If we extend this index-of-usefulness concept to the entire list of 20 activities, we obtain the results shown in <b>Table 19</b>, which presents the percentage of amputees reporting use of the prosthesis every time the occasion arose for performing the activities. If, further, it is assumed that those activities in which there is the highest degree of prosthetic utilization are activities for which prostheses are most useful (or, more simply stated, easiest to perform with a prosthesis), then <b>Table 19</b> indicates that the below-elbow prosthesis is highly useful or well adapted to performance in most of the 20 activities. For above-elbow and shoulder-disarticulation subjects, the usefulness or adaptability of the prosthesis drops off sharply (i.e., the prosthesis has a high level of usefulness for considerably fewer activities). Nevertheless, some consistency in pattern is evident for the three unilateral amputee types in that activities for which the prosthesis is most useful for the below-elbow group tend also to be easiest for the above-elbow and shoulder-disarticulation subjects. Similarly, the activities that are most difficult for below-elbow subjects also present the greatest difficulty for above-elbow and shoulder-disarticulation amputees. Not readily explained is the fact that the activities for which the prosthesis is apparently most useful generally rank low in frequency of occurrence or importance or both, while activities for which the prosthesis is least useful generally rank high in occurrence and importance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Old Versus New</i></h5> <p><b>Table 20</b> compares reports by unilateral arm amputees as regards the extent of use of the old and the new prostheses. It reveals a consistent but by no means universal trend toward greater utilization of the new prosthesis as compared with the old. It is most apparent in the above-elbow subjects (increase for 17 of the 20 activities), less apparent in the below-elbow and shoulder-disarticulation amputees. As regards specific activities, however, there appears to be no systematic pattern of changes in degree of prosthetic utilization, and hence the general evidence here is rather inconclusive.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Reasons for Performing Activities Without Using the Prosthesis</i></h5> <p>In the foregoing material, consideration has been given to the matter of amputee utilization of prostheses in terms of their use always, sometimes, or never in performing each of the 20 activities under study. When an amputee always uses his prosthesis in the performance of a particular activity, some degree of adequacy of the limb for that task may be assumed. When, however, he "sometimes" performs a task without using his prosthesis, or when he "never" uses the artificial arm in the performance of that activity, prosthetic inadequacy to some degree would seem apparent. An understanding of the specific inadequacies of today's arm prostheses with respect to each of the 20 activities would be of great value in prescription and training as well as in planning research. Accordingly, each amputee who indicated less than full utilization of his prosthesis in a given activity was asked why he didn't use his prosthesis every time he had occasion to perform that task.</p> <p>The most specific, although not the most frequent, reason given for not using the prosthesis in the performance of particular activities was that the terminal device was inadequate. For instance, a given terminal device might be capable of holding a wallet or taking out bills but be ill-suited for holding a fork; it might be suitable for holding a necktie but not for handling a telephone. It may therefore be concluded that one major reason for not using the prosthesis in performing certain activities relates to lack of versatility in the terminal device.</p> <p>Another important reason advanced for failure to use the prosthesis was that the terminal device could not be brought to the appropriate functional position and operated there. Although the exact cause of this difficulty is not apparent from the data, it may be related directly to prosthetic inadequacies. As a matter of fact, not many amputees were able to give clear reasons for not using the prosthesis, so that it is possible only to speculate on the implications of the responses Some subjects stated simply that they "could not perform" the task in question. Since this kind of response may indicate either lack of training or genuine prosthetic deficiency or both, full interpretation requires further investigation. In the absence of a more complete examination, it may only be guessed that poor features in the available prosthetic equipment contributed in some way to its disuse.</p> <p>That an activity was "easier to perform without the prosthesis" was the reason given most frequently for failure to use an artificial arm. Although not especially revealing, such statements reaffirm the conclusion reached for other aspects-that for numerous amputees performance of certain activities presents such difficulty that it is "cheaper" in time, effort, and peace of mind to do without the prosthesis. A sharp rise in the number of "easier-without-prosthesis" responses was noted in the above-elbow amputees as compared with the below-elbow subjects-a result in keeping with earlier findings of decreasing prosthetic usefulness at the higher levels of amputation.</p> <p>A number of amputees reported that the prosthesis was not worn at the time a particular activity was performed. This circumstance may be considered as indicating either that the activity was easier to perform without the prosthesis or that performance without the prosthesis presented no particular problems. Were the prosthesis indispensable, it would be worn on almost all occasions when opportunity to perform the listed activities arose. Since it evidently was not, it must be assumed that some amputees could dispense with their prostheses without (to them) significant functional loss.</p> <p>Two other general observations can be made concerning the reasons for nonuse of the prosthesis. Both reinforce evidence presented earlier. One is that the number of "reasons" for nonuse of the prosthesis increased sharply for the above-elbow group as compared with the below-elbow subjects, which is only to say that more above-elbow amputees than below-elbow amputees report "sometimes" or "never" as regards use of the prosthesis. The other is that some "important" activities and some "occurring frequently" (such as cutting food, tying a necktie, using a telephone, taking bills out of a wallet, unbuttoning the shirt sleeve, tying shoelaces, and so on) are also reported by many amputees as being easier to perform without the prosthesis than with it.</p> <p>In summary, it would appear that in general the statements made by all amputee groups point, either directly or by implication, to functional inadequacies of the prosthesis as the basic reason for failure to make full use of it. The specific inadequacies, and the means of correcting them, are of course not directly or fully revealed by the present data. Even the seemingly straightforward problem of inadequate prehension in terminal devices cannot be solved simply by adding rubber bands or by providing a device with a stronger grasp. Experience has shown that for numerous amputees a lightly loaded hook is adequate for most needs and that they therefore prefer it. They object to the necessity for overcoming heavy resistance in every operation just to accommodate needs occurring infrequently. Nor is the voluntary-closing hook always the answer. Evidence presented in Section V of this series shows that such voluntary-closing devices as are currently available also are not without objectionable features. The solution of such problems must await further research into the total area of prosthetic utilization.</p> <h5><i>Manner of Performing Activities Without the Prosthesis</i></h5> <p>When, in a particular activity, an amputee regards the use of the prosthesis as either impossible or too difficult, awkward, or time-consuming, he is faced with the choice of excluding the activity from his routine of living or of finding some substitute means of accomplishing it. In the NYU Field Studies, those subjects who did not use the prosthesis in one or more of the 20 selected activities were asked what they did when confronted with the task or tasks concerned. By far the most frequent response by all classes of unilateral arm amputees was to the effect that they used the remaining hand, either alone or in combination with some other part of the body or some external object. About 3/4 of all responses told of one-handed performance, and the activities which are normally bimanual but for which performance was actually one-handed were essentially the same ones for all three classes of unilateral amputees. Moreover, activities so performed were for the most part the same ones as those reported to be "easier to perform without using the prosthesis" and also the same as those said to be most difficult to perform with a prosthesis (i.e., least facilitated by assistance from a prosthesis).</p> <p>A second alternative to use of the prosthesis, occurring in about 10 percent of the responses, was the use of substitute devices such as combination knife-forks, telephone holders, or playing-card holders-all simply aids to one-handed performance. As for other methods of accomplishing daily tasks without use of a prosthesis, some 15 percent of the subjects indicated that the services of another person were enlisted. Again, as in the case of one-handed performance, the activities most frequently cited were much the same ones for all three groups of unilateral amputees. Although there is no apparent reason behind the choice of activities for which outside help is to be sought, it is possible that the tasks selected are too difficult to perform alone, either with or without a prosthesis. But of course other factors-an overly solicitous wife, general dependency, lack of training- may well be involved.</p> <p>Two important goals in upper-extremity prosthetics are to help the amputee be independent in the performance of the tasks of daily living and to permit him to function bimanu-ally in as "normal" a fashion as possible. Obviously the final achievement level may be below that of a "normal" person, but nevertheless these goals remain the best standard of comparison. Prosthetic utilisation may be viewed as ranging from an optimum of complete independence and bimanual function to less independent performance with the sound arm alone, either with or without assistive devices, to a complete dependence on assistance from others. The employment of this scale of achievement along with additional measures of the quality or appearance of prosthetic performance should provide a useful basis for evaluating the degree of success obtained in amputee rehabilitation.</p> <p>From the material here presented, we may conclude that, in the 20 selected tasks, the most common substitution for prosthetic use involves use of the remaining "good" hand, either alone or in combination with some other part of the body or some external object. One-handedness, with or without the use of substitute devices, avoids the necessity of dependence on others, but it also leaves much to be desired from the standpoint of simulating "normal" performance. Moreover, one-handed performance of such activities as tying a necktie, or unbuttoning shirt sleeves with the teeth, is not easy. If these methods really are "easier" without a prosthesis, then prosthetic use must indeed be unattractive to the individuals concerned. The general findings of the whole study lead, however, to the obvious conclusion that a prosthesis is at best only a partial replacement for a lost limb. In unilateral arm loss, increased usage of the remaining arm and hand has unavoidably to make up, to greater or lesser degree, for existing prosthetic inadequacies.</p> <h4>Bilateral Subjects</h4> <p>As already pointed out (page 49), the 10 bilateral subjects in the Upper-Extremity Field Studies included 7 bilateral below-elbow and 3 bilateral below-elbow/above-elbow cases. Undoubtedly, the general performance level of the group as a whole was higher than it would have been had the sample included bilateral above-elbow and bilateral shoulder-disarticulation subjects. The extent of prosthetic utilization exhibited must therefore be interpreted accordingly. The responses of the subjects concerning frequency of occasion to perform the 20 selected activities, importance of the selected tasks, and frequency of actual prosthetic performance are presented in <b>Table 21</b>, <b>Table 22</b>, and <b>Table 23</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Frequency of Occasion to Perform Activities</i></h5> <p><b>Table 21</b> presents the responses of the bilateral subjects as to the frequency of occasions for performing the 20 selected activities with prostheses. It will be apparent at once that the activities for which opportunity occurred to the majority of bilateral amputees daily were for the most part the same ones occurring most frequently for unilateral subjects.</p> <h5><i>Importance of the Activities</i></h5> <p>The ratings of the bilateral group as to the significance of the 20 activities are presented in <b>Table 22</b>. On the basis of a composite of the two ratings "very important" and "important," the activities most significant to the bilateral amputees were, with the single exception of sweeping up dirt, the same ones that rated high in importance for the three unilateral groups, and more than half of these were among the ones occurring most frequently. Thus the general pattern of relationship between frequency and importance observed with the unilateral groups appears to apply to the bilaterals also. And again, as with the unilateral cases, the activities of bilaterals that apparently do not conform to this pattern give rise to speculation. A case in point is the matter of using the telephone. Ostensibly an activity which confronts bilateral arm amputees rather infrequently (<b>Table 21</b>), it is rated as significant by all of the ten subjects involved. Either the activity is considered important in spite of infrequent occurrence or, more likely, bilateral amputees avoid use of the telephone because of difficulty in handling it with their prostheses. Avoidance could explain infrequent occurrence.</p> <h5><i>Performance of Activities</i></h5> <p><b>Table 23</b> summarizes the responses of the 10 bilateral amputees as regards utilization of the program prostheses in the performance of the 20 selected activities. The always-or-never characteristic of prosthetic utilization, described earlier for unilateral amputees, is even more evident in the bilateral group. At Evaluation II, only one bilateral amputee reported "sometimes" use of the prostheses in any of the 20 activities. Judging from the proportion that never perform a given activity, the tasks that are the most difficult for bilateral amputees are also among those occurring most frequently for them, or rated most important by them, or both, so that the situation noted earlier for unilateral subjects again applies to bilaterals also. If we take as a basis of comparison the percentage of bilateral arm amputees who always use the prostheses to perform an activity, then as a group bilaterals use their prostheses more extensively than do any of the unilateral groups. The comparative figures, including the apparent anomalies, lead to the logical supposition that, if they can, bilaterals will perform the most difficult tasks in order to be independent but that some tasks may be too complex for them to manage in spite of a strong desire to do so.</p> <h5><i>Reasons for Not Using the Prosthesis and Alternative Ways of Performing Activities</i></h5> <p>Because of the small number of cases involved, and because of the variety of body movements used by bilateral arm amputees to accomplish tasks without prostheses, a detailed analysis of substitution techniques is not warranted, but two general observations may be made nevertheless:</p> <ol> <li>Prosthetic deficiencies related to nonperformance were concerned with inadequate grasp by the terminal device and inability to operate it at the appropriate level.</li><li>The chief remedy for such deficiencies was to have someone else perform the task. Use of substitute devices was confined largely to unbuttoning shirt sleeves, presumably by use of a special buttonhook held in a prosthesis.</li></ol> <h4>Discussion</h4> <p>The NYU Field Studies reveal a number of interesting highlights regarding the utilization of prostheses reported by upper-extremity amputees. With only minor exceptions, the 20 bimanual activities, chosen empirically, occurred in every case with sufficient frequency, and/or affected a large enough proportion of the amputee population, to be considered significant. Among the various amputee groups (unilateral below-elbow, above-elbow, and shoulder-disarticulation cases and bilateral arm cases) there was considerable agreement as to the relative frequency of occurrence of the activities. It must also be noted, however, that among the bilaterals the frequencies of occurrence were much lower than among the other groups. For example, only 10 percent of the bilaterals carried a cafeteria tray as often as once a week, and none of them used a "Flit" gun or rewired an electric plug as often as once a week. Finding such agreement supports the selection of these activities as being highly significant in the activity patterns of upper-extremity amputees.</p> <p>As judged by amputee opinions concerning the importance of the 20 selected activities, the level of significance attached to the individual tasks varied considerably. For unilateral subjects, 10 of the activities were rated as important by 2/3 or more of the group, five were rated as important by 1/3 to 1/2, and five were significant to less than 1/3. For the bilateral group, 11 activities were rated as important by 2/3 or more of the sample. For all amputee types, even those activities rated as important by the least number of amputees could not be regarded as totally insignificant. On the basis of amputee judgments of frequency of occurrence and of importance, therefore, the tasks selected appear to have •constituted a sound basis for study of the patterns of prosthesis usage among arm amputees. Although significant exceptions were apparent, in general the activities occurring most frequently were also rated as the most important.</p> <p>In sum, the data on amputee use of prostheses in performance of the 20 selected activities revealed a number of interesting, if occasionally unexpected, findings. Among these were:</p> <ol> <li>A sharp drop-off in prosthetic utilization from below-elbow to above-elbow to shoulder-disarliculalion amputees, found in an earlier investigation (page 32), was confirmed. While over-all utilization of the prosthesis by all amputee types, including the above-elbow and shoulder-disarticulation cases, was quite remarkable, improved utilization was most striking among the below-elbow and bilateral amputees. More than 50 percent of all unilateral below-elbow subjects reported that they always used the prosthesis in the performance of 19 out of the 20 selected activities (<b>Table 18</b>), and at least half of the bilateral amputees reported 100-percent use in 13 out of 18 applicable activities (<b>Table 23</b>).<br /> Because heretofore prostheses for above-elbow and for shoulder-disarticulation amputees have sometimes been regarded as comparatively useless, the data relating to these types of amputees are perhaps even more dramatic than are the corresponding results for the other two types. In the above-elbow group, 50 percent or more of the sample reported that for widely diverse tasks they always used the prosthesis. In a number of "important" activities, a smaller but still significant proportion of above-elbow subjects always used the prosthesis. If we focus attention on what was done rather than on what was not done, there is considerable evidence that the prostheses had real value even for the shoulder-disarticulation group. Some 50 percent or more of the sample reported that in performing 8 of the 20 tasks they always used the prosthesis. In almost none of the activities could the prosthesis be considered useless. Even for the shoulder-disarticulation amputee, to whom a prosthesis offers the least functional replacement, the fitting and use of a modern artificial arm seems worth while. And a similar conclusion may be drawn from the data presented earlier concerning use of the prosthesis in eating, dressing, and vocational, recreational, and home activities by all classes of amputees, including above-elbow and shoulder-disarticulation cases.<br /> There are, then, two sides to the coin of prosthetic usefulness. One points to the inadequacies of even the most up-to-date equipment and emphasizes the need for much improvement. The other shows that, despite prevailing inadequacies, present-day upper-extremity prostheses are quite useful devices, particularly in those cases once thought incapable of deriving much benefit from any arm substitute.</li><li>An "all-or-none" type of phenomenon in amputee use of prostheses was noted. In any given activity, an amputee tends either always to use his prosthesis or never to use it. While not absolute or universal, the inclination was considered strong enough to be viewed as a general characteristic of prosthetic utilization.</li><li>Paradoxically, the prosthesis was most useful for many activities which occurred less frequently, or which amputees rated as less important. Some of the more frequently occurring, and more important, of the 20 activities, such as "cut food with knife and fork" and "unbutton shirt sleeve," were less frequently performed with the prothesis. This may indicate that the difficulty of performing the task with prothesis influences frequency of prosthetic use more than does the frequency of occasion for use or the importance of the task.</li><li>Although there were definite indications that the program prostheses were used more extensively than were their preprogram counterparts, the increase in utilization was neither universal nor particularly striking. The reasons given by arm amputees for not using their prostheses in the performance of activities pointed generally to prosthetic inadequacies as the basic cause. While lack of a suitable all-purpose terminal device was the only specific item identifiable from the data, it appears that the whole area of amputee use or non-use of an arm prosthesis calls for further and intensive study. Where arm amputees did not use their prostheses in activity performance, the most common substitution among unilateral subjects involved use of the remaining hand, either alone or in combination with some other part of the body or some external object. One-handedness replaced what would normally be bimanual performance. Among bilateral arm amputees, "someone else does it for me" was the most frequent compensation for failure to use prostheses.</li></ol> <p>In the final analysis, the value of any particular set of principles or procedures in upper-extremity prosthetics is reflected by the degree of acceptance and utilization afforded the wearer by the prosthesis after the novelty has worn off and routine operation is expected. As part of the NYU Field Studies, therefore, the opinions of a large and diversified group of arm amputees were obtained on widely separated occasions in response to a series of open-end and multiple-choice questions relating to five key areas of activity considered more or less common to all persons. These reactions, classified and analyzed in terms of amputation type, were augmented by interviewing the same group of subjects with regard to 20 bimanual activities selected empirically as being important and of frequent occurrence in the course of daily living.</p> <p>These two inductive approaches were selected from many possibilities for investigation as being the most practical and appropriate for determining amputee opinions as regards the utility and general value of their prostheses. Though the answers obtained do not provide a completely definitive method for grading success or failure in the rehabilitation of arm amputees, they have nevertheless furnished much useful information on a number of the factors influencing acceptance of prostheses by their wearers.</p> <p>As might have been anticipated, amputees with the more disabling conditions (that is, with higher levels of amputation) were able to employ their prostheses over a smaller range of activities. On the other hand, the greatest increases in prosthetic utilization were found among these very groups. Not anticipated, however, was the indication that, in general, amputees tend to use their prostheses every time they do a given activity or not at all. The frequency of occurrence and the importance of an activity to an amputee were not always indices of the utility of the prosthesis in the particular task. While there were definite improvements in the utilization of program prostheses, a great deal of room for improvement remains, particularly in the bilateral group. Although deficiencies in the prostheses may be responsible, other factors such as training and motivation may also be involved. New studies focused on these questions will be required to illuminate the specific relationships.</p> <h3>Part 2. Amputee Performance With Arm Prosthesis</h3> <p>Since arm amputees, like most people, are not generally capable of a completely realistic self-appraisal, there is an inherent weakness in data which derive solely from verbal reports. For this reason, a second method of evaluation was devised with the purpose of assessing prosthetic use on the basis of more objective information. Based on the assumption that proficiency in use also reflects the value of the prosthesis to the amputee, two types of prosthetic proficiency tests were developed. The first was designed to measure the amputee's skill in prehension and accuracy in positioning the terminal device for prehension. The second was concerned with evaluating skill in performing a series of common daily activities.</p> <h4>Test Rationale and Test Development</h4> <p>Methods of evaluating human performance in physical activities vary from the simple, relatively objective timing of a footrace to the more subjective assessment of figure-skating or fancy diving. In the footrace, effectiveness of performance is determined solely by measuring time, since speed of performance is the main factor. In rating activities of the second type, consideration also is given to such subjective features as timing, rhythm, grace, and form because here both effectiveness and appearance are matters contributing equally to the overall result. Since the total value of performance with a prosthesis involves these two factors, efforts to analyze the quality of prosthetic use in the NYU Field Studies sought information not only on the effectiveness with which the amputee used his prosthesis in activities of daily living but also on his appearance while performing them. In this sense, "effectiveness" refers to the ability to complete a task in a reasonable time. "Appearance" has to do with the relationship between the performance of the amputee and that typical of a normal person.</p> <h4>Abstract-Function Tests</h4> <p>Considering the uses arm amputees make of the various functions provided by modern arm prostheses, it is clear that all artificial arms are employed primarily as prehensile tools. But the ability to grasp with a hook or artificial hand would be extremely limited were the terminal device restricted to one plane or to a single area of operation. The value of other prosthetic functions, whether passively or actively controlled, lies in their usefulness as a means of positioning the terminal device so that work can be performed throughout a large operating sphere. It may reasonably be said that all the motions that can be provided in an upper-extremity prosthesis are capable of classification into one of two functional categories-those involved in the act of prehension itself and those which are used to position the terminal device so that meaningful prehension may be performed. Recognition of these functional divisions led to the development of two tests of abstract function-the prehension test and the positioning test-designed to permit study of some of the factors involved in prehension and positioning. They are tests of "abstract function" in the sense that no purposeful activity is involved and that only the bio-mechanical functions of positioning and operating the terminal device are analyzed. Tests of abstract function were, then, used to assess the amputee's ability to:</p> <ol> <li>operate and control his terminal device in grasping, transporting, and releasing objects.</li><li>position his terminal device accurately and operate it effectively in various places in front and to the side of his body.</li></ol> <h4>Practical-Activities Tests</h4> <p>Tests of practical activities, used in an evaluation of how the amputees performed meaningful activities of daily living, were designed to provide information concerning the facility and appearance of a total performance in order to measure the functional value of the appliance. Selection of the performance tests of practical function was based on three prime criteria-that the activities concerned should normally require bimanual performance, that the activities concerned should be those performed frequently by the subjects being tested, and that performance of the activities should be important to the amputee.</p> <p>Tests of practical function were, then, used to rate:</p> <ol> <li>the effectiveness with which amputees perform common, everyday tasks.</li><li>the naturalness of appearance while amputees perform daily activities.</li></ol> <h4>Standards Of Performance</h4> <p>In the choice of a yardstick with which to measure the quality of prosthetic performance, consideration was given to the purpose of fitting an amputee with an artificial arm. Since the obvious aim is to restore as much as possible of the function lost through amputation, the desired outcome is that the amputee accept and use his prosthesis as naturally and as "normally" as possible. For this reason, normal, two-handed performance of tasks appeared to be a valid criterion. Because, however, it is commonly recognized that an amputee can never attain a completely normal, two-handed pattern of performance, it may reasonably be objected that such a standard is to some degree unrealistic and that the rating of amputee performance in relation to that of other amputees would provide a more reliable comparison. Perhaps it would. But the absence of norms or standards of amputee performance at the time the NYU Field Studies were undertaken precluded any choice in the matter. Consequently, the normal performance pattern was selected as the standard.</p> <h3>Sample</h3> <p>The numbers of below-elbow, above-elbow, and shoulder-disarticulation amputees available for these performance tests varied considerably. Participating in the pretreatment tests were 80 below-elbow amputees, 57 above-elbow amputees, and 4 shoulder-disarticulation amputees representing, respectively, 48 percent, 36 percent, and 17 percent of each amputation type in the sample. Attrition during the pretreatment evaluation was due to nonfunctioning or malfunctioning of arms, amputees appearing for evaluation without prostheses, and breakdown of prostheses during use with consequent inability to complete the test. Owing to the generally better functional condition of arms during the course of the program and to the increase in the number of shoulder-disarticulation and above-elbow amputees wearing arms, the number of subjects available for post-treatment testing was substantially higher: 115 (68 percent) below-elbow, 111 (70 percent) above-elbow, and 17 (74 percent) shoulder-disarticulation cases. To provide the most rigorous analysis that the data will permit, only the performances of the patients available for both pre- and post-treatment evaluations are presented. This restricts the total sample to 75 below-elbow, 51 above-elbow, and 4 shoulder-disarticulation cases. Because there are so few shoulder-disarticulation amputees, their performance ratings are not treated statistically but are described in terms of impressions and trends.</p> <p>All of these amputees took the prehension test, the first to be administered, but somewhat fewer completed the positioning test and the practical-activities tests, either because of breakdown of prostheses during the course of the tests or because of indisposition on the part of the patients.</p> <h3>Procedures</h3> <h4>Abstract-Function Tests</h4> <h5><i>Prehension Test</i></h5> <p>In utilizing his prosthesis in the activities of daily living, the amputee has occasion to grasp objects of various sizes, shapes, weights, textures, and degrees of fragility or hardness. This diversity was recognized by including, in the prehension test, objects which embody many of the variables normally encountered. Of the 12 objects used, six were of metal (five aluminum, one steel) and six of compressible rubber, and all were of one of four basic shapes-cylinders, spheres, prisms, and right-angled forms-in various sizes.</p> <p>In addition, the testing materials included a form board constructed of "Masonite" attached to a three-ply wooden board measuring 17 X 17 in. and into which were cut recesses corresponding to the shapes of the test objects but slightly (1/8 in.) larger. The test objects were arranged on a table near the board and in the same relative position as the recesses in the board so as to reduce the need to search for the proper recess. In the course of the test, the amputee transferred each of the objects from the table to the appropriate recess in the form board. Before the actual test, the amputee was given a trial run to familiarize himself with the objects and to give him an opportunity to decide upon the most efficient way to approach and grasp an object. The test was explained to the amputees as follows:</p> <p>"You are to place each of these objects in the appropriate recess in the form board. Start with the top row and work from left to right. Do each row in the same way.</p> <p>"Work as quickly as you can but also as accurately and neatly as you can; do not waste any time.</p> <p>"If you cannot handle any object after trying for 1 minute, leave it and go on to the next. You will be notified when you have been on any object for 1 minute.</p> <p>"Use only your prosthesis in handling the various objects.</p> <p>"Avoid compressing or distorting the shape of the rubber objects as much as possible.</p> <p>"You are being tested on your ability to grasp the objects and to release them into the recesses in the form board." <b>Fig. 17</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the performance of these tasks, the terminal device is first brought into a position which allows for grasp of the object. The next step, concerned with the grasp itself, involves operation of the prehension mechanism, placement of the fingers to obtain a stable grasp, and control of finger pressures to provide appropriate prehensile forces. To complete the activity, the amputee must transport the object and then position the terminal device so that the object is released at the intended place. The general impression that an amputee's performance makes upon the observer depends upon the body move- ments employed, the number of errors made, and the appearance of the control motion. In addition to these factors, the appearance of the total performance is related to the general ease, grace, and accuracy of movement.</p> <p>In an attempt to appraise in each activity both the functional and the appearance value of the amputee's performance, the significant parts of the performance were rated with regard to positioning movements for grasp and release, appearance and effectiveness of control motion, and control of finger pressure. The ratings were then combined in an over-all score on the basis of the following 10-point scale:</p> <p>Excellent (10). Graceful, rhythmic, fast, accurate performance closely approximating the cosmetic value of a performance by a normal person.</p> <p>Good (8). Smooth, rapid performance involving one or two errors and some slight body and limb distortion in several positions.</p> <p>Average (6). Uneven, somewhat inaccurate performance with occasional errors, some effort, and some body distortion.</p> <p>Fair (4). Slow performance marred by errors and uncosmetic limb and body positions.</p> <p>Poor (2). Awkward, strained, slow performance with fumbling, excessive movement, and many errors.</p> <p>The observer interpolated ratings of 9, 7, 5, 3, and 1 when indicated.</p> <p>The ability of the arm amputee to grasp and hold objects securely with a prosthesis is dependent partly upon the amount of power the man-machine combination can furnish and partly upon the structure, size, and shape of the terminal device. The number of errors made during the test was recorded, two kinds of errors being considered-grasp errors and compression errors. A grasp error was counted when the amputee regrasped an object in an attempt to obtain a more secure grasp, when the object, once grasped, fell from between the fingers of the terminal device, or when the object slipped within the fingers to the extent that the amputee had to reduce his speed or otherwise interrupt his performance to avoid dropping it. The ability to control finger pressure was appraised by tallying the number of compressible objects distorted and judging the extent of the distortion.</p> <p>Considered alone, the time taken to perform a particular activity may not be a satisfactory indication of efficiency. When considered in relation to accuracy and appearance, however, it may be an important factor, particularly in view of frequent amputee complaints regarding inability to work rapidly. In the prehension test, the amputee stood at the table and began at his own volition, a stopwatch being started with his first movement. The watch was stopped as the last object was placed in the appropriate recess on the form board, and the elapsed time was recorded.</p> <h5><i>Positioning Test</i></h5> <p>Although prehension may be considered the primary function of both the normal hand and the prosthetic replacement, the ability to position the hand or its substitute in space is a key factor in utilization. The normal, two-handed person has occasion to reach for, grasp, and release objects in three planes. He commonly handles objects at the level of the mouth, the chest, and the mid-thigh, and objects at chest or waist level up to 1-1/2 feet on either side of him are usually within his reach. To study the ability of the amputees to employ their prostheses in these areas, use was made of the positioning test, which involved six common hand positions. The six exercises devised to assess the ability of an amputee to operate his terminal device at different positions required the subject to place a 6- X 3/8-in. dowel into a clip positioned on the wall and so arranged that release of the dowel was required in both vertical and horizontal positions. Before the actual tests, each amputee was given a trial run to familiarize him with the procedures and to let him decide upon the best approach to each of the test situations. <b>Fig. 18</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the performance of this test, the amputee was required to remain within a rectangle drawn on the floor 18 in. wide and extending 36 in. from a wall. He stood outside this restraining area until, on the signal to begin, he stepped into it. Although he was required to remain there while performing each of the tasks, he was permitted to reach over the restraining lines. The patient was told:</p> <ul> <li>"Hold this stick in your sound hand and stand behind the restraining line."