7 20 371 https://staging.drfop.org/files/original/995448e86e0b5f119a7459b183fd0e92.pdf b21593810340917c87578b184eb75be6 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_03_004.pdf Text Any textual data included in the document <h2>Sockets, Linings, and Interfaces</h2> <h5>Eugene F. Murphy, Ph.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>A prosthesis, whose Greek source means "put to," must of necessity have contact with the residual limb or stump. The functions of this contact region or socket (perhaps supplemented with lining, sock, and further attachments or harness), are to allow the transmission of forces, bending moments, and torques between the amputee and the prosthesis to be as comfortable as feasible in order to sustain body weight and permit locomotion for lower-limb amputees, and to allow purposeful activities by upper-limb cases. Prolonged and vigorous use of a prosthesis should not cause pain, pressure sores, blisters or corns from friction, nor edema from restricted return circulation. Proper ventilation should also prevent such accumulation of moisture as to cause skin maceration.</p> <p>Challenging as these major tasks are, they should not lead to neglect of some of the less obvious functions of a prosthesis. The changing pattern of pressure distribution on the body from the prosthesis should provide important sensory feedback on external forces, on positions of remote portions of the prosthesis, and on events such as knee extension. Professor Ernst Marquartdt,<a></a> realizing the value of the limited sensory information transmitted to the residual limb of an upper-limb amputee by the older soft leather socket, was reluctant to change to rigid plastic laminates despite their other advantages. It should also be possible to control remote joints and locks or external sources of power by small reflex or voluntary motions of remaining muscles in the residual limb and through sensing of mechanical motion or myoelectric activity.</p> <p><i>Historical Notes</i></p> <p>Naturally there is a long history of attempts to meet these challenges, that is scattered in patents, papers, catalogs, and atlases.<a></a> There are records of wooden prostheses and peg legs since antiquity, which presumably were padded with fabric or leather. Medieval prostheses, made by armorers, probably had leather or other materials for liners. In the past century, molded leather shells or lacers supported by metal side bars and cuffs, adapted from orthopedic appliances, were used extensively. These allowed slow adaptation to radial displacement and deliberate readjustment of circumference, and provided some tapered flexibility of radial stiffness above and below the proximal and distal reinforcing cuffs. The typical American artificial limb carved out of wood was completely rigid, though it could be carved deliberately to produce enlargements as desired and could be lined, completely or in selected portions of the circumference, with leather.</p> <p>Felt, wax-impregnated materials slowly displaced under pressure at body temperature, and resilient or slowly compacted foam plastics or rubbers have been used by various developers. Diagonally woven straps or cords (sometimes called Chinese Magic Finger Grip in the U.S., or Nuremberg Witch's Finger in Germany) have been suggested repeatedly as resilient sockets and perhaps as suspension. Parallel vertical cords between upper and lower rigid frames have also been used for both flexibility and ventilation.</p> <p><i>End-Weight-Bearing</i></p> <p>Some early sockets attempted to provide direct end-weight-bearing on the unrestrained end of the amputated residual limb. Typically, the amputated end of the bone without deliberate plugging developed only a thin and flexible closure to resist transmission of end load to the medullary canal, causing discomfort or pain. In addition, the ring of bony cortex tended to produce painful direct loading on the skin at the distal end of the residual limb. Early attempts to leave flaps or pads of muscles or other tissues across the distal end merely led to atrophy. Grey, a former apprentice of James Potts who developed the coordinated-motion above-knee prosthesis later called the Anglesea Leg, was very critical of such misguided efforts to develop end-weight-bearing.<a></a> Except for the Syme,<a></a> the knee disarticulation, the Gritti-Stokes amputation levels, and some attempts to deliberately plug the end of a long bone<a></a>—all relatively rare—there were few attempts to attain any end contact, let alone end-weight-bearing.</p> <p>For generations most prostheses, especially the typical above-knee, caused considerable constriction in the proximal third of the socket, required trial-and-error fitting, and left relatively unsupported the distal end of the residual limb. Because the residual limb was considered "a bowl of jelly," it was constricted proximally but extruded distally in an attempt to secure a firm grip to assist both axial support and control of bending moments. Fortunately, the common firmly-knitted woolen stump sock between the limb and the prosthetic socket—folded over the socket brim and closed at the distal end—supported the skin, fascia, and internal tissues in resisting this distal extrusion and lengthening.</p> <p><i>Stump Socks</i></p> <p>One or more stump socks were typically worn between a hard socket wall and the residual limb. Stump socks were worn for reasonable as well as fallacious purposes.<a></a> Knitted fleece socks provided a slight degree of resiliency and thus redistribution of local radial pressure, especially when freshly laundered. Inevitably, there were mismatches between the residual limb and socket wall caused by slow changes in the limb with edema, atrophy, obesity, or sometimes growth or muscle development. Axial displacement, inaccuracies in the trial-and-error carving of a wooden socket, or even of modification of a plaster model of the residual limb before preparing a plastic socket also led to mismatches. Sock resiliency can overcome minor discrepancies and improve comfort and addition of a sock can help compensate for shrinkage of the residual limb.</p> <p>A major function of the sock is to cling to the residual limb but slide with respect to the socket wall if there are relative motions between stance and swing phases of walking or caused by discrepancy between the natural proximal joint and an external mechanical joint. (This important function is impeded if the socket wall is rough or if a perspiration-soaked sock can stick to the wall but chafe the skin.) The sock should also absorb perspiration, provide wick-like action, and allow for ventilation. The closed end or "toe" should provide some support of the distal tissue.</p> <p>Other than a circular cross-section, addition of one or more socks inevitably distorts the fit. In the triangular below-knee case, although the soft tissues in the posterior portion can change, the bony portions do not, so a spot liner is more appropriate than additional socks.</p> <p>Sometimes the stump sock was misused by patients to compensate for gross changes which required major refitting, or because of misunderstandings or lack of training. About 1947 Dr. John Young of Mellon Institute and this author met a below-knee amputee who wore five firmly packed socks. Though he did not believe in a "green sock," we finally persuaded him to purchase new socks in order to accompany a newly refitted prosthesis adapted to only one or two socks and to wash the socks daily. Such distortions, however, should not distract from the legitimate uses of stump socks.</p> <p><i>Suction Socket</i></p> <p>The suction socket above-knee prosthesis was and is routinely fitted with direct contact against the skin of the residual limb. The original suction socket of the Parmelee patent of 1863<a></a> may have been intended as total contact, though the evidence is not clear.</p> <p>A version of the suction socket which came from Germany in 1946-47, was routinely fitted with a "suction chamber" extending below the end of the residual limb. During donning, the tissues were pulled down through a snugly fitted proximal third by a tube of stockinet which was withdrawn through the valve hole in a side wall, thereby creating a significant distortion and elongation of the residual limb. In some cases, the distal end developed chronic edema or discoloration from disturbed return circulation or small hemorrhages.</p> <p>These problems, as well as basic principles, contact dermatitis, blisters and corns from friction, and cysts just proximal to the brim, were among the major difficulties discussed by Barnes<a></a> and Levy<a></a> in their classic treatment of dermatological problems of the amputee. They emphasized the importance of avoiding stasis in the distal residual limb in encouraging total contact and reducing proximal constriction.</p> <h3>Thoughts And Theories</h3> <p>After the issue of <i>Artificial Limbs</i> by Barnes and Levy was published in 1956, this author was appointed Fulbright Lecturer, based at the Orthopedic Hospital in Copenhagen. In an informal memorandum<a></a> based on years of observations and discussions concerning fitting of both dental and limb prostheses, three major themes were developed:</p> <ol> <li> <p>Minimize the stiffness gradient between the rigid socket wall and the flexible skin; i.e., taper flexibility of the socket brim.</p> </li> <li> <p>Approximately match wall stiffness to that of the tissue supported.</p> </li> <li> <p>Provide a porous wall capable of "breathing" slowly.</p> </li> </ol> <p>We may consider each theme in turn. Both theory and practice can be useful. Practice can develop to a considerable extent without theory; we walked before we learned about the biomechanics of locomotion, and Watt built steam engines before Carnot developed the basic cycle for all heat engines or Rankine the cycle for steam engines. Yet theory can guide our efforts toward improvements, show the areas where greatest progress can occur, and point out the ultimate limits so we do not waste our efforts.</p> <p><i>Tapered Flexibility</i></p> <p>The first theme was eventually published as the introduction to an extensive series of theoretical and experimental papers by Bennett.<a></a> The series ended with limited clinical trials of sockets with flexible brims made of plastic laminates. These sockets appeared to be helpful for patients previously troubled by chronic or recurrent cysts, but the mechanical durability of the laminate was so poor that the sockets often lasted only six months.</p> <p>After the National Institute of Handicapped Research (NIHR) project at Moss Rehabilitation Hospital began working with polyethylene and polypropylene thermoplastics,<a></a> Bennett collaborated with that group on some attempts to develop more durable flexible-brim sockets using thermoplastics. These appeared to be promising, but the major focus of the project was on light-weight prostheses.</p> <p>There have been numerous recent efforts to produce a thermoplastic flexible (and often transparent) inner socket or liner supported by an outer shell or other structure. The Scandinavian Flexible Socket or the similar Icelandic-Swedish-New York (ISNY) Socket, and two recent designs from the New York University Institute of Rehabilitation Medicine<a></a> are examples. If, as in Figure 5 of "Flexible Prosthetic Socket Techniques" by Lehneis et al., the flexible inner liner projects proximally above the more rigid outer laminate shell, it helps to provide the tapered flexibility and transition from rigid socket to flexible skin which was suggested in theme I,<a></a> and which seemed desirable from Bennett's work.</p> <p><i>Matching Wall Stiffness to Tissues Supported</i></p> <p>First, consider the principles. The bony prominences near the surface are very stiff against radial indentation under load, but they do not bulge during walking or change appreciably in size or shape over extremely long periods. In contrast, soft tissues may change much more rapidly by brief displacement of body fluids or in moderate time periods (e.g., weeks) by growth or atrophy. Soft tissues are also much less stiff under loads from internal muscular or hydraulic forces, or from external pressure, provided they can be displaced.</p> <p>Conversely, if fluid-filled soft tissues are sufficiently trapped to avoid displacement, they will behave like an enclosed fluid under hydrostatic pressure. Within the limits allowed by connective tissue, unsupported soft tissue can be displaced a considerable amount, at the expense of distorting blood vessels from their usual circular cross-sections to oval shapes with the same perimeter but a smaller area. Such displacement can also stimulate nerve endings. These displacements may give the illusion of tissue "compressibility."</p> <p>Soft tissue can also accumulate excessive fluid, creating flushing and edema, if free to expand radially from the center of the body mass. External support will assist the "milking" effect from the pulsating action of muscles contracting within fascial compartments in pushing fluid into the veins and lymphatics, while on the contrary either external suction or restriction of the return ducts proximal to the tissue considered will favor edema. Similarly, a localized area, with little or no muscular activity that is free from support within a larger region otherwise firmly supported, will cause "window edema" with bulging of skin and tissue through the opening, as in a small opening in a large plaster cast.</p> <p>Many clinical observations and some systematic tests with sockets, plaster casts, and different designs of prostheses and orthoses relate to this problem of matching socket to residual limb, even though they have been viewed as specific rather than general. The direct comparison of two theories or designs is difficult because methods for preparing the socket and aligning it to the remainder of the prosthesis usually differ. It would seem useful to compare sockets with varying degrees and locations of softness or of flexibility, but similar as to cast, model, and alignment. If different methods or alignments really are needed to optimize results, the reasons should be studied.</p> <p>The original Navy "soft" socket for below-knee amputees of the late 1940's, provided a limited but equal degree of softness in all regions of the circumference. The cast was prepared with the residual limb dipped in relatively dense dental stone while it hardened. Weight was shifted to the cast after the impression was firm but not quite completely set. The socket was formed over a plaster model without modification or contact with the sock-covered distal end of the residual limb. The distal wall was intended to be tangent to the tapering residual limb. The later Navy "closed-end" socket also provided some additional thickness of cellular rubber in contact with the entire distal end of the residual limb, tapering toward the side walls, with the entire socket lined with vinyl. The Schindler soft socket was formed with gores of foam rubber tailored to fit the warped surface of the plaster model, more precisely than was possible with the single sheet wrapped around the model in the simpler Navy technique.</p> <p>The Blevens below-knee socket provided an oval pad of sponge rubber, with tapered edges, trapped between layers of stump sock over the calf region of the residual limb. After this pad was compressed and forced through a snugly fitted proximal portion, it could expand into an enlargement in the rigid socket wall below the popliteal region. It permitted both activity of the remaining remnants of calf musculature, which tended to atrophy in conventional hard sockets, and provided or assisted in support of the prosthesis in swing phase. Its possibilities for control signals remain unexplored.</p> <p><i>Fabrication Methods</i></p> <p>Carved sockets obviously required skill of the prosthetist and tolerance of the user, who was initially asked to try to fit the residual limb into an unduly tight space which was gradually enlarged until a tolerable fit was achieved. Did the residual limb become engorged or injured in the process? Did the amputee eventually tolerate a certain amount of discomfort as he "broke in " the hard limb—or perhaps broke down the soft tissues to conform more closely to the not-quite-perfect fit? Or did he become sensitized to discomfort, aware of its location and cause, and even more demanding?</p> <p>Sockets made over plaster models prepared from plaster casts seem more likely than those carved purely from measurements for an immediate accurate fit, or a fit with minimal trials and adjustments. Even so, the prosthetist usually considers that the manual distortion of the wet plaster during the process of taking the cast and "rectification " of the positive plaster model is necessary to avoid an unduly loose fit, often regardless of the resiliency of stump sock or foam lining. Could this view be the result of past experience in preparing casts from residual limbs which have become enlarged from being unsupported while below the body during the preparation period? Would little or no rectification be needed if the amputee were supine with the residual limb elevated for an "appropriate" period immediately before casting? Have a few anecdotal accounts of such attempts leading to excessively tight sockets reflected unduly long elevation times? Did the Navy dip impression allow the denser dental stone, while still fluid, to squeeze fluids from the tissues by an approximately correct amount before solidifying?</p> <p>Because the socket must transmit the necessary axial forces, bending moments, and torques described by Radcliffe<a></a> for all major levels of the lower limb, and Taylor<a></a> for the upper, the socket wall must be reasonably firm in at least some areas and the interior bone(s) must transfer forces through the skin to the wall in both proximal and distal regions.</p> <p><i>Retention of Fit</i></p> <p>A precisely made hard socket fit with direct contact (as in the suction socket) or with a single thin stump sock might be effective for a time, but it might encounter difficulties even with muscular activities or large motion of the proximal joint as in sitting and bending. More important discrepancies would occur over longer periods from edema, growth, or atrophy.</p> <p>Completely uniform softness might also be questioned because it does not match just those relatively limited areas which alter cyclically with muscular activity or over some time span. Perhaps more critically, uniform softness allows areas of high pressure, intended to match individual tolerance to high pressure, to sink into the soft material and thus to shift some load to areas where the designer desired lower pressure. Beginning in the prosthetics schools in 1957-58, emphasis upon socket planning based on anatomical and physiological considerations and upon avoidance of erratic constriction and looseness was a healthy development.</p> <p><i>Some Suggestions</i></p> <p>The local radial stiffness of the socket wall might be approximately comparable to the stiffness and physiological motion of the tissue which it touches, though changes should occur gradually from place to place to avoid high local shear stresses in tissue. Thus, the wall near bony prominences might be quite firm if precisely fitted to a nonedematous limb.</p> <p>Obviously this notion seems the opposite of the usual concept of cushioning the bony prominences. Much of the traditional objection to a hard socket wall in contact with a bony prominence may be due to two difficulties: (1) unduly concentrated pressure because of poor fitting or displacement from the correct position, or (2) slippage and friction from inadequate suspension or joint location, leading to formation of blisters and bursae.</p> <p>Relatively soft walls opposite soft tissue might allow muscle bulging or tendon tightening at every motion of the limb yet rebound to prevent window edema when relaxed. The stiffness might be chosen to allow deliberate gripping of the wall for control and suspension, somewhat comparable to the German "Haft-prothese"<a></a> with muscular bulging to grip a rigid wall to supplement an above-knee suction socket as well as to help support the Blevens below-knee prosthesis. Some softness opposite tissues which tend to change rapidly might also compensate for slight changes such as growth.</p> <p>Adequate, relatively firm areas must be found for biomechanically necessary forces, including those generating bending moments and torques. In the below-knee case, for example, counterpressure from the posterior wall is needed to hold the condyles anteriorly on their sloping supports. In the above-knee case, the distal lateral and the proximal medial aspects of the femur must generate, yet tolerate, substantial forces to oppose the moment created by body weight acting upon it through the center of gravity appreciably medial to the center of support of the prosthesis during stance phase.</p> <p>The soft tissues, usually present at the distal end, should be encased thoroughly to prevent displacement, extrusion, and edema, yet held precisely in a wall and floor soft enough to prevent localized painful loading. Page,<a></a> an engineer interested in dental prostheses, discussed with this author in 1946 the concept of "muco-static" fitting with tissues trapped so that, much like fluids, they behave almost hydrostatically. The tissues should not be distorted from resting position when the cast is taken, nor should they be displaced towards hollows left by grinding away apparent ridges actually needed to fit into folds in the tissue. Past failures to create end-weight-bearing simply by taking an impression under load or placing a pad of foam rubber on a flat socket floor need not eliminate the possibility of total contact or end-weight-bearing by more sophisticated methods.</p> <p>A socket of the style described might have variable but tapered thickness of resilient material, such as closed-cell foam rubber or plastic. Muscular bulging into such material might be developed as a control signal. Alternatively, but perhaps less precisely, a thin resilient liner might be supported by an outer shell providing firm support where needed but having rounded and outwardly flared windows where expansion should be possible. The thin resilient liner opposite the windows could improve heat transfer, awareness of adjacent surfaces, and comfort when seated. The sockets illustrated by Lehneis, et al.<a></a> seem reasonable steps, though one wonders whether "selected fenestration over pressure sensitive areas " would be as logical as carefully molded and slightly relieved or padded areas. Certainly the transparent socket materials are advantageous for checking fit, supplementing their value in the flared flexible brim.</p> <p><i>Porous Materials</i></p> <p>The skin, as Barnes<a></a> pointed out, normally excretes water, gases and various compounds. An impermeable wall pressed tightly against the skin for many hours at a time can lead to dermatological difficulties.</p> <p>Leather allows some absorption and passage of these excretions, but deteriorates from their presence. Organic materials trapped in the fine pores of leather tend to decompose. The Army Prosthetics Research Laboratory (APRL) developed a protective slightly permeable coating for leather consisting of a particular grade of nylon dissolved in isopropyl alcohol. It is not still commercially available, as it was not very widely used. Care had to be taken to avoid traces of oil on the leather in order to be coated.</p> <p>APRL also developed a "starved resin" process, producing a somewhat porous thermosetting plastic laminate. Unfortunately, the irregular holes tended to become plugged with debris from the stump sock, dead skin cells, etc., and no adequate cleansing method was found.</p> <p>Late in World War II, Quamco was developed for raincoats and aviation clothing to resist penetration by rain or sea water yet allow slow transfusion of perspiration. It received brief attention in the early suction socket program. In recent years, Gore-tex has become increasingly popular for sportswear. Though it is difficult to tailor Gore-tex to complex shapes, the recent availability of a molded sports hat may indicate the possibility of considering an individually shaped socket or at least gently warped segments to mount in a fenestrated socket.</p> <p>Simple mechanical perforations of the socket wall were used, for example, with aluminum sockets, particularly in England. The holes had to be small enough so that the tissue, presumably supported by a stump sock, did not bulge through them. At the other extreme, the mechanically or electrically perforated plastics, studied around 1949 by the Mellon Institute, sometimes had such tiny holes that organic materials became clogged in them as in leather.</p> <p>One could imagine a wick-like, minutely perforated liner—and perhaps wall—permitting rapid and effective cleaning and drying. Air flow must permit ventilation yet allow adequate suction suspension, perhaps assisted by muscular gripping as in the Haftprothese, or by a very flexible inner liner collapsing against and adhering to the residual limb, as in a Northwestern University design<a></a> tested upon both upper- and lower-limb amputees. Care must be taken to provide a suitable balance of wicking capillary pressure in excess of negative air pressure so that moisture is not drawn back into the socket during swing phase. Conceivably, a porous supporting liner within an outer supporting structure might provide total contact and biomechanical reactions for the residual limb, but for a small and slowly ventilated chamber between the two, perhaps serving as a suction chamber during swing phase.</p> <p>One hopes that a simple, inexpensive, individually moldable material with appropriate range of perforations will become available. Ideally it would be available in various thicknesses, stiffnesses, resiliencies, and strengths and in a choice of transparency or appropriate skin colors. Of course it must also be nontoxic, noncarcinogenic, and odorless.</p> <p>Until then, however, we must make do with the increasing array of compromise materials and our growing but imperfect understanding of principles of sockets, linings, and interfaces. Bit by bit, we can improve service to the severely disabled patients whom we serve.</p> <p><b>References:</b></p> <ol> <li>Marquardt, Ernst, Heidelberg, Germany, personal communication, 1961.</li> <li>American Academy of Orthopaedic Surgeons, <i>Orthopaedic Appliances Atlas</i>, Volume 2, J.W. Edwards, Ann Arbor, Michigan, 1960, esp. Chapters 1, 5, and 6.</li> <li>Gray, Frederick, <i>Automatic Mechanism as Applied in the Construction of Artificial Limbs in Cases of Amputation</i>, London, [the NML catalog card did not indicate publisher], 1855 [1857, second edition]; a copy at National Library of Medicine, Bethesda. See also the advocacy of suturing of the deep fascial envelope, criticism of muscles pulled over the end of the bone, but presumption of no end-weight-bearing in Alldredge, Rufus H., and Eugene F Murphy, "The Influence of New Developments on Amputation Surgery," 11, in Paul E. Klopsteg, Philip D. Wilson, et al., <i>Human Limbs and their Substitutes</i>, Chapter 2, p. 19, McGraw-Hill, New York, 1954; reprint edition with additional bibliography, Hafner, New York, 1968.</li> <li>Harris, R.I., "The History and Development of Syme's Amputation," Artificial Limbs, 6:1, 4-43, April 1961; reprinted in Selected Articles from Artificial Limbs, Krieger, Huntington, New York, 1970.</li> <li><a href="http://www.oandplibrary.org/al/1962_02_086.asp">Loon, Henry E., "Below-Knee Amputation Surgery," <i>Artificial Limbs</i>, 6:2, 86-99, June 1962; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</a></li> <li>Murphy, Eugene F., "The Fitting of Below-Knee Prostheses, " Chapter 22 in Paul E. Klopsteg, Philip D. Wilson, et al., <i>Human Limbs and their Substitutes</i>, McGraw-Hill, New York, 1954; reprint edition with additional bibliography, Hafner, New York, 1968.</li> <li>Parmelee, Dubois D., Artificial Leg, U.S. Pat. 37,637, Feb. 10, 1863. See also Murphy, Eugene F., "Patents, Patients, and Patience," commentary on centennial, <i>Artificial Limbs</i>, 7:2, 69-72, Autumn, 1963; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</li> <li>Barnes, Gilbert H., "Skin Health and Stump Hygiene," <i>Artificial Limbs</i>, 3:1, 4-19, Spring 1956; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</li> <li>Levy, S. William, "The Skin Problems of the Lower-Extremity Amputee," <i>Artificial Limbs</i>, 3:1, 20-35, reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</li> <li>"Murphy, Eugene F., "Some Thoughts on Fitting of Prosthetic and Orthopedic Appliances to be Checked and Refined," 10/11/57; mimeographed by Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, New York, 1957, 1961.</li> <li>"Murphy, Eugene F., "Transferring Load to Flesh- Part I: Concepts," <i>Bull. Prosthetics Res</i>. BPR 10-16: 38-44, Fall 1971.</li> <li>Bennett, Leon, "Transferring Load to Flesh," <i>Bull. Prosthetics Res</i>.; Series of Parts:<br />—Part II. "Analysis of Compressive Stress," BPR 10-16:45-63, Fall 1971.<br />—Part III. "Analysisof Shear Stress, "BPR 10-17:38-51, Spring 1972.<br />—Part IV. "Flesh Reaction to Contact Curvature," BPR 10-18:60-67, Fall 1972.<br />—Part V. "Experimental Work," BPR 10-19, Spring 1973.<br />—Part VI. "Socket Brim Radius Effects," BPR 10-20:110-117, Fall 1973.<br />—Part VII. "Gel Liner Effects," BPR 10-21:23-53, Spring 1974.<br />—Summary report at conference research project leaders, with title Transferring Load to Flesh, BPR 10-22, 13-143, Fall 1974.<br />—Part VIII. "Stasis and Stress," BPR 10-23:202-210, Spring 1975.<br />—(See also later progress reports on applying the same concepts under title "Stump Stress Analysis" in BPR 10-24:217-218; BPR 10-25:182-183-inadequate service life despite previous fatigue tests-; BPR 10-26:275-285-fatigue tests of various composites; problems of porosity.)</li> <li>Wilson, A. Bennett, Pritham, Charles, and Stills, Melvin, <i>Manual For An Ultralight Below-Knee Prosthesis</i>, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Temple University, and Drexel University, Philadelphia, Second Edition, 1979.</li> <li>Lehneis, H.R., Chu, Don Sung, and Adelglass, Howard, "Flexible Prosthetic Socket Techniques," <i>Clinical Prosthetics and Orthotics</i>, 8:1, 6-8, Winter 1983-84.</li> <li><a href="http://www.oandplibrary.org/al/1961_01_076.asp">Radcliffe, Charles W., "The Biomechanics of the Syme Prostheses," <i>Artificial Limbs</i>, 6:1, 76-85, April, 1961; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</a></li> <li><a href="http://www.oandplibrary.org/al/1962_02_016.asp">Radcliffe, Charles W., "The Biomechanics of the Below-Knee Prostheses in Normal, Level, Bipedal Walking," <i>Artificial Limbs</i>, 6:2, 16-24, June, 1962; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</a></li> <li><a href="http://www.oandplibrary.org/al/1955_01_035.asp">Radcliffe, Charles W., "Functional Considerations in the Fitting of Above-Knee Prostheses," <i>Artificial Limbs</i>, 2:135-60, Jan. 1955; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</a></li> <li><a href="http://www.oandplibrary.org/al/1957_02_029.asp">Radcliffe, Charles W., "The Biomechanics of the Canadian-Type Hip-Disarticulation Prosthesis," <i>Artificial Limbs</i>, 4:2, 29-38, Autumn 1957; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</a></li> <li><a href="http://www.oandplibrary.org/al/1955_02_022.asp">Taylor, Craig L., and Schwarz, Robert J., "The Anatomy and Mechanics of the Human Hand," <i>Artificial Limbs</i>, 2:2, 22-35, May 1955; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York, 1970.</a></li> <li><a href="http://www.oandplibrary.org/al/1955_03_004.asp">Taylor, Craig L., "The Biomechanics of Control in Upper-Extremity Prostheses," <i>Artificial Limbs</i> 2:3, 4-25, Sept. 1955; reprinted in <i>Selected Articles from Artificial Limbs</i>, Krieger, Huntington, New York 1970.</a></li> <li>Hepp, Oskar, "Haftprothesen," Zeitschrift fuer Orthopaedic und ihre Grenzgebiete, Band 77, 1947-48, 219-279.</li> <li>Page visited the offices of the Committee on Prosthetic Devices, then at Evanston, Illinois, in 1946.</li> <li>ChiIdress, Dudley S., Billock, John N., and Thompson, Robert G., "A Search for Better Limbs: Prosthetics Research at Northwestern University," <i>Bull. Prosthetics Res.