</li> <li>"When I say 'go,' grasp the dowel in your prosthetic hand (hook), step into the restraining area, and place the dowel in the clip on the wall."</li> <li>"Do this as quickly as you can after you receive the signal, but do it as smoothly and as accurately as you can."</li> <li>"If you drop the stick while trying to place it in the clip, or at any other time, pick it up and continue the test."</li> <li>"You are being tested on your ability to place the stick in the clip as quickly as possible with the least amount of excessive movement."</li> </ul> <p> Proficiency in this test depended upon maintaining a relatively normal posture and appearance while operating the terminal device at varying distances and angles from the body. The cosmetic value of the performance was related to ease, grace, and smoothness of body movements and to associated characteristics in prosthetic control motions, while effectiveness was reflected in the speed and accuracy of positioning the dowel in the clip. Rated individually were body- and limb-positioning movements, appearance of prehension control motion, and appearance of elbow-lock control motion. These were then consolidated into a rating of total performance by use of the same type of 10-point scale as in the prehension test: excellent, 10; good, 8; average, 6; fair, 4; poor, 2. Again, ratings of 9, 7, 5, 3, and 1 were interpolated as necessary. The time required to perform each positioning test was recorded by means of a stopwatch. <b>Fig. 19</b>, <b>Fig. 20</b>, <b>Fig. 21</b>, <b>Fig. 22</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Practical-Activities Tests</h4> <p>The practical-activities tests called for each amputee to be tested in the performance of eight activities of daily living selected from the 20 common activities discussed heretofore. For each individual the activities varied in accordance with the criteria of frequency and importance previously mentioned (i.e., each amputee was tested on the eight activities he reported as occurring most frequently in his routine of living). In choosing between activities of approximately equal frequency, those regarded by the subject as of greater importance were selected for test.</p> <p>In the discussion of the temporal sequence of events during performance of the prehension test, it was pointed out that four phases of the performance could be isolated: the positioning movements for grasp, the grasp itself, the transporting of the object, and the positioning movements for release of the object. With one major exception, this breakdown served equally well as a guide to the more complex practical activities. Here, unlike the situation prevailing in the prehension test, the amputee must not only transport an object but must also make sure it arrives at a position where it can be used or manipulated purposefully. Moreover, the nature of the prehension test forced the amputee to pick up each object from the table without use of the sound hand, a feature that made it necessary to position the body and the prosthesis so that the object could be grasped with the terminal device. In routine practice, however, the amputee frequently picks up an object with his sound hand and places it in his terminal device, thus eliminating many of the positioning movements otherwise required for grasp.</p> <p>With special reference to practical-activities tests, therefore, we may speak of "positioning movements for use," as distinct from "positioning movements for grasp or release," to mean the sequence of motions adopted by an amputee to bring an object into position for the performance of a useful task. Each activity was rated according to the normalcy of the pregrasp positioning movements, the security of the grasp, and the adequacy of positioning for use. The first two were scored on the same basis as in the prehension test; the degree of awkwardness in the positioning movements was rated and the number of errors tallied.</p> <p>Positioning for use, however, refers to the manner in which an object is grasped as that relates to the intended manipulation or use of the object. For example, when the normal hand holds a telephone, both mouthpiece and receiver are positioned close to the face for ease and comfort in hearing and speaking. The artificial hand of an amputee may hold the telephone at some distance from the face, thus necessitating some undue amount of compensatory head-bending. Or the hearing end of the telephone may be held against the ear while the mouthpiece is at eye level rather than mouth level. Errors such as these in positioning an object for use may be due either to faulty judgment on the part of the amputee or to limitations inherent in the prosthesis. Whatever the cause, the adequacy of positioning in relation to ultimate use was rated in terms of the deviation from normal position and of the degree of compensatory movement necessitated by the position of the object in the appliance. These scores were then combined in an over-all rating of the functional and cosmetic value of the amputee's performance in each activity. Rating was accomplished on a 10-point scale as follows:</p> <p>Excellent (10). Object position does not deviate from position for normal use, nor are compensatory body and limb positions necessary.</p> <p>Good (8). Object deviates slightly from position in which the normal hand would use it; slight deviations in body and limb positions may also be present.</p> <p>Average (6). Object deviates somewhat from normal position, and some compensatory deviation in body or extremity position is necessary to use the object.</p> <p>Fair (4). Object shows marked deviation from normal position for use and necessitates somewhat awkward body and limb positions to accomplish the task.</p> <p>Poor (2). Object shows marked deviation from normal position for use, accompanied by strained, awkward, or obtrusive body and limb positions.</p> <p>The observer interpolated ratings of 9, 7, 5, 3, and 1 whenever it was felt to be necessary. In the accompanying annotated illustrations are depicted the materials, instructions, and procedures utilized in the administration of the 20 activities comprising the test series. Every time the amputee began one of the practical tests, he was first requested to perform the task in his customary way. He was told that the series of tests was a means of determining how he performed those tasks normally as part of his activity pattern. It was pointed out that he was being rated on how well he did the entire task regardless of the specific use he made of the prosthesis. The basis for rating the over-all appearance of the performance was the same as that for the prehension test, and the time taken to complete each test activity was recorded. <b>Fig. 23</b>, <b>Fig. 24</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Results</h3> <h4>Reliability And Validity</h4> <p>Fundamentally a test is an instrument for measuring the extent or absence of a trait or attribute. To be most meaningful, test results must be both reliable and valid.</p> <p>The reliability of tests which are scored by means of judgmental ratings depends upon the use of consistent standards in rating performances, and ordinarily precautions are taken to ensure a comparable frame of reference among the raters. During the course of these studies, the reliability of the raters' judgments was evaluated periodically and found to be reasonably satisfactory. A stringent statistical analysis at the completion of the studies (Appendix I) confirmed the reliability of the ratings on the abstract-function tests. But because too few practical-activity tests were scored by each rater, the reliability of the practical-activities ratings could not be assessed in the same way.</p> <p>The validity of a test rests upon the degree to which it actually measures what it is designed to measure. Selection of the abstract-function tests was based upon an analysis of the functional requirements of prosthetic utilization, the skills involved being those necessary to operate the prosthesis under any circumstances. Since these tests were designed to evaluate proficiency of prosthetic use by direct measurement of meaningful performance with prostheses, they have a certain amount of face validity. The validity of the practical-activities tests appears to be self-evident, since the amputee's ability to perform a given task was in this case determined by having him actually perform it in the presence of the raters.</p> <h4>Abstract-Function Tests</h4> <h5><i>Prehension Test</i></h5> <p>As might have been anticipated, the ratings of below-elbow and above-elbow cases in the prehension test clearly indicated that performance was related to amputation level. That is to say, the average below-elbow performance level was consistently better than above-elbow performance in both pre- and post-treatment evaluations (<b>Table 24</b>). An important point reflected by these data is that the discrimination of differences by the prehension test may be regarded as evidence supporting the validity of the test. Experience indicates that the below-elbow amputee generally accomplishes more with a prosthesis and performs in a smoother and easier way than does the above-elbow amputee. Since it distinguishes these two groups clearly, the prehension test may be said to measure those qualities which distinguish the adequacy of performance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Comparison of performance ratings in the pre- and post-treatment evaluations, presented in <b>Table 24</b>, reveals a definite but not always statistically significant improvement in prosthetic function. For the 75 subjects comprising the below-elbow sample, the mean for the new arms was 5.8 as compared with 5.5 for the old. Although this difference is not significant statistically, closer study of the scores made at the two evaluations indicates a small but definite improvement in performance, especially through the middle of the score range, where there was a marked decrease in the number of amputees receiving ratings of 4 and 5 and a sharp increase in those receiving ratings of 6. It appears then that, although the treatment program had little effect on below-elbow amputees who exhibited very poor or very superior skills with their old arms, it did improve the "low-average" performers. <b>Fig. 25</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As reported in Part 1 of this Section, the below-elbow group as a whole felt that their new arms were somewhat more useful and easier to operate than the old. But this improvement was less marked than that at other levels of amputation, and some below-elbow subjects even felt that the new prosthesis was inferior to the old. The data thus tend to corroborate an earlier conclusion that for the less severely handicapped below-elbow amputee the improvement in prehension skill was not outstanding. By contrast, the 51 above-elbow cases showed a decided improvement in prehension performance with the prostheses fitted in the Field Studies. Statistically, the 4.9 average achieved with the program prostheses was significantly higher than the 4.0 average attained with the old arms. A comparison of the scores at the two evaluations revealed a clear-cut and consistent shift in the direction of improvement of performance. There was a marked decrease in the number of amputees scoring below 5 and a sharp increase in those scoring above 5. It may therefore be concluded that there was a general elevation of the level of above-elbow performance, the greatest improvement being evidenced among those of low and low-average skills. With only four cases available for analysis, the findings for the shoulder-disarticula-tion amputees are of limited significance, although among the four there was also a definite trend toward improvement in post-treatment performance.</p> <p>In general, the results obtained in the functional tests of the above-elbow and shoul-der-disarticulation amputees correspond to the verbal reports, which strongly indicated that the program prostheses were more useful, easier to operate, and more extensively used. Improvement in these two groups was more marked than in the below-elbow group, and it may therefore be concluded that the more severely handicapped segments of the amputee population derived the most benefit from the program prostheses and that the benefits accrued principally to the poorer performers. <b>Fig. 26</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The speed with which amputees performed the prehension test was also related to level of amputation, the below-elbow subjects taking significantly less time than the above-elbow cases to complete the test at both pre- and post-treatment evaluations. For no group (below-elbow, above-elbow, or shoulder-dis-articulation) did the average amount of time taken to perform the prehension test decrease significantly after treatment. The data for the below-elbow and above-elbow subjects are presented in <b>Table 25</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>According to these findings, improvement in performance skill was not reflected in an appreciable increase in performance speed, but the reasons for this apparent inconsistency are not clear. One possibility has to do with the increase in the number of subjects using APRL terminal devices at Evaluation II as compared with Evaluation I (below-elbow, from 14 to 37; above-elbow, from 8 to 31). The "double-shuffle" control motion involved in this type of device, and the consequent increase in the time required to operate it, may account for the failure to increase speed along with skill and ease of operation. At the same time, however, there is a suggestion that slower operation with APRL devices is accompanied by smoother and easier prehension.</p> <p>Two kinds of errors, grasp and compression, were recorded. Grasp errors were counted when an object slipped or fell from the terminal device or when it had to be regrasped. Compression errors were scored when the rubber objects were distorted by poor control of finger pressure. On both pre- and post-treatment evaluations, the below-elbow cases made fewer grasp errors than did the above-elbow amputees (<b>Table 26</b>). The shoulder-disarticu-lation cases made substantially more grasp errors than did either the below-elbow or the above-elbow subjects. The below-elbow subjects made fewer grasp errors after treatment (average: 8.0) than at Evaluation I (average: 9.2), but the difference was not significant statistically. There was little difference in the number of grasp errors made by above-elbow amputees before (10.0) and after (9.7) treatment. While the shoulder-disarticulation cases showed a stronger trend toward improvement in grasp security than did either of the other two groups, the result should be interpreted cautiously because of the small number of subjects involved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Thus it would appear that, despite the changes made in terminal devices, harnessing, and control-system alignment, grasp security was not greatly influenced by the treatment process. Perhaps the principal limitation was the lack of "all-purpose" versatility in the hook, its rigid structure preventing it from being completely suitable for handling a variety of objects.</p> <p>Unlike grasp errors, compression errors decreased in frequency among both below-elbow and above-elbow cases after fitting with program arms (<b>Table 27</b>), and the shoulder-disarticulation amputees appeared to follow the same trend. Below-elbow and above-elbow cases made the same number of compression errors (6.2) in the pretreatment evaluations. After the treatment procedure, there was again little difference between the scores of the two groups, the averages being 4.5 and 4.8 respectively. As one would expect, the shoulder-disarticulation cases made more compression errors than did either below-elbow or above-elbow subjects.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Better control of finger pressure may be explained by the large proportion of APRL devices fitted in the treatment program and also by the contributions from improved harness and control systems. The apparent influence of APRL terminal devices in improving control of finger pressure without also improving grasp security suggests a deficiency in hook size or shape and perhaps also a general lack of emphasis on training for the proper approach in prehension activities.</p> <h5><i>Positioning Test</i></h5> <p>Skill in performance in the positioning test, as in the prehension test, was related to level of amputation, the below-elbow amputees making consistently higher scores, and the positions in which the below-elbow subjects performed best differed from those in which the above-elbow subjects were most effective (<b>Table 28</b>). The below-elbow amputees were most effective at mouth and waist levels in the centerline (Positions 1 and 2); at chest and waist levels toward the prosthetic side (Positions 4 and 5); somewhat less effective toward the sound side (Position 6); and poorest at mid-thigh level in the centerline (Position 3). Above-elbow subjects were most proficient at two waist-level positions (Positions 2 and 5); somewhat less effective at waist level on the sound side (Position 6), at chest level toward the prosthetic side (Position 4), and at mid-thigh in the centerline (Position 3); and poorest at mouth level in the mid-line (Position 1), all of which suggests that the most efficient use of the above-elbow prosthesis is to be had at 90 deg. of forearm flexion and that less efficient operation occurs when the forearm is flexed appreciably more or appreciably less than 90 deg. Shoulder-disarticulation subjects were most proficient in handling objects at waist level, either in the mid-line or toward the prosthetic side (Positions 2 and 5).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Among both above- and below-elbow patients, skill in operating the terminal device in different positions improved significantly after treatment, a result more positive than that obtained from the corresponding prehension test, where improvement was statistically significant for above-elbow amputees only. Analysis of the pre-and post-treatment ratings of the below-elbow amputees revealed significant improvements (<b>Table 29</b>) in the ability to operate their terminal devices in three positions-at waist level in the mid-line (Position 2), at chest level toward the prosthetic side (Position 4), and at waist level toward the sound side (Position 6).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The time required by the amputees to complete each of the six tests did not appear to be related to the particular position involved, nor did performance time seem to be affected by the treatment process (<b>Table 30</b>). For the below-elbow cases, mean performance times for all six tests varied between 5 and 7 sec. in both pre- and post-treatment evaluations. Similarly, the above-elbow cases performed each of the six tests in approximately the same average time (10 to 16 sec. at Evaluation I, 9 to 14 sec. at Evaluation II).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although by definition the positioning test is "abstract," the level of performance in the several positions bears a relationship to the ability that may be expected in the performance of practical activities in the same positions. Improved performance in the test should be reflected either in greater ease in use of the prosthesis or else in the ability to perform more activities with it. Since in all cases there was an improvement in test performance after treatment, there is strong indication that treatment resulted in im- proved skill in utilizing a prosthesis in the positions required for the pursuit of the normal pattern of daily activities. While the available evidence is not wholly definitive, the distinct shift toward higher scores after treatment must be taken as indicating a general improvement in achievement level.</p> <h4>Practical-Activites Tests</h4> <p>In contrast to the abstract tests of prehension and of positioning a prosthesis, the practical-activities tests were designed to evaluate the amputees' ability to integrate the mechanical operations of prehension and positioning into the efficient performance of a complete and meaningful task. From the list of 20 tasks there were selected for each amputee eight specific test activities which, according to the subject's own statements, occurred most frequently for him in his normal activity pattern and to which he himself attributed the most importance. By virtue of these criteria some tasks were tested less frequently than others. The present analysis involves only those activities performed by 10 or more subjects.</p> <p>On this basis, the below-elbow subjects received substantially higher scores than did the above-elbow cases, a fact which only substantiates the superior ability of the below-elbow amputee in coping with daily needs. The average, weighted, pretreatment performance rating was 6.4 in below-elbow cases, 5.0 in above-elbow cases. After the treatment program, the corresponding figures were 7.0 for the below-elbow and 6.2 for the above-elbow patients (<b>Table 31</b> and <b>Table 32</b>). The scores of the few shoulder-disarticulation cases tested were far below those of either below-elbow or above-elbow amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If we consider that a score of 10 represents normal nonamputee performance, then the average score of 7.0 obtained by the below-elbow population for all 20 activities represents a creditable performance. For some tasks, of course, the average was higher than 7.0, and certain individual amputees consistently outperformed the average. It may thus be con- cluded that below-elbow subjects generally perform common daily tasks in a smooth, relatively unobtrusive, errorless manner. Although they never attain a level of skill equal to that of the nonamputee, they (and particularly the better performers in the group) tend to approach that level of performance.</p> <p>The post-treatment skill of the above-elbow group, represented by an over-all weighted-average rating of 6.2, indicates a relatively high level of performance. While the need for an elbow-lock control motion, together with the greater body distortion that results from the lack of an anatomical elbow, reduces the functional level of the above-elbow amputee to less than that of the below-elbow group, the above-elbow patient is nevertheless capable of more or less skillful use of a prosthesis.</p> <p>In the post-treatment evaluation, the below-elbow subjects generally performed better in all of the 15 activities studied. Increases in the ratings ranged from a low of 0.1 point to a relatively significant 1.5 points. Although the average increase (0.6 point) was not substantial, all of the changes were in the expected direction, an increase of a full point or more being achieved in five of the activities. A similar trend characterized the performance of the above-elbow subjects, where improvement (ranging from 0.1 point to 2.8 points) occurred in all 11 activities studied. In eight of the activities there was a gain of at least one full point, the average for all 11 being 1.2 points. The magnitude of the gains and the number of activities in which significant improvement occurred were both greater than in the case of the below-elbow subjects.</p> <p>It should be noted that most of the 20 shoul-der-disarticulation amputees taking the test at the post-treatment evaluation were capable of performing six to eight of the 20 activities. Apart from considerations of the quality of performance, this outcome represents a significant increase in the number of activities those subjects were capable of performing.</p> <h3>Discussion</h3> <p>Proficiency in the use of arm prostheses is clearly related to level of amputation. The performance of the below-elbow amputees in the NYU Field Studies was found to be consistently better and faster than that of the above- elbow amputees, who in turn performed better and faster than did the few shoulder-disarticu-lation amputees involved. Differentiation of performance was apparent in all tests, both before and after treatment.</p> <p>The most important single reason for the superior performance of the below-elbow amputee lies in his retention of the natural elbow. The above-elbow amputee is required to operate a mechanical elbow scarcely designed to provide all the functions of the natural elbow. Coupled with this mechanical limitation is the relatively high degree of skill required to operate present-day mechanical elbows smoothly and unobtrusively. Together these two factors impose upon the level of above-elbow prosthetic performance an insurmountable upper limit. The difficulty is only magnified in the case of the shoulder-disarticulation amputee, who must operate both a terminal device and a mechanical elbow by scapular abduction, a motion more gross and yet more limited than the humeral flexion normally available to both above- and below-elbow amputees. Further development and refinement of existing elbows and an increased emphasis on amputee training could conceivably elevate the level of above-elbow and shoulder-disarticulation performance to some degree. But radical changes to bring the above-elbow or shoulder-disarticulation amputee functionally up to par with the below-elbow case must await new concepts and designs in the development of components and control systems.</p> <p>As a result of the treatment program in the NYU Field Studies, the ability of all the amputee subjects to use their prostheses improved to varying extent. The superiority of the newer components and newer fabrication procedures, and the systematic training given to each patient as a routine matter, contrived to produce a general benefit differing only in degree from subject to subject and from amputation level to amputation level. That the improvement in performance among the below-elbow amputees was relatively small indicates that as a group they derived the least benefit from the new developments, for the obvious reason that their relatively high level of proficiency prior to the studies discounted their ability to profit greatly from the program. The more significant gains made by the above-elbow and shoulder-disarticulation amputees identified these groups as the major beneficiaries of the Field Studies. Although as a group the above-elbow subjects never quite attained the achievement level of the below-elbow amputees, the gap between them was significantly smaller after the treatment program, and as individuals the few shoulder-disarticulation cases improved markedly.</p> <p>The prostheses prescribed in the program were designed to provide maximum comfort, freedom of movement, and optimal replacement of lost function. The more significant improvements included higher, better-fitting, and better-appearing sockets; more useful and more easily operating elbows; improved efficiency of force transmission through better cable alignment and use of more stable materials; lighter, freer, and more comfortable harnessing; and a marked increase in the use of terminal devices offering improved control of grasp force. The advantages offered by these features were apparent in the prehension test, in which the objects to be manipulated remained stationary and the amputee was required to place himself and his terminal device in the best position for grasp and release. The need for compensatory body movements, which tend to lower performance ratings, was clearly reduced by the increased freedom and mobility of the new arms. The increased control of finger pressure offered by the new devices was reflected in the general and significant decrease in the number of compression errors made at the second evaluation.</p> <p>The value of the newer elbows seemed to be demonstrated by the improvement in performance of the above-elbow cases in the positioning test. The higher scores on the second test were based on more accurate positioning of the terminal device with lessened body contortion-a function of the elbow unit. It is interesting to note that, while performance ratings improved after treatment, speed of performance remained static. With the wider use of APRL devices on the second evaluation, an increase in the time required might have been expected. Since operating time did not increase, improved control of finger pressure was achieved without a concomitant slowing of performance.</p> <p>The similarity in performance patterns in the abstract-function and practical-activities tests may have important clinical consequences. Further study is warranted to see whether proficiency in the practical utilization of a prosthesis is related to, and perhaps reflected by, performance in abstract-function tests. Should such a relationship be found, it would be possible to convert the easily administered abstract-function test from a research tool to a clinical instrument. A combination of the more sensitive and selective elements of the tests could provide the foundation for a reliable system of measuring achievement and proficiency in amputee training.</p> <p>As a result of the Upper-Extremity Field Studies, it is now possible to establish a set of proficiency norms based upon amputee per- formance but retaining as its main criterion the skill patterns of nonamputees. The therapist who trains an arm amputee to use a prosthesis could thus have available a realistic and relatively objective standard against which to evaluate the progress and achievement of each patient, since she would be comparing his performance with that of hundreds of amputees of a similar type. The resulting improvement in the evaluation of training effectiveness should permit a judicious allocation of training time and services. Despite its inadequacies of crude-ness and of administrative difficulty, the performance-evaluation system described here established for the first time a logical plan for ascertaining the degree of functional restoration offered amputees by modern prosthetics services, a problem heretofore frequently bypassed for lack of reliable and valid methods.</p> <h3>Concluding Remarks</h3> <p>Refinement of the existing research tools on the basis of past experience, reapplication of these methods in the light of present knowledge, and the further correlation of results may well make it possible to predict the anticipated outcome when specific prosthetic components are applied to a particular arm amputee. Such an eventuality may lead to major changes in the principles of arm prescription and fitting as currently embodied in the art-science of upper-extremity prosthetics.</p> <p>The results of these studies, which have been analyzed and interpreted in the discussion sec- tions on pages 54-61, 99-103, and 143-149, are not resummarized here by way of concluding this article. It is perhaps sufficient to close with the remark that there has been presented in this article a large volume of information providing new insights-some clear, some tentative-into the over-all problem of evaluating arm prostheses. The surface of this broad field has been partially mapped along with some scattered probings of the substrate; but certainly the way has been opened for those who may elect to pursue this problem a little further.</p> <h3>Appendix I Reliability and Validity of the Test Methods</h3> <h4>Reliability</h4> <p>It is well known that test results are subject to a variety of influences and that therefore errors of measurement are to be expected under the best of experimental conditions. The tests used in the NYU Field Studies were at the time in a developmental stage, and in anticipation of errors tending to reduce reliability several precautionary steps were taken.</p> <p>Three measures were employed in scoring the performance tests-performance rating, number of errors, and time. The reliability of the last two is not open to serious question, since such errors as are likely to occur in counting errors or in reading a stopwatch are not usually of significant magnitude or of a systematic nature and can be expected to vary randomly and "average themselves out." Performance ratings, being based on judgment, are more variable, so that errors tending to reduce reliability are to be expected. Some of the principal sources of bias in this study may have been:</p> <ol> <li>Errors of Leniency. Judges tend to rate higher in the desirable traits the subject they actually know.</li><li>Errors of Central Tendency. Judges hesitate to give extreme ratings and so tend to displace subjects in the direction of the average for the entire group, thus misrepresenting the true variation in the group.</li><li>Halo Effect. We tend to judge in terms of the general mental attitude toward the test situation. Knowing, for example, that a subject is being tested for the second time, with an intervening period of fitting and training, a judge may tend to upgrade the performance unduly.</li><li>Normal Variation in the Attitude of the Judge. As individuals, we are continuously influenced by our physical environment and emotional status, and the net effect may produce variability in judgment.</li><li>Variations in Judges' Values. A judge's preconception about the relative difficulty of activities, or of the value to be placed upon efforts in relation to achievement, may bias his judgment.</li></ol> <p>During the course of the studies, 12 NYU Field Representatives conducted the performance tests over a 3-year period between 1953 and 1956. At no one time were all of the judges active in the work, and as a result they did not conduct equal numbers of tests. Nor was it always possible for the pre- and post-treatment evaluation of a patient to be judged by the same rater. Steps were therefore taken to maintain the reliability of the ratings by familiarizing judges with probable sources of error and by firmly establishing the judgment criteria. In addition, all judges were highly qualified members of the NYU staff, with previous research experience in testing and assessment. All were either graduates of the course in upper-extremity prosthetics at UCLA or else had been given similar instruction at New York University. Moreover, the criteria for evaluating performance were carefully studied in formal sessions by all the judges to aid in the development of consistent standards of judgment. The effectiveness of these steps in maintaining reasonable reliability was gauged by statistical analysis.</p> <p>Evidence of reliability was obtained by comparing periodically the independent but simultaneous ratings of a single performance as arrived at by several judges. The ratings thus obtained were evaluated by means of a statistical procedure involving Kendall's Coefficient of Concordance,<a style="text-decoration:none;">*</a> which indicates the degree to which a number of raters are applying essentially the same standard. Kendall's coefficient (W) is used to evaluate the difference between the variability in a set of ratings actually obtained and the variability to be expected in a hypothetical set of ratings if there were perfect agreement among all the raters. The resulting single measure of the extent of agreement among several judges is usually expressed as a chi-square function [x2 = p(m - 1) W, where m = number of judges and p = number of scores]. If the difference (in degree of variability) between the obtained and the hypothetical sets of ratings is significant (by statistical test), we may assume that not all of the raters were applying the same judgmental standard. Since of the original 12 raters in the Field Studies only eight rated enough cases for the results to be valid, only these eight were included in this and succeeding analyses of homogeneity. The statistical findings (x2 = 14.47; df = 7; P &lt; 0.05) indicated that a hypothesis of no relationship between the sets of ratings given by each rater is untenable. This may, therefore, be considered as indicative of a satisfactory degree of consistency in the judgments of the raters at those times. To test the reliability of the scores given by the judges during the entire test period, another technique, "analysis of variance," was used.</p> <p>"Analysis of variance" is a statistical procedure by which a number of independent samples or sets of scores may be tested simultaneously to determine whether or not they are sufficiently similar to be pooled. It is an efficient method for evaluating inter-rater reliability when more than two raters are involved. The test is expressed in terms of a ratio, F, which describes the relationship between the variability of the scores among the several raters (between groups) and the variability of each rater's scores from the mean of all raters (within groups). Simply stated, it is a test of a hypothesis that the scores given by any one rater did not vary significantly from the average of the scores given by all the raters. As shown in the relationship the larger the variance from one rater to another (between groups) as compared with a single rater's variance from the common mean (within groups), the larger the fraction (F). A large F signifies a great difference between the raters; an F of low value indicates homogeneity in the group. A low ratio therefore indicates that performances were consistently rated, that the raters are therefore interchangeable, and accordingly that all the ratings may be considered as having been given by the same rater. <b>Fig. 27</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because of the small number of cases involved, this technique could not be applied to the data from the practical-activities tests or from the abstract-function tests for the above-elbow sample at the pretreatment evaluation. It was applied to the ratings given the below-elbow cases on administration of both the prehension and the positioning test and to the ratings given the above-elbow cases at the post-treatment evaluations (<b>Table 1</b>). There were thus 21 tests in which individual raters had scored enough cases for reliability studies to be made by this means. Used were only those ratings given to subjects evaluated on both pre- and post-treatment tests by the same group of raters. Which is to say that, although an individual rater may not have scored the same subject on both evaluations, he was a member of a group of raters who had given all the ratings.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Of the 21 tests, 17 were not significantly different (0.05 level). That is, the extent to which they varied is well within the relatively narrow limits of chance fluctuation, which indicates an acceptable degree of consistency and reliability among the raters. Four, footnoted in <b>Table 1</b>, were statistically significant beyond the 0.05 level of confidence (i.e., there was enough variation in the ratings in these tests to raise a question about the consistency of rating standards).</p> <p>Despite the significant F value obtained in the four questionable tests, all results were used in this report. While the lower statistical reliability of the four may indicate rater unreliability or instability due to smallness of the sample (which would suggest the possibility of eliminating either these tests or the extreme raters), they were retained because the results clearly followed the trend of those tests appearing more reliable statistically. Since, furthermore, all of the tests are, or were, in a developmental stage, no theoretical reason could be adduced for their low reliability. There seemed to be greater value in retaining all of the tests and analyzing the conditions affecting reliability than in discarding some tests on statistical grounds alone. Considering the implications of the findings from all 21 tests, the ratings seemed homogeneous enough to warrant pooling.</p> <h4>Validity</h4> <p>To establish the validity of a test on empirical rather than logical grounds requires a previously established independent criterion with which to compare the test in question. The degree of correspondence between the two (i.e., the extent to which the test measures the same variable as does the independent criterion) is the extent of test validity. External criteria usually are: a specific outcome or product of an activity (as, for example, the number of words typed by a typist in a specific time is a criterion of typing speed), or the activity itself (as illustrated by the speed of a runner as a criterion of fleetness of foot), or the judgment of persons qualified in a given field. The abstract-function tests-the prehension test and the positioning test-require activities which correspond closely to the skills being measured (i.e., to the ability to grasp a very wide variety of objects and to operate a terminal device in several useful planes). No other criteria appear more germane. The practical-activities tests derive their validity in the same fashion-each activity is a valid test since it is itself the skill being measured.</p> <p>To go a step further and to determine whether all or none of these tests are also useful measures of "prosthetic utilization" or of "extent of functional restoration" or of "rehabilitation" requires broader study and the use of other criteria. The presently available judgment of qualified clinic personnel may be the most useful criterion with which the tests may be compared. If, for example, the way in which amputees were classified on the basis of the test results was closely related to qualified judgment about amputee achievement, it would tend to establish the validity of the test as a measure of prosthetic utilization. Such an analysis is beyond the scope of the present work but remains as an interesting avenue for further study.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Siegel, S., Nonparametric Statistics for the Behavioral Sciences, McGraw-Hill, New York, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">The five kinds of tasks selected were considered as encompassing the major undertakings in which an arm amputee might use a prosthesis in the course of daily living.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward Peizer, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Associate Director, Children's Prosthetic Study, Research Division, College of Engineering, New York University; formerly Field Supervisor, PDS, NYU.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Associate Director, Prosthetic Devices Study, Research Division, College of Engineering, New York University; formerly Field Supervisor, PDS, NYU.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-027.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-029.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-030.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-028.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-031.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-032.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-033.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-034.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-035.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-036.jpg Figure 11 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-037.jpg Figure 12 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-038.jpg Figure 13 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-039.jpg Figure 14 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-040.jpg Figure 15 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-041.jpg Figure 16 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-042.jpg Figure 17 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-043.jpg Figure 18 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-044.jpg Figure 19 http://www.oandplibrary.org/al/images/1958_02_031/autumn58-045.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 Studies of the Upper-Extremity Amputee VI. Prosthetic Usefulness and Wearer Performance Creator An entity primarily responsible for making the resource Hector W. Kay, M.Ed. * Edward Peizer, Ph.D. * https://staging.drfop.org/files/original/ccadc98869e6d29f1877b5a8fac163d2.pdf 4a2ad8e2d9b2d3bb7c740d25f0dce310 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1962_02_001.pdf Year 1962 Volume 6 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/1962_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1962_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Patellar-Tendon-Bearing Prosthesis</h2> <h5>Gabriel Rosenkranz, MD <a style="text-decoration:none;">*</a><br /></h5> <p>Obviously there is no "ideal" leg substitute short of regenerating or transplanting another normal leg. The surgeon, the prosthetist, and the amputee alike have long accepted major deficiencies in leg prostheses as inescapable concomitants of aid in a situation demanding drastic compromise. Substitution of an artificial leg for a natural one involves not only manual skills and the principles of inanimate mechanisms but is also dependent on anatomy, physiology, and biomechanics. Mutual application of these disciplines toward the advancement of leg prosthetics was slow in coming. As the science of astronomy emerged from the superstitions of astrology, so too there is sound reason to hope that the profession of prosthetics will continue to grow increasingly rapidly beyond the great dependence on "experience in the finger tips" of the ancient skill of limbmaking by adding to its art more general application of the discoveries of science.</p> <p>Time after time, like recurrent approaches of a comet from its far-reaching orbit, dazzling prospects of improvements in prostheses for below-knee amputees have illuminated the prosthetics scene. The slip socket, the many attempts at end-weight-bearing, the "muley" leg without side joints or corset, the single sidebar, the various polycentric joints, and the several attempts at below-knee suction sockets have been spectacular objects visible for varying periods in Europe, the United States, or alternately in both regions. Unhappily, these phenomena, like comets, have often receded into outer darkness as abruptly as they appeared, leaving the typical amputee with crutches, peg leg, or the centuries-old "conventional" prosthesis.</p> <p>Pads, straps, locks, and similar devices often reflect either lack of knowledge or incomplete application of such knowledge as there is to control pressure or to overcome instability. Freedom of the human knee joint, distribution of forces in proportion to tolerance of tissues, improved rather than constricted circulation, and better kinesthetic appreciation-all major goals in recent years-demand simplicity of mechanism and reduction of the false joint between the prosthesis and the body by use of an intimate fit.</p> <p>The patellar-tendon-bearing (PTB) prosthesis developed by the Biomechanics Laboratory of the University of California, to which much of this issue is devoted, combines many long-controversial features-each long used by some, yet rejected by others. PTB is almost a code name integrating a long list of elements which the prosthetist through logical principles and teachable techniques employs to distribute forces comfortably. Because of individual variations, not all so-called "PTB prostheses" contain all the major features. The name implies weight-bearing on the patellar tendon, more properly called the patellar ligament. Because in fact the nearby retinacula also share weight, perhaps the name might well be the "patellar-tendon-bearing" prosthesis! Actually, as later pages of this issue describe, many other areas of the socket (notably the closed distal end) are at least in contact with the stump, and some <i>(e.g., </i>the flares supporting the tibial condyles) share substantial portions of body weight.</p> <p>Because of its typical use of cuff suspension, with consequent freedom from thigh corset, the PTB prosthesis is often erroneously identified with the "muley" leg, which has stomped the field for as much as a century and yet has so often developed complications during prolonged use. One may speculate that the common complaints of instability of the knee attributed to the "muley" principle were at least partially related to poor alignment between socket and foot, excessive extension or even hyperextension of the socket axis and hence of the human knee, and needlessly low brim levels offering less than maximum stability to the stump. Careful prescription and medical supervision, not available for the earlier "muley," should also characterize use of the PTB and greatly enhance its chances of success.</p> <p>This writer's personal observations, from visits to the birthplace of PTB and to numerous clinics throughout the United States, have indicated misconceptions of the role of knee flexion in initial alignment of the socket axis. Certainly hyperextension is to be avoided and mild flexion sought. Because the <i>cast </i>is taken with the knee in substantial (possibly excessive?) flexion, some newly trained prosthetists initially aligned the socket bore similarly but with a very large angle of flexion. The horizontal components of forces on the condyles were reduced; but the resulting extreme bent-knee gait was tiring, the quadriceps were unduly stressed in their atrophied state immediately after their release from bondage within the thigh corset, and the unique mechanical stability of the extended human knee was transformed into the capability of substantial horizontal rotation of the flexed knee. In the below-knee amputee lacking an actively steerable ankle and foot, an unimpaired but controlled horizontal rotation in the knee joint must be considered of added importance. Thus neither the rigid "screw-home" of final extension nor the gross instability of major flexion will be as suitable as mild flexion with control of unencumbered hamstrings as internal and external rotators.</p> <p>In many past efforts too little attention has been paid to the popliteal space. The PTB includes logical principles allowing a higher brim in the popliteal space (and indeed on all aspects) than has been customary in a majority of cases yet freedom for action of the hamstrings and avoidance of bulging of tissue during sitting. The high brims medially and laterally, reflecting better appreciation of anatomy and of the force patterns dictated by biomechanics. should give greater mediolateral stability than was typically available with a "muley" limb. Eventual use of brims of tapering flexibility, by avoiding sharp pressure points at the very edge, may ultimately allow still better fitting.</p> <p>No one, especially among its developers, would acclaim the PTB as the ultimate solution. Some of its features represent successive reincarnations over a century, each with a higher survival percentage. Yet the PTB is only an evolutionary step toward greater mechanical freedom under butter neuromuscular discipline. Many apparent failures can be salvaged by careful adherence to the principles and techniques enunciated in the UCB manual and its recent revision and in the following papers of this issue of Artificial Limbs.</p> <p>The conveniences which the PTB leg accords its wearer are so numerous that continued efforts seem assured. Though a single breaker may recede, the tide is surely coming in.</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>Gabriel Rosenkranz, MD </b></td></tr><tr><td class="clsTextSmall">Surgical Consultant, Veterans Administration Prosthetics Center, 252 Seventh Ave., New York 1, New York.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Patellar-Tendon-Bearing Prosthesis Creator An entity primarily responsible for making the resource Gabriel Rosenkranz, MD * https://staging.drfop.org/files/original/d88a16b9a8be8084709e5e3adb48845a.pdf 3bf668620dc8e9ac8dec0a9782f54663 https://staging.drfop.org/files/original/9821ea432dcfb99e529e07004a2d4b03.jpg 5d9aa8667c4ce230ed99756df8364395 https://staging.drfop.org/files/original/eb06fba52df94637c4b6d85035154ac4.jpg 9af7d40a114f591e59157a8d4bd39d7b https://staging.drfop.org/files/original/71125124f8bf550f9e1870dc7b82f83d.jpg c3f5f019e6bcd04d9fb4bfd8a7ea136b https://staging.drfop.org/files/original/c83141350daa6a9dced25ae8109cb4cb.jpg 0deaeb30af7098bb4cefd892cadccc9c https://staging.drfop.org/files/original/625a51addd8c1771d0fbfb9ff3446faf.jpg 5b7f229a85f9f81fb36df03e125eb95f https://staging.drfop.org/files/original/a65a9477cbb2256a4c408da06fd4df7c.jpg f1fb749d8eb5ae7fdb7aceb732bfd3cc https://staging.drfop.org/files/original/7a19ba2de351fc879c98037e9c7956ca.jpg 0972d0503197bd6c97a29eca33d9dfc3 https://staging.drfop.org/files/original/925e37100e40101885b0398c2f037f9d.jpg 00861f5944bcf0f34911969c8b80d7f8 https://staging.drfop.org/files/original/ae805c38cc6d026abdb67d5c360765fc.jpg 3e1feb6503597f324afdbd0f0eb66669 https://staging.drfop.org/files/original/b73662bf43c27c8c8d15f5062cc7888b.jpg 77cd871c4f3f6062588f8e31b5524165 https://staging.drfop.org/files/original/2815dcc928454d295136ea43e0f41512.jpg 2f18a1dc1f8aad3b6c99e9c30f158861 https://staging.drfop.org/files/original/bc5ce764af992800cce13e2e42da079d.jpg cb14265891e5a2032db169a588dc6af6 https://staging.drfop.org/files/original/216ecc082ecea7c002317a5eb27d1d67.jpg 021d3e3f8d4f67bcbfbc942c5e2fc0f2 https://staging.drfop.org/files/original/33d9ce6aa7d9acddadfc6e4d2e456e03.jpg 8f1a796e02e25b804a1655808e51b6fa https://staging.drfop.org/files/original/be22f04f3641e4eb9b1cef97a00dc965.jpg bd502110b239db19d048a8790d45337b https://staging.drfop.org/files/original/144ae762beee458ea85db2c14acf2563.jpg 896f7b63820817cc7194620990fddbbc https://staging.drfop.org/files/original/a3349004a023470f77a69f0db5586cf6.jpg c41f81120bd300258ce7f60145120ffe https://staging.drfop.org/files/original/3346562c362c352c74f3c5f15478deb2.jpg 7a688ef6fc33cfb6d1e84f5824c83923 https://staging.drfop.org/files/original/fc6361c99f7ba00662630eaca378f5a4.jpg de3ee67c2d6483c25e1eb10f66991303 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_004.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 4 - 43 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1961_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The History and Development of Syme's Amputation</h2> <h5>R. I. Harris <a style="text-decoration:none;">*</a><br /></h5> <p>James Syme (1799-1870), the last and greatest of the pre-Listerian surgeons (<b>Fig. 1.</b>), was renowned in his day as the most eminent surgeon in the English-speaking world. Well informed and well trained by study and travel, he developed in practice the experience, courage, sagacity, and dexterity that enabled him to obtain improved results in the surgical treatment of disease at a time when anaesthesia and antisepsis were unknown. During his occupancy of the Chair of Clinical Surgery at the University of Edinburgh (1833-1869), he developed and perfected many new surgical procedures. Time has outmoded them all save one-his disarticulation amputation through the ankle joint with preservation of the heel flap to permit weight-bearing on the end of the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. James Syme (1799-1870), Professor of Clinical Surgery, University of Edinburgh, 1833-1869. Holl's engraving from George Richmond's drawing of him "in the prime of life." Probably this was Syme's likeness at age 43 when he performed his first amputation at the ankle. From Paterson. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the days before antisepsis, the surgeon's efforts to cure his patients frequently ended in disaster. Compound fractures and operation wounds were almost invariably complicated by one or other of the "hospital diseases"<a></a>: erysipelas, septicaemia, pyaemia, hospital gangrene. The patient was fortunate if he escaped death. On rare occasions his wound might heal by "first intention" or "under a scab." Otherwise the wound became "inflamed." If it discharged "laudable pus," it might heal by "second intention," and if so the outlook was reasonably good. But if the discharge was "thin, watery, sanious, acrid," the future for the patient was ominous. Death too frequently supervened. We know now that these complications were the manifestation of virulent infections. But in 1843, when Syme wrote his first paper <i>On Amputation at the Ankle Joint<a></a>, </i>Pasteur's work on fermentation<a></a> which first revealed to us the world of microorganisms, was still more than a decade in the future (1856), and Lister, the founder of antiseptic surgery, was at age 16 finishing his preliminary education with a view toward entering University College, London. Twenty-four years were to elapse before Lister first wrote on his success in treating compound fractures with carbolic acid (1867). Till then the surgeon resigned himself, as had his predecessors from the dawn of history, to the possibility that his most skillful efforts and even the most simple of his operations would be followed too often by dangerous or even fatal reactions. Writing of this period, Volkmann<a></a> said in flowery simile:</p> <blockquote><p>The surgeon is like the husbandman, who having sown his field, waits with resignation for what the harvest may bring, and reaps it, fully conscious of his own impotence against the elemental powers, which may pour down on him rain, hurricane and hail storm.</p> </blockquote> <p>There is a vivid and moving picture of the surgery of the preanaesthetic and preanti-septic era in the story <i>Rab and His Friends.</i><a></a> The author, John Brown, was Syme's pupil and later his colleague and friend, and he admired him profoundly. In the memorial he wrote after Syme's death, he stated<a></a>:</p> <blockquote><p>He was my master-my apprentice fee bought him his first carriage; a gig, and I got the first ride in it, and he was my friend. He was I believe the greatest surgeon Scotland ever produced; and I cannot conceive of a greater clinical teacher.</p> </blockquote> <p>In the account of Ailie's operation, in <i>Rab and His Friends, </i>Syme is the surgeon, and John Brown is the house surgeon who tells the story. In spite of Syme's skill in removing Ailie's breast for cancer, she develops septicaemia and dies. The agony of her death from this frequent complication of the surgery of those days is so graphically depicted that it brings home to us with dramatic force the immense risks which beset the individual who sustained a compound fracture or was compelled to submit to surgical treatment-all the more impressive because it is told to us by a participant in the tragedy.</p> <p>In the case of open fractures, the complications were so likely to be fatal that the most radical measures were deemed necessary to forestall the spread of "putrefaction." Immediate amputation through the thigh was the standard procedure for compound fractures of the tibia and fibula, amputation at the site of election (a hand's breadth below the tibial tubercle) for caries and compound injuries of the foot <a></a>. Though the mortality from these amputations was 25 percent in the hands of the best surgeons and 50 percent in hospitals less carefully managed<a></a>, the results were better than those to be had from any other form of treatment. The result of conservative treatment was much worse. Mortality from compound fractures of the femur so treated was 80 percent<a></a>, from compound fractures of the tibia 50 percent<a></a>, and from compound dislocation of the astragalus 87 percent<a></a>. Whether patients were treated conservatively or by amputation, the mortality from compound injuries of the foot was shockingly great. Of those who survived compound dislocation of the astragalus without amputation, Syme said<a></a>:</p> <blockquote><p>. . . the foot generally remains in such a state of stiffness, weakness and sensibility to external impressions as to be rather an encumbrance than a support to the patient.</p> </blockquote> <p>For those who survived after amputation of the leg, the disability from loss of the limb also was great. In the words of Syme <a></a>:</p> <blockquote><p>So long as the only alternatives were an attempt to preserve the limb and amputation of the leg, there was a strong inducement to abstain from operating. But if the patient's safety and speedy recovery may be ensured by taking away merely that part of the limb, which in the circumstances can be of little value either to use or ornament, while at the same time a stump is produced in all respects preferable to a shattered, stiff, irritable foot, I think there should be little hesitation in resorting to amputation at the ankle joint under the circumstances in question.</p> </blockquote> <p>During a period of study in Europe (probably in 1822 in Paris, where he attended Lisfranc's course of surgical operations on human cadavers and Dupuytren's lectures and clinical demonstrations), Syme learned the technique of Chopart's amputation for removal of part of a foot damaged or diseased. He introduced the procedure in Edinburgh in 1829, and the results he obtained convinced him of its merit.</p> <p>Chopart's amputation (disarticulation at the mid-tarsal joint, long plantar flap) was seldom complicated by the hospital diseases that made amputations through the leg so dangerous, and it left the patient with a partial foot capable of weight-bearing and with a movable ankle joint above it. We now know that the success of Chopart's amputation was a demonstration of the principle that, in the presence of sepsis, disarticulation is a much safer procedure than is amputation through muscle masses and the open medullary cavities of long bones. Articular cartilage left on the end of a bone, or the subarticular cortical plate and the network of cancellous bone deep to it, serve as barriers to the spread of infection, whereas the intermuscular and interfascial planes of an amputation stump provide easy pathways for invasion by microorganisms. Syme could not know the true reason for the life-saving merit of Chopart's amputation because knowledge of bacteria and of wound infections was still in the future. His conviction of its value was founded on empirical experience.</p> <p>Syme commented upon the merits of Chopart's amputation as follows:</p> <blockquote><p>The operation of Chopart, which leaves only the astragalus and os calcis, is the most valuable of all partial amputations as it commands the largest portion of the foot requiring removal for disease or injury, and at the same time preserves a support for the patient not less useful than that which is afforded by the whole of the tarsus. Its introduction was long opposed on the ground that the extensor muscles of the ankle, acting through the tendo achillis, when no longer antagonized, would draw up the heel and point the cicatrix to the ground. I performed this operation in 1829, so far as I know for the first time in Edinburgh (Great Britain?) and have frequently done so since with the most satisfactory result, no inconvenience having been experienced from the source just mentioned, as the cut ends of the tendons on the forepart of the joint speedily acquired new attachments enabling them to counteract the extensive power.</p> </blockquote> <p>Syme's favourable impression of the merit of Chopart's disarticulation at the mid-tarsal joint led him to apply the same principle to the ankle joint when caries or compound injury involved the astragalus or calcaneus, problems for which Chopart's amputation was inadequate. He performed his first disarticulation at the ankle joint in 1842, thirteen years after his first Chopart amputation. The long delay in applying to the ankle joint the principle which was so successful at the mid-tarsal joint arose from the problem of how to make the long stump bear weight satisfactorily. Disarticulation at the ankle joint might prove as effective as Chopart's amputation in saving the patient's life, but the long stump would prove an intolerable nuisance unless the patient could walk upon it. In Chopart's amputation, walking upon the stump presented no problem since the whole of the posterior half of the sole of the foot remained intact, and upon this the patient walked almost as easily as upon a normal foot. Amputation at a higher level (a hand's breadth below the tibial tubercle) permitted weight-bearing by applying the flexed knee to the padded cleft in the upper end of a crude prosthesis. This was "amputation at the site of election," a useful operation if the patient survived, but the mortality rate was 50 percent.</p> <p>To make disarticulation at the ankle joint a functional success, some procedure was needed which would permit all the body weight to be borne upon the end of the stump in a manner similar to Chopart's stump. Other surgeons had attempted to solve this problem without success. Syme's solution was to detach from the underlying tarsal bones the whole thickness of the posterior half of the sole of the foot, disarticulate the astragalus from the mortise of the ankle joint, remove the malleoli, and then reapply the heel flap to the lower ends of the tibia and fibula. This proved to be the technique necessary for a satisfactory end-bearing stump at the level of the ankle joint for it provided a thick and bulky covering for the end of the stump composed of tissue adapted to weight-bearing.</p> <p>Syme's account of the development of his new operation is interesting<a></a>:</p> <blockquote><p>The idea of amputating at the ankle joint is not new, the operation having been performed on the Continent by different surgeons before I thought of it; and it would probably ere now have become generally adopted but for the doubt that was entertained as to the ends of the bones being sufficiently covered to afford the patient a comfortable and useful support for the limb. For my own part when I read of dissecting flaps of skin from the instep, or sides of the foot, I felt so much distrust in the protection that could thus be effected against the injurious effects of pressure on a part so exposed to it, that I had no desire to try the experiment. But it occurred to me, that by performing the operation in a different way all such objections might be obviated. This was to save a flap from the sole of the foot and the thick integuments of the heel, by making a transverse incision, and dissecting these parts from the os calcis, so that the dense structures provided by nature for supporting the weight of the body, might still be employed for the same purpose. Two trials of this operation having proved satisfactory, I communicated them to the profession, and am glad to find that not only my colleagues in the hospital here, but also practitioners in other planes have already acted upon this recommendation. The additional experience of my own practice now enables me to suggest some improvements in the mode of procedure-point out an error to be avoided [this was cutting the posterior tibial artery before division into the median and lateral plantar branches]-and verify the expectation formerly expressed as to amputation of the leg being hardly ever required.</p> </blockquote> <p>Since Syme does not say why it took him so long to evolve this successful technique, we can only speculate upon the reasons. It may be that the principle of raising a skin flap and then replacing it in a new position was sufficiently radical to make him hesitate. This is a possibility for it was known that amputations with flaps were more prone to postoperative troubles than circular amputations. Or it may be that he was so immersed in the many other new surgical procedures he introduced that time elapsed before he gave thought to disarticulation at the ankle joint. Or it may be that it required thirteen years of experience with Chopart's amputation to convince him that disarticulation was so much more safe than amputation that he would be justified in applying the principle to the ankle joint. Probably this last supposition is important. In the era of "hospital diseases" it was of immense value to know that disarticulations could with certainty be relied upon to heal without the complications which after amputations endangered life and marred the healing of the stump.</p> <p>Syme's first patient <a></a>was a 16-year-old boy who suffered from caries of the tarsal bones, almost certainly tuberculosis. Syme described the problem, the operation, and the result in his first published paper on the subject:<a></a></p> <blockquote><p>John Wood, aged 16, was admitted to the Royal Infirmary on the 8th of September, 1842, suffering from disease of the foot which had suppurated and ulcerated in consequence of a twist he had given to it in walking about twelve months before. The instep was swollen and there were two openings discharging pus. A probe entered the sinuses freely into the substance of the tarsal bones, more particularly the astragalus and os calcis.... As the disease had extended beyond the limits of Chopart's amputation it would have been necessary in accordance with ordinary practice to remove the leg below the knee, but as the ankle joint seemed sound I resolved to perform a disarticulation there. With this in view, I cut across the instep in a curved direction with the convexity towards the toes, and then across the sole of the foot so that the incisions were nearly opposite one another. The flaps thus formed were next separated from their subjacent connexions which was easily effected except at the heel where the firmness of texture caused a little difficulty. The disarticulation being readily completed, the malleolar projections were removed by means of cutting pliers.</p> </blockquote> <p>Although a small slough separated from the edge of the lower flap, in which a counter-opening had to be made for the drainage of matter, the patient recovered with little reaction and left the hospital in three months. Five months after the operation:</p> <blockquote><p>. . . the wounds were soundly healed, and any degree of pressure can be born by the stump which has a round form, well suited for the adaptation of a boot or artificial foot, and is strongly protected from external injury by its thick integument.</p> </blockquote> <p>The success of his first case led Syme to the following conclusion:</p> <blockquote><p>It thus appears that compound dislocation of the astragalus and caries of this bone and the surrounding articular surfaces are the principal cases for amputation of the leg. This amputation can usually be superseded by amputation at the ankle joint. . . . The advantages promised by amputation at the ankle joint instead of operation near the knee are: 1st, That the risk to life will be smaller: 2nd, That a more comfortable stump will be afforded and 3rd, That the limb will be more seemly and useful for progressive motion. ... On these grounds I think amputation at the ankle joint may be advantageously introduced into the practice of surgery. I regret having cut off many limbs that might have been saved by it, and shall be glad if what has been said in its favour encourages others to its performance.</p> </blockquote> <p>Between 1843 and 1846 Syme wrote four more papers on amputation at the ankle joint<a></a>,and he reprinted them with a summary in <i>Contributions to the Pathology and Practice of Surgery.</i><a></a> Therein he states:</p> <blockquote><p>I have operated in more nearly two than one dozen of cases with perfect success.</p> </blockquote> <p>Years later (1857) he wrote again to attest to the satisfactory results obtained by his amputation at the ankle joint.<a></a> He had been aroused by a review in <i>Lancet</i><a></a> of the then new (4th) edition of Fergusson's <i>System of Practical Surgery, </i>in which appeared the following sentence: "Mr. Fergusson states, in relation to removal of the foot at the ankle joint in the manner recommended by Mr. Syme; that he had formed from experience a most unfavourable impression against it." Syme wrote to the editor of <i>Lancet </i>to refute Fergusson's statement. He said:</p> <blockquote><p>Sir,</p> <p>Fifteen years ago I proposed a mode of affording relief from diseases that had been held to require amputation of the leg, by removal of the foot at the ankle-joint. This proposal was favourably received, and has long since been adopted by intelligent surgeons at home and abroad as the established procedure in cases proper for its performance. It is easily executed, and proves in the highest degree satisfactory, if done in accordance with certain principles which have been carefully explained, but is difficult and disastrous if performed incorrectly.</p> </blockquote> <p>He then included letters from three patients upon whom he had performed his amputation at the ankle joint, respectively 10, 14, and 15 years earlier. One of them was his first case. All were well-with useful, painless stumps on which they could walk without difficulty and without a prosthesis if necessary.</p> <p>Before Syme died in 1870, the problem of hospital diseases was in the process of solution as the result of the clinical studies of his son-in-law, Joseph Lister. Today, more than a century since Syme first wrote on amputation at the ankle joint, we have accumulated an immense fund of knowledge on the problem of infection in surgery, and we have at our command effective measures for its control. The technique of aseptic surgery and the rigid standards of cleanliness and hygiene in operating rooms and hospitals have to a large degree enabled us to eliminate infection from our surgical procedures. When infection does occur, we can now do more to control it with antiseptic and bacteriostatic and antibiotic agents than has ever before been possible. Today, therefore, the merit of Syme's amputation lies not chiefly in the circumstance that "the risk to life will be smaller." On the other hand, it still remains the most useful of all amputations of the lower extremity "because a more comfortable stump is provided, and the limb is more seemly and useful for support and progressive motion."</p> <p>Of historical interest in demonstrating Syme's conviction of the merit of end-bearing stumps in the lower extremity is the record of his attempt to devise, at the level of the knee, an end-bearing stump embodying the principles which had proved so successful at the ankle. Two years after his first account on amputation at the ankle joint he reported the results of his attempt on two patients to remove the lower extremity at the knee and to close the wound with a skin flap so that weight could be borne on the end of the stump.<a></a>Both patients seem to have been suffering from tuberculosis of the knee joint. In both, the femur was transected through the condyles just above the carious articular surface, and the end of the stump was covered with a long posterior flap of skin derived from the calf. Both wounds healed without complication, though they took a long time to do so.</p> <p>It seems evident from Syme's presentation of these two cases that he was concerned chiefly with devising an operation safer than amputation through the shaft of the femur and that he believed that transection through cancellous bone just above the articular surface would involve less risk from hospital diseases than would amputation at a higher level. Since he did not cover the end of the stump with skin accustomed to weight-bearing, he evidently believed that the achievement of a healed stump without sepsis and without serious risk to the life of the patient was the prime objective and that good function and even end-bearing would follow good healing.</p> <p>Twenty-one years later<a></a> he wrote again about transcondylar amputation of the femur. His interest had been renewed by Carden's report<a></a> of a method of amputating through the knee or through any part of the lower end of the femur using to cover the end of the bone a single, long, anterior flap composed of skin and subcutaneous tissue only. The muscles were divided at the level of transection of the bone and thus were excluded from the flap as was also the patella. Carden's purpose was to avoid the thin, sensitive, adherent cicatrix ("retreating muscles and obtrusive bone"), which so frequently resulted when equal flaps were used, and to cover the end of the femur with a broad cap of skin and subcutaneous tissue accustomed to bearing the weight of the body in kneeling (<b>Fig. 2.</b>). Syme warmly commended Carden's amputation, which he said could be performed with little risk to the patient and had the additional advantage<a></a> that:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Carden's operation by single flap, <i>a, </i>The line of the skin incision; <i>b, </i>closure of the wound; <i>c, </i>ankylosis of the knee in extreme flexion deformity following fractured patella; <i>d, </i>the end-bearing stump obtained by Carden's operation on the limb illustrated in <i>c. </i>From Carden.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p>. . . the stump proved eminently serviceable since the skin over the bone, instead of becoming thinner, acquired additional thickness so that patients could rest upon it just as they do after amputation at the ankle.</p> </blockquote> <p>In the same publication, Syme acknowledged that his earlier attempt to perfect the technique of transcondylar amputation had failed and that the method had fallen into disuse because the skin flap derived from the calf of the leg "proved very inconvenient." Syme, therefore, nearly achieved success in devising an end-bearing stump at the transcondylar level. He failed because his attention was focused upon the avoidance of sepsis and because he did not appreciate the importance of covering the end of the stump with skin naturally adapted to weight-bearing-a strange circumstance since he seems to have been well aware of the value of "the thick integuments of the heel" in the ankle-joint cases.</p> <h4>DEVELOPMENT OF SYME'S AMPUTATION</h4> <p>Shortly after Syme's first publication on amputation at the ankle joint,<a></a> the operation began to be adopted in England and Scotland, generally with satisfactory results. In subsequent publications Syme stressed details of technique he had found essential for success (i.e., avoidance of damage to the posterior tibial artery, separation of the heel flap by dissection close to the calcaneus, drainage of the dead space, etc.). By 1846 he had perfected the technique of the operation, and from then on he accumulated experience in the application of the procedure to various problems. But he wrote nothing more on the operation except the letter to the editor of <i>Lancet </i>in 1857.<a></a></p> <h4>BAUDENS' TIBIOTARSAL AMPUTATION</h4> <p>On the Continent, and especially in France, there was less ready acceptance of Syme's amputation, partly because a somewhat similar amputation<a></a> had been reported by Baudens (<b>Fig. 3.