</i>, BPR 10-22:200-212, Fall 1974, especially p. 204 on "Self-Contained and Self-Suspended Devices," including atmospheric-pressure suspension. See also Progress Reports, BRP 10- 27:129, Spring 1977, and BPR 10-30, 177-178, Fall 1978.</li> </ol> <div style="width: 400px;"><em><b>*Eugene F. Murphy, Ph.D. </b> Retired, Veteran's Administration-Director, Office of Technology Transfer and Director, Research Center for Prosthetics<br /><br /><br /></em></div> <div style="width: 400px;"></div> Page Number(s) 4 - 10 Year 1984 Volume 8 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Sockets, Linings, and Interfaces Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/600929dee45085ca12ad1bf2f58a604b.pdf 96ef868f6a75c4473d81d11010115943 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1982_02_001.pdf Text Any textual data included in the document <h2>Influence of Government Funding on Prosthetics Research and Development</h2> <h5>Eugene F. Murphy, Ph.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Historically, tragically, warfare has been the major stimulant for the development of prosthetic devices. Much of the early history is traced in the introductory chapter of the <i>Orthopaedic Appliances Atlas, Volume 2</i>, published by the American Academy of Orthopaedic Surgeons in 1960. A fascinating source is the book <i>Historic Artificial Limbs</i> by the Italian surgeon Putti, published by Hoeber, New York, 1930, based upon the outstanding collection of artificial limbs in the Stibbert Museum at Florence, Italy. With that museum's distinguished collection of armor, it was perhaps natural that the byproduct of artificial hands, arms, and legs made by armorers for knights should also be assembled there. The story of the German knight Goetz von Berlichingen, commemorated in a drama by Goethe, stresses the knight's iron artificial hand.</p> <p>Surgery generally and amputation surgery in particular were developed by the French surgeon Paré in connection with the religious wars in France; a corresponding development of artificial limbs was done by a locksmith known as "le petit Lorrain." Very likely only the relatively well-to-do knights and nobility were able to afford these early prostheses, with common people left to relatively crudely carved prostheses or crutches as illustrated, for example, by Breughel.</p> <p>After the American Civil War, the government provided an allowance for artificial limbs for Union veterans. This financial incentive, plus the rapid increase of amputees from industry and railroads, led to great competition among private developers. In that era artificial limbs were essentially sold as commodities rather than fitted as professional services. Some interesting patents are cited in the <i>Orthopaedic Appliances Atlas, Volume 2</i>.</p> <p>In World War I, countries among both the Central Powers and the Allies carried on simultaneous attempts to treat their patients and to develop better methods of surgery and fitting. Work in the Central Powers, notably in German military hospitals and in the Technical University of Berlin under Schlesinger, an engineering professor, was covered in great detail in the classic book <i>Ersatzglieder und Arbeitshilfen</i> (Substitute Limbs and Work Aids) published in 1919. Florent Martin worked extensively in Belgium, developing relatively early methods of fitting of temporary plaster-of-paris sockets on pylons for amputation of the lower extremity. His work was recorded particularly well in his critical analysis, <i>Artificial Limbs; Appliances for the Disabled</i>, published by the International Labour Office at Geneva in 1924. Efforts in England, including development of the specialty of limb fitting surgeon and the standardization of mechanical construction of a series of light metal limbs for many basic levels of amputation, are described in E. Muirhead Little's book Artificial Limbs and <i>Amputation Stumps</i>, published in England in 1922. During World War I, the Artificial Limb Manufacturers Association (ALMA) in the United States developed rapidly to advance the industry and cooperate with the government. Its descendant, the American Orthotics and Prosthetics Association (AOPA), along with the American Board for Certification (ABC), and the American Academy of Orthotists and Prosthetists (AAOP) continue today to develop the profession.</p> <p>In World War II, the ALMA set up a small laboratory on the premises of the Rowley prosthetics facility in Detroit, under the name of the Research Institute Foundation. Its extremely limited financial and technical resources allowed very meager efforts.</p> <p>Late in the war, partly because of growing demands from servicemen and unfavorable publicity, the Surgeon General of the United States Army asked the National Academy of Sciences (NAS) and its operating arm, the National Research Council (NRC), to select and standardize the best artificial limb designs. At a conference in 1945, the only unanimous agreement seemed to be on the concept that the best was not too good and that further improvements were needed on all aspects.</p> <p>The Surgeon General then asked the NAS-NRC to organize a systematic program "to conduct with utmost dispatch research and development in the field of prosthetic devices." The resulting interdisciplinary Committee on Prosthetic Devices initially was financed by the wartime Office of Scientific Research and Development, then the Army briefly, and later the Army and Veterans Administration (VA) jointly. On July 1, 1947, it was reorganized as the Advisory Committee on Artificial Limbs to provide advice to other agencies which wished to conduct their own programs. The NRC committee structure underwent a variety of changes from 1945 to the mid-1970's but has now disbanded. AOPA-ABC-AAOP members were frequent members of committees, subcommittees, and technical groups in this structure.</p> <p>The Army, Navy, and Veterans Administration each operated a laboratory. The VA, initially alone and later in parallel with other agencies, supported a series of projects with universities, industrial laboratories, and, in recent years, particularly through intramural projects in VA Medical Centers. After a change in its basic laws, the Office of Vocational Rehabilitation or its successors, now the National Institute of Handicapped Research (NIHR), has supported an increasing number of Rehabilitation Engineering Centers and projects.</p> <p>In addition to stimulating a wide variety of basic studies on locomotion and arm and hand motions, phantom limb pain, and psychological aspects, and development of a wide range of devices for all levels of upper-and lower-limb prostheses, the total government-supported program became a major force in educational efforts and dissemination of information. The early suction socket schools brought together distinguished surgeons and prosthetists, teaching the surgeons about mechanisms and the prosthetists about anatomy and physiology, as well as fostering team work between the two professions, promptly involving therapists, and helping to upgrade the entire field. Follow-up of the early suction sockets led to organization of formal clinic teams. The suction socket certification program, operated by Orthopedic Appliance and Limb Manufacturers Association (OALMA) in conjunction with the NRC committee and recorded in the Veterans Administration, led to joint certificates and helped to pave the way for the founding of the American Board for Certification with its remarkable interdisciplinary board of directors. The suction socket schools led, in 1953, to organized university-level post-graduate education in prosthetics and later in orthotics.</p> <p>Frustratingly slow as development often seems, nevertheless in retrospect it would appear that numerous major changes in devices, techniques, materials, and management methods were made in this continuing program. Voluntary cooperation was the key element in holding together this loose confederation. Diverse disciplines, many government agencies, some private foundations, separate organizations, sometimes competitive interests, and strong personalities worked together for the improvement of the lives of the disabled.</p> <p>The fact that substantial government funding was available, though never on the scale needed for the awesome task of truly replacing human parts and functions, tended to minimize the importance of private funding for the research and development and even for the dissemination of results. One chronic problem, though, has always been the transition from a reasonably well-developed laboratory model with a very limited clinical experience on "professional" pilot wearers into a routinely available, commercially manufactured component available in high quality and at low cost to skilled and trained practitioners throughout this country and abroad for fitting to large numbers of individual patients.</p> <p>Some devices were purchased in modest quantities for field tests through the National Academy of Sciences itself in the 1950's or through the Veterans Administration Prosthetics Center after that group was organized in 1956. Typically, AOPA was asked to suggest a group of potential bidders to make proposals for tooling and for construction of some modest number of models needed for a wide scale field trail or evaluation. Because of fiscal restraints and practical problems, numbers of copies were usually smaller, and statistical validity was low. (Early attempts to interest other organizations lacking experience and distribution facilities in the prosthetics field had been frustrating and largely disappointing.) Typically, the manufacturer of the initial test models has evolved into the principal, if not sole, manufacturer of the final device-if indeed it proved to be successful in the field trials. The field has been so small that there frequently has been no room for multiple manufacturers of a single relatively complex device, although other versions with somewhat comparable yet somewhat different functions sometimes evolve in parallel. Field trials should refine not only the hardware but the prescription, fitting, and training techniques, the manuals, and the maintenance procedures. All participants in a clinic team become familiar with the new development.</p> <p>There has long been interest in stimulating private support of research and development, presumably based upon the results of fundamental studies conducted under government auspices. The government-supported program has sometimes received or purchased a few early test models of private inventions and has had its intramural or contract laboratories conduct studies with these test models, thereby providing a useful consulting service to the inventor or manufacturer which he probably could not readily obtain otherwise. This kind of independent evaluation may well become increasingly important under the medical device amendments in order to prove safety and effectiveness of new devices.</p> <p>In any evaluation, there are problems in simultaneously assuring competence without bias and in providing constructive criticism in useful form which can be applied to improving the device for all disabled.</p> <p>With the continuing and indeed increasing pressure upon government budgets, it would seem that the developers must increasingly come from private industry. Karl Vesper, the engineer and investment expert who organized the original Hosmer Corporation in the 1940's, was an early participant in the NRC and VA programs. He pointed out that as a private entrepreneur he could effectively estimate the potential strengths of competitors and their ability to develop and market new products within given time periods, so he could make his own choice of development expenditures wisely. Conversely, though, he could not predict what a government agency might do, particularly under political and other pressures. Though the existing government research and development projects are public knowledge, for example through progress reports published in the Bulletin of Prosthetics Research, private developments may well be "proprietary secrets." The net balance between these and other disadvantages and advantages for private development is hard to estimate. From the standpoint of the disabled of the world, one can only hope for a frank, friendly, and cooperative relationship between private entrepreneurs, government sponsors and regulators, government purchasing or using services at all levels, third-party purchasers, and the several professions concerned.</p> <em><b>*Eugene F. Murphy, Ph.D. </b> Director, Office of Technology Transfer Veterans Administration, New York, NY<br /><br /></em> Page Number(s) 1 - 3 Year 1982 Volume 6 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Influence of Government Funding on Prosthetics Research and Development Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/52f7d266c544d7b057ce3f61ff421222.jpeg c442d8b15660c8c79d4df71065ad319d https://staging.drfop.org/files/original/cecb22a00897ba34f840608eed75219c.jpeg 1dad83a740d94fdf8668227e6d78ec45 https://staging.drfop.org/files/original/4840e49061168dd070be6b5f910136d0.jpg bc55027014a65d697e997b2b937c2821 https://staging.drfop.org/files/original/23866a9c822d0eb399417ae71c53afde.jpg de5956ea11e10351dd0edbc4eb3964c7 https://staging.drfop.org/files/original/9654f5f19860f0e88b033d410589d261.jpg 32b34b3e40ced6807f3639dbaa1dc46a https://staging.drfop.org/files/original/208783458811d4c978eb476b9ddc2a62.jpg 1c8a4fce56522125a18f83d04e40f32b Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Text Any textual data included in the document <h2>A Solution For Split-Size Shoes</h2> <h5>Eugenio Lamberty&nbsp;<a style="text-decoration: none;">*</a><br />John Milani&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Despite the almost daily occurrence of new concepts and improvements in Orthotics, many problems remain to be solved. A significant number of these problems result from congenital factors or acquired diseases during childhood. The severely deformed leg and foot have been of major concern, particularly when the deformed foot has been significantly shorter in length than the sound foot (<a href="/files/original/52f7d266c544d7b057ce3f61ff421222.jpeg"><b>Fig. 1</b></a>).</p> <p>In some cases the feet may vary in shoe size by as much as three or four sizes (<a href="/files/original/cecb22a00897ba34f840608eed75219c.jpeg"><b>Fig. 2</b></a>). This becomes quite expensive for the patient, who must either purchase two pairs of shoes to fit each foot properly or custom-made shoes. To reduce this financial burden and yet greatly improve cosmesis, a method of fabrication had to be found whereby the patient would be required to purchase only one pair of ordinary shoes that would be the size of the normal foot.</p> <p>A shoe filler (<a href="/files/original/4840e49061168dd070be6b5f910136d0.jpg"><b>Fig. 3</b></a>), conceived, designed and developed by the authors through the Veterans Administration Prosthetics Center, has solved this problem. This device is placed in the shoe (<a href="/files/original/23866a9c822d0eb399417ae71c53afde.jpg"><b>Fig. 4</b></a>) to take up the excess space of the shortened foot. Then the shoe insert portion of the orthosis is placed into the filler and shoe (<a href="/files/original/9654f5f19860f0e88b033d410589d261.jpg"><b>Fig. 5</b></a>). This results in a highly-cosmetic arrangement (<a href="/files/original/208783458811d4c978eb476b9ddc2a62.jpg"><b>Fig. 6</b></a>) that is also financially beneficial to the patient.</p> <h3>Method of Fabrication</h3> <p>To construct the shoe filler, proceed as follows:</p> <ol> <li> <p>Secure a SACH foot that will fit the size shoe to be worn by the patient. Ensure that the plantar surface of the SACH foot is flat, to prevent the shoe insert portion of the orthosis from rocking. An immediate post-op foot can be used.</p> </li> <li> <p>Vacuum mold the SACH foot with 1/4-inch low density polyethylene. Polyethylene is ideal since it provides good strength and flexibility.</p> </li> <li> <p>When the plastic has cooled, remove it from the SACH foot and initially trim it so that it does not protrude beyond the borders of the shoe. Refer to <a href="/files/original/4840e49061168dd070be6b5f910136d0.jpg"><b>Fig. 3</b></a>.</p> </li> <li> <p>Use standard methods and techniques to fabricate the orthosis.</p> </li> <li> <p>Place the orthosis on the patient. Then place the orthosis on the patient into the shoe and shoe filler while ensuring that the shoe filler does not hinder this process.</p> </li> <li> <p>Further trim the shoe filler along its medial and lateral sides, behind what would normally be the metatarsal heads of the sound foot. This allows the normal toe break of the shoe to function properly and thereby ensure unrestricted motions of the ankle and foot.</p> </li> </ol> <h3>Notes</h3> <p><i>To prevent the orthosis from slipping forward in the filler, the filler should curve around slightly, onto the dorsum of the foot. Refer to<a href="/files/original/4840e49061168dd070be6b5f910136d0.jpg"> <b>Fig. 3</b></a>. This trim, together with a properly laced shoe or a shoe laced with micro straps, should provide the required counterforce to prevent the orthosis from slipping forward in the filler. It is further noted that one patient, who had worn the new orthotic system for one month, required foam padding that was placed anteriorly into the filler to prevent the orthosis from slipping.</i></p> <h3>Summary</h3> <p>The design and development of a shoe filler when bracing the shortened foot is cosmetically appealing and financially beneficial to the patient who is consequently required to purchase only a single pair of ordinary shoes. In addition, fabricating the filler is a relatively simple procedure for the orthotist.</p> <h3>Acknowledgements</h3> <p>The authors would like to express their appreciation to Max Nacht, Technical Writer-Editor, VAPC, for his cooperation and assistance in preparing this article; and to Charles Berman and Anthony Morales, Photographers, VAPC, for their fine photographic work.</p> <div style="width: 400px;"><em><b>John Milani<br /></b>Orthotist-Prosthetist, Veterans Administration Prosthetics Center, 252 Seventh Avenue, New York, NY 10001<br /><b><br />*Eugenio Lamberty<br /></b>Orthotist. Veterans Administration Prosthetics Center, 252 Seventh Avenue, New York, NY 10001</em></div> <br /> <div style="width: 400px;"></div> Page Number(s) 3 - 4 Year 1979 Volume 3 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 5 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1979_04_003/1979_04_003-6.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Solution For Split-Size Shoes Creator An entity primarily responsible for making the resource Eugenio Lamberty * John Milani * https://staging.drfop.org/files/original/e38c9d5be738df236a12e73aa11a7478.pdf 63744e2c2435c2b8aa6be87baa775d5b https://staging.drfop.org/files/original/56b68415d28babc42822184b94ea133f.jpg c1d1ab1268f7d844c5e4adb9f18570b1 https://staging.drfop.org/files/original/468c9f40dadb34370263e2258781e772.jpg 066f09438b83937ce9374ec73d152011 https://staging.drfop.org/files/original/f6b7d160b8278d855a477b3e2ea5c2cb.jpg f93f5d0c017f506a7192b341323b7b69 https://staging.drfop.org/files/original/bf1c26f96bb42345b531ec1166264189.jpg 9fd52199760b1396b088edc497712c32 https://staging.drfop.org/files/original/96c04506d1db97cbfd92fea9a88f48b2.jpg cd55c79d19ab9841de50523ab1e0419a https://staging.drfop.org/files/original/01a220eb783cc84d9ce7dad16b20bdf9.jpg bd31c2caa285cf8fd77da049a48cf137 https://staging.drfop.org/files/original/49d84cfc8f81b98ee25f6ed516a68603.jpg 348aae2a8ee726a6780827ea3caa5d52 https://staging.drfop.org/files/original/f04bf788ae7667d4ba0783d1f063dbeb.jpg fddd1ca9fcc7c38b79f776f973540e84 https://staging.drfop.org/files/original/d15fb9bfe71401e0c9e78eee923227ae.jpg de5d7ef764071728608ace84183afd4a https://staging.drfop.org/files/original/73879f8eef1bcebd75a39d4efb07bbe5.jpg 0c17a23c627102a5b74bfa203bc0affd https://staging.drfop.org/files/original/faf957c4e45f636ead6709d159155cbb.jpg 6a41e41b6042f89654f9aa13b55cff12 https://staging.drfop.org/files/original/e7adf4c708c388d05f78818bc47b73bc.jpg 0224ffefe34ab3baefa64141bd79eaef DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_037.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 37 - 48 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_01_037.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_037.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Mechanical Properties of Bone</h2> <h5>F. Gaynor Evans. Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Bone is the material with which the orthopaedic surgeon deals. Consequently, some knowledge of its mechanical properties is of importance for an understanding of the mechanism and management of fractures, as well as the design of prosthetic or orthotic appliances and protective gear, <i>e.g., </i>crash helmets. The behavior of a body under a load or force is a function not only of the form and structure of the body, but also of the mechanical properties of the material composing the body. For example, a steel beam will support a higher load before breaking and will behave differently under loading than will an oak beam of exactly the same shape and dimensions because of differences in the mechanical properties and structure of steel and of wood.</p> <p>The mechanical properties of bone are determined by the same methods used in studying similar properties of metals, woods, and other structural materials. These methods are based on certain fundamental principles of mechanics, a knowledge of which is essential for understanding the terminology employed.</p> <p><i>Mechanics, </i>the science dealing with the effect of forces upon the form or the motion of bodies, has two subdivisions- statics and dynamics. <i>Statics </i>is the study of bodies at rest or in equilibrium as a result of the forces acting upon them. <i>Dynamics </i>is the study of moving bodies. The mechanical properties of materials are usually studied under static conditions, <i>i.e., </i>under a slowly applied force or load, because the behavior of the test specimen can be more easily analyzed when the load is slowly applied.</p> <p>A <i>force </i>is anything which tends to change the state of a body with respect to its motion or the relative position of the molecules composing the body. More simply stated, a force is a push or a pull. There are three primary kinds of forces: (1) <i>compressive </i>or pushing together forces, (2) <i>tensile </i>or pulling apart forces, and (3) <i>shearing, </i>or forces which make one part of the body slide with respect to an adjacent part (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Types of pure force-stress and strain. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a force is applied to a body, it produces stress and strain within the body. <i>Stress </i>(<b>Fig. 1</b>) is the ratio between the force and the area upon which it acts, <i>i.e., </i>force per unit area. Stress is generally computed in terms of pounds per square inch (psi) or kilograms per square millimeter (ksm). Recently, some investigators of the strength characteristics of bone and other biological materials have been recording stress values in terms of kiloponds, dynes, or newtons per unit area, instead of pounds or kilograms because pounds and kilograms are units of mass as well as units of force. There will be no misunderstanding, however, if one specifies that stress values are in terms of <i>pounds force or kilograms force per unit area. </i>Stress is often used synono-mously with strength, but the term has little value unless the kind of strength, <i>i.e., </i>tensile, compressive, etc., is indicated. All strength values in the following discussion are in terms of <i>pounds force per square inch.</i></p> <p><i>Strain </i>is a change in the linear dimensions of a body as the result of the application of a force (<b>Fig. 1</b>). Since there are no standard units of measurement for strain, it can be recorded as percentage, inches/inch, centimeters/centimeter, etc. Strain can be seen if it is sufficiently large, <i>e.g., </i>as in stretching of a rubber band, but stress, which is only the ratio between force and area, is always invisible. The kind of stress and strain in a body is the same as the kind of force producing it.</p> <p>When stress is plotted against strain, a <i>stress-strain curve </i>is obtained (<b>Fig. 2</b>). From a tangent drawn to the straightest part of the stress-strain curve the <i>modulus of elasticity </i>of the material, or the ratio between unit stress and unit strain, can be computed. The modulus of elasticity is a measure of the <i>stiffness </i>of a material, not its elasticity as one might assume from the name. <i>Elasticity </i>is the property of a material that allows it to return to its original dimensions after the removal of a force or load. The <i>energy </i>the specimen absorbs to failure can be determined by measuring the area below the stress-strain curve.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Stress-strain curves for a dry- and a wet-tested specimen of compact bone from the posterior quadrant of the proximal third of the femoral shaft of a 70-year-old white man who died from pulmonary tuberculosis. The stress values are in pounds force per square inch <a></a>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The method of choice in determining the tensile or compressive strength of a material is to make a test specimen of a standardized size and shape and test it under a pure tensile or a pure compressive force. Under these conditions the cross-sectional area of the specimen is known, or can be easily computed, and only one force—tension or compression—is involved. Furthermore, the force is uniformly distributed over the cross-sectional area of the specimen. Consequently, the ultimate tensile or compressive strength of the material can be easily calculated from the formula <i>S </i>= <i>P/A, </i>in which S is stress, P is force or load, and A is the cross-sectional area of the specimen (<b>Fig. 1</b>).</p> <p>If the specimen is tested like a simple beam (i.e., supported at the ends and loaded midway between the supports) and bending occurs, tensile, compressive, and shearing forces are all involved. Tensile forces develop on the convex side of the bent specimen while compressive forces occur on the opposite (concave) side (<b>Fig. 3</b>). Both types of forces are maximum at the surface and decrease inwardly to zero at the neutral plane or axis. There are also shearing forces which, like the tensile and compressive forces, are not uniformly distributed over the cross section of the specimen. Under bending conditions, the force responsible for failure as well as its magnitude is more difficult to determine. The bending forces in the neck of the femur, as a result of the load applied to the head of the bone (<b>Fig. 4</b>), have been determined by Zarek <a></a> , an engineer who is currently working in biomechanics. For further discussion of forces in bending, see Harris' <i>Strength of Materials</i>. <a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Distribution of tensile and compressive forces in a body tested like a simple beam <a></a>. L = length or span between supports; N. A. = neutral axis or plane; P = force or load. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Stress distribution in the neck of the femur.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The speed at which a force is applied to a specimen influences the values obtained for some of its mechanical properties. Mc-Elhaney and Byars <a></a> found that the ultimate compressive strength and the modulus of elasticity of fresh and embalmed femoral cortical bone from cattle and man increased with higher strain rates of loading while the energy-absorbing capacity and the strain at failure decreased. The effect of high strain rates of loading on specimens of beef bone, cut and tested in different directions, has recently been investigated by Bird et al. <a></a></p> <p>Embalming also affects the mechanical properties of bone, at least those of compact bone. Thus, the mean ultimate tensile strength (in the long axis of the specimen and of the intact bone) is greater at the 0.01 significance level in embalmed wet- and dry-tested tibial specimens than in similarly tested unembalmed specimens <a></a>. Furthermore, embalmed, wet-tested tibial specimens have a higher mean tensile strain, a greater mean single shearing strength (perpendicular to the long axis of the specimen) and are harder (Rockwell No.) than similarly tested embalmed specimens <a></a>. However, the latter type of specimens has a higher mean modulus of elasticity. An analysis of variance showed that the increase in the hardness of the embalmed specimens was significant at the 0.01 level. As far as I am aware, there are no similar studies concerning the effect of embalming on the mechanical properties of spongy bone.</p> <p>Two types or forms of bones are found in the foot-irregularly shaped bones (the tarsals) and miniature long bones (the metatarsals and the phalanges). The tarsal bones are essentially shells of compact bones filled with spongy bone, fat, marrow substance, blood, etc. The actual amount of osseous material in bones, such as the tarsals and the bodies of vertebrae, is not very great. According to Policard and Roche <a></a> the talus and the calcaneus are about 80 per cent nonosseous tissue. The percentage of bone in the bodies of 92 human lumbar vertebrae studied by Bromley <i>et al. </i><a></a> varied from a maximum of approximately 24 per cent to a minimum of 15.5 per cent in males and from 21 per cent to 12 per cent in females at 5 and 70 years of age, respectively. As far as I am aware, there are no studies on the mechanical properties of spongy bone from the foot. Therefore, examination of such properties will be based on data obtained from the human femur.</p> <p>Two types of specimens were used-a rectangular bar (the standard specimen) 0.79 cm. x 0.79 cm. x 2.5 cm. and a cube 0.79 cm. on a side. The specimens were obtained from the head, neck, greater trochanter, and condyles of the femur with the long axis of the standard specimens oriented in different directions.</p> <p>The specimens were tested under direct compression in a Riehle 5000-lb. capacity testing machine, equipped with an automatic stress-strain recorder and calibrated to an accuracy of ±0.5 per cent. The low range scale of the machine (0-200 lbs.) was used with the load registered on the dial of the machine in units of 0.5 lbs. The specimens were loaded at a speed of 0.45 in. per min.</p> <p>All specimens were tested wet to more nearly approximate the condition in the living foot. Drying of compact bone increases its ultimate tensile strength (in the long axis of the specimen), its modulus of elasticity, and its hardness (Rockwell No.) but decreases its single shearing strength (perpendicular to the long axis of the specimen) and its tensile strain.<a></a> Similar studies have not, to my knowledge, been made on spongy bone.</p> <p>The ultimate compressive stress (strength) and strain, the modulus of elasticity, and the energy absorbed to failure were computed from stress-strain curves for wet-tested specimens. The density of air-dried specimens was determined with a strontium 90 densitometer developed by Evans, Coolbaugh, and Lebow <i><a></a>. </i>Dry specimens were used to avoid the effects of moisture that might be trapped within the interstices of the specimens. A total of 69 rectangular (standard) specimens and of 15 cubic specimens from 1 adult, white female, 3 adult, Negro males, and 6 adult, white males were tested. All specimens were kept in saline solution until tested. A minimum of 20 load-deformation readings were taken for each specimen during the test period.</p> <p>The results of the study showed that the mean compressive stress (strength) of the cubic specimens was greater than that of the rectangular (standard) specimens from the same region (<b>Fig. 5</b>). This phenomenon is characteristic of practically all materials. In cubic specimens high frictional forces developed between the ends of the specimen and the testing machine to resist the tendency of the specimen to be squeezed out of the machine. Furthermore, the upper part of the cube tends to be impacted into the lower part. Both of these factors contribute to higher values for compressive stress and modulus of elasticity in cubic than in specimens which are longer than wide. Because of these factors, it is felt that the values obtained from the rectangular (standard) specimens more accurately represent the true mechanical properties of spongy bone.