</b>) in 1842, a year before Syme's first publication. Described as a "tibiotarsal amputation," it involved a procedure in which the foot was removed by disarticulation at the ankle joint accompanied by removal of the malleoli and the posterior half of the inferior articular surface of the tibia by a single saw cut. The end of the stump was covered with a flap from the dorsum of the foot which included in its thickness all the structures from the skin to the tarsal bones and intertarsal ligaments (skin, subcutaneous tissue, tendons, nerves, and blood vessels). Baudens' concern was to secure good healing by a flap which would drape itself over the end of the stump as the patient lay supine in bed and when healed would provide a long stump on the end of which the patient could walk (<b>Fig. 4.</b>, <b>Fig. 5.</b>, and <b>Fig. 6.</b>). When reports of Syme's operation reached France, there was renewed appraisal of Baudens' cases, and the columns of <i>Les Annates de Therapeutique </i>for 1845-1847 contain several references to the problem. The following editorial comment<a></a> is typical:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. J. B. L. Baudens, the French military surgeon who published in 1842 the account of his tibiotarsal disarticulation. <i>Courtesy National Library of Medicine, Washington, D. C.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Baudens' tibiotarsal amputation. Appearance of the stump after removal of the foot. The malleoli have been removed with the posterior margin of the articular surface of the tibia. The long dorsal flap is held up. Left to itself, it fell naturally over the cut ends of the bones and required the minimum amount of fixation. From Baudens.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Baudens' tibiotarsal amputation. Appearance of the foot after its amputation. The denuded area on the dorsum of the foot indicates the extent of the flap and shows that it included in its thickness all the tissues from the skin to the tarsal bones and inter-tarsal ligaments. From Baudens.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Baudens' tibiotarsal amputation, <i>a, </i>End of the stump when completely healed; <i>b, </i>appearance of the stump when bearing weight; <i>c, </i>simple prosthesis fitted into a boot with a high, laced top. From Baudens.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p>Our readers already know the tibiotarsal amputation of the foot which Doctor Baudens performed several years ago on a young soldier at the Gros-Caillou Hospital. We followed the patient in this hospital and then at the Val-de-Grace to which he had been transferred and we were happy one year later to see him walk well with the aid of an ordinary dancing shoe supported by two small metallic splints. This soldier took long walks without fatigue, went upstairs and went down slowly, danced and jumped with agility. His peg leg made him an excellent support and all without even a limp. We were extremely satisfied with this result in spite of the fact that one or two other patients who had had this operation performed upon them by Doctor Baudens had succumbed from gangrene of the flaps. Doctor Baudens' patient was admitted subsequently to l'Hotel des Invalides. Soon we found him again admitted to the Infirmary of the Hotel and for several months he has continued there. His stump has become excessively painful. The cicatrix has re-opened and has ulcerated at several points. Doctor Hutin, the surgeon-in-chief, has been obliged to open two small new abscesses which had formed in the tissue of the scar and it is probable that the underlying bones are affected. The patient complains of acute suffering and he demands with earnest insistence an amputation near the knee. M. Hutin will probably be obliged to come to that. This fact raises questions which demand an explanation. Let us first remark that the indifference with which our surgeons, civil and military, have received the remarkable memoir of M. Baudens is not a proof that the operation is without value for it has been practised in Edinburgh by M. Syme half a score of times with complete success. (We say indifference for the reason that no French surgeon to this day has himself performed or even recommended M. Baudens' valuable operation.) It is true, however, that M. Syme had generally operated only upon children and that he had published only the immediate results of the operation. Now the question is what are the remote effects (of the operation) since the scar in M. Baudens' patient was not inflamed or ulcerated and did not re-open for more than a year after the operation. It is all the more important, therefore, to know the actual state of M. Syme's patients for this knowledge could decide whether in the patient at Les Invalides, the evil in the scar derives from morbid constitutional conditions as we have presumed or to inherent conditions in the form of the flaps or in the stump. We should recall that in M. Baudens' operation the top of the ankle is sawed off after the disarticulation, while M. Syme <i>preserved the ankle intact. </i>Let us say finally that until new facts come to enlighten the above questions and in spite of the very great aversion the civil and military surgeons show to adopting the tibiotarsal amputation, we persist in believing it beneficial in most cases which we have from time to time indicated. Amputation at the wrist is satisfactory; why then hesitate to operate at the same level in the inferior member? We know the reasons of those who oppose. Time and new facts will be the best judges.</p> <p>We should not terminate this article without stating that there prevails in military practice a sort of aversion for all those operations which one could perhaps call <i>de luxe </i>such as partial amputation of the foot, supramalleolar amputation, etc. For several reasons orders have been to adopt the same treatment for all cases. It is otherwise in civil hospitals. We have already discussed the diverse questions connected with these declarations.</p> </blockquote> <p>This editorial was reproduced in the Monthly Journal of Medical Science, where it came to Syme's attention.<a></a> Certain inaccuracies demanded correction, and there was the implication that perhaps Syme's results were not as good as they were said to be or that, if they were, the reason should be found so that Baudens' operation could be modified and made acceptable on its merits.</p> <p>Syme therefore wrote to the editor of the <i>Monthly Journal of Medical Science</i><a></a> to clarify the points in confusion. The gist of his reply was as follows:</p> <ol> <li>He had operated upon a considerable number of patients (more nearly two than one dozen of cases) with complete success.</li><li>Most of his patients were adults (not children as stated by the editor of <i>Les Annates de Therapeutique</i>).</li><li>In one case only did he leave the malleoli intact and that was the case of an infant five months of age with an erectile tumour of the foot.</li><li>His results were satisfactory, in evidence of which he quoted from letters received from his first three patients, each of whom stated that the stump was satisfactory and was scarcely any handicap.</li><li>His mode of performing the operation was to obtain a heel flap of sufficient length by cutting from the tip of one malleolus to the tip of the other. By this the risk of sloughing was lessened if not entirely prevented.</li></ol> <p>The fact is that there was an essential difference between Baudens' tibiotarsal amputation and Syme's amputation at the ankle joint. Both surgeons were striving to devise, for treatment of disease of the foot beyond the scope of Chopart's amputation, an operation which would replace amputation below the knee. They desired to diminish the risks to the patient's life and to leave him with a long, well-covered, unscarred stump capable of total end-bearing. Both surgeons disarticulated the foot at the ankle and removed the malleoli, with or without a thin flake from the lower end of the tibia. The essential difference lay in the nature of the flap used to cover the end of the stump. Baudens used a long flap from the dorsum of the foot because it would drape itself naturally over the end of the stump while the patient lay supine in bed. It required the minimum of fixation and permitted free drainage in the immediate postoperative period. Syme used a plantar flap in order that he might cover the end of the stump with the thick integument of the heel.</p> <p>Syme's amputation at the ankle joint proved superior to Baudens' tibiotarsal amputation even in the days before antisepsis. Today, with infection eliminated as an operative risk, Syme's operation has even more to recommend it as the best operation of the lower extremity.</p> <p>In addition to Baudens' tibiotarsal amputation and Syme's amputation at the ankle joint, several other amputations of the foot in the region of the ankle were devised in the latter half of the nineteenth century with the purpose of avoiding the grave complications of amputation through the leg and to provide an end-bearing stump. Though none of these proved to have the value of Syme's amputation, they are of historic interest.</p> <h4>ROUX'S AMPUTATION</h4> <p>Roux's amputation (1845) was a supramalleolar amputation<a></a> with a medial flap to cover the ends of the tibia and fibula (<b>Fig. 7.</b>). The tibia and fibula were divided transversely above the articular cartilage, and the medial flap included all the skin on the medial side of the foot as far forward as the talonavicular joint and as far inferior as the inner margin of the sole of the foot. The advantages claimed were that the flap had an assured blood supply from the posterior tibial artery and that a weight-bearing stump could be salvaged from a foot with a heel flap damaged too extensively to permit a formal Syme's amputation. The disadvantage proved to be the inadequacy of the flap, which was too thin to withstand the stresses of weight-bearing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Roux's supramalleolar amputation with medial flap, <i>a, </i>Medial view; <i>b, </i>lateral view. Redrawn from Jacobson.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is interesting to record that Roux came to recognize the superiority of Syme's amputation. In 1846, after performing his first disarticulation of the ankle joint by Syme's method, he said:<a></a></p> <blockquote><p>It appears to me that by this operation art modifies without changing the language of nature; in fact, the malleoli being removed, the lower extremity of the leg affords a base of support which transversely exceeds that of the os calcis.</p> </blockquote> <h4>GUYON'S AMPUTATION</h4> <p>Guyon's elliptical supramalleolar amputation with posterior flap (1868) was performed<a></a> by a single elliptical incision which encircled the heel and the front of the ankle joint (<b>Fig. 8.</b>). Only a finger's breadth of skin from the plantar surface of the foot in front of the heel was retained. A flake of the os calcis was removed at the insertion of the tendo achillis and retained with the heel flap, and the tibia and fibula were transected above the articular surface of the tibia. The heel flap, with its flake from the posterior end of the os calcis, was applied to the cut surfaces of the tibia and fibula, and the skin margins were sutured. The weakness of Guyon's amputation lay in the inadequate heel flap, which did not stand up under the stress of weight-bearing, and the small tapered end of the stump, which provided too small an area of support.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Guyon's elliptical supramalleolar amputation with posterior flap. Redrawn from Farabeuf.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>pirogoff's amputation</h4> <p>In 1854, Pirogoff (<b>Fig. 9.</b>), the greatest Russian surgeon of his day, published the account of his new operation at the ankle joint,<a></a> which he intended as an improvement upon Syme's amputation. In 1847, at the Clinic of Professor Chelius at Heidelberg, Pirogoff had seen two patients upon whom Syme's amputation had been performed, and he was impressed with the results. In 1848 and 1849 he performed Syme's amputation on four patients, all of whom died (one of pulmonary tuberculosis, one of scurvy, and two of sepsis, one of whom had gangrene of the heel flap). In a fifth case, an attempt to perform Syme's amputation failed because of gross damage to the heel flap incurred in separating it from the calcaneus. Nevertheless, Pirogoff, in his attempt to deal with compound injuries and caries of the astragalus and calcaneus by some method better than amputation below the knee, continued to use Syme's amputation at the ankle joint as well as Baudens' tibiotarsal amputation and Roux's supramalleolar amputation with a medial flap. From his experience he came to the following conclusions:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Nicolai Ivanovitch Pirogoff (1810-1881), who devised his amputation at the ankle to overcome certain features of Syme's amputation that he regarded as detrimental. From <i>Pirogoff: Collected Works, </i>Vol. 1, State Publications Medical Literature, Moscow-Leningrad, U.S.S.R., 1959. Print obtained through the courtesy of Dr. W. G. Bigelow and the Russian Ambassador to Canada, His Excellency A. A. Aroutunian. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The most difficult part of Syme's amputation is the separation of the heel bone from the skin. Only with great care can the tightly adherent skin be separated without injuring the flap or making it too thin.</li><li>In Syme's operation, the skin over the tendo achillis forms the base of the flap and is much thinner than the apex of the flap. If care is not taken, it may be cut too thin and the flap may become gangrenous.</li><li>A considerable depression remains in the heel flap of Syme's amputation after the os calcis is shelled out. It may form a pocket for the collection of pus.</li><li>In the method of Baudens, the skin over the lower surface of the os calcis is removed. In this operation the creation of a foundation for the stump is not accomplished as it is in Syme's method, where the thick skin of the sole of the heel forms a sturdy covering.</li><li>In Roux's method, the formation of the posteromedial flap is certainly easier than in Syme's method. The base is wider, and necrosis occurs less often because the posterior tibial artery is cut below its division. However, the base of the flap is thinner than the summit. The depression in the flap is just as deep as in Syme's method, and, finally, the Achilles tendon is completely cut at its attachment to the os calcis as in the two previous cases.</li></ol> <p>In order to avoid these inconveniences, Pirogoff devised a new procedure (<b>Fig. 10.</b>, <b>Fig. 11.</b>, <b>Fig. 12.</b>, and <b>Fig. 13.</b>). The skin incisions resembled those of Syme. The skin, soft tissues, and tendons were divided down to the bone, and the ankle joint was entered from in front by dividing the capsule anteriorly. The lateral ligaments were detached from the malleoli and the astragalus displaced downwards. The capsule was then opened posteriorly and the superior surface of the calcaneus exposed. A saw placed through the two vertical limbs of the plantar incision and across the superior surface of the calcaneus behind the body of the astragalus and in front of the tendo achillis divided the calcaneus obliquely from above downwards at the junction of the middle with the posterior third of that bone. The posterior third of the calcaneus and the tendo achillis retained their normal attachments and formed an integral part of the heel flap. The malleoli were divided at their base and removed level with the articular surface of the lower end of the tibia. The inferior articular surface of the tibia was not removed unless it was diseased. When the vessels had been ligated, the heel flap was turned up and secured to the margin of the anterior flap by two or three sutures.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Pirogoffs amputation. Redrawn from Pirogoff<a></a> and Elmslie.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Pirogoff's amputation. Dividing the calcaneus. From Farabeuf.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Pirogoffs amputation. Appearance of the stump after removal of the foot by disarticulation at the ankle. <i>A, </i>Tibia; B, fibula, <i>C, </i>os calcis "sawn behind <i>lig. sustentacula e" </i>Redrawn from Pirogoff.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. PirogofFs amputation. Appearance of the healed stump. Redrawn from Pirogoff.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The operation was ingenious and had certain merits. If the wound healed satisfactorily and the calcaneal fragment fused to the tibia, an end-bearing stump resulted, longer than a Syme's stump, so that no prosthesis was necessary to compensate for the shortening. The patient walked without much "dipping" (limp). Also the heel flap was firmly fixed in place by fusion of the calcaneal fragment to the tibia. But there were risks which could mar the success of the operation. If the calcaneal fragment failed to unite to the tibia, an unstable and painful stump end resulted. If the wound became infected, chronic osteomyelitis with persistently discharging sinuses was prone to establish itself in the calcaneal fragment or in the lower end of the tibia. Weight was borne ultimately upon the skin over the back of the heel, an area not as well suited to weight-bearing as is the plantar surface of the foot. For success, the calcaneus had to be free of disease and the heel flap not seriously damaged by trauma. In an age when the nature and management of infection was unknown, it was an operation technically difficult and uncertain in its results. Pirogoff's first three cases were all complicated by serious sepsis, and many months elapsed before they could walk on their stumps. Even then they still had discharging sinuses. Syme's operation was easier to perform and more certain of a good result, and these advantages still prevail.</p> <h4>SUBASTRAGALAR AMPUTATION</h4> <p>Subastragalar disarticulation was first mentioned by Velpeau in a single small paragraph in his <i>New Elements of Operative Surgery.</i><a></a> He stated that it had been proposed to him by des Lingerolles, who seems not to have been a surgeon. At the time Velpeau had not performed the operation. He merely mentioned it as a promising procedure in selected cases of disease or injury of the foot. Farabeuf<a></a> perfected the operative technique and described it with excellent engravings in his <i>Precis de Manuel Operatoire.</i><a></a> He also discussed its merits and limitations. There is also a paper by Hutchinson,<a></a> which contains a good description of the operation as well as a report upon the end result obtained in six cases. Five of his cases, operated upon by the technique described by Farabeuf, were gratifyingly successful, while the sixth, in which the flap was formed by a technique similar to that of Syme, was imperfect because the heel flap could not cover the head of the astragalus without undue tension.</p> <p>Subastragalar amputation is of value in a limited number of cases, the best technique being that described by Farabeuf.<a></a> A large internal and plantar flap extends to the outer margin of the heel and as far forward as the base of the fifth metatarsal <b>Fig. 14.</b>. The subastragalar and astragaloscaphoid joints are opened from the lateral side, and the heel is inverted until the medial side of the os calcis can be reached. The os calcis is then freed from the heel flap beginning at the medial surface and is removed with the foot. Care must be taken to avoid injury to the posterior tibial artery. The advantages over Syme's amputation, as stated by Hutchinson, are:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Subastragalar amputation of de Lingerolles and Velpeau giving large plantar flap. Redrawn from Farabeuf<a></a> . Dotted line is the plane of subastragalar disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The stump is some 2 in. longer than a Syme's stump.</li><li>It gives a broader base of support.</li><li>The elasticity due to ankle movement is of marked advantage in walking.</li><li>The pad at the end of the stump is much thicker.</li><li>The arterial supply is better and runs less risk during the operation.</li><li>The artificial foot can be better fitted to the stump.</li></ol> <p>Hutchinson states that between 1891 and 1900 Syme's amputation was performed under antiseptic surgery on 27 patients at the London Hospital. The outcome: complete failure, 3 (one died); suppuration and sloughing of flap, 12; good result, 12. Several factors other than imperfection in technique (e.g., difficulty in sterilizing the skin of the heel flap, delay in operating because of patient's "obstinacy," operation in unpromising cases) contributed to the poor results. Even with the advantages of anaesthesia and antisepsis, the results at the London Hospital were inferior to those of Syme. In his meagre accounts of long-term results, Syme makes no mention of a fatality, and the functional results were good. For best results from Syme's amputation, the cases must be selected carefully, and the operation has to be timed wisely and performed skillfully.</p> <p>In Hutchinson's paper also is an informative note, quoted from Clinton Dent,<a></a> on the amputations in the South African War. The following is a summary:</p> <blockquote><p>Syme's amputation was performed in a small number of cases, but the resulting stumps were not entirely satisfactory. Damage of the foot from trauma is perhaps not as good an indication for Syme's amputation as is tuberculosis, because of damage to the skin. Sloughing of the flap sometimes occurred. Syme's amputation depends more than any other upon very careful attention to the details of the technique.... In Syme's amputation it is really impossible to depart from the lines laid down by Syme in the fashioning of the flaps. [It will be remembered that Syme emphasized this in almost the same words in his letter to the editor of <i>Lancet </i><a></a> already quoted.] There may be merit in the subastragalar amputation. English surgeons are too limited in their methods of operating upon the foot and have a good deal to learn from their French colleagues.</p> </blockquote> <p>The variety of ankle amputations introduced in the latter half of the nineteenth century is an indication of a common purpose on the part of the surgeons of that era. They were attempting to replace the dangerous operation through the upper end of the tibia with the safer disarticulation at the ankle and at the same time to provide for the end of the stump a covering which would withstand the period of postoperative sepsis without undue damage and which could ultimately permit weight to be borne upon the end of the stump. When we recall that, in its early years, Syme's amputation was performed without the benefit of anaesthesia, it is not surprising that sometimes it was executed imperfectly. Time has proved that success in Syme's amputation is dependent upon precise adherence to a particular technique. Even in today's era of advanced surgery, it still is necessary, if we are to avoid imperfect results, to use a technique which differs in no essential detail from that used by Syme.</p> <p>In Syme's day, the chief difficulty that hampered the general acceptance of his procedure was the frequent occurrence of necrosis of the heel flap, and we can appreciate from Hutchinson's account that it was still a problem even in 1900 with benefit of antiseptic surgery. According to Dent also,<a></a> necrosis of the heel flap was a complication of Syme's amputation performed on soldiers in the South African War. The chief cause of necrosis of the heel flap was injury to the posterior tibial artery. Syme himself learned, in the hard school of experience, the necessity for preserving this vessel.<a></a> His account is as follows:</p> <blockquote><p>In describing the operation, I have said that care must be taken to avoid cutting the posterior tibial artery before it divides into the plantar branches and I may now explain more particularly the ground on which this advice is founded.</p> <p>Elizabeth Wilson, aged seven, was admitted on the 19th of February on account of disease in her left ankle. . . . The foot was much enlarged, stiff and shapeless; and two sinuses allowed a probe to pass into carious bone.</p> <p>On the 21st I proceeded to amputate at the ankle joint, but finding that anchylosis had taken place between the articular surfaces, I exposed the extremities of the tibia and fibula, and sawed them through without previously removing the foot as usual. In tying the vessels, it appeared that the posterior tibial artery had been divided before its division into the plantar branches, so that one ligature sufficed in place of two.</p> <p>The stump looked remarkably well and the result of the operation was expected to prove very favourable. It was, therefore, with much surprise, and no small disappointment, that in the course of a few days I saw the flap had sloughed through fully half its extent. Recovery was consequently delayed much beyond the ordinary period. . . .</p> <p>I attributed the sloughing in this case to the undue pressure of the bandage; and having occasion soon afterwards to perform the operation on a patient in Minto House, intentionally divided the posterior tibial before its division, in order to obtain the same facility in tying the vessel as on the last occasion. To my surprise and concern, the flap again sloughed to the same extent as in the case just related, and as great attention had been paid to the dressing of the stump, I could not refer this effect to the cause formerly supposed. But as on both occasions the artery had been cut before its division, while in all other cases it had been left entire, and as the flap, being deprived of nourishment from most of its ordinary sources, must be supplied with blood only through the successive anastomoses of small vessels, I concluded that this deviation from usual practice had led to the mischief in question, and I resolved to avoid it for the future.</p> </blockquote> <p>A further cause of poor result from Syme's amputation was damage inflicted on the skin over the heel while the flap was being separated from the calcaneus or while the tendo achillis was being detached from its insertion. Unless the plane of dissection hugged the calcaneus, and unless the dissection was performed with precision and delicacy, the skin was apt to be buttonholed. It was this problem especially that led Pirogoff to introduce his operation and Guyon to devise his elliptical supramalleolar amputation at the ankle joint. Syme's amputation, then and now, is an operation which must conform rigidly to an exact technique. If it is not performed properly when first attempted, many of its advantages will be lost irretrievably. It is interesting that the technique necessary for success is almost exactly that which Syme himself ultimately evolved. As we shall see later in the section on technique, the only addition of proven value is subperiosteal separation of the calcaneus from the heel flap. All other attempts at improvement have failed to achieve the success which follows the use of Syme's original technique.</p> <p>The 1914-1918 war, with its innumerable casualties, renewed interest in amputations. One outcome was the publication of an English translation of the small volume, <i>Artificial Limbs</i><a></a>, written by the French surgeons Broca and Ducroquet. In discussing end-bearing stumps, this monograph makes no mention of Syme's amputation. It lists only supramalleolar amputation, disarticulation at the ankle joint, subastragaloid amputation, and osteoplastic amputation through the ankle joint. An editor's footnote with respect to supramalleolar amputation states, "In England, of course, this is always called a Syme's amputation." This statement is not strictly accurate since an important detail of Syme's amputation contributory to its success is the large area of support provided for the heel pad when the lower end of the tibia is left intact or virtually so. Syme's operation is not a supramalleolar amputation; it is a slightly modified disarticulation. French surgeons, particularly Farabeuf,<a></a> were meticulous in distinguishing between disarticulations (in which group Syme's amputation was included) and amputations (e.g.,the supramalleolar operations of Roux and Guyon). It is true that Syme himself always referred to his operation as "amputation at the ankle joint," but in doing so he evidently used the term "amputation" in a general sense and not in the exact sense of Farabeuf. It is certain from Syme's description of his operations, and from the derivation of his operation from the disarticulation of Chopart, that Syme's operation was in fact disarticulation of the foot at the ankle joint with removal of the malleoli. Had Syme emphasized this as precisely as did Farabeuf, he might have prevented the innumerable supramalleolar Syme amputations which have been performed because of imperfect knowledge of Syme's technique or in the hope of obtaining an improved stump. These are the cases which have cast doubt on the value of Syme's operation, for the resulting stumps are functionally imperfect and may be complete failures.</p> <p>E. C. Elmslie, who translated and edited the English edition of Broca and Ducroquet,<a></a> formed a high opinion of Syme's amputation. In a footnote to the paragraph on low leg amputations allowing walking with end-bearing only, he says, after brief discussion of Pirogoff's amputation, subastragaloid amputation, and disarticulation at the ankle joint: "In fact, in this region there is Syme's amputation and a number of other far inferior amputations which should never be considered when a Syme amputation is possible." In 1924, in the section on amputations which he contributed to Carson's <i>Modern Operative Surgery</i><a></a> Elmslie states with reference to Syme's amputation:</p> <p>When successful it yields an excellent stump which is capable of complete end bearing. It can be fitted with a simple and cheap stump boot known as an elephant boot. Upon such a boot a patient with a Syme's amputation can often walk ten or twelve miles. In fact, Syme's amputation is so satisfactory that it may be said that all other amputations of the foot at a lower level are obsolete except amputation of the toes or parts of the toes.</p> <p>Despite the high regard in which he held Syme's amputation, Elmslie does not appear to have understood how essential for success is exact adherence to the precise details of Syme's technique. For reasons which probably were related to limbfitting problems, Elmslie felt it necessary to secure an improved Syme stump, and for that purpose he devised a modified Syme amputation which is described in his chapter on amputations in Carson's <i>Modern Operative Surgery.</i><a></a> It is the only procedure for Syme's amputation that is described and illustrated there. Syme's original technique is not mentioned. Elmslie does not state clearly why he felt it necessary to revise Syme's technique. However, he does state that the Syme stump was too long and the end too bulky. Almost certainly these represent criticisms by the limbfitters of Elmslie's day, who certainly had difficulties in designing, manufacturing, and fitting a satisfactory prosthesis for a Syme stump.</p> <h4>ELMSLIE'S MODIFIED SYME'S AMPUTATION</h4> <p>Elmslie's modified Syme's amputation<a></a> differed from the classical Syme's amputation in three essential particulars:</p> <ol> <li>The heel flap was smaller.</li><li>The dissection was carried out from the dorsal to the plantar surface.</li><li>The tibia and fibula were transected at a level well above the ankle joint.</li></ol> <p>Apparently the purpose of these changes was twofold: to provide a small, neat, tapered end to the stump and thus avoid the bulge in the prosthesis necessary to accommodate a bulbous-ended stump; and to accommodate more easily the ankle-joint mechanism by high transection of the tibia and fibula.</p> <p>Elmslie was not the first person to advocate high transection of the tibia and fibula to facilitate the introduction of an ankle joint mechanism in the artificial limb for a Syme amputation in the space between the end of the stump and the level of the ground. Henry Thompson,<a></a> at a meeting of the Pathological Society of London on April 21, 1863, shared in the presentation of seven patients with Syme's amputation and two patients with Pirogoff's amputation. As reported in <i>Lancet, </i>Thompson's remarks were as follows:</p> <blockquote><p>He [Thompson] would not enter upon the various points of comparison between Syme's amputation and that modification of it in which a portion of the os calcis is left in the flap, but would only refer to the different results which remained after the two operations [i.e., Syme and Pirogoff] as regards the kind of artificial limb which is applicable afterwards. He thought it very important for the surgeon and the mechanician to act in concert in most amputations of the lower extremity and he therefore showed also two artificial limbs to illustrate the advantage in relation to this matter which the proceeding of Syme offered over that of Pirogoff. In the former the patient enjoyed the advantage of complete ankle joint movement of the limb; while in the other, the stump being so close to the ground, there was no room for it and the best substitute that could be applied was by iron hinges outside of the limb. . . . Mr. Thompson wished to point out the necessity of taking off a sufficient slice of bone, including the two malleoli instead of merely removing the lower portion of the latter, so as to avoid extreme width and a bulbous stump which was more difficult to fit with a well made artificial limb than a stump which tapered gradually from the calf downwards. . . . Mr. Thompson said that the objection to the bulbous form of the stump did not materially apply if the common circular shoe which is laced around the lower part of the leg was worn [elephant boot], but it did to the artificial leg.</p> </blockquote> <p>In Elmslie's operation the skin incision was an ellipse (<b>Fig. 15.</b>) which commenced on the plantar surface of the foot 3/4 in. in front of the point of the heel. Therefrom it extended obliquely upward and forward over either malleolus to a point on the anterior surface of the ankle 1 in. above the joint line. The ankle joint was entered, the foot depressed, and the medial and lateral ligaments of the joint divided from within the joint. The astragalus was then dislocated from the mortise of the ankle joint by depressing the foot still farther. Doing so exposed the tendo achillis, which was then divided at its insertion. The calcaneus was then separated from the heel flap by dissection close to the bone from above downward. The tibia and fibula were transected 3/4 in. to 1 in. above the highest level of the ankle joint, and the heel flap was then closed over the ends of the tibia and fibula.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Elmslie's modified Syme's amputation. Redrawn from Elmslie.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Though Elmslie intended his modified Syme's amputation to be an improvement over Syme's original procedure, the result has not lived up to his expectations, and for three reasons: the small heel flap deprived the stump of an adequate covering of skin and subcutaneous tissue adapted to weight-bearing; the high transection of the tibia and fibula diminished the cross-sectional area of their cut surfaces and impaired their support for weight-bearing; the end of the stump was no longer bulbous but was tapered, a feature that permitted the artificial limb to slip up and down during walking. He succeeded in simplifying the limbfitters' problem, and he succeeded in making the stump neat and tidy, but in so doing he sacrificed the qualities of Syme's amputation essential for success- namely, a bulbous stump end to ensure that the grasp of the prosthesis would be secure and a wide area of bony support covered by a large, thick, heel pad adapted to weight-bearing.</p> <p>Elmslie's modified Syme's amputation thus closely resembled Guyon's elliptical supramalleolar operation with posterior flap.<a></a> It seems probable that in modifying Syme's operation Elmslie adopted Guyon's technique, for the only difference between Guyon's elliptical supramalleolar amputation and Elmslie's modified Syme's amputation was that in the former, unlike the latter, a flake from the posterior end of the calcaneus was removed along with the insertion of the tendo achillis and that later the flake was applied to the cut surface of the tibia when the heel flap was sutured into place. Elmslie's modified Syme's amputation was widely used in England (but not in Scotland) during the period following the 1914-1918 war, probably because of the confidence with which he advanced it as an improvement over Syme's technique and probably also because he made no mention of Syme's technique.<a></a> It is likely that this adoption of his modified Syme amputation in England led to the dissatisfaction with Syme's amputation expressed by Langdale-Kelham and Perkins of Queen Mary's Hospital at Roehampton.<a></a> They said ". . . this type of operation does not stand weight bearing on the average longer than eight years. ... It is to be hoped that the modified Syme's amputation will soon be as obsolete as the original Syme's." The handbook of the British Ministry of Pensions, <i>Artificial Limbs and their Relation to Amputations</i><a></a> also speaks with faint praise of Syme's amputation. In Scotland, in contrast to England, a rigid adherence to the precise details of Syme's original technique resulted in satisfactory end-bearing stumps. In Canada, for a similar reason, experience has also been satisfactory. The favorable results with Syme's amputation in Scotland and Canada as contrasted with the dissatisfaction with Syme's amputation in England is evidence that a wide area of bony support covered by a large, thick, heel pad is essential for a satisfactory Syme's stump. Syme's original operation provided these indispensable features, and consequently his stumps bore weight on the end satisfactorily and more or less indefinitely. Attempts to improve upon Syme's amputation (e.g., the modifications of Roux and of Elmslie), chiefly in the matters of making the end of the stump neat and of providing the limbmaker with more space for the ankle joint of the prosthesis, proved unsatisfactory in the long run because the area of support was too small and because the covering over the end of the stump would not stand up under long-continued end-bearing.</p> <p>Syme was blessed by good fortune as well as good sense. His sound judgment brought him to the conclusion that disarticulation at the ankle joint and removal of the malleoli would constitute a safe and effective means for the removal of a damaged or carious foot. The idea of preserving the heel flap to cover the end of the stump and to provide end-bearing could have come only from profound insight. His courage, boldness, and skill enabled him to devise a simple technique by which these things could be accomplished. It was his good fortune that the operation he planned and the technique he devised have both proved to be of continuing value. He knew nothing of the minutiae which concern us today, and he ill understood the grave complications which often discounted the surgeon's efforts. But he was far-sighted enough and bold enough to embark upon a radically new approach to an old problem, to build upon his first successes, and to eliminate such defects as were present in his first efforts (e.g., to preserve the integrity of the posterior tibial artery).</p> <h4>FUNDAMENTAL PRINCIPLES OF END-BEARING AMPUTATIONS OF THE LOWER EXTREMITY</h4> <p>The essential functions of the normal lower extremity are weight-bearing and locomotion, and amputation stumps in the lower extremity must be designed accordingly. The more perfectly they bear the body weight and transmit the forces of locomotion the more efficiently will they utilize prosthetic appliances. For purposes of weight-bearing, nothing is as satisfactory as a stump which can bear weight upon its end. Propulsion is best accomplished by a leg stump of the greatest possible residual length and with as many normally functioning nerves, muscles, and joints as can be preserved. Only two levels in the lower extremity can be adapted to provide end-bearing stumps-the lower end of the femur with a covering of prepatellar skin, and the expanded lower ends of the tibia and fibula covered by the heel pad.</p> <p>To secure an end-bearing stump in lowerextremity amputations, certain requirements must be met:</p> <ol> <li>In order to provide a broad area of support, the bone must be divided where its cross-sectional area is as great as possible.</li><li>The whole of the cut surface of the bone must be capable of bearing weight. This requirement can be achieved by a strong meshwork of cancellous bone across the whole area, or, in the case of the ankle joint, by retention of the subarticular cortical bone at the lower end of the tibia. The tubular cross-section of the shaft of the tibia at higher levels is unsuited to weight-bearing.</li><li>The skin and subcutaneous tissue covering the end of the stump must be appropriate for weight-bearing.</li><li>The weight-bearing skin must be properly centered upon the area of support and firmly attached to it.</li><li>The end of the stump must be bulbous, thus ensuring that the prosthesis will not slide off the stump or rotate upon it.</li></ol> <p>Syme's operation, properly performed, meets all these requirements. For conditions which require amputation in the vicinity of the ankle joint, it provides a stump superior to all others. But the initial operation provides the sole opportunity for securing a Syme stump satisfactory in all respects. Even minor deviations from detail are prone to result in a stump imperfect in one way or another, and such imperfections usually cannot be corrected by secondary operations. If the imperfection is not great, the stump may function reasonably well, for some time at any rate, but it may not stand up indefinitely, as has proved to be the case with Elmslie's modified Syme's amputation.</p> <p>Because preservation of the unique structure of the heel pad is essential for attaining a perfect Syme stump, it is appropriate now to describe its specialized nature. In the human heel, as in other parts of the body adapted to weight-bearing (finger tips, thenar and hypothenar eminences, ischial tuberosities, and prepatellar pads), the ability to withstand the stresses imposed by the weight of the body and by body movements derives in part from the thickness of the skin and in part from a special elastic adipose tissue beneath the skin. Of the two, the latter is the more important, for without the buffering action of this elastic adipose tissue not even a thick layer of skin can provide satisfactory protection against the stresses of weight-bearing.</p> <p>Kuhns<a></a> has reviewed our knowledge of elastic adipose tissue and has brought to our attention the detailed studies of Tietze<a></a> and Blechschmidt.<a></a> Kuhns shows that the stress-absorbing qualities of the subcutaneous layer in areas adapted to weight-bearing are due to its structure and to the elastic qualities of its connective tissues. In these areas the subcutaneous tissue consists of dense septa of elastic connective tissue which completely enclose spaces rilled with fat cells. Each such loculus is separate from its neighbour, and the fat cells within it are isolated from the surrounding loculi. In the heel pad, the fibrous septa extend from the dermis below and are attached above to the calcaneus posteriorly and to the plantar aponeurosis anteriorly. The flasklike spaces are filled with fat cells, and their walls are reinforced by oblique and spiral bands. These compartments, bounded by sheets of elastic fibrous tissue and filled with semifluid fat, act as hydraulic buffers. Under pressure they change form but not contents. When pressure is released, they resume their normal size and shape owing to the elasticity of the walls. A lateral radiograph of the heel, if not overexposed, often will reveal this fundamental structure of the subcutaneous tissue. The vertical septa of the relatively dense, elastic, connective tissue are readily seen extending upwards from the skin below to be attached above to the calcaneus posteriorly and to the plantar aponeurosis anteriorly (<b>Fig. 16.</b>, <b>Fig. 17.</b>, <b>Fig. 18.</b>, <b>Fig. 19.</b>, <b>Fig. 20.</b>, <b>Fig. 21.</b>, and <b>Fig. 22.</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Structure of the heel pad as revealed by radiograph. Top, without weight-bearing, bottom, patient standing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Structure of the heel pad, diagrammatic representation reproduced from radiographs. Top, without weight-bearing; bottom, patient standing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Anatomy of the field of Syme's amputation. Insert shows the plane of the section. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Structure of the heel pad in Syme's amputation. Coronal section enlarged from Figure 18. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Longitudinal section of foot to show structure of heel pad. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Horizontal section through heel pad to show structure. This specimen is a slice of the heel pad cut parallel to the sole of the foot and midway between the skin and the inferior surface of the calcaneus. The skin surface is on the back and either side of the heel. Insert shows plane of section. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Vertical section through heel flap, approximately 8X. <i>a, </i>Bellies of short muscles of foot; <i>b, </i>plantar aponeurosis; <i>c, </i>specialized elastic adipose tissue; <i>d, </i>skin. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is important to preserve intact this specialized subcutaneous tissue in the heel flap of a Syme stump; otherwise the weight-bearing qualities will be impaired. To do so necessitates removal of the periosteum and the plantar aponeurosis with the heel flap, since these elements form the superior attachment of the septa. If the heel flap is dissected through the layer of subcutaneous tissue (i.e., between the periosteum and the plantar aponeurosis above and the dermis below), the septa will be divided and the loculi opened, thus allowing the fat cells to leak out. In such circumstances, the distinctive structure and function of the elastic adipose tissue is lost, for then the tissue no longer consists of separate, elastic-walled spaces enclosing fat under tension. Once the elastic adipose tissue has been damaged, its stress-resistant properties cannot be restored.</p> <h4>THE TECHNIQUE OF SYME'S AMPUTATION</h4> <p>In the five papers Syme wrote between 1843 and 1846 there is no complete and formal description of the technique of his operation, and there is only one inadequate illustration (<b>Fig. 23.</b>). Scattered throughout the papers, however, are comments on various points in the procedure, and when the articles were gathered together and republished in the volume <i>Contributions to the Pathology and Practice of Surgery</i><a></a> there was included an addendum concerned chiefly with certain details of the operation, particularly the technique for separation of the heel flap from the calcaneus. Therein, after emphasizing the desirability of "preserving entire the thick integuments of the heel to form a cushion for the stump," and after ascribing the known failures either to lack of skill in removing the flap from the calcaneus or to the use of flaps of skin other than that from the heel, Syme describes his technique as follows:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. The only illustration included by Syme in any of his publications on amputation at the ankle joint. It appeared in the <i>London and Edinburgh Monthly Journal of Medical Science</i><a></a> with the following comment in the text: "The stump has the shape here represented, conical in form on the inferior surface and having for its apex, or central point of pressure, the thick integument which covered the heel." This illustration was not included when the five papers<a></a> on <i>Amputation of the Ankle Joint </i>were reproduced in <i>Contributions to the Pathology and Practice of Surgery.</i><a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <blockquote><p>The foot being placed at a right angle to the leg, a line drawn from the centre of one malleolus to that of the other, directly across the sole of the foot will show the proper extent of the posterior flap. The knife should be entered close up to the fibular malleolus and carried to a point to the same level on the opposite side, which will be a little below the tibial malleolus. The anterior incision should join the two points just mentioned at an angle of 45° to the sole of the foot and the long axis of the leg. In dissecting the posterior flap, the operator should place the fingers of his left hand upon the heel, while the thumb rests upon the edge of the integuments, and then cut between the nail of the thumb and the tuberosity of the os calcis so as to avoid lacerating the soft parts which he, at the same time, gently but steadily presses back until he exposes and divides the tendo achillis. The foot should be disarticulated before the malleolar projections are removed, which it is always proper to do, and which may be most easily effected by passing a knife around the exposed extremities of the bones and then sawing off a thin slice of tibia, connecting the two processes.</p> </blockquote> <p>Scattered throughout the five papers are some other details worth noting. Syme found it important to avoid division of the posterior tibial artery above its branching into the median and lateral plantar arteries; otherwise there was risk that the flap would slough. Separation of the heel flap, while not easy, could be accomplished satisfactorily by keeping close to the bone. The heel flap was not to be unduly large lest its circulation be impaired. Though Syme freed the heel flap before he dislocated the talus from the ankle joint, it was not long before surgeons were freeing the ankle joint first and dissecting the calcaneus from the heel flap downward from above, and this approach is part of our present procedure.<a></a></p> <p>Today, when the problem of infection is not paramount, the purpose of the operation is, first, to remove the foot by disarticulation at the ankle joint and without damage to the specialized structure of the heel flap; second, to remove the malleoli and trim the lower ends of the tibia and fibula so as to provide a broad support for weight-bearing; third, to fashion from the heel a flap with unimpaired blood supply and with its weight-bearing mechanism undamaged; and, last, to secure this heel flap firmly and accurately to the lower ends of the tibia and fibula. The resulting stump should have a bulbous end to facilitate maintenance of the prosthesis on the stump. To meet these requirements, the skin incisions should be so designed as to give a heel flap of generous size but not so large that its blood supply will be impaired. This shape and size may be obtained by tilting the plantar incision slightly forward. Syme advocated a smaller heel flap because he feared necrosis from impaired circulation. Today, with the risk of infection removed, the larger heel flap, if carefully separated from the calcaneus, need not suffer from impaired circulation, and when sutured in place it has the advantage of overlapping and protecting the anterior margin of the lower end of the tibia. The lower ends of the tibia and fibula are fashioned with a saw cut which removes the medial and lateral malleoli and shaves off the articular surface of the tibia. The plane of this saw cut must be parallel to the ground when the patient stands (<b>Fig. 24.</b>). That is to say, in all cases the tibia must be transected to suit the individual case and not necessarily in the same plane as the articular surface of the tibia or at right angles to the long axis of its shaft. The transection of the tibia and fibula must be as low as possible to ensure that an area of support as broad as possible is obtained. With the modern type of Syme prosthesis, the resulting long stump presents no problem in fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Proper saw line for Syme's amputation, when tibia is abnormal or deformed. The plane of section of the lower ends of tibia and fibula is not necessarily that of the inferior articular surface of the tibia but must in all cases be parallel to the ground when the patient stands erect. When for example the tibia is bowed, as represented here, the plane of section is horizontal and not at 90 degrees to the long axis of the bone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The fashioning of the heel flap and its proper attachment to the lower ends of the tibia and fibula are important steps in the operation. Preservation of the specialized fibroelastic subcutaneous tissue and the posterior tibial artery can best be assured by subperiosteal separation of the heel flap from the calcaneus. While this is a procedure somewhat more precise than that recommended by Syme (who advised that the flap be separated from the calcaneus by dissection with a sharp knife in a plane close to the bone), today with modern techniques and instruments it is easy to accomplish the desired result. The only step likely to give any difficulty is the detachment of the tendo achillis from the calcaneus, since in this situation there is no plane of cleavage. The tendon must therefore be divided carefully at its insertion close to the bone in order to avoid damage to the skin close behind it.</p> <p>Subperiosteal dissection of the calcaneus from the heel flap has one advantage not envisioned by Syme. Besides preserving the posterior tibial artery and the weight-bearing structure of the heel, it leaves a heel flap lined with periosteum, which more readily and more firmly adheres to the cut surfaces of the tibia and fibula. Henry Thompson<a></a> must have had something of this nature in mind when he advocated leaving a flake of the os calcis in the heel flap. As can be seen in radiographs (<b>Fig. 25.</b> and <b>Fig. 26.</b>), new bone sometimes forms from the periosteal lining of the heel flap, in which case there is very firm fixation of the heel flap to the tibia and fibula. In this connection, it is interesting to note an observation of Jacobson.<a></a> In discussing Syme's amputation, he describes the technique of removal of the calcaneus from the heel flap by an approach from above:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. A flake of new bone laid down in the heel flap of a Syme stump, the result of subperiosteal separation of the heel flap from the calcaneus. Firm fixation of the heel flap to the cut surfaces of the tibia and fibula is thus ensured. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. A large mass of bone laid down in the heel flap of a Syme stump. <i>A, </i>four months after operation; <i>B, </i>one year after operation. This unusually large cloud of new bone resulted from the stimulation of the periosteum by the inflammatory reaction to tuberculosis of the tarsus, the reason for the amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The foot being still more pressed (i.e., downward to dislocate the talus from the ankle joint), the upper nonarticular surface of the os calcis comes into view and then the tendo achillis. This is severed and the heel flap next dissected off the os calcis from above downwards, special care being taken to cut this flap as thick as possible, not to score or puncture it, but rather to peel it off the bone with the left thumb nail kept in front of the knife aided by touches of this.</p> <p>Thereto is appended a footnote:</p> <blockquote><p>If, in a young subject, the epiphysis comes away in the heel flap, it may remain there if the parts are healthy. <i>The same course may be followed with the periosteum if it is found loose and peels away. </i>Mr. Johnston Smith, when amputating both feet for frostbite, left the periosteum on one side; on the other no attempt was made to save it. The first stump was much larger than the other, harder and more rounded, more like that of Pirogoff's amputation.</p> </blockquote> <p>Published in 1889, this comment preceded introduction of the roentgen ray. In all respects, save the radiographic proof, it indicates clearly that subperiosteal separation of the heel flap results in more firm attachment of flap to the tibia and fibula than is the case when the periosteum is not preserved.</p> <p>When stresses come upon a heel flap not firmly attached to the cut surfaces of the tibia and fibula, it wobbles and thus loses some of its functional value. Moreover, the tendo achillis and the peroneal tendons buried therein drag the heel flap this way or that when they contract (<b>Fig. 27.</b> and <b>Fig. 28.</b>). Both of these problems can be eliminated by subperiosteal separation of the calcaneus from the heel flap, for doing so ensures firm fixation of the flap to the cut ends of the tibia and fibula.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Misplaced and unstable ("wobbly") heel flap, the result of tidying up the heel flap by removal of the stumps of the short plantar muscles and with them the plantar aponeurosis and the periosteum of the calcaneus. The result is a heel flap imperfectly fused to the end of the tibia and in bad position. Left, muscles at rest and heel pad held as nearly as possible under the tibia by elastic traction; right, contraction of peroneal muscles drags the unstable heel flap toward the lateral side of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Radiograph of the imperfect Syme stump shown in <b>Fig. 27.</b>. In addition to the unstable and misplaced heel flap, the high level of transection of the tibia and fibula limits the area available for support. In spite of these defects, the stump has functioned reasonably well for 12 years. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A heel flap which has been formed by subperiosteal dissection from off the calcaneus is clumsy and untidy in appearance. It is a deep, cup-shaped structure covered with thick skin and rendered bulky at its anterior end by the inclusion of the bellies of origin of the short plantar muscles. The instinct of every meticulous surgeon is to tidy it by removal of these bulky muscle stumps, but it is best to leave them in place. They do no harm, and any attempt to remove them may damage the specialized, weight-bearing, subcutaneous tissue by removing with them the plantar aponeurosis, from which the fibrous septa originate.</p> <p>The detailed steps (<b>Fig. 29.</b>, <b>Fig. 30.</b>, <b>Fig. 31.</b>, and <b>Fig. 32.</b>) in the operation as at present performed are as follows:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Technique of the Syme amputation. <i>A, </i>Skin incisions from the medial side; <i>B, </i>skin incisions from the lateral side; C, division of the collateral ligaments from within the joint; <i>D, </i>dislocation of the talus downward from the mortise of the ankle joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Technique of the Syme amputation, continued. The talus has been dislocated from the ankle joint. The calcaneus has been separated almost completely from the heel flap by subperiosteal dissection. The tendo achillis is about to be divided at its insertion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Technique of the Syme amputation, continued. Left, the anatomy of the field of operation after the tarsus has been removed from the heel flap; right, closure of the wound with drainage. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Technique of the Syme amputation, continued. The method of strapping the heel flap to the leg to ensure that its position in relation to the cut ends of the tibia and fibula is exactly correct and will remain so. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>Apply an air-pressure tourniquet to the thigh.</li><li>With the foot at a right angle to the tibia, make two incisions: First, from the tip of the lateral malleolus, across the sole of the foot to a point just below the tip of the medial malleolus, the cut being made through all the soft tissues directly down to the tarsal bones. At its center, this plantar incision should be curved slightly forward from the tips of the malleoli, rather than the reverse, so that the center of the flap will be elongated to facilitate covering the anterior margin of the cut surface of the tibia when the wound is closed. Second, a dorsal incision joining the upper ends of the plantar incision and running upward and forward at an angle of 45 deg. from the line of the tibia and from the plantar surface of the foot. It bisects the angle between the tibia and the foot. Through it the ankle joint is entered.</li><li>With the ankle joint open, plantar flex the foot and divide the tibial and fibular collateral ligaments of the ankle from within the joint. On the medial side, be careful to avoid the posterior tibial artery.</li><li>Dislocate the talus downward from the mortise of the ankle joint, open the posterior part of the capsule of the ankle joint from within, and expose the posterosuperior nonarticular surface of the calcaneus and the anterior surface of the tendo achillis just above its insertion.</li><li>With a periosteal elevator (Bristow raspatory), enter the subperiosteal plane on the medial and lateral sides of the calcaneus and extend this subperiosteal dissection to the inferior surface of the bone. Tilt the foot first into inversion and then into eversion and continue the subperiosteal freeing of the calcaneus on its inferior surface. Then work forward in the subperiosteal plane on the medial, lateral, and inferior surfaces of the calcaneus. Detach the origin of the long plantar ligament from the tuberosity of the calcaneus, and continue in the subperiosteal plane until the plantar skin incision is reached and the anterior end of the bone is free. Work backward in the subperiosteal plane until the whole of the calcaneus is free except at the insertion of the tendo achillis. With a knife, carefully divide the tendo achillis working downward from above. Stay close to the bone and avoid damaging the skin flap behind the tendo achillis. Remove the talus and calcaneus together with the damaged portion of the foot. If this step is accomplished successfully, the posterior tibial artery will be unharmed. Only its plantar branches will have been cut by the primary plantar incision. Do nothing to the posterior tibial nerve, which also will have been cut by the primary plantar incision.</li><li>Carefully turn the heel flap backward and upward, and free the malleoli and the lowest 1/4 in. of the tibia. Remove the malleoli and a thin slice of the lower end of the tibia by a saw cut. Be certain that the saw cut will be parallel to the ground when the patient is standing. The amount of tibia removed should be the thinnest possible shaving from its lower end, the sub-articular cortical plate being conserved if possible. In any case, be certain that the largest possible cross-sectional area of the tibia and fibula is obtained to ensure a broad area of support (<b>Fig. 33.</b>).</li><li>Remove the tourniquet and secure perfect haemastasis. Do not trim the heel flap, much as you may desire to make it tidy.</li><li>With interrupted sutures of chromic catgut #0 for the subcutaneous layer and interrupted everting mattress sutures of braided nylon for the skin margins, suture the margin of the heel flap to the margin of the anterior incision across the front of the ankle joint. Suture nothing but the subcutaneous layer and the skin. To drain the dead space, enclose across the wound a section of Penrose tubing and allow the ends to come out at either corner of the wound. The line of suture should be slightly above the anterior margin of the cut surface of the tibia so that cut ends of the bones fit into the cup of the heel flap.</li><li>In closing the wound, pay no attention to the disparity in size, shape, and thickness between the heel flap and the skin margin to which it will be sutured. Center the hollow of the heel flap beneath the cut ends of the tibia and fibula as accurately as possible, and begin the suture line in the center anteriorly and work to either end. Do nothing to the "dog ears" of skin which project at the corners of the approximated skin margins. In time they will shrink and disappear. To trim them invites impairment of circulation.</li><li>The heel flap thus sutured is attached only at its margin and is not yet fixed firmly to the cut surfaces of the tibia and fibula, and accordingly it can be moved about in relation to them. It needs to be secured and maintained in a proper position. To do so, hold the heel flap accurately centered beneath the cut surfaces of the tibia and fibula and secure it in this position by two strips of adhesive tape fastened U-shaped across the end of the stump in the anteroposterior and medio-lateral directions (<b>Fig. 32.</b>). Adhesive tape is better than pins transfixing the heel pad to the tibia, as has sometimes been advocated. Do not apply the adhesive strips too tightly.</li><li>Dress the wound with two layers of surgical pads smoothly applied and held in place by a mildly compressive bandage. Flannelette cut on the bias is ideal, although cotton-crepe bandage (without elastic) will do if not applied tightly.</li><li><i>Important.</i> Open the dressing 24 hours after the operation and every second day thereafter, and inspect the position of the heel flap in relation to the lower ends of the tibia and fibula. Adjust or renew the adhesive strips if necessary to maintain the correct position of the heel flap. If the operative dressing is left unchanged, the heel flap may unite asymmetrically. The stump must be inspected frequently in the postoperative period, and adjustments of the position of the heel flap must be made when necessary. Remove the Penrose tube about the sixth day.</li><li>Maintain a firm dressing until the wound is healed and the stitches are removed (about two weeks). Support the stump thereafter with a cotton-crepe elastic bandage until the first limb is fitted. At the end of four weeks, the patient may begin to put weight on the end of the stump. A prosthesis may be fitted at the end of two months, though it will require a new socket within a year, when shrinkage of the calf muscles is complete.</li></ol> <h3>IMPERFECTIONS WHICH IMPAIR THE FUNCTION OF THE SYME STUMP-HOW TO AVOID OR CORRECT THEM</h3> <p>Not all Syme stumps are perfect, but nearly all imperfections can be avoided by meticulous attention to the details of the operation. Too much emphasis cannot be placed upon a proper understanding of the principles of the amputation and upon its proper performance. Although some imperfections can be compensated for in the fitting of the prosthesis or in the manner of its use, and although some can be eliminated by revision operations, others cannot be overcome at all, usually because of faulty performance of the initial operation.</p> <h4>DAMAGE TO THE WEIGHT-BEARING STRUCTURE OF THE HEEL FLAP</h4> <p>A serious imperfection, which cannot be corrected by further operation, is damage to the weight-bearing structure of the heel flap. This is almost always due to the manner in which the operation is performed. Care must be taken to preserve intact the specialized subcutaneous fibroelastic tissue of the heel pad. As previously indicated, this can be accomplished most certainly by attention to two details in the operation: subperiosteal separation of the heel flap from the calcaneus and avoidance of any attempt to tidy the clumsy flap by removing the stumps of origin of the small muscles of the foot. If these steps in the operation are properly performed, the specialized subcutaneous tissue will remain intact and its function will be unimpaired. On the other hand, if the plane of the subcutaneous tissue is entered during the operation, there will be more or less impairment of its structure and function. This is the prime example of the necessity to perform Syme's amputation by a technique which adheres rigidly to the basic principles of anatomy. There is only one opportunity to fashion a Syme stump of the best quality and that is the occasion of the primary operation. If this is performed skillfully and with due regard for basic principles, it will produce a good end-bearing stump. If the basic principles are disregarded, or if the operation is performed carelessly, the weight-bearing qualities of the flap are likely to be impaired, and they cannot be restored by any subsequent operation.</p> <p>While a defective Syme stump deprives the patient of the comfort and good function he would enjoy with a perfect stump, it may still be sufficiently useful to make it worth while retaining. Reamputation at a higher level is not always inevitable.<a></a> Even an imperfect Syme stump may be more useful than a below-knee amputation. Therefore re-amputation at a higher level because of an imperfect Syme stump should be undertaken only after the most careful consideration of every aspect of the problem.</p> <p>Besides damage to the heel flap, and consequent impairment of the weight-bearing qualities of the stump, a number of other faults can impair the functional value of a Syme amputation.</p> <h4>MISPLACED HEEL FLAP</h4> <p>Care must be taken to secure the heel flap beneath the tibia in such a manner that the plantar surface of the flap is exactly beneath the center of the lower end of the tibia. To keep it there necessitates painstaking care and supervision during the immediate postoperative period. The heel flap being a large, cup-shaped structure, loosely attached to the leg, it must be secured in its proper position by adhesive strips and maintained so until healing has fixed it to the lower end of the tibia (<b>Fig. 32.</b>). If postoperative inspection is neglected, the heel flap may be pushed out of place by the dressing and may unite to the tibia displaced to one side or the other or backward. Its end-bearing capability is then impaired. Fortunately, if the specialized fibroelastic adipose tissue has not been damaged, malposition of the heel flap can be corrected by detaching it and replacing it in its proper position.</p> <h4>SLOPING SURFACE OF LOWER END OF TIBIA</h4> <p>If the cut surface of the lower end of the tibia is not parallel to the ground when the patient stands, the heel flap tends to be pushed to the high side of the slope (<b>Fig. 33.</b>) The plane of transection must therefore be parallel to the ground when the patient stands no matter what its geometric relationship to the long axis of the tibia. If there is any bowing or other deformity of the tibia, the proper plane of transection may actually be oblique to the long axis (<b>Fig. 24.</b>). The particular circumstances in the individual case must be assessed at the time of the primary operation to make certain not only that the plane of section of the lower surface of the tibia is parallel to the ground but also that the maximum area of bony support for the heel flap is secured (<b>Fig. 34.</b>). Any operation to revise an improper bearing surface must necessarily be at a higher level where the cross-sectional area for support is smaller (<b>Fig. 24.</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Oblique transection of lower end of tibia results in displacement of heel pad to high side. <i>A, </i>The stump when no weight is upon it; the heel pad is displaced medially. <i>B, </i>Radiograph of stump; tibia transected obliquely, higher on the medial than on the lateral side. <i>C, </i>The stump bearing weight; the heel pad is markedly displaced to medial side. The function of this heel flap (which already is unstable and misplaced) is impaired still more by the displacement which occurs when weight is borne upon it. This is the result of oblique section of lower end of tibia. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. The proper level for transection of the tibia and fibula in Syme's amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>"WOBBLY," OR UNSTABLE, HEEL FLAP</h4> <p>If the heel flap is loosely attached to the lower end of the tibia, it is easily displaced, and pressure while walking or standing may wipe it to one side or the other or backward. Similarly (<b>Fig. 27.</b> and <b>Fig. 28.</b>), it may be pulled out of place by the stumps of the tendons that are embedded in it, the tendo achillis and the peroneal tendons being the chief offenders. Because the thrust of weight-bearing cannot be maintained through the center of the flap, even when the prosthesis is snugly fitted, an unstable heel flap does not bear weight satisfactorily. The anterior margin of the lower end of the tibia presses through the scar of the anterior suture line, and the patient stands insecurely upon the shifting end of his stump. A flaccid, loose, heel flap occurs when the plane of separation is through the subcutaneous elastic adipose tissue. It can be prevented by subperiosteal dissection of the heel flap. The deep surface of the flap then attaches itself firmly to the cut surface of the bone, and the intact pad of weight-bearing subcutaneous tissue resists changes in shape. An unstable heel flap can be avoided only by proper operative technique. Once it exists it cannot be corrected by further operation though its shortcomings may be minimized by modifying the fit of the prosthesis.</p> <h4>NEUROMA ON POSTERIOR TIBIAL NERVE</h4> <p>In the surgery of the Syme amputation, no attempt should be made to free the posterior tibial nerve and divide it at a high level lest so doing lead to damage of the adjacent posterior tibial artery and consequent impairment of the blood supply to the heel flap. Although a neuroma inevitably develops at the cut end of the nerve, it seldom gives trouble. In the rare case in which the neuroma is sensitive, a cure can be effected by late transection of the nerve at a level well above the ankle joint but without removal of the distal segment of the nerve.</p> <h4>MARGINAL GANGRENE OF THE HEEL FLAP</h4> <p>Except in cases of peripheral vascular disease, marginal gangrene of the heel flap is nearly always due to faulty operative technique. Either the blood supply to the flap is impaired by injury to the posterior tibial artery, or the dressings are put on too tightly, or swelling occurs beneath the adhesive strips and they are not loosened soon enough. With care in operating, there is little danger of necrosis of the flap. Should necrosis occur, the stump is not necessarily ruined unless the loss of tissue is very great (<b>Fig. 35.</b>, <b>Fig. 36.</b>, and <b>Fig. 37.</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Salvage of a Syme stump in spite of marginal gangrene of the flap. This 38-year-old man suffered ischemic necrosis of the muscles of his leg as a complication of fracture of the femur when he was eight years old. He slowly developed a grossly deformed, insensitive foot with trophic ulceration. When the Syme amputation was performed, the posterior tibial artery was inadvertently divided. The result was marginal gangrene of the flap. Separation of the gangrenous margin occurred slowly over a period of eight months. During that time the flap was held in place by adhesive strapping and carefully applied dressings. Wearing an "elephant prosthesis" (<b>Fig. 36.</b>), he first walked five months after his operation. The scar is depressed at the line of suture as the result of the separation of the gangrenous margin of the heel flap. Left, appearance of stump; right, radiograph of stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. The temporary "elephant prosthesis" used on the patient shown in <b>Fig. 35.</b>. It enabled him to walk during the long period of wound-healing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. The final prosthesis provided the patient shown in <b>Fig. 35.</b>. See pages 52-75. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>VASCULAR INSUFFICIENCY IN THE HEEL FLAP</h4> <p>It has been said that the great length of a Syme stump results in vascular insufficiency manifested by a cold, blue, painful stump end, symptoms which are greatly accentuated in cold weather. There has been no such experience in Canada, where, in winter, many of the patients are exposed to very low temperatures. Experience leads to the conclusion that vascular stasis from exposure to cold is not a problem of any importance in the Syme amputation.</p> <h4>TENDER HEEL FLAP WITH CALLUSES</h4> <p>A calloused and tender heel flap is almost always due to failure to preserve the specialized fibroelastic adipose tissue. It is accentuated if the area of transection of the tibia and fibula is small or if there are projecting bone spurs. The problem can be prevented by proper fashioning of the heel flap and by division of the tibia and fibula low enough to provide a broad area of support. If bony spurs are present, they should be removed, but neither a damaged heel flap nor an inadequate area of support can be corrected by any subsequent operation.</p> <h4>IMPERFECT SKIN COVERING OF THE STUMP</h4> <p>In an occasional Syme stump the end is covered with skin ill adapted to weight-bearing. Usually in such cases the extent of the original trauma was such as to leave very little material from which to fashion an adequate heel flap. Sometimes the heel flap is scarred by wounds or infection. Some of the heel flap may have been lost by vascular damage, or the original covering of the stump may have been skin from a site other than the heel. Though little can be done to improve such stumps by further operation, modification of the prosthesis so as to distribute the weight between the end of the stump and the upper end of the socket, as in a below-knee prosthesis, offers promise of improvement. Despite the great importance of covering the end of the stump with skin and subcutaneous tissue accustomed to weight-bearing, there is reason to believe that, when the cut surfaces of the tibia and fibula are as broad as possible, the stresses of weight-bearing are distributed so widely that even ordinary skin and subcutaneous tissue can sometimes function satisfactorily (<b>Fig. 38.</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. A modified Syme amputation in which, because of an injury that completely destroyed the heel flap and the calcaneus, the transected ends of the tibia and fibula were covered with a flap from the dorsum of the foot. Photo shows stump 10 years after amputation, never any trouble; insert is a radiograph showing broad area of support, which probably accounts for the success of this stump despite lack of covering with normal heel pad. Similar to Baudens' supramalleolar amputation.