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Mean and range of variation in some mechanical properties of spongy bone from different regions of the femur. Compressive stress values in pounds force per square inch. Gt. troch. = greater trochanter; Lat. = lateral; Med. = medial; Cond. = condyle. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the living body, most of the bones are subjected to bending action as a result of gravity, muscular activity during movement, and blows. Consequently, the bones are subjected to a combination of tension, compression, and shearing rather than to a single pure force. The question then arises as to why the strength of bone is usually determined by testing the specimens under a pure force. The answer to this question, on mechanical grounds, has already been given. There are, however, other valid reasons for testing the strength of bone under pure tension or compression.</p> <p>Experimental studies with strain sensitive lacquers on bones within the living body as well as outside of it demonstrate that certain types of linear fractures of the skull, the pelvis, and the long bones all arise from failure of the bone from tensile stresses and strains produced in it by bending <a></a>. The determination of the tensile strength of bone under pure tension thus has direct application to the mechanics of fractures of those types. Clinical experience also indicates that tensile forces are important in the production of many types of fractures.</p> <p>Compression fractures are quite common in the bodies of the vertebrae, especially those in the lumbar region, and in the calcaneus, the most frequently fractured of the tarsal bones <i><a></a> . </i>Compression fractures of the talus also occur. There is, consequently, a sound practical reason for investigating the compressive strength of the tarsal bones, especially the calcaneus and the talus although, to my knowledge, it has not been done. The rationale for determining the strength of spongy bone from the femoral head and condyles under direct compression is that these regions of the bone are normally subjected to compression forces in the erect posture <i><a></a> . </i>Specimens from other regions were similarly tested for comparative purposes.</p> <p>When the results of the tests were compared according to the region of the bone from which the specimens were obtained, without regard to the direction of loading, several differences were found. The rectangular (standard) specimens from the neck had the highest and those from the greater trochanter the lowest mean compressive stress. Among the cubic specimens the highest and the lowest mean compressive stresses were found in specimens from the head and the medial condyle, respectively.</p> <p>Regional variation was also found in the modulus of elasticity (stiffness) of the specimens (<b>Fig. 5</b>). The mean stiffness of the rectangular specimens exceeded that of the cubic specimens from the same region except for the specimens from the head. The rectangular specimens from the neck and the medial condyle, respectively, had the highest and the lowest mean modulus. The maximum and the minimum stiffness means of the cubic specimens were found in those from the head and the medial condyle, respectively.</p> <p>Comparison of the mean compressive strain, mean energy absorbed to failure, and mean density of the rectangular and cubic specimens from different parts of the femur also reveals interesting differences (<b>Fig. 6</b>). The cubic specimens showed somewhat more variation in the mean compressive strain than did the rectangular ones, the strain being greatest in the specimens from the head and least in those from the medial condyle. Little difference was found in the mean compressive strain of the rectangular specimens, those from the head having a slightly greater strain than those from the condyles. The cubic and the rectangular specimens from the head had the highest while those from the medial condyle had the lowest mean energy absorbed to failure. However, the former specimens showed more regional difference than did the latter. The mean density for both types of specimens was greatest in those from the head and least in the ones from the lateral condyle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Mean and range of variation of some mechanical properties of spongy bone from various regions of the femur. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A statistical analysis of the above data from the rectangular (standard) specimens revealed the following significant differences between the means. The mean compressive stress of the strongest specimens (from the neck) was greater, at the 0.02 significance level, than that of the weakest specimens (from the greater trochanter). The difference between the mean compressive strain of the specimens from the head, which had the highest, and that of specimens from the medial condyle, which had the lowest, was significant at the 0.01 level.</p> <p>The mean energy absorbed by the specimens from the head was significantly greater, at the 0.02 level, than that absorbed by specimens from the medial condyle. The differences between the means for the other mechanical properties of the rectangular specimens were not statistically significant. The number of cubic specimens tested was not sufficiently large for statistical analysis.</p> <p>Comparison of the maximum compressive stress and modulus of elasticity (<b>Fig. 7</b>) of the rectangular and cubic specimens according to the direction of loading showed that spongy bone is an anisotropic material, i.e., a material that is not equally strong in all directions. The rectangular specimens loaded in the direction of the long axis of the neck of the femur showed the highest, while those loaded in the anterior-posterior direction showed the lowest mean compressive stress. Among the cubic specimens, the highest mean compressive stress was found in specimens loaded in a lateral-medial direction and the lowest in specimens loaded in a superior-inferior direction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Mean and range of variation in some mechanical properties of femoral spongy bone according to the direction of loading. Stress values in pounds force per square inch. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rectangular specimens loaded in a lateral-medial direction had the highest mean modulus of elasticity and those loaded in the anterior-posterior direction the lowest. The cubic specimens loaded in a lateral-medial direction had the highest mean modulus of elasticity while the lowest was found in the specimens loaded in a superior-inferior direction.</p> <p>Considerable variation was also found in the energy absorbed to failure, the compressive strain at failure, and the density of the specimens when evaluated with respect to different directions of loading (<b>Fig. 8</b>). The rectangular specimens loaded in a lateral-medial direction had the highest mean energy-absorbing capacity whereas those located in an anterior-posterior direction had the lowest. The highest mean energy-absorbing capacity among the cubic specimens was found in those loaded in a lateral-medial direction and the lowest in the specimens loaded in a superior-inferior direction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Mean and range of variation in some mechanical properties of femoral spongy bone according to the direction of loading. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The rectangular specimens loaded in a lateral-medial direction had the highest average compressive strain and those loaded in the direction of the long axis of the neck had the least. The compressive strain of the cubic specimens loaded in a lateral-medial direction far exceeded that of all other specimens. The lowest compressive strain among cubic specimens was found in those loaded in the superior-inferior direction.</p> <p>Surprising differences were found in the density of specimens cut in different directions. The density of rectangular and cubic specimens cut in the lateral-medial direction was the same but greater than that of any other specimens. The rectangular specimens cut in the superior-inferior and in the anterior-posterior direction were the least dense. Cubic specimens were the least dense when cut in the superior-inferior direction. These differences in density of the specimens suggest directional variation in the orientation and abundance of trabeculae in various parts of the femur.</p> <p>A statistical analysis of the means for the various mechanical properties with respect to the direction of loading revealed the following significant differences. The variation between the energy absorbed by rectangular specimens, loaded in the lateral-medial direction, was significantly greater at the 0.01 level than that of the specimens subjected to anterior-posterior and to superior-inferior loading. The difference between the maximum compressive strain (found in lateral-medial loading) and the minimum strain (found in specimens loaded in the direction of the long axis of the neck) was significant at approximately the 0.04 level. No other significant differences were found between the means for the other mechanical properties when analyzed with respect to the direction in which the specimens were cut and loaded.</p> <p>Although spongy bone is much weaker than compact bone (<b>Fig. 9</b>), its foam-like structure makes it a good energy-absorbing material, as demonstrated experimentally more than a century ago by Dr. Physick <a></a> and more recently suggested by Evans, Pedersen, and Lissner <i><a></a> . </i>The presence of fat, marrow substance, and blood in the interstices of spongy bone in the living condition enhances its energy-absorbing capacity by making it act like a quasi-hydrostatic system. The capacity of bone to absorb energy is one of its important mechanical properties as far as fracture mechanics is concerned because, as pointed out by Lissner and Evans, <a></a> all physical injuries arise from the absorption of energy. Most fractures are produced by impacts or blows and thus involve energy absorption.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Mean and range of variation in strength of various bones according to type (compact or spongy) and. direction of loading <a></a>. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another mechanical property of bone to be considered is its fatigue life. This is especially important in relation to march, stress, or fatigue fractures which are most common in the metatarsal bones although they have also been reported in other bones. These fractures are thought to be the result of repetitive loading such as occurs during marching, hence the name "march" fracture.</p> <p>The only investigation known to me on the fatigue life of intact bones is one we made several years ago <i><a></a> . </i>In this study the strength of intact human metatarsal bones was determined by loading them to failure in a Sonntag Flexure Fatigue machine equipped with an automatic counter (which recorded the number of cycles to failure) and shutoff. The chief advantage in using this type of fatigue machine is that it has an inertia force-compensator spring which absorbs or eliminates all unknown inertia forces. Consequently, the force in the specimen being tested, regardless of its rigidity, is equal to the known force produced by the oscillator assembly.</p> <p>Forty-one bones were tested with a force of 15 lbs. (the maximum that could be applied with our machine), 3 bones with 12 lbs., and 8 bones with 10 lbs. Only the second through fifth metatarsals were tested because the first one was too large for the fatigue machine. The influence of moisture upon the fatigue life of the specimens was investigated in 10 bones by allowing water to drip on them during a test. The bones were not degreased and all were tested at room temperature. None of the bones exhibited any known pathologic condition. In order to hold the bone in the fatigue machine during a test, the ends were embedded in Selectron 5026 plastic. The number of repetitions to failure was automatically recorded and the machine shut off as soon as the specimen broke. A cycle means the bone is bent once up and once down.</p> <p>Comparison of the results obtained for the wet- and the dry-tested specimens showed that drying tended to decrease the fatigue life of the bones (<b>Table 1</b>). The probable explanation is that drying increased the modulus of elasticity of the bone and hence the specimens were stiffer. The number of repetitions to failure, with a 15-lb. force, varied from 1,000 to 10,297,000 for the dry specimens and from 150,000 to 13,908,000 for the wet specimens. Metatarsals 2 and 3 showed the greatest fatigue life when tested wet. No consistent relations were found between the fatigue life of the bones and their size or age of the individuals from whom they were obtained. The type of fracture produced experimentally (<b>Fig. 10</b>) was similar to some reported <a></a> in the clinic literature (<b>Fig. 11</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Experimentally produced fatigue fracture of an intact human metatarsal bone. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. A clinical fatigue fracture of a metatarsal bone.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is interesting to speculate how long an individual must walk before the metatarsals would be subjected to the same number of repetitions at which failure occurred in our experiments. If it were assumed that an individual walked at the army pace of 120 steps per min., walking 50 min., resting 10 min., one would have to walk continuously for almost a month before the second metatarsal would be subjected to the number of repetitions at which the failure occurred in the present study. During each cycle of loading, the bone was bent up and down in a vertical plane. The fracture was probably a tensile failure initiated on the side which, at the instance of failure, was the convex or tensile side.</p> <p><b>References:</b></p> <ol> <li>Bird, F., H. Becker, J. Healer, and M. Messer, <i>Experimental determination of the mechanical properties of bone</i>, Aerospace Med., 39:1:44-48, 1968.</li> <li>Bromley, R. G., N. L. Docku, J. S. Arnold, and W. S. S. Jee, <i>Quantitative histological study of human lumbar vertebrae</i>, J. Geront., 21: 537-543, October 1966.</li> <li>Evans, F. G., <i>Stress and strain in bones, their relation to fractures and osteogenesis</i>, Charles C Thomas, Springfield, Ill., 1957.</li> <li>Evans, F. G., <i>Significant differences in the tensile strength of adult human compact bone</i>, in H. J. J. Blackwood, Proceedings of the first European bone and tooth symposium, pp. 319-331, Pergamon Press, Oxford, 1964.</li> <li>Evans, F. G., <i>Relazioni tra alcune proprieta meccaniche e struttura istologica dell'osso compatto umano</i>, Arch. Putti, in press.</li> <li>Evans, F. G., <i>Relation of the physical properties of bone to fractures</i>, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 18:110-121, 1961.</li> <li>Evans, F. G., and M. Lebow, <i>Regional differences in some of the physical properties of the human femur</i>, J. Appl. Physiol., 3:9:563-572, March 1951.</li> <li>Evans, F. G., and M. Lebow, <i>The strength of human compact bone as revealed by engineering technics</i>, Amer. J. Surg., 83:3:326-331, 1952.</li> <li>Evans, F. G., C. C. Coolbaugh, and M. Lebow, <i>An apparatus for determining bone density by means of radioactive strontium (Sr90)</i>, Science, 114:2955:182-185, 1951.</li> <li>Evans, F. G., H. E. Pedersen, and H. R. Lissner, <i>The role of tensile stress in the mechanism of femoral fractures</i>, J. Bone Joint Surg., 33A: 485-501, 1951.</li> <li>Harris, C. O., <i>Strength of materials</i>, American Technical Society, Chicago, 1963.</li> <li>Key, J. A., and H. E. Conwell, <i>The management of fractures, dislocations, and sprains</i>, C. V. Mosby, St. Louis. 1951.</li> <li>Koch, J. C, <i>The laws of bone architecture</i>, Amer. J. Anat., 21:177-298, March 1917.</li> <li>Kraus, G. R., and J. R. Thompson, <i>March fracture: An analysis of 200 cases</i>, J. Roent. Radium Therapy, 52:281-290, 1944.</li> <li>Lease, G. O'D., and F. G. Evans, <i>Strength of human metatarsal bones under repetitive loading</i>, J. Appl. Physiol., 14:1:49-51, 1959.</li> <li>Lissner, H. R., and F. G. Evans, <i>Engineering aspects of fractures</i>, Clin. Orthop., 8:310-322, 1956.</li> <li>McElhaney, J. H., and E. F. Byars, <i>Dynamic response of biological materials</i>, Amer. Soc. Mech. Eng., 65-WA/HUF-9, December 1965.</li> <li>Policard, A., and J. Roche, <i>La formation de la substance osseuse</i>. Essai de coordination des donnees histologiques et biochimiques. Ann. Physiol. Physicochim. Biol., 13:645-703, 1937.</li> <li>Wistar, C, <i>A system of anatomy</i>, Ed. 4, Carey, Lea and Carey, Philadelphia, 1827.</li> <li>Zarek, J. M., <i>Biomechanics: Its application to surgery</i>, Chap. 6 in L. Gillis, Modem trends in surgical materials, Butterworth and Co. Ltd., London, 1958, pp. 106-123.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Kraus, G. R., and J. R. Thompson, March fracture: An analysis of 200 cases, J. Roent. Radium Therapy, 52:281-290, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Kraus, G. R., and J. R. Thompson, March fracture: An analysis of 200 cases, J. Roent. Radium Therapy, 52:281-290, 1944.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Lease, G. O'D., and F. G. Evans, Strength of human metatarsal bones under repetitive loading, J. Appl. Physiol., 14:1:49-51, 1959.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Evans, F. G., Relation of the physical properties of bone to fractures, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 18:110-121, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Lissner, H. R., and F. G. Evans, Engineering aspects of fractures, Clin. Orthop., 8:310-322, 1956.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Evans, F. G., H. E. Pedersen, and H. R. Lissner, The role of tensile stress in the mechanism of femoral fractures, J. Bone Joint Surg., 33A: 485-501, 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Wistar, C, A system of anatomy, Ed. 4, Carey, Lea and Carey, Philadelphia, 1827.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Koch, J. C, The laws of bone architecture, Amer. J. Anat., 21:177-298, March 1917.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Key, J. A., and H. E. Conwell, The management of fractures, dislocations, and sprains, C. V. Mosby, St. Louis. 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Evans, F. G., Stress and strain in bones, their relation to fractures and osteogenesis, Charles C Thomas, Springfield, Ill., 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Evans, F. G., C. C. Coolbaugh, and M. Lebow, An apparatus for determining bone density by means of radioactive strontium (Sr90), Science, 114:2955:182-185, 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Evans, F. G., and M. Lebow, Regional differences in some of the physical properties of the human femur, J. Appl. Physiol., 3:9:563-572, March 1951.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Evans, F. G., and M. Lebow, The strength of human compact bone as revealed by engineering technics, Amer. J. Surg., 83:3:326-331, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bromley, R. G., N. L. Docku, J. S. Arnold, and W. S. S. Jee, Quantitative histological study of human lumbar vertebrae, J. Geront., 21: 537-543, October 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Policard, A., and J. Roche, La formation de la substance osseuse. Essai de coordination des donnees histologiques et biochimiques. Ann. Physiol. Physicochim. Biol., 13:645-703, 1937.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Evans, F. G., Relazioni tra alcune proprieta meccaniche e struttura istologica dell'osso compatto umano, Arch. Putti, in press.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Evans, F. G., Significant differences in the tensile strength of adult human compact bone, in H. J. J. Blackwood, Proceedings of the first European bone and tooth symposium, pp. 319-331, Pergamon Press, Oxford, 1964.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Bird, F., H. Becker, J. Healer, and M. Messer, Experimental determination of the mechanical properties of bone, Aerospace Med., 39:1:44-48, 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">McElhaney, J. H., and E. F. Byars, Dynamic response of biological materials, Amer. Soc. Mech. Eng., 65-WA/HUF-9, December 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Zarek, J. M., Biomechanics: Its application to surgery, Chap. 6 in L. Gillis, Modem trends in surgical materials, Butterworth and Co. Ltd., London, 1958, pp. 106-123.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Evans, F. G., Relation of the physical properties of bone to fractures, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 18:110-121, 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Harris, C. O., Strength of materials, American Technical Society, Chicago, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Zarek, J. M., Biomechanics: Its application to surgery, Chap. 6 in L. Gillis, Modem trends in surgical materials, Butterworth and Co. Ltd., London, 1958, pp. 106-123.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Evans, F. G., and M. Lebow, Regional differences in some of the physical properties of the human femur, J. Appl. Physiol., 3:9:563-572, March 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>F. Gaynor Evans. Ph.D. </b></td></tr><tr><td class="clsTextSmall">Department of Anatomy and Highway Safety Research Institute, The University of Michigan, Ann Arbor, Mich. 48104.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_037/spring69-33.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_037/spring69-34.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_037/spring69-35.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_037/spring69-36.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_037/spring69-37.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_037/spring69-38.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_037/spring69-39.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_037/spring69-40.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_01_037/spring69-41.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_01_037/spring69-42.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_01_037/spring69-43.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_01_037/spring69-44.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Mechanical Properties of Bone Creator An entity primarily responsible for making the resource F. Gaynor Evans. Ph.D. * https://staging.drfop.org/files/original/1bda4488b7bcaad58f689c611e408747.pdf 3dbe8feffcd1fb52115ac4f72537fb35 https://staging.drfop.org/files/original/2b5c10bb36baba4b040aee904e471d71.jpg 58a95731305645b10b6f85d8f67c0245 https://staging.drfop.org/files/original/7eafccb497b126ccef5122f33650546e.jpg 95f4117b856b786b71073155002d428d https://staging.drfop.org/files/original/fb0a7e94a169ec63ff7cf95527d469db.jpg bfcf718cf5f1dbeb7d91194c1cd973f3 https://staging.drfop.org/files/original/2afccc1e2421258e552469eb88bf971e.jpg 9b7fc5a4e7b85110d68fd68f2807d779 https://staging.drfop.org/files/original/38d490d55a00c077b1478f5a0103487b.jpg 45ffc4432052bb51531a1472db207f25 https://staging.drfop.org/files/original/fbd0d897aea6ec8ffb409a610bdb0565.jpg 1391815c9cc113e718f2a49af9320dd0 https://staging.drfop.org/files/original/e74beaad9794f0c38e5b4a2167e3ad53.jpg 0b0a047d912ac402d46d3935c3b9c31e https://staging.drfop.org/files/original/300d567518504315a715a10eb776fea3.jpg 65e2651387f382c71b4515df75547aeb https://staging.drfop.org/files/original/bd66530125b2eec809b4a982578e7298.jpg a604f5d8d25c448cebce95a930d473b4 https://staging.drfop.org/files/original/8c57d9a3ad45c3dddd9363974ba16cbf.jpg c00ad4fa54bb32068faf2b1ce4351adf https://staging.drfop.org/files/original/5ef1b1af6313f0e9535a397f23f3dc8e.jpg 9f2caa21c1bd051f677d1a98f1525b34 https://staging.drfop.org/files/original/3b4dfae891f5fe8d20b4805a2c42caad.jpg f62e04fc490408ac07010086995967df https://staging.drfop.org/files/original/f101f2f8cfe7c638bd4fe254d6a41eeb.jpg ddecbf2853ea7cf90f4c5ea0d633cba4 https://staging.drfop.org/files/original/e2fd7092fcbfa3cff3fcdb2b8d67522f.jpg d7cdaf9276e991c1515ed26738370b8b https://staging.drfop.org/files/original/7c9b09638c60a8e08f198d66a29c3e89.jpg eeec08eb556f5a122fd20be791683be6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_01_015.pdf Year 1971 Volume 15 Issue 1 Page Number(s) 15 - 21 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_01_015.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_01_015.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Technique for Forming Sockets Directly on Above-Elbow Stumps</h2> <h5>F. L. Hampton, C.P. <a style="text-decoration:none;">*</a><br />J. N. Billock, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The ability to make a socket by applying a thermoplastic material such as Poly-sar X-414 (Polymer Corp. Ltd. TM) directly to an amputee's stump offers many advantages to the prosthetist, as pointed out by Wilson. <a></a> Direct forming obviously eliminates the casting procedures necessary to produce a good modified replica of the stump and eliminates the laminating procedures necessary to produce the socket. The thermoplastic properties of Polysar X-414 allows quick postforming of the socket in areas which may require relief, and the material lends itself well to the attachment of components during assembly. These time-saving advantages enable the prosthetist to fit amputees with a temporary prosthesis much earlier than the time normally required for a definitive fitting. This hastens the amputee's rehabilitation and helps to condition him <i>and </i>his stump for the definitive prosthesis. The prosthetist also has the advantage of noting any corrections which are applicable to the definitive prosthesis. These advantages are also helpful to the research prosthetist, for he can save valuable time in evaluating new control techniques and testing new components.</p> <p>A direct-forming technique related to those developed by Staros and Gardner <a></a> for below-knee PTB sockets and by Labate and Pirrello <a></a> for below-elbow sockets using Polysar X-414 has been developed for above-elbow sockets. If done properly, this technique will provide a well-fitting socket which has the above-mentioned advantages. A complete above-elbow prosthesis can be fabricated in approximately three hours.</p> <p>The technique was used at this center to construct Polysar sockets for four above-elbow amputees who participated in an evaluation study of externally powered upper-extremity prosthetic components. Each amputee (described briefly below) wore his prosthesis successfully for two hours a day, three days a week, during a two-month period without problems.</p> <p><i>D. H., </i>a 38-year-old male, with a right above-elbow amputation 11 in. distal to acromion, acquired in June 1964. He was fitted with a standard above-elbow prosthesis, which he has used actively as a laborer since.</p> <p><i>R. W., </i>a 35-year-old male congenital amputee, with a right 11-in. above-elbow stump from the acromion. He was fitted with his first standard above-elbow prosthesis in June 1954, and has been an active prosthesis wearer since that time. He is presently employed as a hotel clerk.</p> <p><i>J. H., </i>a 44-year-old male with a left above-elbow amputation 8% in. distal to the acromion, acquired in March 1964. He was fitted with a standard above-elbow prosthesis and has been an active prosthesis wearer since that time. He is presently employed as a quality-control inspector for a leather factory.</p> <p><i>R. R., </i>a 22-year-old male with a left above-elbow amputation 9 1/2 in. distal to the acromion, acquired in November 1968. He was fitted with a standard above-elbow prosthesis and has used it actively since. He is a student in college at the present time.</p> <h3>Materials and Equipment</h3> <p>A tube of the synthetic rubber 3 in. ID x 1/4 in. x 12 in. is adequate for the average above-elbow stump. The diameter can be reduced for smaller stumps by elongating the tube after it has been heated. Larger sizes of tubing should be used for larger stumps.</p> <p>The only special equipment needed is a deep, water-filled container, approximately 20 in. in height and 8 in. in diameter. The water should be preheated to a temperature of 160 degrees F to 180 degrees F.</p> <p>The following materials and equipment should be available within the prosthetic facility:</p> <ul> <li>Two 1 in. x 40 in. elastic webbings</li> <li>Four Yates clamps</li> <li>Tubegauz (TM), size #56 (tubular gauze)</li> <li>Heavy cast sock</li> <li>Braided Dacron (TM) line, approximately 130-lb-test</li> <li>Standard Hosmer elbow turntable</li> <li>Hose clamp, expandable to 11-in. circumference</li> <li>Hot plate</li> <li>Parallel bar</li> <li>Pressure-sensitive tape</li> </ul> <h3>Preparations for Casting</h3> <p>Cut a length of tubular gauze approximately 18 in. longer than the stump and slit it 6 in. from the proximal end. Apply the tubular gauze with the slit in the axilla, allowing the tubular gauze to encompass the shoulder proximal to the acromion process. Pass a piece of 1-in. elastic webbing under the axilla on the sound side and attach it to the anterior and posterior wings of the tubular gauze (<b>Fig. 1</b>). Cut the toe from a heavy cast sock and slit the proximal end in the same manner as the tubular gauze. Pull the cast sock on the distal third of the stump, with the slit under the axilla (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Tubular gauze suspended with elastic webbing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Heavy east sock applied to distal one-third of stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Mark the proximal section of the synthetic rubber tube to be cut out for the axilla. The width of the section will depend on the stump size, and the depth must be sufficient to allow the synthetic rubber to pass over the acromion. The synthetic rubber stretches well; therefore, caution should be taken not to cut out too large a section. For average stumps, a section 3 in. x 3 in. is adequate.</p> <p>Completely immerse the synthetic rubber tube in the preheated water. The tube will rise to the surface when it has reached the appropriate temperature. Remove it from the water and cut out the axilla section (<b>Fig. 3</b>). Allow the tube to cool until the hand may be placed inside the tube without discomfort.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Cutting out axilla section after tube is heated. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Application of Synthetic Rubber</h3> <p>Stretch the proximal end of the tube at the axilla level to aid in starting the tube on the stump (<b>Fig. 4</b>). Roll the axilla edge to provide a good flare for the axilla (<b>Fig. 5</b>). Insert the tubular gauze and cast sock through the tube and apply the tube to the distal third of the stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Synthetic rubber tube stretched at axilla level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Medial edge rolled to provide a good flare for axilla. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The tubular gauze is anchored to a parallel bar so that the amputee can apply tension on the tubular gauze. The tension will compress the stump tissues and prevent tissue-bunching while the synthetic rubber tube is being applied. An adjustable webbing belt with an O ring is used as the anchoring point on the parallel bar (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Synthetic rubber tube applied to the distal end of the stump and tension applied to the tubular gauze. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Stand the amputee away from the parallel bar with the stump in abduction and the shoulder in depression. This will assist in placing the tube well into the axilla. Pull the synthetic rubber tube onto the stump, using the cast sock to work it up the stump (<b>Fig. 7</b>). Make sure it is well into the axilla and over the acromion. Support the tube with a piece of elastic webbing in the same manner as the tubular gauze (<b>Fig. 8</b>). This will also aid in forming the proximal end of the socket. Eliminate any wrinkles in the cast sock by pulling on it at the distal end of the tube.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Synthetic rubber tube is pulled up the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The tube suspended with elastic webbing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Contouring the Socket</h3> <p>When contouring the socket for a left amputee, place the left hand firmly into the axilla, keeping the hand parallel to the sagittal plane. Have the amputee move back to the parallel bar, adduct his stump, and elevate his shoulder to the neutral position (<b>Fig. 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Left hand in the axilla and right hand contouring distal end of socket to accept elbow turntable </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Firm tension should be maintained on the tubular gauze without causing the amputee to strain. Only the shoulder muscles should be used to maintain the tension. The finished socket will be loose if the stump muscles are contracted during contouring of the socket.</p> <p>Reduce the diameter of the synthetic rubber distally to conform to the stump and to approximate the circumference of the turntable if necessary (<b>Fig. 9</b>). Mold the proximal section by placing the right hand so that the thumb and forefinger outline the anterior and posterior borders of the deltoid muscle group. The thumb is used to mold the anterior wing, and the remaining fingers to mold the posterior wing (<b>Fig. 10</b>). Hold the socket in this manner until the synthetic rubber cools enought to retain the contours.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Right hand contouring the proximal socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Mark the proximal trim line before removing the socket. Either the conventional trim line can be used or the open-shoulder described by McLaurin et al. <a></a> After the trim line is cut out, the edges can be finished with a felt cone, fine-sand cone, or toluene.</p> <h3>Attachment and Alignment of Turntable</h3> <p>Determine the proper distance for the elbow center from the acromion process and mark where the turntable will be located on the tube. Reheat the distal end of the tube approximately one-half inch above the mark by immersing it in water. Insert the turntable into the tube and work the synthetic rubber into the knurling and tie-off groove. Secure the synthetic rubber by wrapping 130-lb-test, braided Dacron (TM) line around the tube and pulling it into the tie-off groove (<b>Fig. 11</b>). Two passes of line are sufficient. Cut away the excess tubing and apply pressure-sensitive tape around the tube, making sure the synthetic rubber conforms to the turntable (<b>Fig. 12</b>). A hose clamp can be used for more strength if necessary (<b>Fig. 13</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Turntable tied in place and excess synthetic rubber trimmed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Socket compressed against turntable with pressure-sensitive tape. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Turntable attached with hose clamp. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Attach the elbow unit and forearm section and check the alignment of the turntable. If it is not properly aligned, reheat the distal end in water and realign.</p> <p>The harness and cable system are attached in the conventional manner (<b>Fig. 14</b> and <b>Fig. 15</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. The completed prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. The completed prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Acknowledgments</h3> <p>The authors wish to thank Miss Carole Herhold and Dr. Dudley S. Childress for their help in the preparation of this report.</p> <p><b>References:</b></p> <ol> <li>Labate, Gennaro, and Thomas Pirrello, Direct forming of below-elbow sockets, Artif. Limbs, 14:1:65-72, Spring 1970.</li> <li>McLaurin, C. A., W. F. Sauter, C. M. E. Dolan, and G. R. Hartmann, Fabrication procedures for the open-shoulder above-elbow socket, Artif. Limbs, 13:2:46-54, Autumn 1969.</li> <li>Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, Artif. Limbs, 14:1:57-64, Spring 1970.</li> <li>Wilson, A. Bennett, Jr., A material for direct forming of prosthetic sockets, Artif. Limbs, 14:1:53-56, Spring 1970.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">McLaurin, C. A., W. F. Sauter, C. M. E. Dolan, and G. R. Hartmann, Fabrication procedures for the open-shoulder above-elbow socket, Artif. Limbs, 13:2:46-54, Autumn 1969.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Labate, Gennaro, and Thomas Pirrello, Direct forming of below-elbow sockets, Artif. Limbs, 14:1:65-72, Spring 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Staros, Anthony, and Henry F. Gardner, Direct forming of below-knee PTB sockets with a thermoplastic material, Artif. Limbs, 14:1:57-64, Spring 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., A material for direct forming of prosthetic sockets, Artif. Limbs, 14:1:53-56, Spring 1970.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>J. N. Billock, C.P. </b></td></tr><tr><td class="clsTextSmall">Research Prosthetist, Northwestern University Prosthetic Research Center.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>F. L. Hampton, C.P. </b></td></tr><tr><td class="clsTextSmall">Coordinator, Prosthetic Research and Education, Northwestern University Prosthetic-Orthotic Center.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1971_01_015/1971_01_015-15.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Technique for Forming Sockets Directly on Above-Elbow Stumps Creator An entity primarily responsible for making the resource F. L. Hampton, C.P. * J. N. Billock, C.P. * https://staging.drfop.org/files/original/708fa372e3aa806c06ea2cec87c6d54d.pdf 9a1fac5f9d62e7f6b1c6180a01f964f8 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_001.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_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>Artificial Limbs-Today and Tomorrow</h2> <h5>F. S. Strong, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>Ours is an age of scientific research and development in almost every field of human interest. Some work to make man live longer, to make him more comfortable, more mobile, more informed. Some devise ways to maim or destroy him. This report and others to follow will tell the story of those who strive to replace what war, accident, or disease have removed, or what nature simply failed to provide. This is concerned with what modern science and engineering skill can do today-and what may be expected in the future-for the person in need of a substitute for normally standard equipment-an artificial limb for a missing arm or leg.</p> <p>From the dawn of history men have contrived replacements for lost extremities, particularly the lower. The loss of an arm, while causing inconvenience, has not resulted generally in serious handicap. But without a leg, a man becomes immobilized. Thus, over the years there has come about a considerable development until today some of the better types of artificial legs afford reasonably satisfactory service, always provided they are well fitted and aligned by qualified prosthetists. The same has not been true of upper-extremity devices. And so when young men returned from World War II with missing limbs, while the lower-extremity amputee could expect a replacement of some merit, the man who needed an arm was definitely in trouble. As a matter of fact, the entire field of artificial limbs needed serious attention to bring amputee service more in line with the scientific and engineering progress which has become synonymous with America in the modern world.</p> <p>To meet this need, not only for the benefit of veteran amputees, but also to help all similarly handicapped individuals everywhere, a program was established at the end of the war under the sponsorship of the Armed Services and the Veterans Administration and was later implemented on a permanent basis by the Eightieth Congress through Public Law 729. This act authorizes the expenditure of $1,000,000 annually "to aid in the development of improved prosthetic appliances ..." and designates the Veterans Administration as the appropriate agency for the administration of the funds thus made available.</p> <p>The activities encompassed within the framework of these endeavors have come to be known as the Artificial Limb Program. And since the field, though serving less than a million persons, of whom only some 27,000 are veterans, involves the cooperation of several scientific disciplines as well as various organizations both civil and military, a special structure had to be contrived for successful operation. This was done through a contract between the Veterans Administration and the National Academy of Sciences, by means of which an Advisory Committee on Artificial Limbs of the National Research Council has been established for general supervision and coordination, and through other contracts between the Veterans Administration and various educational and industrial organizations for research and development. In addition the Surgeons-General of the Army, Navy, and Air Force, and the Chief Medical Director of the Veterans Administration, have made available the services of certain laboratories and personnel in further support of the over-all program. While in the early stages of this undertaking, it was necessary to proceed generally on a broad front in order to explore and define the complete problem so that at one time as many as sixteen contracts were in force, at present the number has been reduced to three only, and an operational structure has been evolved through which a long-range plan can be followed with reasonable hope of success</p> <p>The word "prosthetics" has been found a convenient term to define the general field of amputee service. Since the problems of replacement in the lower extremity are quite different from those in the upper, the field is divided into two parts. Lower-extremity research and development are centered at the University of California, Berkeley Campus, while upper-extremity studies are similarly covered at the University of California at Los Angeles, all under a contract between the Veterans Administration and the University. Assisting in lower extremities is the Oakland Naval Hospital Artificial Limb Department while the Army Prosthetics Research Laboratory at Walter Reed Army Medical Center cooperates in the development of artificial arms and terminal devices Finally, through a contract with New York University, and with the cooperation of the VA Prosthetic Testing and Development Laboratory in New York well-defined methods of testing and field application assure that devices and techniques developed under the program are, before acceptance, in fact useful improvements in amputee rehabilitation.</p> <p>For general technical guidance in these two branches, standing committees, in lower- and upper-extremity prosthetics respectively, have been constituted, each composed of specialists in the fields of medicine, engineering, prosthetics, and the like, and each under the chairmanship of the leader of the appropriate University of California research project. These groups meet annually, or more frequently if necessary, to review progress, define requirements, and recommend action to the Advisory Committee on Artificial Limbs, to the artificial-limb industry, or to others interested in amputee rehabilitation problems. In addition smaller research and development panels have been appointed from these technical committees to supervise current activities between meetings of the larger groups. In this work, definite transition procedures have been adopted for orderly progress from the inception of ideas for improved devices and techniques to their final application in the limbshop or rehabilitation clinic.</p> <p>By these methods the results of some eight years of research and development are now being channeled as directly as practicable to the service of amputees, rather than indirectly merely through the issuance of reports or through publication in scientific journals. In order that physicians, prosthetists, rehabilitation specialists, insurance carriers, and other interested individuals and organizations may be informed of advances in this field as promptly as possible, this series of reports is being undertaken. While the Advisory Committee on Artificial Limbs has previously issued monthly progress reports on a limited basis to those immediately concerned, and although the various contractors and governmental laboratories associated with the program have contributed reports and other data on specific subjects, this will be the first organized attempt to disseminate timely information to a broad list of individuals and institutions interested in the rehabilitation of the amputee. This is being done in furtherance of the intent of the Congress which, in Public Law 729, authorizes the Administrator of Veterans' Affairs "to make available the results of his investigations to private or public institutions or agencies and to individuals in order that the unique investigative materials and research data in the possession of the Government may result in improved prosthetic appliances for all disabled persons."</p> <p>In offering these reports to the reader who has not been in a position to follow recent progress in this field as unfolded through the Artificial Limb Program it can be stated that the views and information to be set forth in this and Subsequent issues are the result of long and objective study by specialists in the various branches of science and engineering involved. These findings, therefore, can be accepted with considerable confidence as indications not only of the present state of the art but also as to future trends And where these findings may appear at variance with previous traditional concepts or the writings of earlier authorities, it can be said simply that the field of prosthetics is even today largely uncharted and untraversed-that it is a field where the marvels of modern science and engineering have yet to leave their mark.</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>F. S. Strong, Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Advisory Committee on Artificial Limbs, National Research Council.</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 Artificial Limbs-Today and Tomorrow Creator An entity primarily responsible for making the resource F. S. Strong, Jr. * https://staging.drfop.org/files/original/9e338894b1f207843da22d94280a118d.pdf 3393a872a919021256b2ab1ef2371b05 https://staging.drfop.org/files/original/4fee943f810bcedb55cf94bac3f60253.jpeg 0b6369b919b0a4c5d421fce6886e6d5e https://staging.drfop.org/files/original/6396c81100371bfe9d8ac940075631cb.jpg 023518571192ab6721498d9b4a8f7662 https://staging.drfop.org/files/original/0d2768cace046397bbf7d7040508d863.jpg 07e13ce84947e5b2f1732d2de5338794 https://staging.drfop.org/files/original/d83594653570ca96f690044f2b1d657d.jpg 8bc03b7ee87b349b287b877e8a698bc0 https://staging.drfop.org/files/original/8a3452f59a563b52f53eb6f67c8a4be4.jpg 470315d686168817996c70c6a4928ce9 https://staging.drfop.org/files/original/1f8be944e589b7eac3c9645bca1a26e8.jpg 59b8b275e0cb6ce51b166ec3ae492e31 https://staging.drfop.org/files/original/aec7299a96361a338ddc5dacbcdf4e28.jpeg cf51d6d972c19f2beaaeced91b298b2e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1977_02_004.pdf Text Any textual data included in the document <h2>The Geriatric Amputee</h2> <h5>Florence T. Leist, P.T.&nbsp;<br /><br /><a href="/files/original/4fee943f810bcedb55cf94bac3f60253.jpeg">Fig 1: Florence Leist</a></h5> <p><i>Presented at the Annual Meeting of the American Physical Therapy Association of Md., Inc., November 13, 1976.</i></p> <p>The purpose of this presentation is to challenge each of you to become an advocate for the geriatric amputee, and to evaluate his potential on factors other than his age.</p> <p>To dispel the theory of a person being too old to use a prosthesis I would like to share a couple of real situations.</p> <p>We had a dear 77-year-old man receive his prosthesis at our clinic at Deer's Head in the spring. Last summer I met his grandson, and when I asked him how his grandfather was, he replied, "oh, he's fine now that he has his new leg. He's even courting a girl friend." Then there is the 85-year-old woman who received a new prosthesis and yet another new one at the age of 87 to enable her to continue caring for and babysitting her great grandchildren.</p> <p>This afternoon I would like to talk <em>first</em> about factors to be considered in the management of the geriatric lower-limb amputee, and then present some statistics gathered from a review of the amputees who received their prostheses through the clinic at Deer's Head Center during its first two years of operation.</p> <p>The management of the amputee can be divided into three phases:</p> <ol> <li> <p>Post amputation and/or pre-prosthetic training.</p> </li> <li> <p>Prescription.</p> </li> <li> <p>Post prosthetic training.</p> </li> </ol> <p>One of the problems we had in the management of the geriatric amputee was the scarcity of information provided by the referring physician. We sometimes got little more information than that the patient had had an amputation - not even a mention of whether it was an AK or BK, or whether it was on the right or the left.</p> <p>To help overcome this situation we developed a questionnaire to develop not only the necessary basic history, but, more importantly, information such as cardiac status and the condition of the remaining lower limb. We also included the question "is he able to increase exertion 50 per cent more than is required for normal walking or wheelchair use."</p> <p>We used the reference "On energy requirements for prosthesis use of geriatric amputee" to establish that question (Peizer, E. <i>On the energy requirements for prosthesis use by geriatric amputees, in "The Geriatric Amputee,"</i> Committee on Prosthetics, Research and Development, National Academy of Sciences, 1961).</p> <h3>Depression</h3> <p>In the pre-prosthetic period there are many apsects to consider. From our first contact with the geriatric amputee we usually get a definite feeling about his general mental status. We often find that he is depressed: his self-image has been shattered; he is suddenly unable to walk, work, or even get out of the house; he is faced with a great fear of the future. "What," he asks, "is going to happen to me and my family?"</p> <p>To help him cope with these many frightening problems, the social worker, who we feel is an important member of the team, can be of value from the beginning by helping him face reality, helping solve some of his problems, and by giving him added encouragement.</p> <h3>Range of Joint Motion</h3> <p>Loss of range of motion is more rapid in the geriatric patient because of loss of tissue elasticity. Management is to institute bed positioning and range of motion exercises and encourage freedom of movement as soon as possible. Our goal to have not more than 10 deg. of flexion contracture in hip and knee. Stretching exercises must be carried out if contractures have developed, but one must remember that the older patient tolerates stretching poorly.</p> <h3>Muscle Strength</h3> <p>There is a generalized decrease in strength with age which is compounded by the effects of surgery and forced inactivity. Management is through general strengthening exercise, but the cardiac status and other systems must be considered in planning the exercise program. Usually we must accept less than what is considered as ideal strength. The goal is that the patient be able to support himself by a walkerette or crutches.</p> <p>Often times the geriatric amputee has poor balance and is fearful of falling. He has to be encouraged to try walking with crutches or walkerette and must be well guarded to prevent failing. Ideally our highest pre-prosthetic goal is independence in walking with crutches, however, as we are more concerned with safety and realize the older person does not have the agility and balance of a younger person, walking independently with a walkerette is acceptable. Our chief concern is the safety of the patient and his ability to function. We emphasize the specific stump exercises for extension and abduction of the hip for the AK and the quadriceps for the BK.</p> <h3>Shaping the Stump</h3> <p>In the older amputee generalized soft tissue atrophy is already present and stump wrapping should be monitored carefully. The patient and his family usually lack a clear understanding for the need of stump wrapping, so clear explanations and instructions should be given to insure proper shaping of the stump.</p> <h3>Length of Time Before Prescription</h3> <p>We usually find that most new amputees are presented at our Prosthetic Clinic about 2 months post amputation. Sometimes it is more than that and once in a while less. If it has been 2 months or longer, usually there has been adequate time for reduction of contractures, an increase in strength, proper shaping of the stump, and for learning to walk with assistive devices. If the time is shorter and the patient is able to handle himself on crutches or walkerette but still lacks range of motion or has not stabilized in the shrinking process, we usually go ahead and present him at clinic. The physician in charge of the clinic at DHC has at times given a provisional prescription, stating that when the contracture has been reduced or shrinkage has stabilized the prosthetist may proceed with fabrication of the prosthesis.</p> <p>The team approach is used at the clinic at DHC. The team consists of the physician in charge, the prosthetist, the physical therapist, the occupational therapist, the social worker, counselors from the Division of Vocational Rehabilitation, the patient, and his family, whenever possible.</p> <h3>Prescription for the Geriatric Amputee</h3> <p>Usually, when a patient has worn a prosthesis previously, a prescription for a duplication of the present prosthesis is made, i.e., when a person has a plug socket or a thigh corset, it is duplicated as closely as possible. For a new amputee, we try to prescribe components to meet the criteria which we developed during our evaluation.</p> <h3>Sockets</h3> <p>Quadrilateral sockets with partial suction and valve, usually fitted with a heavy cotton sock, is the design of choice unless there is extensive soft tissue atrophy, when a 5-ply woolen sock is used.</p> <h3>Suspension</h3> <p>A hip joint with pelvic band gives greater security. Suction is generally not prescribed for the geriatric patient because he does not have the muscle strength or tone to use it. At times a "Silesian bandage," or belt, is prescribed, but the patient often has difficulty with internal rotation of the prosthesis when he pulls the "bandage" tight. We recently had to change a "Silesian bandage" to hip joint and pelvic band for a woman.</p> <h3>Knee</h3> <p>Maximum stability at heel strike is necessary for the geriatric patient. The manually locked knee joint provides this stability in ambulation. It does result in gait deviations, but safety with the geriatric patient is our chief concern. It is better to have gait deviations than no gait at all. To help overcome partially the need to circumduct or vault the prosthesis is generally made 1/2 to 1-in. shorter than the contralateral leg.</p> <p>Another knee component that is prescribed sometimes is the BOCK safety knee which provides stability through friction upon weight-bearing.</p> <h3>Foot Components</h3> <p>When a locked knee is used a single-axis foot is desirable because it permits the entire plantar surface of the foot to make contact with the floor early in the stance phase. With a person who is not a vigorous walker, such as an older person is apt to be, an extra soft heel bumper is indicated.</p> <p>When a SACH foot is used with an articulated knee an extra soft heel cushion is desirable.</p> <h3>Post-Prosthetic Training</h3> <p>Post-prosthetic training for a geriatric amputee should be considerably different from that for a young vigorous person. Balance, strength, agility, and endurance will all be reduced greatly and we must proceed more slowly. Goal setting will vary greatly from individual to individual - from limited use in the home to general activities of daily living, to return to work, from walking with no assistive device, to walking with cane or canes, crutches, or walkerette.</p> <p>We must set realistic goals for the geriatric amputee. Many of these people have not been active for a long period before amputation, and they will probably not regain vigorous strength and agility. But if we can return them to the life style to which they were accustomed then I think we have reached our goal.</p> <p>As I have said several times before, we are concerned with safety. While we would like to have a perfect gait, without any assistive device, we settle for safe gait with an assistive device. But when a 75-year-old man can climb on and run a tractor on the farm, what difference does it really make if he uses a cane? Or, if a 75-year-old woman is taking care of herself, staying by herself most of the day and performing household chores, is it so awful she uses a walkerette?</p> <p>Last year we conducted a review of the patients who received a prosthesis through our clinic during the first 2 years of its existence. The purpose of this was to ascertain whether or not the clinic was meeting the needs of the patient; i.e., were we prescribing the proper kind of prosthesis for the individual? And, we felt, this would be partially determined by the use the patient made of his prosthesis. All patients had had their prosthesis for at least a year.</p> <p>We interviewed each of these 24 patients on the day of the clinic, having them complete a questionnaire. Level of amputation, age group, and cause of amputation are given in <b>Table 1</b>. Five of these questions with the result are given in <b>Table 2</b>, <b>Table 3</b>, <b>Table 4</b>, <b>Table 5</b>, and <b>Table 6</b>.</p> <strong>Table 1. Classification of Patients</strong><br /><img src="/files/original/6396c81100371bfe9d8ac940075631cb.jpg" alt="Italian Trulli" width="368" height="158" /><br /><br /><strong>Table 2. I Wear My Artificial Limb:</strong><br /><img src="/files/original/0d2768cace046397bbf7d7040508d863.jpg" br="" width="580" height="179" /><br /><strong><br />Table 3. When I Wear My Limb It Is On:</strong><br /><img src="/files/original/d83594653570ca96f690044f2b1d657d.jpg" br="" width="602" height="134" /><br /><br /><strong>Table 4. When My Limb Is On I Can:</strong><br /><img src="/files/original/8a3452f59a563b52f53eb6f67c8a4be4.jpg" br="" width="565" height="224" /><br /><br /><strong>Table 5. When I Walk I Use:</strong><br /><img src="/files/original/1f8be944e589b7eac3c9645bca1a26e8.jpg" br="" width="571" height="127" /><br /><br /><strong>Table 6. I Need Someone To Assist Me When I Walk:</strong><br /><img src="/files/original/aec7299a96361a338ddc5dacbcdf4e28.jpeg" br="" width="566" height="74" /> <p>It was apparent to us from these statistics that we evidently were meeting the needs of the patients and that the amputees over 60 years of age function about on the same level of those under 60.</p> <p><b>References:</b></p> <ol> <li>Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, <i>The management of lower-extremity amputations</i>, Prosthetic and Sensory Aids Service, Veterans Administration, TR 10-6, August 1969.</li> </ol> Page Number(s) 4 - 7 Year 1977 Volume 1 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-6.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Text Copy Edit Figure 7 http://www.oandplibrary.org/cpo/images/1977_02_004/1977_02_004-7.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 Geriatric Amputee Creator An entity primarily responsible for making the resource Florence T. Leist, P.T.  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/971d394bd3cab6b56131702cf9304cfc.pdf f2823830773aab477c31ef87b7ef4503 https://staging.drfop.org/files/original/19d63adbf4fba399327be2d43c975736.jpeg ddab110728e3ce26e0c64c15d5a8fee2 https://staging.drfop.org/files/original/5f71f091dd01239060dbc584eb8435a2.jpg 06f5cd1d15bf80197630f436ea40479a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_03_001.pdf Text Any textual data included in the document <h2>Prosthetic Sensory Feedback Lower Extremity</h2> <h5>Frank W. Clippinger, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />James H. McElhaney, Ph.D&nbsp;<a style="text-decoration: none;">*</a><br />Maret G. Maxwell, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />David W. Vaughn, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Grace Horton, R.P.T.&nbsp;<a style="text-decoration: none;">*</a><br />Linda Bright, R.N.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>This is a progress report of a Duke University research project involving sensory feedback from lower extremity amputation prostheses.</p> <p>It has been assumed for many years that replacement of sensory function in prosthetic limbs was a nearly impossible task. Developments in electronics have made possible small amplifier systems and usable transducers, but the basic difficulty remains that of getting the signals into the central nervous system in a fashion that is interpretable, comfortable, consistent, and convenient.</p> <p>The problem has not been ignored and the obvious routes-auditory signal, electrical stimulation of intact skin, mechanical stimulation, and developments leading to solving the skin barrier with compatible percutaneous materials have been explored.</p> <p>From 1969 to 1975, this laboratory developed the mechanism to produce sensation from upper limb prosthetic terminal devices. This system was built around the concept of proportional peripheral nerve stimulation by means of a surgically implanted, induction coupled radio receiver-pulse generator, driven by an external amplifier and transmitter that relayed frequency modulated signals, controlled by a strain gauge transducer in the terminal device.</p> <p>The conclusions from this study were:</p> <ol> <li> <p>The system is feasible and signals can be interpreted with reliability relative to the stimulating activity.</p> </li> <li> <p>The brain interprets the signal as coming from the normal peripheral distribution of the nerve stimulated.</p> </li> <li> <p>Signal threshold and nerve excitability does not deteriorate with time, at least in this application.</p> </li> <li> <p>The implanted device is reliable, and durable, there having been no implant failures in twelve years.</p> </li> </ol> <p>In 1975, a grant was received from the National Cancer Institute to apply this technique to the lower limb amputee. This study is to determine whether sensory feedback, in addition to that provided normally from the stump-socket interface and terminal knee impact, useful or advantageous.</p> <p>To date, 21 patients have been fitted with a lower extremity sensory feedback system, including below knee, above knee, and hip disarticulation amputees. The majority of these have been cancer patients.</p> <p>The new amputee from malignancy presents a special problem. It is difficult to subject a person recently amputated for cancer to another surgical procedure to insert a stimulator implant. In addition, the amputation is followed by months of chemotherapy during which time wound healing is compromised and the patient does not feel well. Emotional factors must be considered also.</p> <p>For this reason, it was necessary to develop a noninvasive system as well as the implanted nerve stimulator. After a brief unsuccessful trial with a skin vibrator, the auditory route was selected.</p> <p>The electronic systems of both the implanted and auditory devices are similar. The system consists of a set of strain gauges which measure anteroposterior and mediolateral bending moments incorporated into the below knee segment of the prosthesis utilizing an endoskeletal unit developed by the Department of Bioengineering at Duke, hybridized with Ottobock endoskeletal prosthetic components.</p> <p>In addition to the strain gauges, a pressure activated piezo-electric crystal is imbedded in the heel of a SACH foot. This is activated on heel strike.</p> <p>When the weight is balanced in mid stance or when the prosthesis is unloaded, as with the patient sitting, there is no signal produced by any of the transducers. The system is designed to provide proportional feedback as soon as weight is biased in any direction.