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>INDICATIONS FOR SYME'S AMPUTATION</h4> <p>With a technique that ensures a satisfactory end-bearing stump, Syme's amputation is indicated for all destructive, infective, or other disabling lesions of the foot that cannot be dealt with by a transmetatarsal amputation. The skin over the heel must be intact. Syme's amputation should replace Lisfranc's and Chopart's whenever these amputations are apt to be unsatisfactory, as is often the case. The following are the principal conditions for which Syme's amputation is most frequently performed.</p> <h4>SEVERE INJURIES OF THE FOOT</h4> <p>Compound and comminuted fractures of the tarsus and metatarsus and crushing injuries of the foot are usually best treated by Syme's amputation. If damage to the skeleton of the foot is severe, it is often impossible to salvage a useful and painless foot. As soon as this circumstance becomes apparent, or if from the beginning it is obvious that much of the foot must be lost by reason of the injury or that the foot will ultimately become deformed, rigid, and painful, a Syme's amputation is indicated. It should be performed as soon as the risk of infection can be eliminated. With antibiotics available, the amputation can sometimes be performed as a primary measure. More frequently it will be wise to perform it as a secondary procedure after infection has been brought under control and the wound has healed or nearly healed. In dealing with injuries to the foot, especially war injuries, the advantages of the Syme amputation should be borne in mind so that, instead of immediate resort to a mid-tibial amputation, a two-stage operation can be planned, the primary stage being to remove the shattered and infected distal portions of the foot while preserving the heel flap, the second to effect a formal Syme amputation after the wound has healed or after infection is under adequate control.</p> <h4>INTRACTABLE INFECTIONS OF THE BONES AND JOINTS OF THE FOOT</h4> <p>Today infection is less often an indication for Syme's amputation than it was formerly. Antibiotics give us such control over infections (including tuberculosis) that amputation is seldom necessary as a life-saving measure. It still has a place in the eradication of persistent, chronic infection and in the management of a few unusual infections, such as blastomycosis. Syme's first operation was for tuberculous infection of the talus and calcaneus. It is a tribute to the operator that in a day of uncontrolled infection the result was completely successful.</p> <h4>DEFORMITIES OF THE FOOT</h4> <p>Foot deformities that cause serious disablement from rigidity and localized pressure and that are incapable of correction are indications for Syme's amputation. Although the chief cause of such deformities is previous trauma or infection, conditions such as old clubfoot with intractable deformity can also be well treated by Syme's amputation.</p> <h4>WAR INJURIES</h4> <p>Because battle wounds commonly cause gross damage to tissues, and because they must often be treated hastily, in large numbers, and usually under conditions less than ideal, the merits of Syme's amputation must be emphasized lest the soldier be deprived of its advantages. Every war injury of the foot should be regarded as a condition that might ultimately best be treated by Syme's amputation. Even in questionable cases, consideration should be given to a two-stage procedure: first, removal of the damaged parts with concomitant control of infection; second, a formal Syme amputation when healing of the first wound is well along.</p> <h4>FROSTBITE AND IMMERSION FOOT</h4> <p>Extreme cold causes thrombosis of the smaller vessels of the foot, especially of the distal portions, so that gangrene of the toes develops in severe cases. Foot damage from frostbite, if of considerable extent, is well treated by Syme's amputation. Less severe cases may recover without amputation, or escape with amputation of the toes, or with transmetatarsal amputation.</p> <h4>SELECTED CASES OF OBLITERATIVE VASCULAR DISEASE</h4> <p>Contrary to expectation, it has proved possible to deal with certain cases of Buerger's disease and of arteriosclerotic vascular disease by Syme's amputation. Buerger's disease is more often suitable for Syme's amputation than is arteriosclerotic vascular disease. The most suitable case is a young or middle-aged man suffering from obliterative disease with gangrene of the toes and neighboring parts and a favourable response to lumbar sympathetic block. In such cases, a lumbar sympathectomy, followed by Syme's amputation, will often provide a useful stump that will last for years. Dr. Gordon M. Dale<a></a>, who has had considerable experience with the Syme amputation for obliterative vascular disease (page 44), has had success in 50 percent of his cases. The Syme stump has provided much better function than would have been possible with amputation at a higher level, a matter of special importance since these patients constantly face the possible loss of the other leg at a later date for the same disease.<a></a></p> <h4>CERTAIN NEUROLOGICAL LESIONS</h4> <p>Neurological diseases occasionally produce in the foot changes which impair its usefulness and which may transform it into an encumbrance. If infection supervenes, the patient's life may be endangered.</p> <p>Neuropathic joints in the foot can develop from tabes dorsalis, syringomyelia, or Charcot-Marie-Tooth neuromyopathy. If the disability and deformity from these problems is severe, a Syme amputation is a valuable procedure. It removes the damaged joints and provides the patient with a useful end-bearing stump.</p> <p>The sensory loss which accompanies irreparable sciatic-nerve lesion or spina bifida is prone to result in trophic lesions of the skin of the sole of the foot. These skin lesions occur most frequently in the anterior portion of the foot, where the metatarsal heads press unduly upon the skin which underlies them. When ulceration of the skin develops, infection follows. It must be quickly and completely eradicated. The skin beneath the heel is less often involved because of the thickness of the heel pad. The ulcers beneath the metatarsal heads are so situated that a transmetatarsal amputation is seldom possible because the skin available is inadequate to cover the end of the foot without tension. Such cases are well treated by Syme's amputation.</p> <h4>SYME'S AMPUTATION IN CHILDREN</h4> <p>Syme's amputation can be utilized in children as successfully as in adults, especially in the treatment of destructive foot injuries and of certain congenital foot deficiencies and deformities. Indeed, if properly performed it has in children two special advantages not applicable to adults. Provided the lower epiphyseal line of the tibia is preserved intact, the growth in length of the tibia is but little diminished. Secondly, progressive growth does not project the lower ends of the bones through the skin, as happens all too frequently when amputation through the shaft of the tibia is performed in early childhood.</p> <p>The chief indications for the operation in children are trauma that results in irreparable damage to distal parts of the foot, vascular accidents that terminate in ischemic necrosis or gangrene of the toes and associated parts, and congenital deficiencies and deformities that result in a foot so imperfect as to be an encumbrance. It is of importance that the lower epiphyseal line of the tibia be undamaged and that an area of support as broad as possible be obtained. In children, accordingly, little more should be done to the bones than to remove the malleoli. The lower articular surface of the tibia is left untouched, while the calcaneus is removed from the heel flap by subperiosteal dissection.</p> <p>The Syme amputation can be performed in children as early as the second or third year, with great benefit to the patient. Even if it does nothing more than postpone a formal, mid-tibial amputation until growth has ceased, it is worth performing<a></a> since it ensures a shank of more or less normal length (<b>Fig. 39.</b> and <b>Fig. 40.</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. The Syme amputation in children. This 18-year-old boy suffered embolism or thrombosis at the bifurcation of the aorta as a complication of septicaemia at the age of seven years. Gangrene of his right toes and of the left foot occurred. A Syme amputation was performed on the left foot in May of 1948. He has had a perfectly satisfactory stump for 11 years. Left, the stump (in 1958) shows a large heel pad which moves rather loosely on the ends of the bones; right, radiograph of the stump showing that the transection was rather high. The left tibia is 2 1/8 in. shorter than the right. There is no projection of the bone ends through the end of the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Lower extremities of a 70-year-old man whose Syme amputation was performed 65 years ago for deformed foot resulting from a severe injury at the age of two. Left, appearance of the stump; right, radiographs of the stump. The heel flap is large and soft, moves rather freely on the ends of the bones, and can be moved voluntarily by contraction of the tendo achillis. There is very little shortening of the tibia. Patient has led a very active life (squash-rackets champion at one time) and has had no trouble with his stump. He wears a Marks prothesis (wooden bucket closed with leather flaps over a tongue, solid ankle, and sponge-rubber foot). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is interesting to record that among Syme's earliest cases were three children,<a></a> ages respectively 11 years, 10 years, and 5 <i>months. </i>In all three a good result was obtained.</p> <h4>MALIGNANT DISEASE OF THE FOOT</h4> <p>Malignant disease of some part of the foot, for example malignant melanoma, is an occasional indication for Syme's amputation. Under appropriate circumstances, tumours of the tarsus, such as osteoclastoma, may be well treated by Syme's amputation. As already noted, one of Syme's outstanding successes was an amputation at the ankle joint performed for "an erectile tumour of the foot" (probably a haemangioma). In general, it may be said that any tumour of the foot which can be completely removed without sacrificing any of the principles of the amputation should be regarded as a problem suitable for treatment by Syme's amputation.</p> <h3>RESULTS AND CONCLUSIONS</h3> <p>It is difficult to discuss the results of Syme's amputation because success or failure is so much dependent upon the manner in which the operation has been performed. No matter how many Syme's stumps may be examined to ascertain the end results, the conclusions will be misleading unless the technique of the operation is known for each case. If the basic principles have been observed, and if the operation has been performed properly, the result is an assured success. If any of the fundamental principles have been disregarded, the result may be unsatisfactory, and it may not be possible to improve it. The four basic principles are simple and clear-cut: 1. to remove the damaged foot by disarticulation at the ankle joint; 2. in doing so to preserve the heel flap with its blood supply and weight-bearing qualities unimpaired; 3. to remove the malleoli and the articular cartilage on the lower end of the tibia leaving a surface of support as broad as possible; and 4. to secure the heel flap to the ends of the tibia and fibula in the best position for weight-bearing. When these principles have been followed and the operation has been performed properly, the result almost invariably is a satisfactory end-bearing stump (<b>Fig. 41.</b> and <b>Fig. 42.</b>). But the less perfect the operation the less perfect the result. If some of the principles have been imperfectly applied or some of the details of the operation neglected, the result will not be an ideal Syme's stump, though it may serve the patient's needs with reasonable satisfaction for some period of time. If the principles have been completely neglected and the operation performed without regard to the precise details of technique, the resulting stump will be unsatisfactory and beyond improvement by any subsequent operation limited to the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. A good functional Syme stump. The heel flap is large and firmly fixed to the lower end of the tibia in good position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Radiograph of the Syme stump shown in <b>Fig. 41.</b>. The area of support is as broad as possible. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Where, in the past, tradition has given rise to a somewhat blind but devoted adherence to Syme's perfected technique, the result has usually been a firm conviction that Syme's amputation is a good amputation. Where attempts have been made to improve upon the operation, usually in an attempt to simplify the limbmaker's problem or to provide a smaller and neater stump, the results have been indifferent or poor, and the operation has been condemned on inadequate grounds. This paper is the first since Syme's day to explore the reasons for the success of Syme's amputation in his hands and in the hands of those who followed him and for the failure of otherwise able surgeons to achieve equal success when they neglected or modified Syme's technique. The first merit which Syme claimed for his new procedure was "that the risk to life will be smaller." That indeed was the case in his day, when it spared the patient the dangerous amputation at the upper end of the tibia. Today this argument in favour of Syme's operation is no longer valid, since we now know the nature of infection and have solved the problem of its control. Though the environment of surgery has changed fundamentally from the preantiseptic era of Syme to the aseptic, bacteriostatic, and antibiotic era of today, his amputation at the ankle joint still has the other merits he claimed for it-"a more comfortable stump, more seemly and useful for support and progressive motion." When circumstances permit it to be performed, Syme's amputation provides indeed the most useful of all amputation stumps of the lower extremity.</p> <p>The history of Syme's amputation during the years since Syme first performed it shows that it has been used widely throughout Europe and North America with variable results. Syme's early cases had the good fortune to escape the complications due to sepsis, such as marred Pirogoff's early experience with the operation. Syme built on the experience he gained in his early successes and gradually perfected a technique which gave a good stump. In Syme's papers on the subject there is no record of a failure or a death, a circumstance extraordinary in view of the sepsis which to some degree complicated every surgical procedure of that day and also in view of the fact that many of his amputations were undertaken for tuberculous caries of the ankle joint or subastragalar joint. The explanation may lie in the fact that in Syme's day operations in the home and in small private hospitals were much less likely to be complicated by "hospital diseases" than were those performed in public hospitals. From 1829 to 1833, all of Syme's operations were performed in the private hospital he established in Minto House. Even after his appointment to the Chair of Clinical Surgery in the University of Edinburgh in 1833, he continued for another 15 years to act as the consulting and operating surgeon of Minto House Hospital and Dispensary, though wards in the Edinburgh Royal Infirmary were assigned to his official position. Syme was well aware that hospital diseases were in some way related to the overcrowding and filth that were universal in public hospitals of that day. The Minto Surgical Hospital, which he founded and controlled, was much less troubled with these complications because he was able there to avoid overcrowding, to ensure adequate ventilation and sanitation, and to segregate ailing patients from those in good health. In discussing compound dislocation of the astragalus, for example, he makes the following reference<a></a> to this aspect of the surgery of his day:</p> <blockquote><p>Compound dislocation of the astragalus with or without that curious displacement of the astragalus, which results from falling with great force on the heel, was formerly held to require amputation of the leg. The authority of Sir A. Cooper's experience encouraged attempts to preserve the limb in such cases; and in private practice both forms of injury are now frequently conducted to a successful issue, though in general through a protracted period of recovery. But it must be admitted that many lives have been lost, especially in hospitals, from trying to retain the limb. In the Royal Infirmary I find that of thirteen patients who had suffered compound dislocation of the ankle, and were not subjected to amputation, only two recovered.</p> </blockquote> <p>When Syme assumed charge of wards in the Edinburgh Royal Infirmary, he bent all his energy toward improving sanitation by providing adequate space between beds, by better ventilation, and by more cleanliness. An interesting outcome of this activity was his insistence that the Governors establish a separate hospital for the treatment of burns. The story is well told by Simpson and Wallace.<a></a> Syme's purpose was not so much to improve the treatment of burns as to remove the unfortunate burn victims, with their offensive wounds and filthy dressings, from his surgical wards to avoid contamination of his operative cases. Pirogoff's experience with his first four cases of Syme's amputation, all of whom died (of scurvy, tuberculosis, and sepsis), must surely be an indication that the surgical wards of Russian hospitals provided an environment much less favourable to surgical operations than did Syme's private hospital at Minto House or his surgical wards at the Edinburgh Royal Infirmary.</p> <p>It is said of Syme that he never wasted a drop of blood, never wasted a drop of ink, and never wasted a word. His publications on the subject of his amputation at the ankle joint were limited to the five papers<a></a> finally gathered together in <i>Contributions to the Pathology and Practice of Surgery</i><a></a> and to his letter to the editor of <i>Lancet.</i><a></a> Having developed a new operation and perfected it to his satisfaction, he published the account of its value. He indicated how the complications and imperfections could be avoided and then left it to stand on its own merit. It must be said also that in Edinburgh his operation has always been held in high repute and that his technique for the procedure has been taught without change to successive generations of students. From the present survey it seems clear that when Syme's operation is condemned because of a poor stump it is almost always because of some obvious failure to follow Syme's technique. As time goes on, more and more evidence accumulates to demonstrate that Syme's operation, properly performed, will provide a good stump. Imperfections are almost invariably the result of failure to follow strictly the details of technique.<a></a> </p> <p>It is strange that over the years there has been such imperfect appreciation of the principles of Syme's amputation. In Syme's own day, Guyon, Roux, and Pirogoff modified Syme's procedure in the hope that they might avoid certain complications. After the 1914- 1918 war, Elmslie introduced his modification, which he confidently believed to be an improvement upon Syme's original technique. Even during the 1939-1945 war, and in subsequent years, the basic principles of Syme's operation were imperfectly understood. <b>Fig. 43.</b> and <b>Fig. 44.</b>, taken from standard texts of that era,<a></a> advocate such a high transection of the tibia and fibula that the result would certainly be an imperfect stump. None of these changes in Syme's procedure has improved the results.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Drawings from Kirk<a></a> showing misconception of the principle of Syme's amputation as late as the year 1942. The indicated level of division of the tibia and fibula is too high; description of Syme's amputation as a "supramalleolar amputation" is incorrect; the skin incision shown is that of Elmslie's modification of Syme's operation, not that used by Syme himself. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Drawing of Syme's amputation showing division of tibia and fibula at a level much too high for a satisfactory stump. From Vasconcelos.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Such misunderstandings must be due to several factors. For one thing, Syme himself wrote about his amputation at the ankle joint in a limited way only, in a style always terse and often obscure, and he published nothing on the subject after 1846. In his publications there is only one inadequate illustration (<b>Fig. 23.</b>). For another, in Syme's day the matter of prime importance was to remove the patient's damaged or infected foot with minimum risk to life. That accomplished, perfection of the stump and fit of the prosthesis were secondary considerations, important but not vital. When infection disappeared as a major problem, the new mastery of surgery, derived from anaesthesia and antisepsis (later asepsis), led surgeons to think that their new freedom in operating should make it possible to refine the procedure and thus to produce a more tidy, more elegant, and more useful stump. Besides this, the demands of the limbmakers led them to believe that high transection of the tibia and fibula would ensure that the patient could more readily be fitted with a satisfactory prosthesis. Whereas in the preanaesthetic and preantiseptic days, the emphasis in operating was upon speed, dexterity, and the control of haemorrhage, in the new freedom of painless and aseptic surgery there was a widespread impulse to devise more sophisticated operations. While the functional value of Syme's amputation derived chiefly from the resulting weight-bearing properties, the stump seemed bulky, clumsy, and unsightly to the new generation of surgeons. Their success in other fields of operative procedure naturally led them to the opinion that Syme's amputation, already good, could be made still better by refining the details of the technique, and the entry into the picture of highly skilled limbfitters encouraged a belief in the necessity for certain modifications to facilitate limb-fitting.</p> <p>Today, fortunately, the perfection of a new type of Syme prosthesis (page 52) has eliminated the ankle-joint problem and minimized the bulbous appearance of the perfect Syme stump. Seldom in the history of surgery has it been necessary to adhere rigidly to the technique of an operation developed and perfected in preantiseptic days. Yet such is the case with Syme's amputation. The simple technique devised by Syme to spare his patients the risks of amputation at the site of election and to give them an end-bearing stump still provides the best end-bearing stump of the lower extremity.</p> <p>Finally, and in summary, the conclusions to be drawn from this examination of the history and development of Syme's operation are as follows:</p> <ol> <li>The stump resulting from a Syme operation has great merit. It bears all the weight of the body on its end and withstands the stresses of locomotion without difficulty and for an unlimited time. It is the most satisfactory amputation of the lower extremity and should be utilized whenever circumstances permit.</li><li>A satisfactory Syme stump can be assured if the principles underlying the operation are understood and if the technique of the operation is followed strictly.</li><li>Deviation from the basic principles or from the details of the technique of the operation will impair the perfection of the stump, and imperfections thus incurred cannot be corrected by subsequent operation.Though imperfect, a Syme stump may still be useful, but sometimes it is ruined irreparably.</li><li>All surgeons who have occasion to deal with trauma or disease of the foot which may require amputation should be familiar with the merits of Syme's amputation and should be prepared to utilize it when the occasion arises. They must be familiar with the principles of the procedure, and they must perform the operation with meticulous adherence to the technique which has proven successful. Interestingly enough, that is the technique which Syme himself perfected.</li></ol> <p>This account of the history and development of Syme's amputation cannot end better than with Syme's own summary of the operative problem, which has been quoted earlier:</p> <blockquote><p>THE AMPUTATION IS EASILY EXECUTED AND PROVES IN THE HIGHEST DEGREE SATISFACTORY IF DONE IN ACCORDANCE WITH CERTAIN PRINCIPLES WHICH HAVE BEEN CAREFULLY EXPLAINED, BUT IS DIFFICULT AND DISASTROUS IF PERFORMED INCORRECTLY.</p> </blockquote> <h3>ACKNOWLEDGMENTS</h3> <p>My thanks are due to many colleagues who have permitted me to see their patients and to reproduce in this paper their photographs and radiographs. Dr. Robert Salter, of the Hospital for Sick Children, Toronto, brought in the patient illustrated in <b>Fig. 37.</b>. Dr. Donald E. Starr, of Vancouver, sent me the photographs and radiograph shown in <b>Fig. 38.</b>. Miss Patterson and her staff at the Library of the Academy of Medicine, Toronto, have rendered me invaluable service in securing from the most distant sources journals of a hundred years ago. Without their assistance, it would have been impossible to compile these historical notes. I am indebted also to the Librarian of the Royal College of Surgeons of Edinburgh for much assistance. I am particularly indebted to Miss Alexandra Birinkova for the translation of Pirogoff's paper,<a></a> to Mrs. Hannah Parnas for the translation of Volkmann's address,<a></a> and to Beatrice Harris for the translation of relevant material from the publications of Baudens,<a></a> Farabeuf,<a></a> and Velpeau,<a></a> and from <i>Les Annates des Therapeutique.</i><a></a> My secretary, Miss Florence Spencer, has spent untold hours of unstinted labour in preparing the manuscript from my notes. I am deeply grateful to her for her devoted work on my behalf.</p> <p>Both the editor and the publisher of the British Edition of the <i>Journal of Bone and Joint Surgery </i>have kindly permitted me to utilize certain illustrations which appeared in a previous publication of mine on Syme's amputation.<a></a>. Their courtesy has enabled me to use material not available elsewhere.</p> <p>-R.I</p> <p><b>References:</b></p> <ol> <li><i>Artificial limbs and their relation to amputations,</i> British Ministry of Pensions, His Majesty's Stationery Office, London, 1939. P. 55.</li> <li>Baudens, J. B. L., <i>Nouvelle methode des amputations,</i> Premiere Memoire, <i>Amputation Tibio-tarsienne, </i>Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</li> <li>Blechschmidt, E., <i>Die Architektur des Fersenpolsters,</i> Morphol. Jahrb., 72:20-68 (1933).</li> <li>Broca, A., and C. Ducroquet, <i>Artificial Limbs,</i> Military Medical Manuals, English ed., Sir Alfred Keogh and R. C. Elmslie, eds., 1918. Pp. 77 and 78.</li> <li>Brown, Dennis, personal communication, 1955.</li> <li>Brown, John, <i>Horae subsecivae, </i>new ed. in 3 vols., Adam and Charles Black, London, 1897. Second series, p. 363. See also Everymans Library, <i>Rob and his friends and other papers, </i>by John Brown, J. M. Dent and Sons, London, 1906.</li> <li>Brown, John, <i>Horae subsecivae, </i>new ed. in 3 vols., Adam and Charles Black, London, 1897. First series, p. 360.</li> <li>Carden, H. D., <i>On amputation by single flap, </i>Brit. Med. J., 1:416 (1864).</li> <li>Dale, G. M., personal communication, 1960.</li> <li>Dent, Clinton T., <i>Surgical notes from the military hospitals of South Africa, </i>Brit. Med. J., 1:1313 (1900).</li> <li>Elmslie, R. C, in Carson's <i>Modern operative surgery, </i>1st ed., Cassel &amp; Co., London, 1924. Vol. 1, section on amputations, p. 132.</li> <li>Farabeuf, L. H., <i>Precis de manuel operatoire (ligatures, amputations), </i>G. Masson, Editeur, Paris, 1881. P. 473.</li> <li>Fergusson, <i>System of practical surgery, </i>4th ed., review in Lancet, Vol. II, p. 394 (1857).</li> <li>Godlee, Sir Rickman, <i>Life of Lord Lister, </i>3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</li> <li>Guyon, F., <i>Gazette des hopitaux, </i>p. 514 (1868), quoted from Farabeuf, <i>Precis de manuel operatoire (ligatures, amputations) </i>G. Masson, Editeur, Paris, 1881. P. 543.</li> <li>Hancock, Henry, <i>On operative surgery of the foot and ankle joint </i>(1873).</li> <li>Harris, R. I., <i>Syme's amputation, </i>J. Bone &amp; Joint Surg., 38B:614 (1956).</li> <li>Hutchinson, J., Jr., <i>On the substitution (when practicable) of subastragalar for Syme's amputation, </i>Brit. Med. J., 2:1169 (1900).</li> <li>Jacobson, W. H. A., <i>The operations of surgery, </i>First American ed., Blakiston, Philadelphia, 1889. Pp. 939-943.</li> <li>Kirk, N. T., <i>Amputations, </i>W. F. Prior Co., Inc., Hagerstown, Md., 1942.</li> <li>Kuhns, J. G., <i>Changes in elastic adipose tissue, </i>J. Bone &amp; Joint Surg., 31A:541 (1949).</li> <li>Kuhns, J., and P. D. Wilson, <i>Major amputations-analysis and study of end results in 428 cases, </i>Arch. Surg., 16:887 (1928).</li> <li>Langdale-Kelham, R. D., and G. Perkins, <i>Amputations and artificial limbs, </i>Oxford, London, 1942. P. 3.</li> <li>LeMesurier, A. B., personal communication, 1952.</li> <li>Paterson, R., <i>Memorials of the life of James Syme,</i> Edmonston and Douglas, Edinburgh, 1874.</li> <li>Pirogoff, N. L, <i>Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, </i>J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,<a></a> <i>Precis de manuel operatoire (ligatures, amputations), </i>G. Masson, Editeur, Paris, 1881. P. 527.</li> <li>Roux, J., <i>Annales de Therapeutique, </i>Paris, 1846, quoted from Farabeuf, <i>Precis de manuel operatoire (ligatures, amputations), </i>G. Masson, Editeur, Paris, 1881. Pp. 500-515.</li> <li>Shellswell, J. H., <i>Svme's amputation, </i>Lancet, Vol. II, p. 1296(1954).</li> <li>Simpson, D. C, and A. B. Wallace, <i>Edinburgh's first burn hospital, </i>J. Roy. Col. Surg. Edinburgh, 2:134 (1956).</li> <li>Syme, J., <i>On amputation at the ankle joint, </i>London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</li> <li>Syme, J., <i>Amputation at the ankle joint, </i>London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVIII, April 1843, p. 274.</li> <li>Syme, J., <i>Amputation at the ankle joint, </i>London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</li> <li>Syme, J., <i>Amputation at the ankle joint, </i>London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</li> <li>Syme, J., <i>On amputation at the knee, </i>Monthly Journal of Medical Science, Vol. 5, No. LIII, p. 337, 1845.</li> <li>Syme, J., <i>Amputation at the ankle, </i>Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</li> <li>Syme, J., <i>Contributions to the pathology and practice of surgery, </i>Murray &amp; Gibb., Edinburgh, 1848. Pp. 114-147.</li> <li>Syme, J., <i>Mr. Syme on amputation at the ankle joint,</i> Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (1857).</li> <li>Syme, J., <i>On amputation at the knee, </i>Edinburgh Medical Journal, Vol. XI, p. 871 (1866).</li> <li>Thompson, Henry, Reported in the account of the meeting of the Pathological Society of London for April 21, 1863, and published in Lancet, Vol. I, p. 525 (1863).</li> <li>Tietze, A., <i>Uber den Architektonischen Aufbau des Bindegewebes in der Menschlichen Fussohle, </i>Beitrage zur Klin. Chir., No. 123, p. 493 (1921).</li> <li>Valery-Radot, R., <i>Life of Pasteur, </i>Doubleday, Page &amp; Co., New York, 1919. Chapter IV.</li> <li>Vasconcelos, E., <i>Modern methods of amputation,</i> Department of War Medicine, The Philosophical Library, New York, 1945.</li> <li>Velpeau, A. A. L. M., <i>New elements of operative surgerv, </i>First American Ed., Samuel and William Wood, New York, 1847. P. 595.</li> <li>Volkmann, Richard, <i>Sammlung klinischer Vortrage,</i> Vol. III, #221, (Surg. 70), p. 1878, Die Moderne Chirurgie (1882).</li> <li>Warren, R., I. Thayer, H. Achenbach, and L. Kendall, <i>The Syme amputation in peripheral vascular disease, </i>Surgery, Vol. 37, p. 156 (1955).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Harris, R. I., Syme's amputation, J. Bone &amp;Joint Surg., 38B:614 (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>2.</b> </td><td class="clsTextSmall">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Velpeau, A. A. L. M., New elements of operative surgerv, First American Ed., Samuel and William Wood, New York, 1847. P. 595.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Volkmann, Richard, Sammlung klinischer Vortrage, Vol. III, #221, (Surg. 70), p. 1878, Die Moderne Chirurgie (1882).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Pirogoff, N. L, Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,12 Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 527.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Vasconcelos, E., Modern methods of amputation, Department of War Medicine, The Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Kirk, N. T., Amputations, W. F. Prior Co., Inc., Hagerstown, Md., 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Kirk, N. T., Amputations, W. F. Prior Co., Inc., Hagerstown, Md., 1942.</td></tr><tr><td class="clsTextSmall"><b> 42.</b> </td><td class="clsTextSmall">Vasconcelos, E., Modern methods of amputation, Department of War Medicine, The Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Kuhns, J., and P. D. Wilson, Major amputations-analysis and study of end results in 428 cases, Arch. Surg., 16:887 (1928).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Syme, J., Mr. Syme on amputation at the ankle joint, Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (1857).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr><tr><td class="clsTextSmall"><b> 31.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVIII, April 1843, p. 274.</td></tr><tr><td class="clsTextSmall"><b> 32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 33.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</td></tr><tr><td class="clsTextSmall"><b> 35.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle, Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Simpson, D. C, and A. B. Wallace, Edinburgh's first burn hospital, J. Roy. Col. Surg. Edinburgh, 2:134 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 33.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Brown, Dennis, personal communication, 1955.</td></tr><tr><td class="clsTextSmall"><b> 24.</b> </td><td class="clsTextSmall">LeMesurier, A. B., personal communication, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Warren, R., I. Thayer, H. Achenbach, and L. Kendall, The Syme amputation in peripheral vascular disease, Surgery, Vol. 37, p. 156 (1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Dale, G. M., personal communication, 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Shellswell, J. H., Svme's amputation, Lancet, Vol. II, p. 1296(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>19.</b> </td><td class="clsTextSmall">Jacobson, W. H. A., The operations of surgery, First American ed., Blakiston, Philadelphia, 1889. Pp. 939-943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Thompson, Henry, Reported in the account of the meeting of the Pathological Society of London for April 21, 1863, and published in Lancet, Vol. I, p. 525 (1863).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Jacobson, W. H. A., The operations of surgery, First American ed., Blakiston, Philadelphia, 1889. Pp. 939-943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr><tr><td class="clsTextSmall"><b> 31.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVIII, April 1843, p. 274.</td></tr><tr><td class="clsTextSmall"><b> 32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 33.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</td></tr><tr><td class="clsTextSmall"><b> 35.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle, Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Blechschmidt, E., Die Architektur des Fersenpolsters, Morphol. Jahrb., 72:20-68 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Tietze, A., Uber den Architektonischen Aufbau des Bindegewebes in der Menschlichen Fussohle, Beitrage zur Klin. Chir., No. 123, p. 493 (1921).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Kuhns, J. G., Changes in elastic adipose tissue, J. Bone &amp;Joint Surg., 31A:541 (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>1.</b> </td><td class="clsTextSmall">Artificial limbs and their relation to amputations, British Ministry of Pensions, His Majesty's Stationery Office, London, 1939. P. 55.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Langdale-Kelham, R. D., and G. Perkins, Amputations and artificial limbs, Oxford, London, 1942. P. 3.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Broca, A., and C. Ducroquet, Artificial Limbs, Military Medical Manuals, English ed., Sir Alfred Keogh and R. C. Elmslie, eds., 1918. Pp. 77 and 78.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Guyon, F., Gazette des hopitaux, p. 514 (1868), quoted from Farabeuf, Precis de manuel operatoire (ligatures, amputations) G. Masson, Editeur, Paris, 1881. P. 543.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Thompson, Henry, Reported in the account of the meeting of the Pathological Society of London for April 21, 1863, and published in Lancet, Vol. I, p. 525 (1863).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Broca, A., and C. Ducroquet, Artificial Limbs, Military Medical Manuals, English ed., Sir Alfred Keogh and R. C. Elmslie, eds., 1918. Pp. 77 and 78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Broca, A., and C. Ducroquet, Artificial Limbs, Military Medical Manuals, English ed., Sir Alfred Keogh and R. C. Elmslie, eds., 1918. Pp. 77 and 78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Dent, Clinton T., Surgical notes from the military hospitals of South Africa, Brit. Med. J., 1:1313 (1900).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Syme, J., Mr. Syme on amputation at the ankle joint, Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (1857).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Dent, Clinton T., Surgical notes from the military hospitals of South Africa, Brit. Med. J., 1:1313 (1900).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Hutchinson, J., Jr., On the substitution (when practicable) of subastragalar for Syme's amputation, Brit. Med. J., 2:1169 (1900).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Velpeau, A. A. L. M., New elements of operative surgerv, First American Ed., Samuel and William Wood, New York, 1847. P. 595.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Pirogoff, N. L, Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,12 Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 527.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Pirogoff, N. L, Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,12 Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 527.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Elmslie, R. C, in Carson's Modern operative surgery, 1st ed., Cassel &amp;Co., London, 1924. Vol. 1, section on amputations, p. 132.