<br /><br /><a href="/files/original/19d63adbf4fba399327be2d43c975736.jpeg"><strong>Figure</strong></a></p> <p>For the implant system, the signal to the nerve is frequency-modulated with the frequency of stimulus increasing from 0 to 90 Hertz proportionate to the load. With frequencies greater than 90 Hertz, a decrease in signal or complete loss of signal has been experienced routinely. Voltage is adjusted to a level that is comfortable for the patient. Threshold in these patients has varied between .5 and .9 volts.</p> <p>The implanted receiver is identical to that used in the upper limb project except that four electrodes are placed around the sciatic nerve in the buttock rather than the two that were used for the median nerve in the upper limb project. The receiver is placed subcutaneously in the lower abdominal wall and the antenna is taped to the overlying skin. Only two electrodes are stimulated and the pair which produces the best response is selected. Electrode orientation is important and this is a compromise. The alternative would be to do the surgery with the patient awake which has obvious disadvantages.</p> <p>In all patients, an interpretable signal was produced although the mental imaging, which was 90 percent correct in the upper limb, has been haphazard in the lower. No patient has reported that the stimulus or the mental image produced was uncomfortable, unpleasant, or confusing, however.</p> <p>The auditory system uses the same external transducer unit, but the signal is fed to a hearing aid earpiece placed behind the ear without blocking the external auditory canal.</p> <p>In that the end result of any sensory feedback is a subjective response, it is difficult to determine its effect in scientific terms.</p> <p>A gait laboratory has been developed to analyze walking with and without the sensory feedback system. This provides computer-assisted analysis of force plate and segmental accelerometer data. This facet of the study has just started and at the moment, insufficient data analysis is available to be meaningful.</p> <p>It is felt, however, that the subjective individual patient response will actually be more helpful in the long run. This is "quality of life" response and is voiced as statements like: "I can walk out in the driveway at night without worrying", "I feel better about going downstairs", "I can play basketball better with it turned on", "I can control the accelerator on my car far better".</p> <p>Not all the subjects have found the system useful. <b>Table I</b> outlines the patients who have had the sensory feedback systems and their outcome. Most of those who have abandoned it, however, have had the auditory unit.<br /><br /><strong>Table I</strong></p> <img src="/files/original/5f71f091dd01239060dbc584eb8435a2.jpg" h3="" />Conclusions <ol> <li> <p>Sensory feedback systems in lower extremity amputees appear to have advantages. How much better the amputees are is still under investigation and whether the system is cost effective is still not determined.</p> </li> <li> <p>The auditory system is somewhat confusing and cumbersome. It may end up being a good training apparatus but not appropriate for long term use.</p> </li> <li> <p>The electronics package in the below knee segment of the prosthesis presents some problems related to the cosmetic cover which has to allow frequent access for adjustment and battery changes. An attempt is underway at present to replace the instrumented pylon with an instrumented ankle bolt.</p> </li> <li> <p>Investigation is still needed to determine exactly what information is useful. Knee position, for instance, may be more useful information than the direction and magnitude of loading.</p> </li> </ol> <em><b>*Linda Bright, R.N. </b>Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><b><br /><em>*Grace Horton, R.P.T. </em></b><em> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*David W. Vaughn, C.P.O. </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*Maret G. Maxwell, Ph.D. </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*James H. McElhaney, Ph.D </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*Frank W. Clippinger, M.D. </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em> Page Number(s) 1 - 3 Year 1981 Volume 5 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1981_03_001/1981_03_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 2 http://www.oandplibrary.org/cpo/images/1981_03_001/1981_03_001-2.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 Prosthetic Sensory Feedback Lower Extremity Creator An entity primarily responsible for making the resource Frank W. Clippinger, M.D. * James H. McElhaney, Ph.D * Maret G. Maxwell, Ph.D. * David W. Vaughn, C.P.O. * Grace Horton, R.P.T. * Linda Bright, R.N. * https://staging.drfop.org/files/original/48ab984f63ee9944e8e12c1bf86b8f60.pdf eb995e5594f719eb9d7d1ab8a1c490d7 https://staging.drfop.org/files/original/30569f396b331fcb2e12947a520b6ac1.jpg b543805b7c4b513f32d0060281f28c1e https://staging.drfop.org/files/original/0bc95d63b994e86882e4517d2359f830.jpg 0069caac4493054393b8321505a3418b https://staging.drfop.org/files/original/0ac31bbaa9a0a7f0fec072dd32eb01f6.jpg 19f787d2297a18ef0b242b756a3d565c https://staging.drfop.org/files/original/56454d222bdd3468d5eed2e8285140ef.jpg 04a3c0120545162192a92cc89fdd5ea9 https://staging.drfop.org/files/original/b3e026292277cb859e0e3f4e1784de44.jpg 04e4a36aff5d4f3465d4ab2fe4c2eb7e https://staging.drfop.org/files/original/a446473c17f3288b20207e31bf640f91.jpg 3dd944585433639209e6aba1f6d7e02b https://staging.drfop.org/files/original/b4220edb41cf61a457cbce3d8d3a85e0.jpg dad70000c6445e43ad5115934dfa2024 https://staging.drfop.org/files/original/1a34ee9269e75b1fa11438a645cd9358.jpg 2359c6121a81674e01e8e0aa1813a104 https://staging.drfop.org/files/original/3b83b9695f8d5a45b85fa5f3a3ce8226.jpg b08bd2cf52601d42a9580945fdf0d194 https://staging.drfop.org/files/original/5f2a0eb01af4723d6ad1e673e29af358.jpg d7d0dd21ba3d40e30d463c485cd9df31 https://staging.drfop.org/files/original/a17dff824e882e699ea4241bfdbf1846.jpg 509a6217d3f638c8106e4550bf96d6fc https://staging.drfop.org/files/original/c30118b21e4ccd90a540f956aff44c6b.jpg 5f8d71453173a61fea69ddf09fcf2826 https://staging.drfop.org/files/original/5777bdcd4ca4e1a7990e70d71a0df8e7.jpg 312c5c5027c454f6003665d2d9181936 https://staging.drfop.org/files/original/b80f2cd616a14438719aca13ed27bc35.jpg 6b1cc88760e3fbc9d7438c15ca4ca148 https://staging.drfop.org/files/original/343ea7b1198667406303ad4a8eac51f4.jpg 17767ee459c4d8018faba396f8f5c19e https://staging.drfop.org/files/original/963b2539a143b91e55ee0cf19833183e.jpg 76527cfc69d9e0f23e1f447c0cbf9c91 https://staging.drfop.org/files/original/2a72f1972ae1c761efec324edc5046c8.jpg a02cf0378a7b652331dfffc2f591a00e https://staging.drfop.org/files/original/9f3416f8d473f377d1f6f6ac162f7396.jpg 0cae68f411ca1165884fc7275b632e7a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_01_003.pdf Year 1964 Volume 8 Issue 1 Page Number(s) 3 - 27 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_003.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_01_003.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 Hemipelvectomy Prosthesis</h2> <h5>Fred Hampton, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>A Hemipelvectomy amputation involves removal of the entire lower extremity and half of the pelvis, separation generally being effected at the sacroiliac and symphysis pubis joints. Whenever possible the gluteus maximus and oblique abdominal muscles are preserved and usually are sutured together along the lower anterior aspect of the abdominal cavity. Because of disease or trauma, it is often necessary to remove the gluteus maximus, in which case the "stump" consists simply of a skin-covered abdominal cavity. The operative procedure is described and pictured in detail in <i>An Atlas of Amputations </i>by Dr. Donald B. Slocum.<a></a></p> <p>Because there is no longer a skeletal structure on the affected side to assume the forces required during ambulation with a prosthesis, many workers have attempted to design sockets that will transfer weight-bearing loads directly to existing bony structure. Some have tried to use the ischial tuberosity on the unaffected side to support body weight, but with limited success. Others have felt it necessary to extend the socket so that the rib cage can absorb most of the weight-bearing forces, but this arrangement greatly restricts body motion and heat dissipation.</p> <p>However, it has been found that it is entirely feasible for the "stump" to carry the loads if the socket is designed so that the semisolid abdominal mass of the stump is upward and medially toward the somewhat firmer area of the lower rib cage. Sometimes it is possible to utilize the sacrum for some support but relief for the coccyx must be provided because pressure on this sensitive bone almost always results in pain. Some additional support can often be achieved by utilizing the area of the gluteus maximus on the unaffected side.</p> <p>Such support may be achieved by means of a piece of 1-in. Dacron webbing anchored to the inner distal area of the socket so that the anchor point is anterior to the ischial tuberosity on the sound side. The Dacron tape is led from its anchor point in the socket, under the gluteus maximus on the sound side, passing just distal to the trochanter and then diagonally across the anterior of the socket to a buckle (<b>Fig. 1</b>). Because the strap passes across the sound side at the level of the trochanter, it acts as a counterforce to the shearing action of the stump slipping in the socket under weight-bearing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Sketch shows webbing used as additional support to help to stabilize the amputee in the socket during stance phase. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This article describes a method for fitting the hemipelvectomy patient in such a manner that the major loads are carried through the stump. The hemipelvectomy prosthesis incorporates many of the features of the Canadian hip-disarticulation socket, which was fully discussed in the Autumn 1957 issue of <i>Artificial Limbs. </i>However, the opening used for donning the prosthesis has been moved from the anterior portion to the lateral side of the socket. Greater stability is achieved by this arrangement since both the anterior and the posterior sections of the socket can contribute more support.</p> <p>The hip-disarticulation socket utilizes the ischial tuberosity on the amputated side to support the patient in the socket, and the crest of the ilium for suspension of the prosthesis. In the hemipelvectomy case, the skeletal structure is absent and support of the patient in the prosthesis depends upon oblique upward pressure on the stump with an equivalent opposing pressure on the sound side, obtained by the shape of the socket <a></a> (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Hemipelvectomy socket. Arrows indicate pressure applied by the socket to the "stump," upward and medially. Shaded areas indicate bulges produced by the use of hip sticks. The bulges aid in suspension of the prosthesis, in preventing rotation, and serve as guides for correct alignment while donning the prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>During casting, hip sticks (<b>Fig. 3</b>) are used to obtain the desired contours of tissues necessary for good suspension of the prosthesis.<a></a> Casting a patient while suspended in a sling is one method of compressing tissues in an upward oblique direction, resulting in a cast of the desired shape.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Hip sticks. <i>A, </i>two sticks, approximately 14 in. in length, 1 in. in diameter, joined by a piece of 2-in. webbing, adjustable by means of a buckle. <i>B, </i>hip sticks as applied to the "stump" during casting to create relief for the crest of the ilium on the sound side and desired shape of tissues on the amputated side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The hemipelvectomy prosthesis utilizes the principles of alignment of the Canadian-type hip-disarticulation prosthesis. Moreover, the mechanics of the hemipelvectomy prosthesis are essentially the same as those of the hip-disarticulation prosthesis.<a></a></p> <p>New features incorporated in the hemi-pelvectomy prosthesis are: First, silicone foam is used in the socket construction to fill the cavity at the location of the hip joint; silicone foam is nontoxic, easily used, and provides a surface that is not as slippery as the polyester laminates. Second, the attachment for the hip joint is an integral part of the socket. Third, there is an articulated thigh fairing which is lightweight, easily fabricated, allows reduction in the size of the thigh block, and greatly enhances cosmesis in both the sitting and standing positions. Fourth, there is a support strap under the ilium and around the trochanter.</p> <p>The prosthesis includes the use of a single-axis knee and a SACH foot with a very soft heel wedge. This soft heel wedge increases the stability of the prosthesis at heel strike.</p> <h3>Examination of the Amputee</h3> <p>When an amputee with a hemipelvectomy stump is first seen, a visual examination will reveal scar tissue or other surface conditions that may affect the design of the socket. The location of sensitive areas should be noted so that they may receive special treatment if necessary. All hemipelvectomy amputations are not sectioned at the same level; some surgeons leave behind a small amount of the ilium or a small amount of the pubic bone. Palpation of the stump will usually permit determination of any remaining bony structure, but for definitive evaluation an x-ray of the pelvic area is desirable.</p> <p>When all the conditions relative to the amputation are known and recorded on the Prosthetic Information Form (<b>Fig. 4</b>), the prosthetist is ready to proceed with the first step of prosthesis fabrication; namely, production of a model of the stump and adjacent areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Prosthetic Information Form. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Casting the Stump</h3> <p>It has been found that a minimum of modifications to the positive model is required if the cast is taken under weight-bearing conditions. To achieve these conditions, a simple adjustable overhead sling is used. The arrangement shown in <b>Fig. 5</b> utilizes existing structure in the laboratory and a tent-rope tension bar to achieve height adjustability, but a number of equally satisfactory designs can be devised.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Adjusting the sling to obtain proper height. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The seat area of the sling may be made with a piece of 6-in. or 8-in. stockinette tied to the rope at both ends. The stockinette should be long enough to clear the outline of the superior brim of the socket.</p> <p>In taking the cast, hip sticks are used to assist in locating and providing relief for the anterosuperior spine of the ilium on the sound side, and to produce a similar impression on the amputated side. This impression assists in suspension of the prosthesis and helps to prevent rotation of the socket on the stump. Materials required for taking the cast are:</p> <table> <tbody> <tr> <td> <p>4-in. or 6-in. plaster bandages</p> </td> <td> <p>Indelible pencil</p> </td></tr> <tr> <td> <p>3-ft. length of 8-in. or 10-in. stockinette    </p> </td> <td> <p>Plumb bob</p> </td></tr> <tr> <td> <p>Two 3-ft. lengths of 1-in webbing</p> </td> <td> <p>Yardstick</p> </td></tr> <tr> <td> <p>Four harness clamps</p> </td> <td> <p>Paper</p> </td></tr> <tr> <td> <p>Container with water</p> </td> <td> <p></p> </td></tr></tbody></table> <h3>Preparation of the Patient</h3> <p>A 3-ft. length of stockinette (8-in. or 10-in. width as required) is pulled up on the amputee until it is quite snug on the sound thigh. Proximally, it should cover half the thorax. The stockinette is secured with 1-in. webbing over the shoulders and should be pulled tight enough to give some support to the stump mass (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Tentative outline of socket drawn on stockinette. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The distal portion of the rib cage and any areas that need relief are outlined with an indelible pencil. The remaining anterosuperior spine of the ilium is located and outlined. The trochanter on the sound side is located and marked.</p> <p>An approximate outline of the socket is drawn (<b>Fig. 6</b>). The anterior distal portion of the outline starts at the pubic ramus and arcs upward along the inguinal crease onthe sound side with clearance for the sartorius muscle, then passes down to a point just superior to the trochanter. The posterior distal portion of the outline passes from the midline of the body to a point just lateral to the ischial tuberosity, then arcs upward to join the anterior line superior to the trochanter. The proximal outline circumscribes the body at the level of the tenth rib.</p> <h4>Sling Orientation</h4> <p>The amputee is seated in the sling after it has been positioned approximately for height. Pressure on the stump should be diagonally upward and toward the opposite shoulder. Therefore, the sling should pass diagonally across the body to the sound side. A piece of 1-in. webbing under the axilla on the sound side will hold the rope away from the neck and face of the amputee.</p> <p>A slot is cut in the sling posteriorly and just superior to the seat area. Another slot is cut opposite this in the anterior section. A piece of 1-in. webbing is pulled through these slots, around the thigh, and clamped together to prevent the seat from sliding on the stump (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Orientation of amputee in sling. Retention strap adjusted just distal to trochanter on sound side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee is instructed to place more weight on the sling than on the sound leg, and the sling is adjusted for height. It is ascertained that the seat area is contacting the remaining ramus.</p> <p>The setting of the hip sticks is checked. The length of the webbing should be adjusted to fit the patient so that the groove for relief of the remaining ilium and a corresponding groove on the amputated side will be in the proper position. The fulcrum of the hip sticks should be slightly posterior to the crest of the ilium to obtain leverage necessary to bring adequate pressure against the proximal posterior portion of the plaster wrap.</p> <h4>Wrapping The Stump</h4> <p>The procedure of wrapping the stump usually requires two people. Except for obese cases, the patient is removed from the sling for application of the plaster wrap. This is done to contain the tissues and so prevent lateral distortion of the stump when weight is reapplied in the sling. An obese amputee, however, should not be removed from the sling. The wrap cast should be made to incorporate the stockinette initially, because it is too difficult to wrap the stump and properly orient the patient back into the sling before the plaster starts to set.</p> <p>The wrap is started at the lateral proximal brim on the sound side and is brought diagonally upwards across the anterior (<b>Fig. 8</b>). Moderate pressure is placed on the wrap, but ridges should be avoided. The stump should be completely wrapped just past the outline previously drawn on the stockinette. Care must be taken to include the trochanter on the sound side. While the wrap is still wet, the amputee is positioned back in the sling, and the ropes are adjusted until he is standing erect, with at least equal weight being borne on the amputated side.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Beginning diagonal wrap of stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The webbing of the hip sticks is placed across the back of the patient and under the stockinette sling, if it is bridging. The sticks should slant diagonally down just medial to the anterosuperior spine of the ilium on the sound side and a corresponding position on the amputated side. The crest of the ilium on the sound side is palpated by hand to ensure that the hip sticks are not impinging on the anterosuperior spine of the ilium. When the hip sticks are in the correct position, they are held with sufficient pressure to ensure adequate relief. At the same time, an oblique upward pressure is exerted to the lateral distal area of the stump and a counterforce is applied on the opposite ilium. This condition is maintained until the plaster is set. The hip sticks are removed, and the cast is reinforced with additional bandages over the sling. The wrap should touch the remaining ramus, and a portion of the gluteus on the sound side should be included.</p> <p>The trochanter is marked (<b>Fig. 9</b>), and the amputee is removed from the sling.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Locating trochanter on sound side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient is then placed on a table with the stump toward the near side of the table. The gap between the plaster cast and the patient's abdomen is checked to determine if alteration to the wrap is required to contain the viscera and ensure an intimate fit to the socket (<b>Fig. 10</b>). The plaster wrap is cut from the proximal to the distal rim just medial to the socket section. The gap, if there is one, is eliminated by pushing the cast down to meet the abdomen, care being taken not to squeeze the cast mediolaterally and so disturb the placement of the bulge caused by the hip sticks on the sound side (<b>Fig. 11</b>). One side of the cut is covered with vaseline to a depth of approximately 4 in. to facilitate removal of the cast.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Checking the gap between the cast and the patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Closing the gap by downward pressure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A panel of plaster-of-Paris bandages approximately 8 in. wide is formed and laid across the front of the cast, the cast being held in the desired position. Lines to relocate the position of the panel and the cast are drawn, and the cast is secured on the patient by means of a web belt. This will prevent the cast from spreading when the amputee stands and will result in more accurate datum lines.</p> <p>With the amputee standing, the cast is checked for lit and comfort.</p> <h4>Reference Lines</h4> <p>To provide datum lines for alignment of the prosthesis, vertical reference lines are marked on the cast at this time.</p> <p>The amputee should stand erect using an adjustable support under the cast. The spine should be straight and the shoulders level and at right angles to the line of progression.</p> <p>A plumb bob is suspended from the sternum (<b>Fig. 12</b>), and a vertical line is drawn on the cast. A plumb bob is suspended from the spine, and a vertical line is marked on the cast. A plumb bob is suspended from tinder the axilla to bisect the trochanter on the sound side, and the line is drawn on the cast.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Use of plumb bob to obtain reference lines on cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast is removed from the amputee and, after being cut down to the outline previously drawn on the stockinette, is used as a check socket. It should be checked for support and comfort under weight-bearing while the amputee is standing, for pressure on the rib cage, and for clearance of the sound leg while the amputee is sitting. The area of the coccyx should be checked, also the area providing relief for the anterosuperior spine of the ilium on the sound side.</p> <p><b>Pouring the Plaster Positive Model</b></p> <p>The common method of forming the plaster positive model is to pour the negative cast full of a plaster slurry. A mixture of plaster and vermiculite in equal proportions results in a lighter model and one that is quite easy to work. A slush, or hollow model, may be used, but care should be taken to make the model thick enough for it to withstand the pressures involved when lamination is carried out.</p> <p>The leg opening is closed, and the cast is reinforced with plaster bandages. A separator such as vaseline or silicone spray is applied to the inside of the cast.</p> <p>The reference lines are reestablished if they were covered by the reinforcement.</p> <p>A sheet of paper large enough to extend beyond the cast is laid out and divided into four equal parts by means of two perpendicular lines. The cast is placed on the paper so that the vertical reference lines on the cast coincide with and are vertical to the lines on the paper. The cast is secured in this position by blocking it up with plaster.</p> <p>After the plaster has been poured into the cast to form the positive model, a pipe is inserted not only to provide for ease of handling but also to act as a pathway for the air to be drawn out of the laminate by a vacuum pump. A paper cup is installed on the pipe, as shown in <b>Fig. 13</b>, to keep plaster from clogging holes that have been drilled in the pipe to allow the passage of air. The pipe is inserted so that it is aligned with the vertical reference lines; thus it can be used as a reference line when the negative mold has been removed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Setting pipe vertically using vertical lines on cast as reference. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Location of the Hip Joint</h3> <p>Before any modifications to the positive model are undertaken, a buildup is made so that the finished socket will contain a flat area suitable for installation of the hip joint. Instructions given here are for the so-called Northwestern hip joint,<a style="text-decoration:none;">*</a> a unit which provides for alignment adjustment.</p> <p>The hip joint should be placed laterally to provide adequate clearance in the crotch area, placed well forward to ensure adequate stability during the stance phase of walking, and high enough so that the extension stop does not interfere with sitting.</p> <p>If the hip joint is placed too far to the rear, the amputee will be insecure, the joint will interfere with sitting, and more energy will be expended in walking. If it is placed too far forward, the prosthetic knee will extend past the normal knee when the patient is seated. This condition can be partially alleviated by shortening the thigh and lengthening the shank. However, a compromise in the location of the joint is essential.</p> <p>Location of the hip joint in approximately the optimum position may be achieved by the following method:</p> <blockquote><p>Before the positive model is removed from the cast, a reference trochanter, the point on the cast directly opposite the trochanter on the sound side, is established. By means of a height gauge, the trochanter mark on the cast is transposed to a point vertical to the layout line on the opposite side. A point on the surface of the cast 1 1/2 in. vertically below this point is marked. Through this last mark, a line is drawn on the cast at an angle of 45 deg. A useful aid for this is a piece of wood approximately 1 in. thick, cut on an angle of 45 deg. (<b>Fig. 14</b>). In scribing the line, the pencil must be held flat on the 45-deg. surface. All reference lines from the cast are cut through to the positive model by use of an awl. When the cast is removed, the lines are marked on the model with an indelible pencil.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Scribing 45-deg. line on cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>An outline of the socket is drawn on the model. Heretofore, it has been the common practice to cut the anterior portion of the socket to allow entry and exit of the torso. Experiments at the Northwestern University Prosthetics Research Center have shown that more stability between patient and socket can be achieved if the opening is made on the lateral wall.</p> <h3>Modification of the Positive Model</h3> <p>To provide additional relief for the antero-superior spine of the ilium on the sound side, a skived piece of leather or a plaster buildup 1/4 in. thick on the positive model should be adequate.</p> <p>The anterior section of the model usually has a ridge caused by overlapping during the casting procedure. This ridge should be eliminated by removal of plaster. If there is a large bulge posteriorly in the gluteal area, the bulge should be reduced by removal of plaster. Sometimes the angle of the lateral wall will continue to the ramus. If this is apparent, the distal seat area may be modified and flattened slightly by removal of plaster in order to minimize slipping. Any other ridges should be removed, and the entire model should be smoothed with files, wire screen, or sandpaper. A good finish may be obtained by wet sanding with a piece of Wetordry Fabricut.</p> <p>Moisture must be contained in a new model to prevent the PVA bag used as a separator from becoming wrinkled. Application of a sealer, such as Ambroid or parting lacquer, will serve to retain moisture.</p> <p>Leather tongues used at the closure of the socket will deteriorate from sweat. A molded flexible polyester tongue is more durable and sanitary. It should be formed to the model before the flare is added to ensure a smooth transition from the tongue to the socket surface. The tongue is made by laminating four staggered pieces of nylon stockinette across the proposed opening with a flexible mixture of polyester resin (60 per cent Laminac 4134 to 40 per cent Laminac 4110 is an adequate mix). After the tongue has set, it should be trimmed to the desired shape and taped to the model.</p> <p>The outline of the socket on the model is built up to provide a flare with a radius of approximately 3/4 in. The buildup is accomplished by folding a piece of 4-in. plaster bandage lengthwise approximately seven times, wetting it, and laying it on the outline as a beading. The plaster bandage is formed over the tongue to provide a lateral opening at least 1 in. wide. The beading is formed to the desired flare and smoothed with plaster (<b>Fig. 15</b>). The flare should be coated with Ambroid or parting lacquer.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Construction of flaring. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The model is now inverted and mounted in a vise with the sagittal plane vertical. The mounting pipe should be set at an angle of 45 deg. to the horizontal, with the anterior surface of the model upward (<b>Fig. 16</b>). The 45-deg. line on the model should now be vertical, and it should be extended past the flare, both proximally and distally.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Positioning joint on positive model using 45-deg. line as reference. (Model is held in vise at 45-deg. angle, so 45-deg. line, previously scribed, is now vertical.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The configuration of many hemipelvectomy sockets will not allow sufficient clearance for the joint in the crotch area. To allow the joint to be placed more laterally and to provide a flat area for mounting the joint, it is necessary to build up the positive model with rigid poly-urethane foam.</p> <p>The principal considerations in planning the joint location are: First, the flat area must be large enough to receive the mounting plate (about 2 3/4 in. in diameter). Second, the flat area will be horizontal when the model is mounted at the 45-deg. angle. Third, usually the axial center of the joint is somewhat anterior to the 45-deg. line. (It should be kept as close as possible to the line, but the joint must not be permitted to interfere with the sitting position.) Fourth, in most hemipelvectomy sockets, the joint will project beyond the lateral edge of the socket, but it should not project further from the midline of the body than the corresponding joint of the sound leg.</p> <p>Cardboard is formed on the positive model to form the buildup for the joint location and to allow for contours that will blend well with the socket. Polyurethane foam (Pelron 4-lb. density No. 9664<a style="text-decoration:none;">*</a>) is mixed and poured into the cardboard form (<b>Fig. 17</b>). As the foam is being shaped, care should be taken to shape the area immediately medial to the joint to permit full adjustment of the joint. <b>Fig. 18</b> shows the completed buildup on the positive model for the location of the hip joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Pouring polyurethane foam into cardboard form. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Anterior view of positive model showing flat area necessary to receive hip joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Socket Fabrication</h3> <p>Although it is not necessary to use any specific laminating procedure, the vacuum technique described in this article is presented as one that has produced consistently good results in the Northwestern University Prosthetics Research Center.<a></a> </p> <p>Radial suction grooves are cut with a sharp knife from the crest of the flare on the positive model to the cup, or approximately eight 1/8-in. holes are drilled through the model into the cup, the holes being so situated as to ensure the evacuation of air from undercuts.</p> <p>A thin smear of vaseline or motor oil is applied over the sealed surfaces of the model and the polyurethane foam buildup. (Caution: Ambroid should not be applied to the polyurethane foam; the thinner in the Ambroid will soften the foam.) A light plaster slurry is used to blend the edges of the foam into the contours of the socket. A light plaster wash is then applied to the foam and allowed to dry. Ambroid, then vaseline or oil, may be applied to facilitate pulling the PVA separator over the model.</p> <p>A tailored PVA bag is pulled down over the positive model. One end is gathered and tied over the area of the sound leg. The other end is taped tightly around the pipe. Three or four holes are punched in the bag near the cup.</p> <p>Fabric is applied as follows:</p> <ul> <li>1 layer 1/2-oz. Dacron felt.</li> <li>1 layer nylon stockinette.</li> <li>7 layers of glass cloth over the joint and seat areas. The pieces of cloth should be of varying size to produce a gradual transition in rigidity.</li> <li>1 layer Dacron felt over all.</li> <li>5 layers of nylon stockinette pulled on tight and tied to the pipe. A PVA bag is pulled down over the layup and taped tightly to the pipe.</li> </ul> <p>Resin, in an appropriate amount, should be prepared in the proportion of 80 per cent rigid Laminac 4110 to 20 per cent flexible Laminac 4134. ATC catalyst-2 per cent of the weight of the resin mixture is added and spatulated thoroughly. Appropriate pigment, amounting to about 2 per cent of the weight of the resin mixture, should be added: 12 drops of Nauga-tuck # 3 promoter results in approximately 20 min. working time. This will vary according to temperature and humidity.</p> <p>One method of impregnating the fabric with the resin is to pour the resin into the top of the outer PVA bag and "string" the resin downward, working it into the layup, especially into the reinforced seat area, to obtain complete saturation. After the resin has been "strung" into the layup, the vacuum is applied and a head of resin is maintained at the top to prevent air from being sucked into the laminate. Insofar as possible, air is excluded from the top of the PVA bag, and the bag is tied off tightly at the top.</p> <p>Another method is to apply vacuum prior to "stringing" the resin into the layup. In this procedure, the resin is poured into the top of the PVA bag, which is then tied off and vacuum is applied. The resin is then "strung" down into the layup.</p> <p>In both procedures, the hands must be used to force the resin from undercuts, considerable "stringing" downward must be done to remove bubbles, and "stringing" upward to remove excess resin.</p> <p>Low negative pressure should be maintained until the plastic has set (<b>Fig. 19</b>). Excessive vacuum will pull the resin from the laminate, causing "starving."<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. View of laminate of socket using vacuum technique. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Removal of Socket from Positive Model and Replacement of Polyurethane Foam Buildup with Silicone Foam</h3> <p>With the flare as a guide, a Stryker cast cutter is used to cut through the laminate along the outline of the socket. If a molded tongue has been attached to the positive model, care should be taken when making the cut on the lateral side. It is prudent to leave a little extra laminate for subsequent trimming.</p> <p>The polyurethane buildup for the location of the hip joint is removed from the positive model. The positive model is smoothed in this area, and a thin smear of vaseline is applied. A piece of lightweight stockinette is stretched over this part of the model and stapled in place.</p> <p>Using the back plate as a template, three 1/4-in. holes are drilled. The center hole is drilled with a 1/2-in. drill. The back plate is mounted in the socket with two bolts and nuts. The bolts should not be cut.</p> <p>The socket is replaced on the stump model and secured tightly with a web belt or friction tape (<b>Fig. 20</b>). It is in position for the injection of silicone rubber through the 1/2-in. center hole in order to provide support for the amputee over the area of the hip joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Socket replaced on stockinette-covered cast preparatory to injection of foam. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In choosing the silicone rubber to be used, it should be remembered that Silastic 386 Foam Elastomer is relatively soft and may not be capable of supporting the weight of the amputee, while Silastic 385 Elastomer forms a solid rubber which will, if used by itself, add considerable weight to the prosthesis. Accordingly, a mixture of 70 per cent by weight of 386 with 30 per cent by weight of 385 is recommended. This is poured into a caulking gun. The 386 catalyst-6 per cent by weight of the mixture-is added, and the mixture is spatu-lated for 25 seconds. Because of the small amount of catalyst, the viscosity of the Silastic, and the shape of the chamber of the caulking gun, it is very difficult to get a homogeneous mix if spatulated by hand. A mixing rod should be formed that can be used in conjunction with a 1/4-in. electric drill. A rotary up and down movement should be used, mixing for 25 seconds. It is then injected through the center hole of the spherical plate to fill the socket cavity (<b>Fig. 21</b>). The mixture will expand approximately four times its volume during foaming. If necessary, more of the same mixture is added until the cavity is filled.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Injection of silicone foam through center hole of spherical plate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is removed from the cast. The silicone pad is removed and the nuts are removed from the two bolts. The spherical plate is attached to the socket with three 1/4-in. flat head bolts. The bolts should be locked tight with a locking compound. The bolts are threaded into the spherical plate with a screwdriver, but they should be tightened with vise grip pliers applied to the protruding threaded portion of the bolt. If this spherical plate is not tightened sufficiently, movement and noise will result. The bolts should then be cut and ground to maintain the spherical contour (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Socket with spherical plate attached. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The edges of the socket are sanded and buffed to provide a smooth radius.</p> <p>For fitting purposes, the foam pad is secured in the socket by means of friction tape. It can be glued to the socket when the prosthesis is being completed. The edges of cloth reinforcement on the foam should be trimmed, and the surface coated with a skin of Medical Silastic S-5391 Elastomer (<b>Fig. 23</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. View of silicone foam pad with stockinette reinforcement. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Layout of Thigh Block</h3> <p>One method of determining the configuration of the thigh block is as follows:</p> <ol> <li>On a large piece of paper, line A is drawn to represent the length of the foot (<b>Fig. 24</b>). The distance from the end of the heel to the center of the ankle bolt is measured and marked on line A.</li><li>Line B is drawn perpendicular lo line A from the point representing the foot attachment bolt. The length of this line is the distance from the ischial tuberosity to the floor.</li><li>On line B a point is located equal to the height of the medial tibial plateau (MTP) plus 1 1/4 in. for adults. The location of the hip joint often causes the prosthetic knee lo protrude beyond the sound knee when the patient is in the sitting position unless the thigh is shortened and the shin is lengthened. Therefore, 1 1/4 in. is added to the dimension between the floor and the MTP.</li><li>Two inches above this point a 6-in. line is drawn to represent the attachment plate of an adjustable leg. This line is drawn 3 1/2 in. anterior of and 2 1/2<i> </i>in. posterior of line B.</li><li>A line is drawn at right angles to line B at its topmost point. This line, D, represents the height of the level of the seat of the ischium from the floor.</li><li>From a point 1 in. behind the heel, line E is drawn to intersect the prosthetic knee center (PKC) and the horizontal line D.</li><li>The socket is superimposed on the layout, with the joint attached and in a neutral position. The inner edge of the socket must fall on line D and the hip joint center must pass through line E.</li><li>The hip joint is adjusted so that the angle of the straps with line D is 73 deg. in order to maintain the 45 deg. originally planned for the placement of the hip joint.</li><li>The position of the side straps is marked and outlined, line F, and also the offset for the shoulder of the straps, line G.</li><li>There should be 1/4 in. of wood anterior to the hip joint. Therefore, from a point 1/4 in. anterior to the shoulder of the side strap outline, a line should be drawn connecting with the anterior end of the socket attachment plate line. (Angle <i>a </i>in <b>Fig. 24</b> is the flexion angle.)</li><li>From a point 1/4 in. posterior to the shoulder of the side strap outline, a line is drawn to form the posterior outline of the thigh block. Often, this is not a direct connection with the posterior end of the socket attachment plate line, as this would not provide sufficient thickness of wood for screws at the attachment plate of the adjustable leg.</li><li>An anterior view is drawn of the thigh section in which the proximal center point is offset the equivalent of the distance from the center of the artificial hip joint to the vertical support line on the prosthesis, less 1 in. (distance H in lower part of <b>Fig. 24</b>). This establishes the approximate angle of adduction needed in the thigh block. The objective is to place the artificial foot in the approximate amount of adduction.</li><li>The thigh block, of correct length, is positioned with the lateral side up and angle <i>a, </i>obtained from step 10 above, is inscribed upon it.</li><li>The thigh block is positioned with the posterior side up. A goniometer is placed with one arm parallel to the lateral side of the posterior wall; the other arm, set in the angle required, should lie across the posterior wall and connect with the flexion angle previously established. If the adduction required is excessive, it is sometimes necessary to bend the side straps. A bend of approximately 8 deg. is usually sufficient. Care must be taken not to produce nicks and notches in the side straps which may cause premature fracture.</li><li>The table of the saw is set at the adduction angle and a cut is made along the flexion line.</li><li>The hip joint is centered on the thigh block, and the width of the straps is marked. The outline of the straps should be left showing after the excess wood has been cut away. Enough wood must be left for the socket attachment plate. Care must be taken that the distance between joints is accurately reproduced on the thigh block, otherwise binding will result when the joint is assembled and shimming will become necessary.</li><li>The joint is clamped to the thigh block. After the two indicated 1/4-in. holes have been drilled, the joint is bolted to the thigh block.</li></ol> <h3>Bench Alignment of Prosthesis</h3> <p>Two general rules to be followed in the bench alignment of the prosthesis are: First, the socket should be the correct height above the floor, with the transposed point of the ischium directly over the center of the foot. Second, the knee should be set in slight hyper-extension so that a straight line drawn through the hip joint intersects the floor about 1 to 1 1/2 in. behind the heel.</p> <p>It is recommended that a SACH foot with a soft heel wedge be used. A knee extension aid is important; it is provided by a piece of 1-in. elastic which also functions as a stride length control. This is adapted for temporary use on the adjustable leg by mounting a piece of leather on the socket approximately 2 in. behind the hip joint in such a way that the elastic strap can pass through the attachment. For a woman, the extension aid is built into the knee mechanism and the socket bias strap is secured to the distal thigh block. One end of the elastic is screwed to the shin 2 in. down from the PKC, and the other end of the elastic is secured by a buckle mounted in the corresponding position on the other side of the shin. A keeper of 1/2-in. Dacron webbing, with a buckle, is positioned about 1 1/2 in. proximal to the knee bolt. This keeper should be adjusted so that it holds the bias strap anterior to the knee bolt center when the patient is standing and walking but allows it to pass posterior to the knee bolt center when the patient is sitting.</p> <p>Velcro offers a convenient method of closure for the lateral opening of the socket (<b>Fig. 25</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Arrangement of closure straps using Velcro. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When the prosthesis is assembled, the axes of the hip joint and of the knee joint should be essentially parallel to the floor and at right angles to the line of progression.</p> <h3>Static and Dynamic Alignment</h3> <p>Satisfactory suspension of the prosthesis often depends upon the proper application of the socket (<b>Fig. 26</b>). The stump should be forced as far laterally as possible and the closure straps should be tightened alternately until the amputee is well supported. The ischial support strap should be secured last. The relief provided by the socket for the an-terosuperior spine of the ilium on the sound side is a useful guide in orienting the socket to the patient. The socket should then be checked for fit and comfort under weight bearing in the areas of the ramus, the coccyx, and the rib cage. Lateral stability of the socket should be evaluated by supporting the prosthesis against a chair and asking the patient to raise his good leg without leaning over the prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Socket mounted on adjustable leg preparatory to dynamic alignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The alignment line from hip center through PKC to a point behind the heel should be verified for stability. It should be ascertained that the height of the prosthesis is correct; that the extension bias strap is forward of the PKC; that there is no friction in the knee joint; and that the bumper and stop are in contact. The patient should not be in a forced position of lordosis, and the socket should not exert pressure proximally in the back. If either of these conditions exists, the bumper is contacting the stop too soon and the socket should be tilted backward by means of the adjustable hip joint. If the bumper is not in contact with the stop, correction should be made by adjustment of the hip joint.</p> <p>The amputee should then sit upright in a hard chair, and the anterior distal portion of the socket should be inspected for clearance of the thigh. If the amputee tends to lean to the amputated side, the exterior gluteal area of the socket should be built up with foam for support and to improve cosmesis. It should be ascertained that there is no pressure between the proximal edge of the socket and the rib cage; that the thigh block clears the chair; that the shank is vertical; that the prosthetic knee axis does not protrude excessively beyond the normal knee center; that toe-out is approximately correct; and that the extension bias strap is holding the shank in flexion.</p> <p>In training the amputee to walk, he should be impressed with the importance of standing upright by holding his hands parallel to or slightly posterior to the long axis of his body. If he leans forward to watch his feet, the hip bumper will not contact the stop, making it impossible to propel the leg forward. He should alternately bear his weight on the prosthesis and then lift it clear of the floor. To initiate flexion of the knee, the amputee should be instructed to "scoop" his stump and pelvis forward and flex his spine. This should be jepeated a few times and the bias strap ad-rusted to obtain the proper stride length.</p> <p>The amputee should be instructed to take a few steps. If the knee appears unstable just after heel contact, the durometer of the heel wedge should be checked, and it should be determined whether the shank is reaching full extension; whether the knee is in some hyper-extension; whether the hip joint is contacting the stop before the foot is flat on the floor; and whether the alignment line runs correctly from the center of the hip joint through the center of the knee joint to 1 1/2 in. behind the heel of the shoe. To eliminate medial or lateral whip, rotational adjustments are necessary at the knee or hip axis.</p> <p>Many amputees wear a stump sock, which decreases the friction between the patient and the socket during the stance phase and loses some of the socket's support. To increase the friction, it is sometimes advantageous to line the lateral aspect of the socket with a rubber material or with horsehide.</p> <p>If toe clearance is still a problem, the length of the prosthesis should be reduced. The hemipelvectomy amputee will tend to vault on the sound foot to increase the clearance of the prosthesis. This tendency should be minimized as much as possible, but it must be remembered that the patient cannot "hike" his pelvis on the amputated side since there is no remaining skeletal structure. Where obesity is a problem, it is sometimes necessary to use a shoulder strap to aid suspension.</p> <p>If the patient experiences rotational instability in the socket, a "teardrop" cutout on the lateral aspect of the socket will help to alleviate the problem and to aid suspension. The cutout should be approximately 2 in. wide at the lateral proximal edge of the socket and extend three-quarters of the length of the socket (<b>Fig. 27</b>). The foam insert in the socket should be removed before the panel is cut out. The edges of the panel should be sanded smooth to prevent cracking. A strap and buckle or Velcro should be attached proxi-mally for closure of the cutout. When the prosthesis is donned, this strap should be loose and should be tightened last.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Teardrop opening in socket on amputated side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Duplicating and Finishing</h3> <p>For duplicating and finishing, the socket is removed and the duplicating jig is used; excess wood is removed from the thigh block and the block is faired into the knee; the knee, thigh, and shin sections are laminated; the keeper for the extension bias strap and all straps and buckles are riveted; and the prosthesis is reassembled (<b>Fig. 28</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Finished thigh block in reassembled prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Thigh Fairing</h3> <p>The chief purpose of the thigh fairing is to compensate for the differences in circumference between the thigh block and the sound leg, both in standing and in sitting. This must be done without impairing the function of the prosthesis.</p> <p>A light, articulated fairing has been developed at the Northwestern University Prosthetics Research Center. It utilizes a piece of 1/32-in. light aluminum alloy, 1/8-in. Kemblo rubber, and lightweight horsehide, with Velcro for closing. It is pivoted distally by two screws just superior to the knee bolt and fastened proximally by a snap fastener to the anterior wall of the socket.</p> <p>A piece of cardboard is used to make a pattern for the aluminum (<b>Fig. 29</b>). Distally, it should be wide enough to receive the pivot screws approximately l 1/2 in. superior to and vertical to the knee bolt center. Anteriorly, it forms an upward arc. To allow the pivot action, the posterior section is open and the anterior proximal section is cut away so that the socket can be fully flexed without touching the cardboard. The posterior medial and lateral edges govern the amount of anterior displacement of the fairing in the sitting position and the fullness of the thigh in the standing position. In the sitting position, both edges should be in full contact with the seat of the chair (<b>Fig. 30</b>). The cardboard pattern should fit close to the anterior thigh block in the standing position and should be cut and formed to allow the medial and lateral contours of the Kemblo rubber fairing to blend in with the contours of the socket (<b>Fig. 31</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Cardboard used as template for metal portion of thigh fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Template shown on prosthesis in sitting position. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Contouring rubber portion of thigh fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the aluminum has been cut out, it is formed to the desired shape and attached with a screw to the knee. A sheet of 1/8-in. Kemblo rubber is wrapped around the metal to obtain the desired fullness (<b>Fig. 32</b>). The Kemblo should be long enough to start at the distal end of the aluminum and fair in proximally to the contours of the socket. The distal edge is skived to blend in with the metal form. The anterior proximal edge of the Kemblo should come up to meet the socket in the sitting position. The posterior proximal edge should meet the socket during the stance phase. The Kemblo is glued to the aluminum form.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Open view of completed thigh fairing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Kemblo rubber is covered with lightweight horsehide, and the leather is rolled over the edges of the rubber.</p> <p>The fairing is attached to the socket anteriorly by means of a snap fastener. The leather continues from the medial and lateral sides to produce a triangle anteriorly with enough slack to allow displacement of the fairing in the sitting position. In the standing position, the attachment should return the fairing and eliminate any slack in the attachment area.</p> <h4>Acknowledgments</h4> <p>For valuable assistance in the development of this prosthesis (<b>Fig. 33</b>) and for help in the preparation of this article, I am most grateful to Colin A. McLaurin, B.A.Sc, Robert G. Thompson, M.D., H. Blair Hanger, C.P., Edwin A. Bonk, Mary Farnan, Walter Horiuchi, and Paula Hamilton.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. View of finished prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Schematic drawing (not to scale) for layout of thigh block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Lyquist, Eric, <i>Canadian-type plastic socket for a hemipelvectomy, </i>Artificial Limbs, Autumn 1958, pp. 130-132.</li> <li>McLaurin, Colin A., and Fred Hampton, .4 <i>method of taking hip disarticulation casts using hip sticks, </i>Orthop. &amp; Pros. Appl. J., June 1960, pp. 71-77.</li> <li>McLaurin, Colin A., and Fred Hampton, <i>Fabricating hip disarticulation sockets using the vacuum method, </i>Orthop. &amp; Pros. Appl. J., June 1960, pp. 66-70.</li> <li>Radcliffe, Charles W., <i>The biomechanics of the Canadian-type hip-disarticulation prosthesis, </i>Artificial Limbs, Autumn 1957, pp. 29-38.</li> <li>Slocum, Donald B., <i>An atlas of amputations, </i>C V. Mosby Co., St. Louis, Mo, 1949, pp. 244-249.</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">At sea level, the atmosphere will support a column of mercury 30 in. high. Most vacuum gauges, therefore, are calibrated in inches of mercury (in. Hg.), reading from 0 to 30. 10 in. Hg. negative pressure means 10 in. of mercury below atmospheric pressure.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">McLaurin, Colin A., and Fred Hampton, Fabricating hip disarticulation sockets using the vacuum method, Orthop. &amp;Pros. Appl. J., June 1960, pp. 66-70.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Pelron Corp., Lyons, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">NHJ-100, Hosmer Corp., Santa Clara, Calif.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., The biomechanics of the Canadian-type hip-disarticulation prosthesis, Artificial Limbs, Autumn 1957, pp. 29-38.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">McLaurin, Colin A., and Fred Hampton, .4 method of taking hip disarticulation casts using hip sticks, Orthop. &amp;Pros. Appl. J., June 1960, pp. 71-77.</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">Lyquist, Eric, Canadian-type plastic socket for a hemipelvectomy, Artificial Limbs, Autumn 1958, pp. 130-132.</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>5.</b> </td><td class="clsTextSmall">Slocum, Donald B., An atlas of amputations, C V. Mosby Co., St. Louis, Mo, 1949, pp. 244-249.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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 Hampton, C.P. </b></td></tr><tr><td class="clsTextSmall">Assistant Project Director, Northwestern University Prosthetics Research Center.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-05.jpg Figure 7 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-06.jpg Figure 8 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-07.jpg Figure 9 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-08.jpg Figure 10 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-09.jpg Figure 11 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-10.jpg Figure 12 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-11.jpg Figure 13 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-12.jpg Figure 14 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-13.jpg Figure 15 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1964_01_003/1964_01_003-19.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 A Hemipelvectomy Prosthesis Creator An entity primarily responsible for making the resource Fred Hampton, C.P. * https://staging.drfop.org/files/original/bce63a5f984a2b7e266ad41c794457eb.pdf 3336381361b926e881b5e08b4d5a104f https://staging.drfop.org/files/original/8984ef005962175cd2cd9ca4c67dd953.jpg 27b4bfe13ac727d78e188ef5c0b67354 https://staging.drfop.org/files/original/abfa246572131fe9dd3cdcbd55538f20.jpg a393b0f058bc54700d9c3ab34b65c9f4 https://staging.drfop.org/files/original/b1236f8892840de73e07786a00477f27.jpg 17ad3bcf73e9cc611c2f726000e15585 https://staging.drfop.org/files/original/f423924d489cce78f8517b42ebf79aae.jpg da4e43f799a904dc23d6620dc6553989 https://staging.drfop.org/files/original/1605ed8928919d3ac2b4a9755e041d30.jpg 36995fceb11605d7162400a6c40443e0 https://staging.drfop.org/files/original/999e0f60cb6a02c2a0115145cf515482.jpg 1dad4baf20341bf6baeb1f03138e9898 https://staging.drfop.org/files/original/f6b705039b55b6defd8e13b6e9c13e02.jpg abe2f39e1bd4137970fc50bef98c633e https://staging.drfop.org/files/original/59c9f866e0c4115b40694ac727ab58e3.jpg 22142ed910fdea4adda64f3b92d3480d https://staging.drfop.org/files/original/c807f2e8e367587163feae6926ca1b81.jpg 5f9b6c07208aad1b7d1c8f17934ec314 https://staging.drfop.org/files/original/74e60652660a7f2fade6c3f7f604d916.jpg 4c8a84c66cf97e3b930c25c10fce434a https://staging.drfop.org/files/original/0422d5a84c721d8228bef8e3651da68e.jpg 4c29f85936b1ff8d7fde5e8a6c90e7a8 https://staging.drfop.org/files/original/9a2d677825dd94e876b15c4dd04e83bc.jpg e5ef2eba763449d1d7606f322f5ae139 https://staging.drfop.org/files/original/07ea344764325dbc83c30b93217adcb4.jpg a579c5f3e92ff8e9ead1a6975eb28f55 https://staging.drfop.org/files/original/a4abcb85f4dca41eb258db103a1b6758.jpg 33f7ded8889906f86c4011008830c2f7 https://staging.drfop.org/files/original/b37d8f6126d94e2d7899983c1a474c0f.jpg 1fe5f44a5993f642ec0619a7eab4ef46 https://staging.drfop.org/files/original/3af334d9f215fbfc19ea5de010c1cd7c.jpg f585c5ed5d6d36c905cf9769833bd923 https://staging.drfop.org/files/original/a4a20ebdca1ecd21eaae49d233d5ce56.jpg 63ada1bca5d0c342a0eb4a5ac485ec14 https://staging.drfop.org/files/original/766e46411ccd23ec701dab020f5f81ba.jpg 80998bfac3aa008d9f07c6c5a820fa6b https://staging.drfop.org/files/original/137b1d7a083dea7f124c935af402eed6.jpg 19c2b24e6295de60f62d98abb36ee83e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_02_005.pdf Year 1966 Volume 10 Issue 2 Page Number(s) 5 - 26 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_02_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_02_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>Suspension Casting for Below-Knee, Above-Knee, and Syme's Amputations</h2> <h5>Fred Hampton, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The suspension casting technique permits the casting of an amputee's lower-extremity stump while it is being held in an attitude simulating stance-phase weight-bearing in a prosthesis. This is accomplished through application of the principle of the Chinese finger trap; namely, when a cloth cylinder of suitable weave is stretched longitudinally, the circumference of the cylinder is decreased.</p> <h3>Suspension Casting of the Below-Knee Stump</h3> <p>In casting below-knee stumps, a cast sock clamped in a ring is the cloth cylinder. As the amputee bears weight on the suspended sock, the sock stretches longitudinally and constricts circumferentially, thereby firming the tissues of the stump during the application of the plaster wrap. The amputee is properly oriented in an upright position for casting and for producing accurate alignment lines on the cast. The tissues are firmly contained, edema is restricted, and bony prominences are emphasized. Distal redundancy is held firmly in the correct position by the suspension sock. While the stump is suspended, areas requiring relief can be definitively outlined and, if necessary, build-ups of appropriate thickness can be applied to the suspension sock prior to wrapping. <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>Equipment required includes:</p> <ol> <li>A ring, approximately 6 1/2-in. inside diameter.</li><li>A rubber gasket.</li><li>A hose clamp.</li><li>A VA or a Berkeley casting stand with vertical adjustment.</li><li>Bathroom scale and platform.</li></ol> <p><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>Data to be obtained and recorded are:</p> <ol> <li>The length of the normal leg from the medial tibial plateau to the floor, with the shoe off.</li><li>The shoe size.</li><li>The anteroposterior dimension of the stump, measured with a VA caliper while the stump is fully relaxed and supported by the prosthetist.</li><li>The mediolateral dimension of the stump just proximal to the tibial plateau, measured with a VA caliper.</li><li>The length of the stump, measured from the end of the stump to the level of the midpatellar tendon. A small square is used to obtain this measurement; the blade of the square should contact the crest of the tibia.</li></ol> <p><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><b>PREPARATION OF MEDIAL TEMPLATE.</b> Because the medial flare of the tibial condyle is a particularly good weight-bearing area, it is desirable to construct a medium-weight cardboard template of the medial aspect of the stump for use as a guide in checking and maintaining the contours of the positive model in this important area. A cast sock is pulled over the stump and held with moderate tension by the amputee. To prevent bulging of the gastrocnemius during the tracing, the weight of the stump is supported by the prosthetist. The pencil is held vertically and slight pressure is exerted against the stump as the outline is drawn. The outline should extend from the proximal border of the femoral condyle to the midline of the distal aspect of the stump. After the medial tibial plateau is marked on the outline as an important landmark, the template is cut out and checked against the stump. <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><b>PREPARATION OR RELIEF PATCHES.