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Pirogoff, N. L, Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,12 Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 527.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Pirogoff, N. L, Osteoplastic elongation of the bones of the lower leg in conjunction with release of the foot from the ankle joint, J. Military Med., St. Peters-berg, 63:83 (1854). See also Farabeuf,12 Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 527.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Farabeuf, L. H., Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. P. 473.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Guyon, F., Gazette des hopitaux, p. 514 (1868), quoted from Farabeuf, Precis de manuel operatoire (ligatures, amputations) G. Masson, Editeur, Paris, 1881. P. 543.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Hancock, Henry, On operative surgery of the foot and ankle joint (1873).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Jacobson, W. H. A., The operations of surgery, First American ed., Blakiston, Philadelphia, 1889. Pp. 939-943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>19.</b> </td><td class="clsTextSmall">Jacobson, W. H. A., The operations of surgery, First American ed., Blakiston, Philadelphia, 1889. Pp. 939-943.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Roux, J., Annales de Therapeutique, Paris, 1846, quoted from Farabeuf, Precis de manuel operatoire (ligatures, amputations), G. Masson, Editeur, Paris, 1881. Pp. 500-515.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle, Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Baudens, J. B. L., Nouvelle methode des amputations, Premiere Memoire, Amputation Tibio-tarsienne, Germer Bailliere, Libraire, Editeur, Paris, 1842. See also Annales des Therapeutique, Paris, Vol. 3, pp. 274, 484 (1845), Vol. 4, pp. 220, 316, 348, 343 (1847).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Syme, J., Mr. Syme on amputation at the ankle joint, Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (1857).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Carden, H. D., On amputation by single flap, Brit. Med. J., 1:416 (1864).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the knee, Edinburgh Medical Journal, Vol. XI, p. 871 (1866).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Carden, H. D., On amputation by single flap, Brit. Med. J., 1:416 (1864).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the knee, Edinburgh Medical Journal, Vol. XI, p. 871 (1866).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the knee, Monthly Journal of Medical Science, Vol. 5, No. LIII, p. 337, 1845.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Fergusson, System of practical surgery, 4th ed., review in Lancet, Vol. II, p. 394 (1857).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Syme, J., Mr. Syme on amputation at the ankle joint, Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (1857).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVIII, April 1843, p. 274.</td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle, Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr><tr><td class="clsTextSmall"><b> 37.</b> </td><td class="clsTextSmall">Syme, J., Mr. Syme on amputation at the ankle joint, Letter to the Editor, Lancet, Vol. II, p. 394 and 480 (1857).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Godlee, Sir Rickman, Life of Lord Lister, 3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Godlee, Sir Rickman, Life of Lord Lister, 3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Godlee, Sir Rickman, Life of Lord Lister, 3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr><tr><td class="clsTextSmall"><b> 31.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVIII, April 1843, p. 274.</td></tr><tr><td class="clsTextSmall"><b> 32.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 4, No. XLIV, August 1844, p. 647.</td></tr><tr><td class="clsTextSmall"><b> 33.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 5, No. LIII, May 1845, p. 341.</td></tr><tr><td class="clsTextSmall"><b> 35.</b> </td><td class="clsTextSmall">Syme, J., Amputation at the ankle, Monthly Journal of Medical Science, Vol. 6, No. LXVII, Aug. 1846, p. 81.</td></tr><tr><td class="clsTextSmall"><b> 36.</b> </td><td class="clsTextSmall">Syme, J., Contributions to the pathology and practice of surgery, Murray &amp;Gibb., Edinburgh, 1848. Pp. 114-147.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Brown, John, Horae subsecivae, new ed. in 3 vols., Adam and Charles Black, London, 1897. First series, p. 360.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Brown, John, Horae subsecivae, new ed. in 3 vols., Adam and Charles Black, London, 1897. Second series, p. 363. See also Everymans Library, Rob and his friends and other papers, by John Brown, J. M. Dent and Sons, London, 1906.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>14.</b> </td><td class="clsTextSmall">Godlee, Sir Rickman, Life of Lord Lister, 3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</td></tr><tr><td class="clsTextSmall"><b> 44.</b> </td><td class="clsTextSmall">Volkmann, Richard, Sammlung klinischer Vortrage, Vol. III, #221, (Surg. 70), p. 1878, Die Moderne Chirurgie (1882).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Valery-Radot, R., Life of Pasteur, Doubleday, Page &amp;Co., New York, 1919. Chapter IV.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Syme, J., On amputation at the ankle joint, London and Edinburgh Monthly Journal of Medical Science, Vol. 3, No. XXVI, Feb. 1843, p. 93.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Godlee, Sir Rickman, Life of Lord Lister, 3rd ed., Clarendon Press, Oxford, 1924. Chapter X.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Paterson, R., Memorials of the life of James Syme, Edmonston and Douglas, Edinburgh, 1874.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>R. I. Harris </b></td></tr><tr><td class="clsTextSmall">M.C., M.B., F.R.C.S. Can., F.R.C.S. Eng. (Hon.), F.R.A.C.S. (Hon.), F.R.C.S. Edin. (Hon.), Lecturer in Surgery, University of Toronto, Toronto, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1961_01_004/a001.jpg Figure 2 http://www.oandplibrary.org/al/images/1961_01_004/a002.jpg Figure 3 http://www.oandplibrary.org/al/images/1961_01_004/a003.jpg Figure 4 http://www.oandplibrary.org/al/images/1961_01_004/a004.jpg Figure 5 http://www.oandplibrary.org/al/images/1961_01_004/a005.jpg Figure 6 http://www.oandplibrary.org/al/images/1961_01_004/a006.jpg Figure 7 http://www.oandplibrary.org/al/images/1961_01_004/a007.jpg Figure 8 http://www.oandplibrary.org/al/images/1961_01_004/a008.jpg Figure 9 http://www.oandplibrary.org/al/images/1961_01_004/a009.jpg Figure 10 http://www.oandplibrary.org/al/images/1961_01_004/a010.jpg Figure 11 http://www.oandplibrary.org/al/images/1961_01_004/a011.jpg Figure 12 http://www.oandplibrary.org/al/images/1961_01_004/a012.jpg Figure 13 http://www.oandplibrary.org/al/images/1961_01_004/a013.jpg Figure 14 http://www.oandplibrary.org/al/images/1961_01_004/a014.jpg Figure 15 http://www.oandplibrary.org/al/images/1961_01_004/a015.jpg Figure 16 http://www.oandplibrary.org/al/images/1961_01_004/a016.jpg Figure 17 http://www.oandplibrary.org/al/images/1961_01_004/a017.jpg Figure 18 http://www.oandplibrary.org/al/images/1961_01_004/a018.jpg Figure 19 http://www.oandplibrary.org/al/images/1961_01_004/a019.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The History and Development of Syme's Amputation Creator An entity primarily responsible for making the resource R. I. Harris * https://staging.drfop.org/files/original/c737cb139033e8c4e783bb778fe2e303.pdf afba2b2f06d76842bef498473100a1b1 https://staging.drfop.org/files/original/53a89d8480ff368ebfc6962ec042be72.jpg b2d8f26b2c1cafd28d9b7ad03029a668 https://staging.drfop.org/files/original/2ef1058566b5da2b2e748d2d399df4c3.jpg a8237eb97aeffbee15ffa247a537a667 https://staging.drfop.org/files/original/0e0af5faf2d7d019ccf6efbf80ecc4e4.jpg 81b5c27b0158cb11f17f9b3811ec9ac7 https://staging.drfop.org/files/original/9fae0d917cf822fda036ea66b7f8ff35.jpg 39a6b402d16ad8e2ef8e5667351eef50 https://staging.drfop.org/files/original/fda55ff8d76b3af1f4afc1d3a8cc3787.jpg a25e75a93fc30ecdd9c8b6975d942de6 https://staging.drfop.org/files/original/635c07500a4b3f511b40baacfd0ec89f.jpg adb8ecb8590d21be56e26f5405cf8bf4 https://staging.drfop.org/files/original/881b402166909b183a592b5b932f5677.jpg 7a3a00e45dd8702373b17959937a5126 https://staging.drfop.org/files/original/867e91a41092a8cb68da465cd4034cf0.jpg da1b4fa8505ac79518e6226d88cac8c5 https://staging.drfop.org/files/original/05fd05eb81ff45ee5e7dcdccc396ce52.jpg dc75320f708c13452a69fae429e97894 https://staging.drfop.org/files/original/e6f7b2da3a4fadbf8a3a527edd3b5316.jpg 374c020c738c1a7a0b67d6f9b7e5072f https://staging.drfop.org/files/original/b0841997a49c9c7aab4eec937823c93b.jpg af43b44b1a7974fa376e7e9cc4272e4a https://staging.drfop.org/files/original/3ecc27bcefe23c8876046fa46a244a58.jpg 0cc9e916aae2a19c818aa922e2e9dd6d https://staging.drfop.org/files/original/3f61c1ac694eecb5767bc99734eebdca.jpg 84b791ff84fc7c8e0ba091dd088d83ad https://staging.drfop.org/files/original/6c08a4ed2a642bee3bf78630fcb66ac5.jpg 4dd94891a6ce8096342cf7ecff639b6e https://staging.drfop.org/files/original/b3b7237e745179d1ea21a21d0e3d3ecc.jpg d402232aa9be558b350be8c78a1075dc https://staging.drfop.org/files/original/b8ba70d807eb81df01ce717eb7db28ef.jpg cc62f2333467e76a57f6725f0c159351 https://staging.drfop.org/files/original/9cb3b4e808194b8ed3234d51106c404f.jpg 74505ee95ad7d6144a9d5ef5dff2fc5f https://staging.drfop.org/files/original/67170ee9e96df59048a0de1aa68a16c4.jpg ced97b253b8926ea606e2d78a8c894ab https://staging.drfop.org/files/original/8d01098d0675e6e9c890d0e24af2e450.jpg c3cd02b27f4bda7a2e64bc3d1b4b3807 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_004.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 4 - 30 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_004.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>Studies of the Upper-Extremity Amputee V. The Armamentarium</h2> <h5>Edward R. Ford, CP. <a style="text-decoration:none;">*</a><br />Earl A. Lewis, M.A., R.P.T. <a style="text-decoration:none;">*</a><br /></h5> <p>One of the most interesting aspects of the evaluation procedures is concerned with comparisons between the prosthetic equipment worn by the participating amputees prior to the NYU Field Studies and that later provided as part of the studies. Some amputees entering the program were found to be wearing modern arms based on the latest components and materials and constructed according to the latest methods of fabrication. Others had outmoded and sometimes outworn prostheses. And a third group either had never worn prostheses before or else were not wearing a prosthesis at the time the program began. Accordingly, the data gathered were not only on the new program prostheses but also on the old arms previously worn, if any, and hence the present analysis deals not only with the effects of program arms but also to a considerable extent with comparisons between the old and the new prostheses.<a style="text-decoration:none;">*</a> Of the 1630 arm amputees involved in the NYU Field Program, 359 were available for comprehensive investigation throughout the period covered by the evaluation studies. Of the 359, which together form the basis for this discussion, 168 were below-elbow amputees, 158 were above-elbow amputees, 23 had shoulder disarticulations, and 10 were bilaterals. Those who had prior experience with prostheses were used to form the comparative analysis of old vs. new.</p> <p>Although the subjects making up the group were generally available for intensive study, it was not possible to obtain from every amputee an answer to every question. In other instances, the investigators received multiple responses to questions. Moreover, certain areas of investigation called for responses in relation to the number of components involved, in which case the number of responses varied with the bilateral group and with those patients who utilized more than one terminal device. Although the reflection of these factors in the data causes some inconsistency in numbers of replies, it does not reduce the over-all value of the results.</p> <p>For purposes of identification, all prostheses worn by the amputees prior to inception of the NYU Field Studies are here referred to as "old prostheses" or "preprogram arms," although in a few cases they were rather new and reflected some of the latest techniques and components. All prostheses fitted during the course of the research studies are identified as "program" or "new" prostheses, although some of the components and techniques had for some time enjoyed either limited or general use in the prosthetics field. While the "old prostheses" represent an admixture of various techniques and components, some old, some new, the "program prostheses" represent the best of the old plus the latest innovations in the field of limb prosthetics at the time.</p> <p>In passing, it should perhaps be noted that the data concerned were for the most part gathered on program prostheses fabricated shortly after the prosthetists' completion of the prosthetics courses at the University of California at Los Angeles. The skills and experience available for handling the latest components, materials, and techniques were therefore somewhat limited during the early days. As experience and attendant skills increased, the quality of the prostheses improved. No apology for the program treatment procedures and prostheses (which, as will be seen, were clearly superior to preprogram efforts), this circumstance indicates that expansion of present gains can be expected as prosthetists and prosthetics clinics continue to accumulate experience with latest procedures.</p> <h3>Terminal Devices</h3> <p>The artificial hand or hook is generally considered to be the most important single component of an artificial arm. A major functional purpose of all other components of the upper-extremity prosthesis is to make it possible for the terminal device to be positioned and the function of grasp to be utilized. Moreover, the hook or hand is important from the standpoint of aesthetics, since it is exposed to view almost constantly and is a matter of curiosity to all who recognize it as a prosthetic device. Today's prosthetic armamentarium presents a choice, from a selection of hooks and hands, of terminal devices most likely to meet the wearer's needs. Within this framework are devices which operate on the voluntary-opening or the voluntary-closing principle<a></a>. Available hands are either essentially cosmetic or else are designed to provide prehension as well as cosmesis<a></a>. Either type permits the functions of pushing, pulling, and holding down objects.</p> <p>Were any one of these devices completely satisfactory, it would enjoy exclusive use by all wearers of arm prostheses. Since such is not the case, amputees frequently interchange two or more terminal devices, say a hand and a hook, and some even interchange two hooks of different shapes and operational characteristics. In any event, many factors influence the selection of terminal devices<a></a>, so that what- ever is chosen usually represents a compromise based upon consideration of the psychological, environmental, and biomechanical circumstances of the individual amputee.</p> <h4>The APRL Hand and Glove</h4> <p>One of the most widely publicized developments in the Artificial Limb Program has been the APRL voluntary-closing terminal devices—the APRL hook and the APRL hand with its companion glove of plasticized polyvinyl chloride<a></a>. Prior studies<a></a> had established the usefulness of these devices, and the Upper-Extremity Field Studies presented a unique opportunity to introduce these items into many more clinics over the country and to obtain additional information concerning the value of the devices to amputees. The APRL hand was therefore prescribed in almost all research cases where a prosthetic hand was indicated (285 out of 291). Four patients expressed strong desires to continue with voluntary-opening hands, while two others elected to continue with passive, cosmetic hands.</p> <p>Tests showed that grasp forces available with the APRL hand, in which grasping force is related directly to the force that can be exerted by the wearer, were much higher than those to be had with other types of functional hands. Almost all wearers of the APRL hand (89 percent) could exceed 20 lb., a force not uncommon in the palmar prehension of non-amputees <a></a>. Voluntary-opening mechanical hands, in which the force is limited to that available from springs or rubber bands, showed a maximum prehension force of 5 lb.</p> <p>When these tests were completed, the subjects were questioned regarding their reactions toward the APRL hand in the areas of usefulness, appearance, ease of operation, and weight.</p> <h5><i>Usefulness</i></h5> <p>Most of the amputees considered the APRL hand to be a useful device or at least one of limited use. Less than 12 percent considered the hand to be of no use. But the pattern of responses clearly indicates that the hand becomes less useful to the wearer as the level of amputa- lion becomes higher, presumably owing to the increased difficulty of using a prosthesis with decreasing stump lengths.</p> <p>The ability to control grasp and to maintain it (by automatic locking) was well received by 50 percent of the amputees for whom APRL hands had been prescribed, and increased function over a wide range of activities elicited important voluntary comments from another 27 percent. The choice of using either the large or the small finger opening prompted positive comments by 11 percent of the sample. When comparisons were made of the amputee reactions to usefulness, the APRL hand was rated considerably higher than other types of hands previously worn. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Appearance</i></h5> <p>Noted was an exceptionally high degree of amputee satisfaction with the appearance of the APRL hand. As might have been expected, level of amputation did not seem to influence the wearers' reactions in this area. More than 90 percent of all the amputees felt the APRL hand and glove to be either "very satisfactory" or "satisfactory" in appearance. In no other component of the prosthesis do we have such a large number of amputees exhibiting this degree of positive response.</p> <p>The size of the APRL hand was felt by 6 percent of the wearers to be a problem. Discoloration and difficulty in keeping the glove clean elicited negative comments from 12 percent of the subjects. Poor wear characteristics of the glove (abrasion, tearing, rubbing through) elicited negative comments from 9 percent of the sample. When amputee reactions to the appearance of the AFRL hand were compared with the corresponding reactions to the appearance of other hands previously worn, the results were very favorable toward the APRL device.</p> <h5><i>Ease of Operation</i></h5> <p>Almost 72 percent of the amputees for whom an APRL hand had been prescribed felt that it was easy to operate, another 26 percent considered it somewhat difficult to operate, and less than 3 percent found it very difficult to operate. Below-elbow amputees experienced the least difficulty in hand operation. As expected, fewer found the APRL hand "easy" to operate as the level of amputation became more proximal. <b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some of the amputees had worn other "functional" hands prior to the APRL device. When they compared ease of operation of their old prosthetic hand with that of the APRL hand, the APRL model was preferred. It is interesting to note that the shoulder-disarticulation and above-elbow cases exhibited dramatic changes in their reactions to use of functional hands, a fact which would suggest that the APRL hand has much greater applicability than the older hands. For one thing, in the dual-control system<a></a> the cable-excursion requirements are lower for voluntary-closing devices than for voluntary-opening devices, and this circumstance exerts an important influence on the use of above-elbow and shoulder-disarticulation prostheses. Apparently the additional control motions needed for operation of voluntary-closing devices did not constitute an objection insofar as ease of operation was concerned.</p> <h5><i>Weight</i></h5> <p>Judging from amputee opinions relating to the weight of the APRL hand (15 oz. with glove), the below-elbow group found the weight more satisfactory than did any other. In view of the greater residual anatomy in the below-elbow case, this result is generally understandable even though the short below-elbow case, without assistive forearm lift<a></a> is at a disadvantage. It is significant to note that 42 percent of all amputees for whom a hand had been prescribed felt that the APRL hand was somewhat heavy or very heavy, an indication that further improvements, aimed at weight reduction, are needed. Nevertheless, amputees who had worn other hands considered the APRL hand lighter. All in all, the wearers' reactions consistently favored the APRL hand.</p> <h5><i>Discussion</i></h5> <p>It should be understood that amputee reactions toward the APRL hand were of special interest to the research program. Consequently, many such hands were prescribed not for specific vocational or avocational reasons, nor because of patient interest, but to observe the effects upon a rather large number of amputees who had no specific objections to being fitted on a trial basis. Many confirmed hook wearers were therefore included in the group fitted with APRL hands.</p> <p>The data show that mass fitting (285) of the APRL hand caused an additional 27 percent of the patients to wear hands on a more or less regular basis. Very few amputees expressed serious over-all negative feelings toward the APRL hand and glove.<a style="text-decoration:none;">*</a> Apparently, however, 25 percent of the patients for whom APRL hands had been prescribed wore them less than one day a week. Some, after a brief experience with the hand, declined to wear it at all and preferred to return to exclusive use of a hook. Since this response cannot be related to any specific dislike for the APRL hand and glove, it appears to relate more to a basic preference for a hook.</p> <p>A number of improvements in the APRL hand were suggested during interviews with the amputees. One was that a range of sizes would be most welcome since the one size available at the time was often either larger or smaller than the corresponding normal hand. Amputees with large hands seemed to feel that the APRL hand and glove were too small and effeminate. Another, cited especially by those with the higher levels of amputation, concerned the need for reducing the weight of the APRL hand. Other proposed improvements related to appearance and durability (especially of the glove) and to the complexity of function arising from the double control motion required for locking and unlocking.</p> <p>In brief, the APRL hand, with its two-position prehension range, its voluntary-closing self-locking mechanism, and its cosmetic glove, showed superior grasp forces and was considered to be more useful, easier to operate, and much better in appearance than other mechanical hands. Although the wearers indicated that weight reduction in the APRL hand would be welcomed, the existing hand was considered more satisfactory than other mechanical hands. Despite these positive findings, it was apparent that design changes directed toward weight reduction, improved durability in the cosmetic glove, establishment of a range of sizes, and simplification of operating requirements would improve the device significantly.</p> <h4>Rubber-Band-Loaded Hooks</h4> <p>The type of hook which, historically, is the standard in the prosthetics field, and the one to which all other designs are compared, is the steel or aluminum voluntary-opening split hook in which the fingers rotate about a single pivot and are held in the closed position by the contraction of rubber bands that stretch during opening<a></a>. Addition of more and more rubber bands increases the maximum available finger forces at the expense of added work in opening.</p> <p>Many variations in finger shape are to be had. Some fingers are lined with rubber to reduce slippage, others are unlined. In the studies concerned, prescription of rubber-band-loaded hooks was often on the basis of previous amputee experience. Sometimes clinical judgment favored them, especially for use with bilaterals, because of the simplicity of operation as compared with voluntary-closing, self-locking terminal devices which, although superior in grasp forces, demand additional control motions, a requirement generally considered to be a shortcoming. In tests involving 68 of these simple hooks as worn by amputee subjects, it was found that the rubber bands had been selected to yield prehension forces ranging from 1 lb. to 14 lb. (average, 4.3 lb.), depending on individual preference.</p> <p>With regard to usefulness, appearance, ease of operation, and weight, amputee reactions to rubber-band-loaded hooks are rather consistent regardless of level of amputation. Although in general there is a high degree of acceptance, 21 percent of the below-elbow amputees and 8 percent of the above-elbow cases indicated that rubber-band-loaded hooks are of limited use only. Thus again improvement is needed. The subjects themselves suggested more durable rubber inserts for the fingers, elimination of rubber bands, and reduction in the conspicu-ousness of the hook without reducing its functional value. <b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Sierra Two-load Hook</h4> <p>A relatively new design for voluntary-opening hooks, which traditionally have used rubber bands for closing, is the Sierra two-load hook featuring a spring to close the fingers<a></a>. Heavy or light closing forces are selected by positioning a small mechanical switch located on the post provided for attachment of the control cable. The case which houses the operating mechanism is made of aluminum, and the hook fingers, also of aluminum, are lyre-shaped and lined with neoprene for increased security of grasp.</p> <p>The novel design of the two-load hook, with its simplicity of operation (voluntary-opening) and choice of two grasp forces, interested both clinics and amputees. Consequently, 64 of these devices were prescribed in the study. Data taken on 51 subjects show that pinch forces averaged 3.4 lb. for the light-load setting of the mechanism, 6.6 lb. for the heavy loading.<a style="text-decoration:none;">*</a> <b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Amputee reactions to the two-load hook were generally positive insofar as usefulness, ease of operation, weight, and, to a lesser extent, appearance were concerned. As with rubber-band-loaded hooks, there were indications of need for improvement, for 13 percent of the below-elbow amputees and 12 percent of the above-elbow cases indicated that the two-load hook was of limited use only. That 12 percent of the above-elbow amputees felt the device somewhat difficult to operate is a finding hard to interpret, unless perhaps these particular subjects had been accustomed to extremely light loadings on hooks operated by rubber bands.</p> <p>In general, there was a favorable reaction toward the availability of two levels of grasp force from which to select. Although apparently the light load was used most often, the wearers found that the heavier loading was sometimes very desirable. The indications were that a desirable improvement could be effected if the ranges of prehension force could be made adjustable by the wearer (perhaps by use of a simple tool). When amputee comments were compared (two-load hook versus rubber-band-operated hooks worn previously), there was no clear-cut preference for either type, although the two-load fared slightly better in all areas except appearance. <b>Fig. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>APRL Hook</h4> <p>The APRL hook is, like the APRL hand, a voluntary-closing, automatic-locking terminal device<a></a>. The body and fingers are of aluminum to keep weight within reasonable limits, the fingers being lyre-shaped and lined with neoprene to increase the security of grasp. Opening ranges of approximately 1-1/2-in. or 3 in. are selected by manipulation of a small switch protruding from the hook case. The control cable attaches to a lever arm projecting from the side of the housing for the mechanism. As with the APRL hand, prior studies<a></a> had established the general acceptability of the hook, and the NYU Field Studies presented a unique opportunity to gain additional insight into its application and to introduce it into more climes throughout the country.</p> <p>The basis for prescription was to furnish the APRL hook in a majority of cases where a hook was required. The only exceptions were those cases where a clear contraindication was apparent (for example, in cases of patient refusal to wear any type of hook, or to change from some other type to the APRL hook, or where occupational requirements demanded extremely rugged construction, or where the subject was interested in trying the Sierra two-load hook). Consequently, rather large numbers of amputees in the study were equipped with the APRL hook.</p> <p>The data obtained with 228 hooks were similar to those obtained with the APRL hand when it was compared to voluntary-opening hands. Grasp forces were found to be considerably higher with the APRL hook than with voluntary-opening hooks. Eighty-nine percent of the wearers could exert forces over 9 lb., 54 percent over 20 lb.</p> <p>Although amputee reactions to the APRL hook were generally positive, the present design evidently leaves much to be desired in the area of appearance and, to a lesser degree, in the area of usefulness. In interviews, the amputees mentioned:</p> <ol> <li>The possibility of reducing length and bulk by incorporating the terminal-device mechanism in the forearm.</li><li>Dissatisfaction with the reliability of operation (locking after closing), although some wearers were generally aware that the fault might lie with themselves in not permitting the mechanism to alternate.</li><li>Backlash, which in varying degrees caused some wearers distress.</li><li>The potential advantages (aesthetic as well as functional) of having the hook "thumb" as well as the moving finger on the medial aspect. At present, when the "thumb" is on the medial side the moving finger is on the lateral side and opens away from the wearer's body. If the wearer wants the moving finger to open toward him, the "thumb" is placed on the lateral side.</li></ol> <p>Some interesting points are observed when we compare the responses to the APRL hook with those to the APRL hand. Since in general hooks are conceded to be more functional than artificial hands, it comes as no surprise that in the area of usefulness the APRL hook rated higher than did the hand. As regards appearance, reactions were much more favorable to the hand than to the hook, but, in the case of the latter, amputation level had no apparent effect on amputee feelings. In any event, a significant number of patients found both hand and hook unsatisfactory in appearance. <b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>More than 80 percent of the amputees wearing the APRL hook indicated that it was easy to operate regardless of amputation level. Conversely, responses by wearers of the APRL hand indicated that operation became somewhat more difficult at the higher levels of limb loss. By far the majority of wearers registered satisfaction with the weight of the hook (8-1/4-oz.), whereas the weight of the gloved hand (15 oz.) was less well received. The higher the level of amputation the more critical weight became. Next to be considered are the reactions voiced in regard to the usefulness, appearance, ease of operation, and weight of rubber-band-loaded hooks (voluntary-opening) worn prior to the studies and of the APRL hook (voluntary-closing) supplied during treatment. The below-elbow and shoulder-disarticulation wearers considered the rubber-band and APRL hooks approximately equal in usefulness, while the above-elbow wearers felt the APRL hook to be somewhat more useful. As for appearance, about 70 percent of the subjects found both APRL and rubber-band hooks generally "satisfactory." Whereas 15 percent indicated dissatisfaction, the remaining 15 percent said that in appearance both hooks were "very satisfactory." When ease of operation was considered, the below-elbow and above-elbow wearers favored the APRL hook slightly, although both hooks were rated highly with regard to operating characteristics.</p> <p>The wearers of shoulder-disarticulation prostheses showed a distinct preference for the APRL hook with respect to ease of operation, probably because of the ease with which closure can be effected and because of the low excursion requirements peculiar to voluntary-closing terminal devices. This finding may indicate that rather light prehension forces are used by most wearers of shoulder prostheses, for were this not the case they would react against the difficulty of reopening the hook. There is no indication from the data that the additional control motions required for use of the APRL hook made hook operation less "easy." <b>Fig. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Hook weight appeared to present no major problem regardless of level of amputation. Although the 8-1/4 oz. APRL hook was generally considered by the wearers to be more satisfactory than the Dorrance No. 555 (3 oz.), the Dorrance No. 5 (7 oz.), or the Dorrance No. 7 (8-3/4 oz.), the responses may have been influenced by the use of a new prosthesis, which very often was better fitted, more comfortable, and more efficient than the old arm with the rubber-band hook.</p> <p>It is apparent from the foregoing discussion that functional, split hooks were rather highly valued regardless of type. In all cases, usefulness, ease of operation, and weight were apparently quite acceptable to almost all wearers. Only in the area of appearance did a significant number of subjects indicate dissatisfaction, and even then most of the amputees accepted prevailing appearance.</p> <p>The amputees who used rubber-band-closing hooks prior to the study and changed over to the APRL hook during the study were in an excellent position to compare terminal devices. The below-elbow amputees felt that the APRL hooks and those of the rubber-band type were approximately equal in usefulness, the responses favoring the APRL hook slightly. The above-elbow cases seemed to favor the APRL hook rather strongly, the responses indicating an attitude considerably more positive toward the usefulness of the new hooks. The shoulder-disarticulation cases seemed to favor the rubber-band hooks slightly with respect to usefulness, but the smallness of the sample (13 patients) prohibits drawing any conclusions in favor of either type of hook for this special group.</p> <p>In sum, it appears that the rubber-band and the APRL types are about equal in usefulness, the data favoring slightly the APRL design. No clear-cut advantage in the use of one over the other is evident from amputee reactions. In all probability, personal preference based on past experience, influence of the clinic team, or other intangibles are contributing factors. The entire area affecting the choice of terminal devices is one that should be given additional study.</p> <h3>Wrist Units</h3> <p>Prosthetic wrist units are designed to facilitate attachment of the hand or hook to the forearm and to permit pronation-supination of the terminal device<a></a>. The most common type (screw-in type) bears a female thread such as to accept the terminal-device stud, and a rubber washer and retaining plate are used to control the tendency toward excessive loosening or tightening when the terminal device is rotated. A newer type of wrist unit, intended to provide not only for easy rotation but also for easier interchange of terminal devices, incorporates a control button which, when depressed, frees the hand or hook for rotation. Further depression of the control button permits removal of the terminal device from the wrist unit, the need for unscrewing being thus eliminated. In still another wrist, also designed for quick interchange of terminal devices, the turn of a knurled ring releases the hand or hook for rotation or removal. <b>Fig. 8</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the NYU Field Studies, prescription of wrist units favored the button- or ring-operated wrist (plug-in type) wherever more than one terminal device was to be used. When a single terminal device was prescribed, the screw-in type was generally favored, since then interchange was not a major consideration. Plug-in wrists fitted to 266 research patients and screw-in types fitted to 93 were followed over an average wear period of six to nine months, and amputee reactions were obtained concerning two aspects of wrist function-attachment and removal of the terminal device, and pronation-supination to achieve acceptable attitudes of approach. Of the 359 amputees wearing program arms, those equipped with plug-in units were slightly more satisfied with the attachment function than were those who wore screw-in wrists. Pronation-supination was fairly satisfactory with both types.</p> <p>Despite the general amputee acceptance of both types of wrist, however, there was also evidence of substantial dissatisfaction. Interviews with the amputees and observation of their performance revealed that a simpler and faster method of exchanging terminal devices was required, as were also improvements in the cable connections, which were then cumbersome and difficult to manipulate with one hand. Evidently, improved rotation mechanisms were needed to permit easy correction of terminal-device attitude for best angle of approach.</p> <p>When specific wrist features (ease of operation, usefulness, weight, and appearance) were explored (page 16), the wearers were even more positively inclined toward the plug-in wrist unit. The reactions of 138 amputees who had screw-in wrists on their old arms and plug-in wrists on their program arms show that, insofar as exchanging terminal devices was concerned, the plug-in wrists were favored by a greater percentage of the below-elbow wearers than were the screw-in wrists. The opinions of the above-elbow amputees showed only a slight trend in favor of the plug-in wrists. Because only a small number of shoulder-disarticulation cases changed to plug-in wrists, their reactions were not recorded. The responses of 107 amputees who had used screw-in wrists on their old arms and plug-in wrists on the program arms showed that the plug-in type of wrist was considered by below-elbow wearers to be easier to rotate than was the screw-in type.</p> <p>Opinions concerning the locking function of wrist units are of interest since only the plug-in type locks the hook or hand in its selected attitude, the screw-in type depending upon friction to maintain terminal-device orientation. In 106 cases, both below-elbow and above-elbow wearers considered the plug-in type of wrist (with its ability to permit rotation of the terminal device as well as to lock it) somewhat more useful than the screw-in, nonlocking type.