</b> Relief patches should be prepared prior to suspension of the amputee in the ring. Various materials may be used for the patches, such as 1/8-in. Kemblo rubber, 1/8-in. adhesive-backed felt, or any foam material 1/8-in. thick and of sufficient density for dimensional stability. Areas usually requiring relief are the tibial tubercle, the tibial crest, the distal end of the tibia, the leading edge of the lateral tibial condyle, and the head and distal end of the fibula.</p> <p>The patch for the head of the fibula should extend at least 1/4 in. beyond the bone area. If the head of the fibula is prominent, a double patch is sometimes indicated.</p> <p>The patch for the tibial crest should be 1-in. wide. This will allow 1/4 in. of plaster on each side for blending the edges of the positive stump model. The actual relief remaining is 1/2-in. wide, sufficient to cover the lateral edge of the tibial crest and blend into the medial tibial surface. <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><b>SIZING THE CAST.</b> The dimensions of the negative cast produced are dependent upon the stump, the number and weight of the socks used, and the tension with which the plaster bandages are applied. One heavy cast sock is used to accommodate the fit of a stump wearing a three-ply wool sock in a hard socket. For a mature stump, two heavy cotton cast socks are used to accommodate a five-ply wool-sock fit in a hard socket. For a socket incorporating an insert, one light-weight cotton cast sock is used. Both socks and relief patches are removed from the negative cast before the plaster is poured to form the positive stump model. <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><b>ASSEMBLY OF EQUIPMENT AND SUSPENSION OF AMPUTEE.</b> Preparatory to taking the negative cast of the stump, the distance from the end of the stump to a point 4 in. above the proximal edge of the patella is marked on a heavy cast sock, the ring is mounted horizontally on the vertical stand, and the cast sock is centered in the ring with the mark showing. The gasket is then applied over the sock and secured with the hose clamp.</p> <p>Next, the ring is lowered on the easting stand to facilitate entry of the stump into the sock. Then the ring is raised until one-half of the body weight is borne by the stump sock, as indicated by the scale. Under these conditions, the suspension sock should contain the thigh to a point 3 in. above the superior border of the patella. The height of the ring should be adjusted until the amputated side is slightly high,so that further stretching of the suspension sock will be accommodated during the wrapping process.</p> <p>The amputee should be positioned so as to obtain a correct base of support and so that his thigh is vertically centered in the ring. The knee should be flexed so that the stump is approximately 12 deg. from the vertical, measured along the crest of the tibia. Excessive flexion will result in loss of support or cause bridging of the sock along the posterior aspect of the stump. The stump is palpated, and areas requiring relief are outlined. The relief patches are glued to the appropriate areas. and the flexion angle of the knee is checked. <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><b>WRAPPING THE STUMP.</b> Starting from a level just proximal to the top edge of the patella, four wraps of 4-in. plaster bandage are firmly applied. As noted previously, the medial flare of the tibial condyle is a good weight-bearing area. For emphasis, the plaster bandage is applied with firm tension diagonally upward in this area. The plaster bandage is then spiraled downward until the remainder of the stump is completely covered.</p> <p>Before the plaster begins to set, it is worked by hand to ensure an intimate contact between the wrap and the stump, to emphasize bony areas including the patella, to enhance the texture of the plaster, and to assist in obtaining a smooth inner surface in the cast.</p> <p>Several techniques and devices may be used when casting a below-knee stump to locate and define the patellar tendon and the support area posteriorly. Later in this article some of the variations will be presented.</p> <p>When the suspension casting technique was used initially, no attempt was made to deform the cast permanently at the patellar tendon or in the popliteal area. The patellar tendon was defined by a light massaging action on the cast, using the web of the hand between the thumb and index finger, and by applying a light counter-pressure posteriorly with the other hand. The hands were removed after the contouring, and the plaster was allowed to set. This method kept distortion of the tissues to a minimum and preserved the contours of the medial flare of the tibia.</p> <p>This technique has been modified to the extent that the hands are held in such a manner as to deform the cast permanently, producing a patellar-tendon bar anteriorly and a flattening of the popliteal area posteriorly. Any distortion of the contours of the medial flare of the tibia is corrected later by use of the template (previously discussed) when modifying the positive model of the stump. <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><b>ALIGNMENT LINES.</b> After the plaster has set, two vertical alignment lines are scribed on the cast with the use of a plumb bob while the amputee is standing in a position simulating stance phase in a prosthesis. Half of his weight should be borne on the amputated side. The pelvis should be level and at right angles to the line of progression. One line, scribed on the anterior aspect of the cast, will be used as a reference for the correct adduction or abduction angle of the socket during bench alignment. The other line, scribed on the lateral aspect of the cast, will serve as a reference for the flexion angle of the socket.</p> <p>In order to remove the cast, the hose clamp is released to allow rotation of the ring in the stand. After the ring has been lowered sufficiently to permit the amputee to sit down, the hose clamp, gasket, and ring are removed. Care must be taken to avoid distortion of the cast during its removal.</p> <p>Before plaster is poured to form the positive model of the stump, the cast socks and relief patches are removed from the negative cast, and the cast is oriented with the reference lines vertical. Orientation can be accomplished by setting the distal end of the cast in plaster and using a square to obtain the correct alignment. A Milmo vertical transfer jig is a useful device for this procedure and also provides a means for holding the pipe vertically in the cast until the plaster hardens. <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><b>MODIFICATION OF THE POSITIVE MODEL.</b> Modifications of the plaster model of the stump are made in accordance with the principles developed at the University of California Biomechanics Laboratory, Berkeley and San Francisco. <a></a></p> <p>An essential prerequisite to the modification of the plaster model is a complete examination and evaluation of the stump by the prosthetist. Variations in modification will necessarily be based upon this evaluation.</p> <p>An outline of the socket is drawn on the plaster model of the stump. This outline extends from the midpatellar level anteriorly to 2 1/2 in. to 3 in. above the midpatellar tendon level on the medial and lateral aspects of the model, down to a point 1/2 in. above the midpatellar-tendon level on the posterior aspect of the model.</p> <p>The anteroposterior dimension of the positive model will be determined by the type of socket to be fabricated. For a socket with a soft insert, the anteroposterior dimension of the model should be modified to that of the stump. For a hard socket, the anteroposterior dimension of the model should be 1/4 in. greater than the measured anteroposterior dimension of the stump; for example, if the anteroposterior dimension of the stump is 3 in., the anteroposterior dimension of the model should be 3 1/4 in.</p> <p>The following example is offered for guidance in determining the amount of plaster to be removed from the patellar-tendon area of the stump model as opposed to the amount to be removed from the popliteal area. Assuming that the anteroposterior dimension of the stump is 3 in. (to which 1/4 in. must be added for a hard socket) and that the anteroposterior dimension of the slump model is 4 in., it follows that 3/4 in. of plaster should be removed (that is, 4 in. less 3 1/4 in. equals 3/4 in.). Two-thirds of this amount, or 1/2 in., is removed from the patellar-tendon area (that is, 2/3 of 3/4 in. equals 1/2 in.). The remainder, or 1/4 in., is removed from the popliteal area (that is, 3/4 in. less 1/2 in. equals 1/4 in.).</p> <p>To prevent restriction of circulation in the stump, the plaster is removed posteriorly to produce a flattened surface rather than a bulge. The deepest removal of plaster is opposite from and just distal to the midpatellar-tendon level-thus creating the start of a radius proximally-and is continued downward to blend in toward the distal aspect of the stump model. <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><b>MODIFICATION OR THE POSITIVE MODEL.</b> Starting approximately 1/4 in. from the edge, plaster is removed from the reliefs to blend the edges into the contours of the stump model. Plaster is removed from the area of the medial shaft of the tibia to within 1 in. of the end. The angulation of the shaft must be maintained. The amount of plaster removed is dependent upon the amount of tissue covering the shaft. Approximately 1/8 in. to 1/4 in. of plaster is removed from the anterolateral aspect of the model, starting at the distal border of the relief for the leading edge of the flare of the lateral tibial condyle and continuing to within 1 in. of the end of the tibia. The template made from the stump is used as a guide in modifying the flare of the tibial condyle. The mediolateral dimension of the model should be reduced to within 1/8 in. to 3/16 in. of the measured mediolateral dimension of the stump. Usually, smoothing this area of the model with wire screening is all that is necessary.</p> <p>If warranted, 1/8 in. of plaster may be added to the relief of the anterodistal aspect of the tibia. The patella is smoothed by a wash of plaster rather than removal of plaster. Along the previously drawn posterior trim line of the socket, a build-up of plaster is applied to a height, of about 3/4 in. The build-up should be given a generous flare, and the distal border of the liare should be blended into the contours of the model, especially in the area of the hamstrings. Plaster should be added to eliminate any groove between the junction of the posterior plaster build-up and the medial or lateral side of the model. A piece of plastic screen or line sandpaper should be used to smooth the entire surface of the model. <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><b>BUILD-UP FOR RTV PAD.</b> When a Silastic RTV pad is to be used in the socket of the finished prosthesis, an additional plaster build-up about 3/4 in. high is formed on the distal aspect of the model. A piece of cardboard is applied to the cast to serve as a form for the plaster to be added. The form is sloped away from the distal anterior aspect of the tibia to provide any additional relief required. If the pipe is held vertically when the plaster is poured, a flat distal surface incorporating the correct angular alignment will result. All edges should be feathered into the contours of the model, especially in the tibial area.</p> <h3>Variations in Suspension Casting of the Below-Knee Stump</h3> <p>Since the introduction of the suspension casting concept, many variations have evolved in its use. These variations are mainly in the wrapping, the forming of the patellar-tendon bar, the modification of the wrap cast, and the modification of the positive model of the stump. <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><b>CALDWELL PROCEDURE.</b> In the procedure followed by Mr. Jack L. Caldwell,<a style="text-decoration:none;">*</a> gypsona plaster bandage is used in place of standard plaster bandage, a clamp (the Caldwell clamp) is used to measure the anteroposterior dimension of the stump and to contour the patellar-tendon bar and the popliteal area into the wrap cast, one heavy-cast sock is used during the wrapping procedure, the flare for the posterior proximal edge of the socket is formed in the wrap cast prior to pouring the plaster to form the positive model of the stump, and the distal portion of the stump is wrapped first for contouring purposes.</p> <p>In the Caldwell procedure, measurements are taken and recorded on a measurement chart before casting is begun. The patellar-tendon bar of the Caldwell clamp is pressed gently against the amputee's patellar tendon, and the reading made on the clamp scale is recorded. After the stump has been wrapped, the dimension should be approximately 1/8 in. greater than the measurement made on bare skin. Before the contouring clamp is applied to the gypsona-wrapped stump, the popliteal pad and the patellar-tendon bar should be greased with vaseline, since gypsona has an adhesive property not present in the ordinary plaster of Paris or elastic plaster. <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><b>CALDWELL PROCEDURE.</b> As soon as the wrap is completed, the clamp should be slipped onto the amputee's stump and the popliteal pad pressed into the proper area gently and correctly. With the contouring clamp in place, the wet plaster is worked into the medial tibial condylar shelf.</p> <p>A line is drawn circumscribing the wrap cast at the midpatellar-tendon level, also the socket trim line. <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><b>CALDWELL PROCEDURE.</b> After the cast has been trimmed along the proximal trim line, several longitudinal cuts about 1/2 in. in length are made downward from the trim line in the area above the popliteal fossa. The cut area is reinforced with small strips of wet gypsona plaster. The use of warm water will reduce the time required to handle the plaster. The inside of the cast where the cuts were made is smoothed with a paste of warm water and plaster-of-Paris powder. <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><b>FOORT PROCEDURE.</b> In a procedure developed by Mr. James Foort,<a style="text-decoration:none;">*</a> one heavy cast sock is used routinely, no relief patches are applied to the suspension sock prior to wrapping, plaster is used to provide reliefs during modification of the positive model of the stump, the distance between the hamstrings is measured and used as a control for the posterior outline of the socket, the modification of the positive model under the flare of the medial tibial condyle is extended posteriorly to include the hamstring tendons, and the position of the posterior flare on the plaster model of the stump is located at the midpatellar-tendon level.</p> <p>A fixed ring holds the casting sock at the top, a clamp ring binds the sock against the fixed ring, a clamping screw is used to force the clamp ring out against the fixed ring, and a pin connects the ring assembly to the UCB stand.</p> <p>The distance between the outer edges of the tensed hamstring tendons is measured and recorded.</p> <p>After the plaster wrap has been applied to the stump, the patellar tendon is defined by pressing the thumb tips on either side of it. At the same time, light counterpres-sure is exerted with the fingers across the back of the stump. This procedure is similar to the technique described in <i>The Patellar-Tendon-Bearing Prosthesis </i><a></a> and subsequently modified as reported in <i>Air-Cushion Socket for Patellar-Tendon-Bearing Below-Knee Prosthesis. <a></a> - <b>Fig. 16</b></i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>FOORT PROCEDURE.</b> When the plaster stump model has been cast, plaster is removed from the sloping surface of the medial flare with a curved l 1/2-in. rasp. The purpose here is to prepare the surfaces for supporting weight. Coupled with pressures from lateral surfaces, the medial flare helps to stabilize the stump mediolaterally in the socket. But very little adjustment of this surface is required. A 1/4-in. adjustment at the deepest part of the shelf, tapering off to nothing along the vertical portions, would be the greatest amount removed. If the model is of a seasoned stump, it is sufficient merely to work this area smooth with wire screening. The screening should be swept around the natural contours of the flare, into the posterior area, and over the hamstring tendons.</p> <p>Plaster is added to the stump model in bony areas to provide relief. In addition, a posterior flare is constructed on the model by means of a plaster build-up. This is done by pouring plaster over the posterior surface above the circumscribed mid-patellar-level line until the addition is 1-in. thick. The plaster is spread with a wet spatula, and the flare is formed with wet fingers and thumb. The back flare is not grooved for the hamstring tendons. Instead, a broad surface is provided against which the tendons can rest when the amputee is seated. The build-up for the posterior flare should be trimmed to about 3/4 in. with a flat rasp. <a></a> - <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><b>VARIATION USED AT NUPRC.</b> Another slightly different procedure sometimes used at the Northwestern University Prosthetics Research Center incorporates a patellar-tendon pad and a popliteal pad into the wrap during suspension casting. The pads used were developed at the Veterans Administration Prosthetics Center in conjunction with a pneumatic casting svstem. These pads define the patellar-tendon bar and the popliteal depression, and their use results in a positive stump model with an anteroposterior dimension that is within 1/16 in. of the measured anteroposterior dimension of the stump. <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><b>VARIATION USED AT NUPRC.</b> Two wraps of standard plaster bandage are applied to the proximal aspect of the stump, covering the patellar-tendon area. The protuberance of the pad is positioned over the patellar tendon and covered with two additional wraps of bandage applied with firm tension to hold the pad in place.</p> <p>The popliteal area is then covered with two wraps of plaster bandage, and the pad is placed so that its top edge is approximately 1/2 in. above the top of the proximal border of the head of the fibula. The lateral edge of the pad should be placed 1/2 in. medial to the medial border of the head of the fibula. The pad is covered with two additional wraps of plaster bandage, and firm tension is applied during the wrapping. The wrap is then spiraled down to include the rest of the stump, and the plaster is worked by hand to emphasize bony areas.</p> <p>If the resulting stump model has a depression in the popliteal area, some plaster is removed from the medial and lateral border of the depression so as to prese nt a flatter posterior surface. A slight screening is usually all that is necessary to finish the patellar-tendon bar. The medial template should be used when modifying the cast to arrive at a true contour of the medial flare of the tibial condyle.</p> <h3>Suspension Casting of the Above-Knee Stump</h3> <p>Suspension casting of above-knee stumps may be used in conjunction with a UCB casting stand and brims. The technique permits the firming of stump tissues that are not in contact with the brim. It is also a means of controlling bulges at the distal end of the brim and the adduction angle of the femur. The technique results in a smooth interior to the negative cast of the stump. <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><b>CASTING THE ABOVE-KNEE STUMP</b>. The major equipment required is a UCB stand, a set of brims, and a roll of 4-in. tubular gauze.</p> <p>Initially, the stump is correctly fitted into the brim, in accordance with the instructions contained in <i>Adjustable-Brim Fitting of the Total-Contact Socket</i>. <a></a> The brim is set in the stand horizontally. When all the necessary conditions-such as, the correct anteroposterior and mediolateral dimensions and the circumference of the brim-are satisfied, a piece of tubular gauze approximately 1-yd. long is applied to the brim. The tubular gauze is held to the outside of the brim with adhesive tape and is then draped down through the brim. A stump sock is then applied to the amputee's stump. The distal end of the stump sock is pulled down through the tubular gauze, and the stump sock is removed entirely while pulling the stump into the brim.</p> <p>Pulling the stump into the brim in this manner results in a bulging of the stump around the distal edge of the brim. To alleviate this situation, the amputee is instructed to flex his trunk over the brim as far as possible, thereby easing the gluteal muscles proximally. As the amputee straightens up in the brim, the tissues should be gently eased proximally in the anterior area of the brim. When the amputee bears weight on the brim, some of the bulging will have been eliminated. <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><b>CASTING THE ABOVE-KNEE STUMP.</b> The tubular gauze distal to the brim is grasped and pulled downward, causing the tubular gauze to stretch longitudinally and reduce circumferentially, thereby compressing the stump tissues. With one hand, the prosthetist maintains tension on the distal end of the gauze as he grasps the gauze at the distal end of the stump with his other hand. The amputee is instructed to remove some weight-bearing from the brim, and the gauze is tied with string at the distal end of the stump. Weight-bearing should be reapplied to equal approximately one-half of the amputee's weight. A piece of 1-in. elastic webbing is tied to the distal end of the gauze and passed under the arch of the amputee's foot, usually from the lateral to the medial side. Sufficient force is applied to the elastic to maintain the correct adduction attitude of the femur. <b>Fig. 21</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><b>CASTING THE ABOVE-KNEE STUMP.</b> A firm, even wrap of standard plaster bandage is applied, enclosing the stump completely. While the plaster is still wet, the prosthetist palpates the stump to locate the distal end of the femur. He then applies gentle pressure approximately 1 in. above the end of the femur until the plaster sets.</p> <p>Before the plaster is poured to form the positive model of the stump, the tubular gauze is removed from the brim area down to its contact with the plaster wrap.</p> <h3>Suspension Casting for the Syme's Amputation</h3> <p>The suspension casting technique provides a means of wrapping a Syme's stump with plaster bandages under weight-bearing conditions. It is an excellent means of holding an unstable heel flap or supporting redundant tissue in the correct position during the casting procedure. It firms tissues, resulting in a smooth interior to the wrap cast, and it provides a means for checking the size of the medial opening prior to laminating the socket. <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 /> <p><b>CASTING THE SYME'S STUMP.</b> The equipment used is the same as that used for casting below-knee stumps; namely, an adjustable vertical stand, a ring, a gasket, a hose clamp, a cast sock, and a scale.</p> <p>A light-weight cast sock is used because it has more stretch than a heavy cast sock and can conform intimately to the contours of the stump. The sock should contact the thigh approximately 3 in. above the patella, with one-half of the amputee's weight borne by the sock.</p> <p>With the amputee supported in a level position, blocks are placed under the stump to contact its distal surface. Areas requiring relief are located by palpation and outlined. An outline of the medial opening is planned and drawn on the suspension sock, as described in <i>VAPC Technique for Fabricating a Plastic Syme Prosthesis with Medial Opening</i>. <a></a></p> <p>The largest circumference at the bulbous end of the stump is measured, and a horizontal line is drawn just proximal to this. The stump is then measured proxi-mally until the same circumference is obtained, and another horizontal line is drawn at this level. A line is drawn along the crest of the tibia. Just 3/4 in. medially from the tibial line another line is drawn parallel so as to intersect the two horizontal lines. The width of the cut-out is usually equal to 1/4 of the circumference measured. This remaining vertical line is drawn following the posterior contour of the stump to complete the medial opening. Relief patches 1/8-in<i>. </i>thick are prepared and applied to the areas previously outlined on the suspension sock. <b>Fig. 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 /> <p><b>CASTING THE SYME'S STUMP.</b> The blocks are slid from under the stump, and the amputee retains weight-bearing on the sock. Plaster bandages are contoured to the distal end of the stump, and the bulbous end is wrapped up to the distal horizontal line of the medial panel. The plaster bandage is applied vertically to cover the stump to the anteromedial and posteromedial vertical outlines of the panel, and horizontally to include the top edge of the patella down to the top line for the medial opening. After wetting his hands, the prosthetist works the plaster to ensure an intimate contact of the wrap, especially in the area just proximal to the bulbous end. If necessary, one wrap of plaster bandage can be applied in this area to prevent possible bridging.</p> <p>The wooden blocks are then slid back under the plaster wrap of the distal stump. Slight contact pressure is all that is required to provide a flattened surface to the distal end of the cast. If too much weight is borne on the blocks, the amputee should be raised slightly by vertical adjustment of the casting stand. <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 /> <p><b>CASTING THE SYME'S STUMP.</b> The plaster is worked along the stump and around the proximal aspect of the wrap. The prosthetist locates and defines the patellar tendon and flattens the wrap cast posteriorly just below the midpatellar-tendon level. After the plaster has set, the remaining area to be covered is evident. Vaseline is applied to the uncovered portion of the sock and 1 in. to 1 1/2 in. along the plaster cast bordering the area. A splint of plaster bandages is made, large enough to cover the opening but not so large as to extend beyond the lubricated areas of the wrap cast. The splint is applied to cover the medial opening and worked well by hand to obtain an intimate mating along all the edges. <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><b>CASTING THE SYME'S STUMP.</b> After the panel covering the opening has set, alignment lines are drawn on the cast to be used later for bench alignment. The amputee is oriented so that his pelvis is level, with half of his weight borne on the amputated side. Using a plumb bob, the prosthetist draws a vertical line on the anterior aspect of the wrap cast to determine the adduction angle of the socket and another vertical line on the lateral aspect of the cast to determine the flexion angle of the socket. Before removing the panel, the prosthetist draws two horizontal lines on the panel extending onto the body of the cast for positioning purposes.</p> <p>The clamp on the casting stand is loosened to permit the amputee to be seated. The clamp and ring holding the cast sock are removed. The prosthetist slides a knife under the edges of the medial panel and exercises care to avoid distortion during removal. The exposed cast sock is cut, and the stump is withdrawn from the cast.</p> <p>The cast sock and relief patches are removed from the interior of the wrap cast, and the medial panel is replaced and held in position with additional strips of plaster bandage.</p> <p>The positive stump model is then poured into the wrap cast, with the wrap cast held so that the alignment lines are vertical. The holding pipe is inserted vertically and should be invested into the plaster to within 1/2 in. of the end of the cast.</p> <p><b>References:</b></p> <ol> <li>Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1963.</li> <li>Foort, J., and D. A. Hobson, A pylon prosthesis system for shank (BK) amputees, Prosthetics and Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, Winnipeg, November 1965.</li> <li>Iuliucci, Louis, VAPC technique for fabricating a plastic Syme prosthesis with medial opening, Veterans Administration Prosthetics Center, New York, September 1959.</li> <li>Lyquist, E., L. A. Wilson, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, April 1965.</li> <li>Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 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>3.</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>1.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Foort, J., and D. A. Hobson, A pylon prosthesis system for shank (BK) amputees, Prosthetics and Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, Winnipeg, November 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Lyquist, E., L. A. Wilson, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, April 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Technical Director, Prosthetics-Orthotics Research and Development Unit, Manitoba Rehabilitation Hospital, 800 Sherbrook St., Winnipeg 2, Man.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Manager, J. E. Hanger, Inc., of Florida, 938 South Orange Ave., Orlando, Fla. 32806.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Radcliffe, C. W., and J. Foort, The patellar-tendon-bearing below-knee prosthesis, Biomechanics Laboratory, University of California, Berkeley and San Francisco, 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>Fred Hampton, C.P. </b></td></tr><tr><td class="clsTextSmall">Assistant Project Director, Northwestern University Prosthetics Research Center, 401 East Ohio St., Chicago, Ill. 60611. The work of the Center is supported by U. S. Veterans Administration Research Contract V1005M-1079.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1966_02_005/aut66-2-19.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 Suspension Casting for Below-Knee, Above-Knee, and Syme's Amputations Creator An entity primarily responsible for making the resource Fred Hampton, C.P. * https://staging.drfop.org/files/original/80c2672becb304a755607958b8b3c960.pdf f647e29523f0bb254a98b3e47c5cfca4 https://staging.drfop.org/files/original/f95345137c719c2af67d3301523b3afb.jpg d6fcf2d9d9b48a1a4abf9da786e34eaa https://staging.drfop.org/files/original/752ebfc3ea102a5175fc0fb02e645908.jpg 5350192b793bb2e68a1dbc04c7211858 https://staging.drfop.org/files/original/9c6d7cf4e0c09122676c79d5d6d61204.jpg 902056a0233b4f2c12423310fba95867 https://staging.drfop.org/files/original/fec489d1be2e1025db85614faa8ae709.jpg 0a36603eee31a4a2a19d429958545543 https://staging.drfop.org/files/original/cec2ebadd71bf2d6eaca13a56f774b7c.jpg 0c0ee61bafc622396bcac40f430d3bff DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1964_02_028.pdf Year 1964 Volume 8 Issue 2 Page Number(s) 28 - 44 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1964_02_028.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1964_02_028.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>Turntable Lock for Elbow Units</h2> <h5>Fred Sammons, B.A. <a style="text-decoration:none;">*</a><br /></h5> <p>In the conventional elbow unit (Hosmer E 400) for above elbow and shoulder dis articulation amputees, manual control of humeral rotation is permitted by virtue of cork and teflon gaskets providing mechanical friction between the top of the main portion of the elbow unit and the turntable to which the upper arm shell or socket is fastened.