</p> <p>In the areas of weight and appearance, the plug-in type was again, and somewhat surprisingly, favored over the simpler, screw-in unit. Despite the fact that the plug-in wrist is actually heavier than the screw-in type, amputees favor it. Apparently the "halo effect" of the new prosthesis with its generally superior comfort, appearance, and efficiency may be responsible for the positive responses in the areas of wrist weight, wrist appearance, and ease of wrist rotation.</p> <p>In summary, the plug-in type of wrist was favored slightly over the screw-in type, first because of the relative ease with which terminal devices could be exchanged and second because the hand or hook could be locked in any desired attitude of pronation-supination. Below-elbow amputees seemed to favor the plug-in type more than did the above-elbow group, an understandable result when it is considered that below-elbow wearers are generally more active with their prostheses and more inclined to exchange terminal devices than is the case with above-elbow amputees. In any event, it was apparent from observations and from amputee remarks that improved cable attachments were needed to facilitate ease of connecting and disconnecting hands or hooks. Despite the fact that some below-elbow wearers considered rotation of terminal devices easier with plug-in wrists, observation leaves little doubt but that the screw-in type is superior in rotation features. It seems clear that attitudes toward the rotational qualities as well as toward the weight and appearance of the plug-in wrist were positively affected by concomitant reactions toward superior locking and attachment qualities. <b>Fig. 9</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Elbow Joints for Below-Elbow Prostheses</h3> <p>Almost all below-elbow prostheses are suspended from cuffs fitted above the bony prominences of the elbow joint. The cuff and prosthetic forearm are connected by means of mechanical elbow joints, some of which (rigid hinges) are designed to permit flexion and extension only, others (flexible hinges) permitting also pronation and supination.<a></a> Metal hinged joints are generally used for shorter stumps where stability against inadvertent rotation is a major requirement. Flexible leather, steel-cable, or fabric-type joints are generally used in prostheses for longer stumps where residual, natural forearm rotation can be utilized. Short stumps typically have limited purchase in the prosthesis and therefore require a snug, high-fitting socket in order to obtain forearm stability<a></a>. But the high-fitting socket often restricts the wearer's range of flexion owing to crowding of flesh as the forearm is raised. Special joints, known as "step-up" joints<a></a>, are designed to relieve this condition and to produce an increased range of flexion. Since in such a case the range of motion increases at the expense of lifting power, it is sometimes necessary to use an assistive forearm lift similar to that commonly used with above-elbow prostheses <a></a>. Whenever the very short below-elbow stump is un-suited for lifting the prosthetic forearm, it is fitted with locking joints actuated either by movement of the stump or by a cable control similar to that used for the above-elbow case.<a></a></p> <p>Evaluated comprehensively with both old and new prostheses were 136 unilateral below-elbow amputees, the elbow components of the prostheses being as follows: <b>Fig. 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The data show that in general the new arms permitted a greater range of forearm flexion than did the preprogram arms, partly no doubt because of an increased use of step-up joints in the new prostheses and partly because of improved socket shaping to avoid restriction of flexion through crowding of flesh at the brim of the socket. <b>Fig. 11</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before the advent of the Upper-Extremity Field Studies, use of flexible elbow joints had been reserved almost entirely for patients with wrist disarticulations or long below-elbow stumps. Of all the amputees in the group investigated, only 17 had had flexible joints in their preprogram arms, and of these only one had a stump shorter than 6-1/2 inches. Moreover, the available stump rotation was rather good, only one having less than 20 deg. of pronation-supination. Experience indicated that even still shorter stumps might retain slight but useful rotation and that patient comfort might be increased and clothing damage decreased with use of flexible hinges. Consequently, during the program many stumps within the group of 136 amputees (74 arms) were fitted with flexible joints even though the rotation possibilities were knowingly limited (22 cases with residual stump rotation of less than 20 deg., 13 patients with stumps shorter than 6-1/2 in.).</p> <p>As expected, the average rotation range for the entire group with the new prostheses decreased as compared with the average rotation range of the 17 who had been provided with flexible hinges on their old arms. But it must be pointed out that many more amputees now had not only the facility of active pronation-supination but also the greater comfort and reduced clothing damage inherent in the use of flexible joints. The 16 amputees who used flexible hinges on both old and new arms exhibited the same range of pronation-supination with the two prostheses. <b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The reactions of the below-elbow subjects to the various elbow joints evaluated during the study were in general very positive in the areas of usefulness, ease of operation, and weight but a great deal poorer in the area of appearance. Although the step-up and stump-actuated joints were unacceptable to a few amputees, negative generalizations are impossible because the size of the sample was too limited (24 step-up joints, 7 locking joints). And indeed these components must be widely acceptable, judging from the overwhelming percentages of positive responses. The negative comments made by wearers of step-up joints indicate an inability to stabilize the forearm sufficiently to obtain effective use of the terminal device. The development of locking step-up joints has been suggested as a means of stabilizing the prosthetic forearm for amputees with short or very short stumps.</p> <p>The principal findings with regard to elbow joints for below-elbow prostheses center around a shift toward increased use of flexible hinges and a corresponding decrease in the number of rigid joints used.<a style="text-decoration:none;">*</a> Of special interest is the finding that stumps shorter than 6-1/2 in. should also be considered for flexible elbow joints. Although the shorter stumps can be expected to provide only minimal pronation-supination, even slight gains in rotation are important for hand and hook positioning. There was no reported instance of socket instability on the shorter stumps fitted with flexible joints on program arms, and the gains in patient comfort and in reduction of clothing damage lead to the conclusion that use of any joint other than flexible should be advocated only after serious consideration of the specific needs of the individual patient. Although the sample using step-up or locking joints was small, and although it is apparent that the joints were generally satisfactory, development of a step-up joint capable of locking the prosthesis in flexion seems quite desirable, since stabilization of the forearm for effective terminal-device operation or for lifting objects appeared to be difficult with the step-up joints used both before and during the study.</p> <h3>Elbow Joints for Above-Elbow and Shoulder-Disarticulation Prostheses</h3> <p>Positioning of the prosthetic forearm and terminal device of a modern above-elbow or shoulder-disarticulation prosthesis in the flexion-extension plane requires that the elbow be unlocked. Locking of the elbow permits control-cable forces to by-pass the forearm lift and to act upon the terminal device.<a style="text-decoration:none;">*</a> Rotation of the prosthesis about the humeral axis to facilitate mediolateral positioning of the forearm is accomplished by means of a turntable incorporated in the elbow and controlled by a friction element which resists free movement.<a></a> In general, about 2 lb. of force and half an inch of cable travel are needed to lock present mechanical elbows, about 5 lb. to unlock. But the exact figures vary slightly from elbow to elbow and from manufacturer to manufacturer. Program arms fitted during the early phases of the study were built around Sierra Model C elbows<a></a>, which had unlocking forces (6.3 lb.) and excursion requirements (9/16-in.) slightly higher than those of the Hosmer E-400 units (4.0 lb. and 1/2 in.), which in turn became available to the clinics later in the study and which were identical in operating principle. Besides this, the Hosmer E-400<a></a> was at the time a new component, clinics were therefore particularly interested in its application, and consequently it was prescribed almost routinely during the latter part of the program. Of the 170 internal elbows fitted and evaluated during the study, 110 were Sierra Model C's, 42 were Hosmer E-400's, and 18 were Hosmer E-300's (an earlier elbow incorporating a locking mechanism of quite different design, now discontinued). External elbow locks<a></a>, intended for amputees with long humeral stumps or with elbow disarticulations, were used in 11 cases.</p> <p>Above-elbow and elbow-disarticulation amputees achieve elbow locking and unlocking by a combined extension-abduction of the humeral stump, a motion which exerts pull upon a control cable attached between the elbow and the shoulder harness.<a></a> Alternate pulls on the elbow-lock control cable result in locking and unlocking or vice versa. Shoulder-disarticulation amputees usually control the elbow lock by elevating the shoulder on the side of the amputation, thus exerting pull on a control cable attached between elbow lock and waistband. <a></a> </p> <p>All of the elbow-disarticulation, above-elbow, and shoulder-disarticulation prostheses provided in the program were equipped with locking elbows of the alternating type. Of the 181 cases (170 internal locking, 11 external locking) available for study, 76 had had prior experience with prostheses incorporating the older manual locks, and 18 had worn arms without locking elbows. Fifty-two had previously used alternating elbows of the type used in the program arms. In 35 cases, either the patient had not previously worn an arm or else the type of elbow was unknown.</p> <h4>Internal-locking Elbows</h4> <p>The data show that a considerable number (36 out of 101) of the preprogram arms provided little or no initial elbow flexion, owing chiefly, no doubt, to fabrication technique and workmanship rather than to the nature of the elbow units themselves. Program arms tended to group around the standard of 10-15 deg. of initial flexion, a feature that tends to make initiation of forearm lift less difficult. Moreover, forearm flexion was restricted in the old arms, less than a third of them being capable mechanically of approaching 135 deg. of flexion. In general, program arms could be flexed to much greater extent, almost two thirds of the subjects reaching or surpassing 135 deg.</p> <p>As for other deficiencies in the new arms, 35 cases exhibited serious impairment of elbow-lock operation, primarily because of harnessing inadequacies. A considerably larger number of prostheses showed less than optimal elbow function, mostly because of poor arrangement of the elbow control cable and the front support strap. In 12 cases, malfunction of the elbow mechanism was apparent, and 37 of the new prostheses required adjustment for insufficient initial elbow flexion. Thirteen arms required attention to correct friction characteristics in the elbow turntables.</p> <p>Generally, then, more careful attention to adjustments and to harnessing detail for elbow-lock operation was obviously required. Direct amputee reactions to the cable-controlled, internally locking elbows were quite favorable, only 4 of the 170 wearers experiencing negative feelings when all aspects of elbow use were considered. Of the few negative comments made (25), the majority related to lack of dependability in elbow operation, probably because of such factors as careless harnessing or inadequate training in the required operational pattern. As might have been expected, the cases with the shorter stumps found operation of the lock more difficult than did those with the longer stumps. Except where the fitting of the short-above-elbow patient was expertly done, the shoulder-disarticulation cases had less difficulty in elbow locking and unlocking by means of shoulder elevation than did the short-above-elbow cases using the same control motion.</p> <h4>External-locking Elbows</h4> <p>External-locking elbow joints are sometimes used for elbow disarticulations and for very long above-elbow cases<a></a>. Although in the study 11 elbow-disarticulation amputees were fitted with external joints, only 8 had had experience with internal-locking elbows on their old arms. From the viewpoint of usefulness, they favored the internal mechanism slightly, perhaps because of the rotation turntable and because of the greater number of available locking positions in the internal elbows. As for appearance, the arms fabricated with outside-locking elbows seemed to be more acceptable than those constructed with internal units because, while the outside-locking units protrude on the medial aspect of the arm, internal units may be fitted to elbow disarticulations and to very long above-elbow cases only by lowering the elbow center abnormally.</p> <p>Ease of operation gave rise to some differences in amputee reactions toward internal as compared with external elbows. Since the forces and control motions are essentially identical in the two types, the discrepancies probably relate more to the nature of the harnessing or to the skill of the patient than to the particular characteristics of the elbows themselves.</p> <p>As one might have anticipated, amputee reactions to weight favored the outside-locking units, which are somewhat lighter than the internal elbows. <b>Fig. 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Summary</h4> <p>To summarize, only 29 percent of the 181 amputees studied were known to have worn on their preprogram arms locking elbows of the alternating type. In the studies, all unilateral above-elbow patients were fitted with the more modern locking units, thus freeing the normal arm from the responsibility of operating a manual lock for the amputated side. Program arms had greater ranges of forearm flexion and were adjusted to provide greater initial flexion so as to make it easier for the patient to lift the forearm. But elbow-lock operation with the new arms was often impaired by poor harnessing arrangements that required correction. While in general the amputees were quite favorably disposed toward the cable-controlled, locking elbows, infrequent negative complaints of lack of dependability related to inadequacies in harnessing and to poor operational patterns on the part of some wearers. A limited number of amputees fitted with external-locking joints provided sufficient positive evidence to ensure the future of these components in the array of items available for long-above-elbow or elbow-disarticulation patients.</p> <h3>Harnessing</h3> <p>If the upper-extremity prosthesis is to be of functional use to the amputee, two basic needs must be met. A suitable attachment of the prosthesis to the body must be made, and power must be provided for operating and controlling the limb. Although the socket is made to conform to the stump, it tends to become displaced, especially during lifting. The prosthesis is therefore suspended from the shoulder by means of a harness which keeps the socket in close contact with the stump and resists any tendency for the prosthesis to shift out of position. Usually the same harness serves as the force-transmitting medium between body sources of power and the cable system of the prosthesis<a></a>. For both above- and below-elbow amputees, two basic types of harness are in common use today-the figure-eight harness and the chest-strap harness <a></a>. Commonly, the chest-strap design is applied in the shoul-der-disarticulation case too <a></a>.</p> <p>Of all artificial arms, the unilateral below-elbow prosthesis is perhaps the simplest to suspend and to power. In the figure-eight method, suspension is obtained by a loop of 1-in. fabric tape passing under the axilla on the sound side and over the shoulder on the amputated side, the front end of the tape being attached to a biceps cuff (which in turn supports the elbow joints connecting to the prosthetic forearm), the other end (the back) to the control cable for the terminal device. Forward rotation of the arm upon the shoulder on the amputated side causes forces to be applied to the cable and gives the excursion necessary to operate the hook or hand. In the chest-strap method, suspension of the biceps cuff is achieved through use of adjustable leather or fabric straps attached to the anterior and posterior aspects of a leather shoulder saddle, and the control cable is attached to an adjustable fabric tape sewn to the chest strap in the region of the seventh cervical vertebra. Although the figure-eight type of harness is used almost universally for the unilateral below-elbow prosthesis, it is considered by some that the chest-strap type, with its broader weight distribution over the shoulder, is indicated for amputees anticipating extremely heavy-duty services or for those who cannot tolerate the axilla pressures typical of the figure-eight loop <a></a>.</p> <p>For the unilateral above-elbow prosthesis, the figure-eight and the chest-strap harnesses enjoy in general a more equal popularity. Program arms tended strongly, however, toward the simpler figure eight, in which the fabric tape loops over the sound shoulder, under the axilla on the sound side, and then over the shoulder on the amputated side <a></a>. It is generally conceded that the above-elbow chest-strap harness, which uses a leather or fabric saddle to reduce the unit pressure on the shoulder, is preferred whenever the patient anticipates activities involving heavy lifting or when he cannot tolerate the axilla pressure characteristic of the figure-eight harness <a></a>.</p> <p>For the unilateral shoulder-disarticulation or forequarter amputation, the most common harness in use today is that of the chest-strap type, elbow locking and unlocking being achieved by elevation of the shoulder on the amputated side. A fabric tape extends from the elbow-lock control cable and attaches to another surrounding the waist. Scapular abduction gives power and excursion for forearm lift or, when the elbow is locked, for terminal-device operation <a></a>.</p> <p>In the evaluation studies, harnesses were individually prescribed according to type and made in accordance with the latest techniques. But because the harness is always a custom-made item fitted by the prosthetist according to the requirements of the individual patient, there were introduced a number of variables involving such intangibles as skill and judgment. Although in program prostheses each harness had to meet certain requirements designed to ensure proper suspension and adequate power and excursion, it was apparent almost from the beginning that serious harnessing problems existed. About 45 percent of all arms showed harness deficiencies at checkout. The above-elbow prostheses were notably troublesome, 375 harnessing faults showing up on the 303 arms going through checkout. The below-elbow prostheses, though considerably simpler, were also a source of difficulty, 150 harnessing faults being discerned on 361 below-elbow patients. The shoulder-disarticulation group of 53 patients had 39 harnessing faults. <b>Table 1</b>, <b>Table 2</b>, and <b>Table 3</b> reflect the types of harnessing faults found at clinical checkout of the program arms.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It should be pointed out that the prostheses were rated at checkout according to criteria evolving from material presented at the prosthetics courses offered as part of the program. Accordingly, any deviations from the accepted harnessing practices taught in the courses were considered "faults." But it was recognized that arm harnessing is an individualized procedure and that therefore certain faults might be less critical than others depending upon the amount of deviation from the standard, the physique of the patient, his threshold of tolerance for discomfort, and other intangible considerations. Consequently, it should be made clear that recognition of a fault did not necessarily mean the prosthesis was unusable but, more often than not, that the limb simply was not operating at a peak level of performance and/or comfort. Fortunately, the problems encountered with the harnesses at checkout were markedly reduced as the prosthetists gained experience. Strict adherence to the checkout standards, along with increased understanding and skill, served to ensure that each arm wearer was ultimately harnessed so that he could use the prosthesis in a functional manner. After checkout (and prosthetic corrections, when indicated), the amputees embarked upon a long-term period of wearing the new prosthesis.</p> <p>Amputee reactions to the new arm harnesses were checked with regard to comfort, appearance, and fit as these matters affected the function of the prosthesis. Generally, the wearers' reactions were quite favorable, and it was apparent that the subjects generally had a higher regard for the new harnesses than they had for the old (<b>Table 4</b>). Although program harnesses scored highly with all amputee groups, the above-elbow amputees consistently rated their harnesses slightly lower than did the below-elbow or shoulder-disarticulation groups, probably because the above-elbow figure-eight harness is more com- plex and in comparison with below-elbow harnesses somewhat more snug-fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Interviews with the amputees disclosed that most participants who had worn prostheses prior to the studies felt that the new harnesses were much better than the old ones. Particular comments evidenced satisfaction with reduction in amount of harness needed to obtain satisfactory prosthetic function with the new arms. Some wearers commented upon possible areas of improvement, a response which almost always involved the desire to be burdened with no more harness than necessary to control the arm. A number of subjects indicated discomfort at the axilla, and problems relating to shift of the harness out of place were not uncommon. Although difficulty in operating the elbow lock was corrected in most cases, some wearers felt that other means should be sought for control of elbow lock.</p> <h3>Power-Transmission Systems</h3> <p>To achieve functional use of a prosthesis, the amputee must be able to avail himself of residual sources of body power. Flexion, extension, and abduction of the arm, extension of the forearm, shoulder elevation, scapular abduction, and chest expansion are the most common power sources harnessed by the prosthetist to provide movement of the artificial arm.<a></a> Transmission of the forces thus generated is accomplished by the use of Bowden cables connecting the points of force generation (harness components) and the points of force application (forearm or terminal device). In the below-elbow prosthesis, forward movement of the shoulder on the sound side, flexion of the arm on the amputated side, singly or in combination, exerts against the harness system a force that is transmitted for operation of the terminal device, the forearm being lifted by the stump. Above-elbow and shoulder prostheses utilize the same type of power-transmission system, except that with arms of this type the cable is used also to lift the prosthetic forearm whenever the elbow is unlocked (dual control). <b>Fig. 14</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Prior to the Upper-Extremity Field Studies, many arm amputees had been using Bowden cable for power transmission. Others used steel cable without housing, nylon cord, leather or rawhide thongs, and other miscellany, as shown in <b>Table 5</b>. But all program arms were equipped with Bowden cable and subjected to checkout procedures to ensure that minimum standards of power-transmission efficiency (below-elbow prostheses, 70 percent; above-elbow and shoulder-disarticu-lation prostheses, 50 percent) were met. When checked, the program arms showed for every amputation level substantial increases in efficiency over the standards shown by the power-transmission systems of the corresponding old prostheses. Indeed, the new arms exceeded the minimum efficiency standards with such regularity that raising of the standards is now indicated.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Full opening and closing of the terminal device was possible for an increased number of amputees through use of the new arms. When function of the terminal device was tested at each of four operating positions (at full extension, at 90 deg. of flexion, at waist, and at mouth), the results showed a marked increase in opening range for each amputee type at all four positions.</p> <p>Doubtless this improvement was due to the use of better harness and belter-fitting sockets, with better transmission of force and excursion through the cabling system, if not to application of the voluntary-closing terminal devices, which inherently use less excursion than do the voluntary-opening hooks that predominated in the old prostheses. <b>Fig. 15</b>, <b>Fig. 16</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Initial checkout of all patients provided with program arms revealed some problems in application of the Bowden cable (<b>Table 6</b>). faulty placement of retainers, improper cable lengths, and poor. soldering of connections were the main sources of trouble. Of course some of the arms had more than one fault, whereas about half of the 790 arms fitted and checked out in the study had no faults at all in the transmission system.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Those in the study who had used power-transmission systems in both old and new arms (285) generally found the Howden-cable system easy to use, acceptable in noise level and in appearance, kind to clothing, and free of excessive maintenance requirements. Of these amputees, 201 responded to questions intended to elicit preference either for their old or for their new cable systems. Only 10 of the 201 in the group preferred their old power-transmission systems, 103 preferred the new. Yet 88 had no preference, which indicates that a significant number of preprogram arms had the advantage of an adequate power-transmission system.</p> <p>Suggestions for improvement indicated that the amputees would have liked to have seen the cables concealed within the prosthesis, although the existing appearance was not considered unsatisfactory. Easier and quieter operation might also constitute an improvement, although here again there appears to have been no major criticism. <b>Fig. 17</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Complete Prosthesis</h3> <p>Thus far we have considered only the individual elements of the prosthesis. A matter of equal importance, however, is the consideration of the prosthetic appliance in its entirety and of the effects of clinical treatment and training with the prosthesis. Although the data presented here concern the below-elbow, above-elbow, and shoulder-disarticulation cases only, findings from the 10 bilateral amputees who were available for evaluation may also be considered indicative of probable trends. The responses of the small bilateral group, consistently positive toward the new program arms, were substantially in agreement with the responses from the other amputees. Although most wearers considered their new arms to be useful, the desire for further improvement was reflected in the significant percentage of wearers who considered the arms to be of limited use only. When the amputees compared the general usefulness of the old prostheses with the general usefulness of the new arms, the new arm was preferred. The greatest improvement showed up in the shoulder-disarticulation and above-elbow groups. When all amputation levels were considered together, only 59 percent of the wearers felt that the old prosthesis was "useful." With the new arms, the figure went up to 79 percent. While nearly 5 percent of the wearers felt the old arm to be of no use, less than 1 percent reacted in this manner to the new arms.</p> <p>Perhaps the most meaningful gains in function were made in the area of harnessing and in routine use of locking elbow joints for above-elbow and shoulder-disarticulation cases. Although harnessing problems existed initially with program arms, the checkout procedures brought the difficulties to light so that suitable improvements could be made. Certainly arm harnessing was a major problem prior to the Field Studies also, as indicated by the fact that the new harnesses were preferred over the old by a ratio of five to one (<b>Table 4</b>). Locking elbow units, which stabilize the forearm and terminal device for above-elbow and shoulder amputees, are obviously superior to nonlocking elbows from a functional standpoint. For without elbow lock, prehension is handicapped, pushing and pulling with flexed elbow are seriously impaired, and carrying with flexed elbow (as in carrying a coat over the arm) is so difficult as to be impractical. Although manual elbow-locking mechanisms are effective, the newer elbows, operated through the harness system, free the sound hand for more important services. But it must be remembered that all these gains, which now bring prostheses for all types of arm amputation to a relatively high level of usefulness, depend upon a number of factors, including prescription of suitable components, quality of design and construction, and training in prosthesis use, all of which doubtless contributed to the positive attitudes displayed by the test wearers.</p> <p>The appearance of the new plastic-laminate arms was accepted in a perfunctory way only, most of the arms being considered "satisfactory." When 266 amputee responses were compared (appearance of new arm vs. that of old arm), it was evident that positive changes in reaction had taken place. In general the amputees favored the newer arms. It is in the area of appearance alone that the responses indicate serious reservations in acceptance of any artificial arm, old or new. Since under certain social conditions amputees might well be inclined to limit their activities rather than bring attention to the fact that an artificial arm is being worn, sensitivity toward appearance is extremely important. Even the best arm prostheses available today fall far short of being cosmetically adequate and cannot hope really to satisfy either wearers or observers. <b>Fig. 18</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Ease of operation of the new prostheses apparently left something to be desired for a substantial number of the amputees, especially those of the above-elbow and shoulder-dis-articulation types. Simpler elbow-lock operation and reduction in the difficulties of terminal-device positioning (perhaps by providing more mobility at the wrist) were mentioned as important areas requiring improvement. When the amputees compared old and new prostheses with respect to ease of operation, the new arms nevertheless proved superior. Many amputees (59 percent) felt that operation of their old prostheses was "easy." But when later they were asked to comment on the ease of operation of their new arms, 84 percent replied that operation was "easy." Slightly over 7 percent of the wearers felt that operation was "very difficult" with the old arms, whereas less than 1 percent felt that way about the new arms. Although again these important gains were most prevalent among the shoulder-disarticulation and above-elbow cases, significant improvements were noticed among the below-elbow amputees also. <b>Fig. 19</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although to date very little attention has been given to study of its significance, the weight of the prosthesis has always occasioned a great deal of interest. Generally speaking, the practice has been to keep weight at a minimum, since amputee weight tolerance has not as yet been determined specifically. The data indicate that the below-elbow arms furnished in the program were slightly lighter than the corresponding preprogram arms (1.8 lb. compared with 2.1 lb.). Above-elbow prostheses weighed an average of 2 3/4 lb., there being no significant differences between the old and the new. The average weight of the new shoulder-disarticulation arms was about 3 1/2 lb., about 1/2 lb. heavier than preprogram types. Amputees at all levels generally felt that the total weight of the new prosthesis was satisfactory, although there were some indications that further weight reduction would be welcomed. About 7 percent of the subjects felt that the prostheses were somewhat heavy, less than 2 percent that they were very heavy. But 33 percent of the wearers considered the new prostheses more acceptable in terms of weight than the old arms, even though only slight differences in actual weight were noted. Such reactions are thought to be related to increased function, improved comfort, better fit, and/or improved weight distribution in the new arms. <b>Fig. 20</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When comparisons were made between amputee reactions to the old and to the new arms, the data for all levels of amputation clearly favored the newer, program-type, plastic-laminate prostheses. Such endorsement by wearers reflects not only the superior construction and the improved mechanical components incorporated into the newer prostheses but also the values of the patient-management procedures advocated by the program-prescription of carefully selected arm components, checkout to ensure basic adequacy of the fitting, and finally proper training in the use of the prosthesis.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., and Eugene F. Murphy,<i>Prosthetics research and the amputation surgeon</i>, Artificial Limbs, 1(3): 4 (September 1954).</li> <li>Fishman, Sidney, and Norman Berger, <i>The choice of terminal devices</i>, Artificial Limbs, 2(2): 66 (May 1955)</li> <li>Fletcher, Maurice J., <i>New developments in hands and hooks</i>, Chapter 8 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Fletcher, Maurice J., <i>The upper-extremity prosthetics armamentarium</i>, Artificial Limbs, 1(1): 15 (January 1954).</li> <li>Fletcher, Maurice J., and A. Bennett Wilson, Jr., <i>New developments in artificial arms</i>, Chapter 10 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Fletcher, Maurice J., and Fred Leonard, <i>The Principles of artificial-hand design</i>, Artificial Limbs, 2(2): 78 (May 1955).</li> <li>Leonard, Fred, and Clare L. Milton, Jr., <i>Cosmetic gloves</i>, Chapter 9 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>New York University, Prosthetic Devices Study,Report No. 115.09 [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Field test of the APRL hook</i>, April 1950.</li> <li>New York University, Prosthetic Devices Study,Report No. 115.12 [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Field test of the APRL hand and glove</i>, April 1951.</li> <li>Pursley, Robert J., <i>Harness patterns for upper-extremity prostheses</i>, Artificial Limbs, 2(3): 26 (September 1955)</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity</i>, Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Taylor, Craig L., <i>The biomechanics of control in upper-extremity prostheses</i>, Artificial Limbs, 2(3): 4 (September 1955).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, 2(3): 4 (September 1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, 2(3): 4 (September 1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 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>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, 2(3): 4 (September 1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr., New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr., New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr., New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Dual control. See Pursley 10 or Taylor 11.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">See Artificial Limbs, Spring 1958, p. 77.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 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>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr., New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,Report No. 115.09 [to the] Advisory Committee on Artificial Limbs, National Research Council, Field test of the APRL hook, 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>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The prehension forces of the two-load hook are predetermined at time of manufacture and are not readily adjustable as are those in the simpler hooks, where rubber bands can be added or removed.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Fishman, Sidney, and Norman Berger, The choice of terminal devices, Artificial Limbs, 2(2): 66 (May 1955)</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Norman Berger, The choice of terminal devices, Artificial Limbs, 2(2): 66 (May 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Less than 3 percent had over-all negative reactions to the hand; 6 percent had over-all negative reactions to the glove.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,Report No. 115.09 [to the] Advisory Committee on Artificial Limbs, National Research Council, Field test of the APRL hook, April 1950.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,Report No. 115.12 [to the] Advisory Committee on Artificial Limbs, National Research Council, Field test of the APRL hand and glove, April 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and Fred Leonard, The Principles of artificial-hand design, Artificial Limbs, 2(2): 78 (May 1955).</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Norman Berger, The choice of terminal devices, Artificial Limbs, 2(2): 66 (May 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and Fred Leonard, The Principles of artificial-hand design, Artificial Limbs, 2(2): 78 (May 1955).</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The data reported here were all recorded on forms similar to those shown in Appendices IIB, IIIA, and HID of the issue of Artificial Limbs for Spring 1958 (pp. 25-28, 29-31, and 40-45).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Earl A. Lewis, M.A., R.P.T. </b></td></tr><tr><td class="clsTextSmall">Field Supervisor, Prosthetic Devices Study, Research Division, College of Engineering, New York University; formerly Field Representative, PDS, NYU.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward R. Ford, CP. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetics Laboratory, Orthopedic Aids, Inc., Garden City Medical Center, Garden City, N. Y., and Consultant, Prosthetic Devices Study, Research Division, College of Engineering, New York University; formerly Project Coordinator, PDS, NYU.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Studies of the Upper-Extremity Amputee V. The Armamentarium Creator An entity primarily responsible for making the resource Edward R. Ford, CP. * Earl A. Lewis, M.A., R.P.T. *