<a></a> The amount of friction is determined by the tension maintained by the stud and attaching nut. Since humeral rotation great as to rule out easy adjustment. At the same time there must be enough resistance to rotation to accomplish most activities. </p> <p> There are times when a rigid arm is desirable; for example, when climbing ladders, using a shovel for long periods, carrying an object balanced on the forearm, or carrying an object held away from the body. To provide rigidity for such demanding tasks, the North Western University Prosthetics Research Center has developed a manually controlled lock which can be mounted on the area provided for a forearm lift assist on the Hosmer E 400 elbow unit. A spring forcefully engages the locking pin in one of three holes drilled through the turntable for this purpose. Since the turntable possesses enough friction for most activities, the locking pin need only be used to overcome the tendency of the forearm to rotate gradually when shoveling, to provide the extra margin of safety when climbing vertical ladders, or to supply the rigidity needed in certain other tasks. The amputee returns the locking pin to the disengaged position when the task is completed. </p> <p> Installation of the lock requires: first, drilling the indexing holes in the turntable; second, revising the plastic cap on the elbow unit and mounting the locking device; third, cutting a notch in the cork and teflon gasket to make room for the locking pin and regluing the gasket to the elbow unit. </p> <p><b>Fig. 1</b> and <b>Fig. 2</b> are views of the locking device, and <b>Fig. 3</b>, <b>Fig. 4</b>, and <b>Fig. 5</b> show details of its installation. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Installation of lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. View of modification showing indexing holes in turntable. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Drawing of base of lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Drawing of lock components. A, Pin; B, Cap; C, Spring </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Drawings of modified turntable. The radius of the indexing holes may be determined by using a 1/8-in. diameter scriber in the lock base mounted on the elbow and scribing directly on the turntable. The amputee can best select the locking positions after completion of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The first prototype (not shown) of the lock was fitted to DM, a 38 year old farmer who is a left above elbow amputee. The lock was mounted on the posterior rim of the elbow frame. A 3/16 in. locking pin was used and has proved to be very durable. The lever which latches and unlatches the lock has been replaced because of breakage. A disadvantage was the requirement for modification of the elbow frame and extensive modification of the cork and teflon gasket. Another disadvantage was the location of the lock lever at the back of the elbow rather than at the side. The device has been worn continuously for 20 months with no malfunction in the locking pin. One unit of the second prototype (as shown in the illustrations for this article) of the lock was fitted to EA, a 38 year old farmer and bulldozer operator who is a right above elbow amputee. The device has functioned well for a period of more than 16 months, and the amputee reports that he uses il several times daily. He is able to lock and unlock the device without removing winter clothing. </p> <p> Another unit of the second prototype of the lock was fitted to IS, a 40 year old farmer who is a right above elbow amputee. The device malfunctioned after six months when the elbow became free moving without the usual amount of friction. This caused excessive strain on the locking pin, which bent under the load. The pin was replaced, friction was restored, and the device has worked for 10 additional months. The amputee reports using the lock when holding materials to be butt welded, when climbing ladders, and in other situations where a static arm is required. </p> <p><b>References:</b></p> <ol> <li>Aitken, George T., T. J. Bushey, Edward R. Ford, and Fred Leonard, <i>Upper-extremily components</i>, Chap. 2 in <i>Orthopaedic Appliances Atlas</i>,Vol. 2, Edwards, Ann Arbor, Mich., 1960.</li> <li>Sammons, Fred, <i>Elbow rotation lock</i>, Northwestern University Prosthetics Research Center, July 1964.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Aitken, George T., T. J. Bushey, Edward R. Ford, and Fred Leonard, Upper-extremily components, Chap. 2 in Orthopaedic Appliances Atlas,Vol. 2, Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Fred Sammons, B.A. </b></td></tr><tr><td class="clsTextSmall"> Research Associate, Northwestern University Prosthetics Research Center, 401 E. Ohio St., Chicago, Ill. 60611.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1964_02_028/1964-Autumn-41.jpg Figure 2 http://www.oandplibrary.org/al/images/1964_02_028/1964-Autumn-42.jpg Figure 3 http://www.oandplibrary.org/al/images/1964_02_028/1964-Autumn-43.jpg Figure 4 http://www.oandplibrary.org/al/images/1964_02_028/1964-Autumn-44.jpg Figure 5 http://www.oandplibrary.org/al/images/1964_02_028/1964-Autumn-45.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 Turntable Lock for Elbow Units Creator An entity primarily responsible for making the resource Fred Sammons, B.A. * https://staging.drfop.org/files/original/58b9ac3acbd103e06a1b89d3952822dc.pdf 0a1ffc6373173388efb41ba207d3695b https://staging.drfop.org/files/original/484b8daccf6ce6c0aece26201505c00e.jpg 0b54c5978606817a280da5a93803beba https://staging.drfop.org/files/original/c48afbc6a0c4b0e08fe65bc1293586dc.jpg 5610616274d318d4c61c5f823dccceb4 https://staging.drfop.org/files/original/7ad84a93475df636cf432dd2ed54559a.jpg 98eb6b4ed650868e68250eae91be6158 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_036.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 36 - 46 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_02_036.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_036.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Some Problems in the Management of Upper Extremity Amputees</h2> <h5>Frederick E. Vultee, Capt., USA (MC) <a style="text-decoration:none;">*</a><br /></h5> <p>Experience in the rehabilitation of upper extremity amputees in recent years has highlighted the advantages of many concepts not previously considered or else heretofore noted only superficially. Not only has the development of prosthetic devices assured a greater degree of rehabilitation of many more amputees, but consideration of the amputee as a whole also has played a major role. It is now well recognized that, in times past, attention was too often directed only to the amputation stump. After the wound had healed, the patient was referred to a prosthetist without benefit of a physician's final evaluation. The development of the clinic team approach<a></a> foreshadowed the end of such practices, and with the growth of the clinic team has come the all important factor of considering the patient as a whole.</p> <p>Implicit in such an approach is the concept that complete upper extremity rehabilitation can rightly be expected only when the amputee has been afforded adequate training in efficient utilization of the prosthesis with which he has been fitted. Incomplete or unsystematic training is, at best, responsible for improper habits in prosthetic usage and hence for awkwardness and inefficiency. In the extreme case, it may lead to discard of the prosthesis entirely even though the components involved may themselves be of the greatest utility to an accomplished amputee wearer. The therapist has thus come to be looked upon as an important member of every prosthetics clinic team.</p> <p>The importance of good health also has come to be realized. The patient who suffers from complicating injuries or diseases may not be able to cooperate fully, and when cooperation is limited, interest and motivation die rapidly. For example, the obese patient will profit by guided weight reduction and proper weight stabilization, and the anemic and allergic will benefit by proper corrective measures. Dermatological problems frequently are a serious complication for the amputee, especially when involvement of the stump is threatened or when harnessing excoriates areas of existing dermatitis. Here proper therapeutic measures may permit continued use of the prosthesis or ensure only a temporary suspension of its use. If, however, such conditions are allowed to continue unchecked, they may result in a prolonged period of inactivity.</p> <p>Equal in importance to good physical condition is a healthy mental attitude. Unless rehabilitation therapy includes consideration of the patient's mental outlook, the entire process of recovery may result in complete failure. Accordingly, some cases may require the assistance of specialists in psychiatry and related fields.</p> <p>With respect to the patient's mental condition, an important factor relates to vocational and avocational pursuits. Whether an amputee can engage successfully in work and recreation to his own liking, and whether he has a taste for such activities as are possible to him, may together spell the difference between success and failure in any given case. Proper attention by a qualified occupational therapist is therefore essential.</p> <p>Functional loss aside, a number of other problems arise from hand loss. In addition to the functions of grasp and tactile sense, the hand is used in many symbolic patterns in benediction, in supplication, in the salute, in the handshake. These are ancient and time honored functions denied the person who has suffered loss of the hand. In the rehabilitation of the upper extremity amputee, too much stress often is laid upon the restoration of functional losses relating to prehension, often forgetting the extraprehensile activities essential to the amputee's existence.</p> <p>In addition to these matters are the problems associated with the importance of early fitting and those involved in the special cases of multiple amputation. And finally, mention deserves to be made of the largely faulty but widespread notion that people are inherently right handed or left handed. In the rehabilitation of the upper extremity amputee, the popular concept of hand dominance leads to one of the most difficult problems to be overcome.</p> <p>Since each of these individual problems is closely interrelated with all the others, the order in which they are considered by the clinic team is of no particular significance. Of greatest importance is that they all <i>be </i>considered and that over all evaluation of the amputee's status take into account all the individual factors that, together, constitute total rehabilitation.</p> <h3>The Problem of Hand Dominance</h3> <p>Most people define handedness solely on the basis of whether the right or the left hand is used in writing, or in throwing a baseball, or the like. The less specific definition of a medical dictionary, which describes handedness as the preferential use of one hand over the other, is perhaps more acceptable, for handedness does not appear to be a flat case of one "necessary" and one "nice to have" hand but rather a case of two cooperating members either one of which could be trained as the leader. Nevertheless, the concept of dominance is so widely established that loss of the writing hand is considered by most compensation authorities to constitute severe disability, whereas loss of the other often is viewed lightly. Similarly, loss of one hand in the ambidexterous generally is considered to present no great rehabilitation problem.</p> <p>How do we determine whether an individual is right or left handed? When the average person is asked which is his dominant hand, he usually selects the writing hand. In the upper extremity amputee, we seemingly are presented with a case of "dominance" or "sub dominance." Simply to ask the patient whether he is, or was, right or left handed is, in most cases, a wholly inadequate method of determining the degree of dominant handedness. It produces premature evaluations of disability and of future rehabilitation problems, both of which may need complete revision before the patient is discharged from the care of the clinic team. The problem of handedness is of primary interest to those directly responsible for all phases of training the upper extremity amputee. It is during the preprosthetic stage that the real aspects of dominance present themselves, for during this period the patient is a one handed individual.</p> <h4>The Dictates of Convention</h4> <p>Judging from the design of many of the articles we use daily, it appears that society already has dictated that ours shall be a colony of right handed individuals. From the position of the knife and fork at the table to the placement of the gearshift lever on the modern automobile, we are reminded constantly that we are expected to use our right hand much more than our left. This decision of engineers and of authorities in etiquette causes no small concern to the parents of children who seem to use the left hand more than the right. Parents recall other left handed individualsindividuals who always find themselves crowded when seated at the dinner table (<b>Fig. 1</b>), or whose bodies assume the position of an animated corkscrew when attempting to write at a desk. For these and other reasons, parents try subtly to encourage the use of the right hand in the young child, despite some of the beliefs of medical science. Even the garmentmakers have conspired against the man who uses his left hand for some tasks. Commonly, a button is placed over the left hip pocket, where it seems understood the wallet will be placed, while the right hip pocket is free for easy withdrawal of the handkerchief. The man who uses the left hip pocket for the handkerchief has no protection for the wallet when it is kept on the right.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The southpaw at dinner. Convention dictates the norm; habits in conflict with the established pattern usually lead to trouble. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Popular Fallacy</h4> <p>These elementary observations indicate that hand usage is dictated by habit patterns, possibly as a means of conforming to the norms of the society in which we live (page 9). It is important, however, to consider whether or not truly right or left handed individuals exist and, if so, to consider what is meant by the terms. As has been noted, when the arm amputee first is questioned about handedness, writing is apt to be the first thing considered, and the answer is likely to be made on that basis. Additional questioning usually reveals that, although the patient may have used the right hand for writing, many other tasks requiring delicate, coordinated movements might have been done with the left hand, or vice versa.</p> <p>Too many persons believe that the writing hand also is the only hand capable of performing all other smoothly coordinated tasks. As more probing questions are asked of the patient, it may be evident that the opposite hand also performs many functions. If the keys or small change are carried in the pocket opposite from the hand used in writing, bilaterality rather than simple dominance may well be indicated. Information in this connection can be elicited more readily with male patients by asking which pocket carries the handkerchief, which pocket holds the wallet, which hand holds the pipe or cigarette, and which hand is used to strike a match.</p> <p>It often is surprising to find that, with the exception of writing, almost all daily activities involve equal participation of both hands, one serving as a helper to the other with interchangeable ease. When loss of the use of a hand occurs, either temporarily or permanently, the most frequent problem stems not from the inability to write but rather from the inability to perform the tasks requiring use of both handstying shoes, buttoning clothes, cutting food, and so on. Hence, it is important that a prosthesis be designed to restore bilateral activity rather than dominance or the ability to write. When a patient loses a so called "subdominant" hand, he soon expresses some degree of surprise at the number of jobs formerly done by the missing member. He also notes, with as much surprise, that many tasks are quite difficult for the remaining hand alone, even though it be the dominant or leading hand. But the amount of time required to relearn all these tasks, including writing, with some degree of agility is quite short. Except in bilateral cases, the patient soon becomes reasonably independent. If allowed to continue as a one handed individual, the unilateral arm amputee soon learns short cuts that permit him to be more independent and ultimately to feel that he has no need for a functional replacement of the missing hand.</p> <p>Such a patient gives the greatest cause for concern. Perhaps the inability of some to recognize the absence of a true dominance or to understand the rapidity with which a one handed individual can adjust and become reasonably independent may, in some measure, account for a number of failures in upper extremity rehabilitation. Certainly there are other causesinadequate surgery, poor prosthetic replacement, inadequate training contributing to these failures. But only when all of these factors are considered and eliminated can full utilization of the prosthesis be expected.</p> <p>The patient who has learned to do reasonably well with one hand is the very patient most likely to be a failure when fitted with a prosthesis. His training will be most difficult and frustrating for all concerned simply because he cannot recognize the need for a prosthesis. Training for such a patient comprises largely a program of unlearning all of the grotesque contortions to which he has become accustomed. Because here the individual, having been pleased with his one handed accomplishments, must learn to be a two handed person again somewhat against his "better judgment," frustration becomes an important consideration. The more complicated the prosthesis, the lower is the frustration tolerance of the patient because he cannot accept the need for a device which seems to complicate rather than to simplify his life.</p> <h4>A Two-Handed World</h4> <p>One might now properly ask why so much concern should be shown for such a patient. Would it not be easier to permit his unilateral activities to continue and thereby eliminate all problems of fitting, training, and further care? Unfortunately, the solution is not so simple. We live in a two handed world. To maintain our place in society, two hands are needed, or at least substitutes for them. One need only consider the obvious difficulties encountered by the one handed individual when carrying a loaded cafeteria tray, serving himself at the table, or attempting to tie up a parcel (<b>Fig. 2</b>). In the effort to prevent similarly embarrassing situations, the one handed person may gradually seek less and less public contact, social and vocational, and with this self inflicted isolationism ultimate loss of his own security may develop. Despite all short cuts and self helps, the amputee who remains without a prosthesis must still require a degree of additional assistance for many tasks. A functional prosthesis offers independence. An unfitted stump usually leads only to a gradual but ultimate deterioration of self pride in all tasks, public or private.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The empty sleeve versus the upper extremity prosthesissome examples. Although the unilateral arm amputee may learn to perform well with the remaining sound hand many activities formerly conducted with the amputated member, and although the stump and other parts of the anatomy may be called upon to substitute in "two handed" activities, a great many essential functions are carried out awkwardly, if at all, by the arm amputee who remains unfitted. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Psychological Problems</h3> <p>When it appears that a patient has emotional complications that are not responding to treatment, he should be referred to other medical specialists. Such emotional problems may occur at any phase of the patient's course, and the use of proper specialists will, in many instances, permit the rehabilitation team to continue its work while the patient receives the indicated treatment. Prompt recognition and treatment of such unfortunate situations often will salvage the patient, where otherwise he might drift aimlessly through prosthetic fitting and training until the symptoms are so pronounced as to be recognized by everyone on the street.</p> <p>Initial interviews rarely, if ever, disclose an amputee's underlying feelings about his loss. As he advances through the rehabilitation processes, the amputee may feel that it is too late to open questions of fear and misgiving, in which case his feelings of insecurity are only perpetuated. Hence, it is wise for the physician to suggest possible questions and answers when the amputee is first interviewed. To focus attention upon likely questions may offer an opportunity for the patient to talk about his family's acceptance of his amputation, to discuss social problems resulting from his physical and mental condition, and to air any other problems peculiar to the individual. Unfortunately, no hard and fast rule can be applied; for no two amputees are alike, either in physical or mental make up or in social and economic status. In any given case, each question should be answered as frankly as possible, and, if the answer is not known, every effort should be made to provide one as quickly as possible. Although left to themselves most amputees ultimately find the answers to their own questions, the answers thus obtained usually come only after many frustrations and sometimes after severe emotional stress.<a></a></p> <h3>Medical Problems</h3> <p>The problems of pain, real and phantom, and of phantom sensation, sometimes are so difficult as to postpone actual fitting and training or even to suspend use of the prosthesis after it has been fitted. Recently, phantom pain and phantom sensation have been explored at length<a></a> and more complete concepts of etiology and treatment now are evident. When it is caused by thin or densely adherent scar tissue, neuromata, or bony spurs, stump pain is one of the most common causes for delayed initial fitting or for abandonment of the fitted prosthesis.</p> <p>In such cases it is futile to delay treatment in the hope that actual fitting, continued use of the prosthesis, exercise, or physical therapy may render a neuroma painless or reduce a spur so that it no longer is troublesome. As time passes and the pain or tenderness persists, the patient is entirely justified in questioning whether or not he ever will be able to wear a prosthesis. Specific difficulties that do not respond to conservative measures should be corrected surgically and with the least possible delay. When it seems wise to attempt a conservative approach to minor stump difficulties, an explanation will ensure the patient's continued confidence in the physician. During such a period, the patient's progress must be evaluated regularly. When and if the conservative treatment fails, more radical measures are in order.</p> <h3>Vocational Problems</h3> <p>All amputeesthose, like the housewife, engaged in the home as well as those employed in business and industryhave vocational problems at one time or another. Again, the patient requires much honest and factual reassurance. Although the trend in employment of the physically handicapped is much more gratifying now than it has been in previous years, rose colored pictures of industries seeking amputees for all types of employment lead only to false comfort and to eventual disillusionment of the patient. Although true vocational counseling has become a specialty in itself, the physician must never lose sight of the fact that the job of restoring the patient to useful function is his, the physician's, personal responsibility. Even though the patient may at some time be evaluated by a vocational counselor, the physician must regard the evaluation as a type of referral with continued follow up to ascertain the progress being made.</p> <p>Proper use of the social worker may prove invaluable in maintaining close liaison with the employer and the rehabilitation team.<a></a> The employer should be encouraged not to discharge the amputee patient until the possibilities of further employment have been fully explored. To the new amputee still in the hospital, nothing can be more devastating than a notice to the effect that he has lost his employment as a result of his newly acquired handicap (<b>Fig. 3</b>). Assurance that there is a reasonable chance of continued employment, or that efforts are being made to place the patient in some similar position, will do much to speed his total recovery and to provide motivation, the one factor without which there can be no genuine rehabilitation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The pink slip versus the helpful proprietor. In total amputee rehabilitation, morale is important. Full cooperation of the employer is essential to the success of the prosthetics clinic team. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is fortunate that current trends in aiding the physically handicapped are toward providing vocational training and placement rather than monetary compensation and the subsequent opportunity to sit in the park and collect the pitying, sideward glances of the passers by. The amputee who formerly held a job requiring bilateral hand use very early recognizes the need for a prosthesis, accepts it readily, and receives training as quickly as possible. With the younger, inexperienced person, who perhaps has drifted aimlessly through several more or less unproductive jobs, the problem of prosthetic acceptance and use is more complicated. Such a person has yet to learn the true value of two hands.</p> <p>Unfortunately, some of the veterans of World War II and of the Korean conflict have been victims of such an experience. These men, many coming directly from high school or from odd jobs, had no opportunity to learn vocations or skills requiring use of two hands. Consequently, many of them accept a prosthesis, cooperate halfheartedly in training and follow up, and then discard the prosthesis to look the country over for a job they can do with one hand and sympathy. When an effort is made to offer these people vocational guidance, many indicate they are "going to school," apparently in the belief that one can get through school with one hand. But as a matter of fact the process of education more often than not demands bilaterality, and the inability to recognize the value of a prosthesis constitutes the principal reason why many amputees eventually withdraw from schools.</p> <h3>Training Problems</h3> <p>Although there can now be no doubt of the value of prosthetics training, it is interesting to note that many amputees, usually those who have worn a prosthetic device for many years, indicate that they see no need for training. The patient and prosthesis become one, and little tricks of operation and short cuts, all of which lead to increased efficiency, become second nature. From such a peak of efficiency it is difficult to remember the basic training required to perfect every motion, In the past, moreover, training rarely was conducted as intensively as it is today. Simple instruction in the use of the terminal device, usually by the prosthetist, was about all the patient could expect, and he depended on trial and error and the passage of time for the remainder of his training.</p> <p>A patient who has gone through such a procedure may scoff at the prolonged period of time now thought necessary to assure adequate training in prosthetic control. But the time thus spent really is immeasurably short because it saves the patient much false motion and wasted effort and prepares him to resume his place in society more quickly than the patient with no training. Of course, training must not be confined to the period of prosthetic wear; rather, it must start as soon as the condition of the stump permits.<a></a> Prepros thetic training includes maintenance of joint mobility and muscle strength as well as maintenance of cerebral patterns of motion.</p> <h3>The Problems of Multiple Amputation</h3> <p>The bilateral hand amputee presents both to the patient and to the medical staff a problem of the greatest difficulty. The patient who has lost both hands still possesses two stumps which afford some means of gross prehension. A pencil can be grasped for crude writing, an eating utensil can be held between the stumps for clumsy eating, and the stumps fill out the sleeves. But all delicate prehension, all discrete tactile senses, are lost. Initially, the bilateral amputee is apt to be deeply depressed, and he therefore usually responds poorly to the first rehabilitation contacts. He requires as rapid a fitting as possible, because otherwise he remains almost completely dependent for all necessities, not only economically but, more important, socially and in the home. The latter situation is the one usually most devastating and the one which unfortunately most often is brushed over when the patient first is met. He must have assistance not only in eating but in all toilet activities as well and finds himself relegated to a crude and almost infantile existence.</p> <p>Prosthetic training is much more detailed and prolonged for the bilateral amputee than for the unilateral because the patient has no remaining natural hand for a prosthesis to assist. All acts of dexterity must be accomplished by one or the other terminal device. The therapist cannot consider training complete when the patient meets the requirements of the unilateral amputee but must, in addition, cover use of the prostheses in all acts of everyday lifefeeding, toilet care, and dressing. It is fortunate that such activities are well within the realm of accomplishment for the bilateral hand amputee, especially when the stumps are comparatively long and the natural elbows are intact.</p> <p>An additional complication, usually resulting from trauma, involves amputation of part of a leg in addition to loss of an arm. In the light of present experience, neither amputation truly can be said to take priority over the other, and each case must be considered on an individual basis. In every case, body mechanics and sense of balance are impaired seriously. Gait training becomes more difficult when a part of an arm has been lost. Similarly, upper extremity training is made more difficult without the use of both normal lower extremities. The patient is necessarily confined to bed or uses a wheel chair or crutches for support. If one of the arms is artificial, crutches are used only with difficulty and often in a manner potentially dangerous. The patient may find his arm prosthesis so attached to the crutch that, in the event of a fall, he is unable to free himself rapidly and to discard the crutch. There is thus always the possibility of damage to the stumps or other parts of the body. Considering these potentials, it would seem best to undertake gait training first. When it can be instituted safely, this practice seems to present fewer problems to all concerned.</p> <h3>The Problems of Early Fitting</h3> <p>Early fitting of the prosthesis has come to occupy a major place in present day concepts of amputee management. To postpone fitting until maximum stump shrinkage has occurred often gives the patient those few extra weeks of one handed experience that lead him to believe he does not need a prosthesis. Although there is no known criteria for determining exactly when a stump has stopped shrinking, it now appears that the greatest incentive to maximum shrinkage is actual wear and use of a prosthesis. Once the patient is shown that early fitting and constant practice are the shortest roads to recovery, he usually cooperates willingly.</p> <p>With early fitting naturally comes the problem of continued stump shrinkage, which usually results in a loose socket. It is entirely possible that fabrication of a second socket may be necessary before complete adjustment has taken place. The patient should be made aware of this possible complication, and, when it appears that a second socket may be required, the added cost might be included in the price of the prosthesis. In a patient's decision to abandon a device, repeated expenditures for prosthetic adjustments often play as important a role as does a loose socket. But if initially the patient is told the reasons for possible additional expenditures, more than likely he will accept the conditions without protest and without discouragement.</p> <h3>Some Solutions</h3> <p>What can be done to solve some of the problems that are potential sources of failure in the proper utilization of an arm prosthesis? First, it must be realized by all concerned with the management of upper extremity amputees that the present concept of dominance is a relative one. The person who loses the so called subdominant hand is just as seriously disabled as is the one who loses the dominant hand, and he stands just as much chance of becoming a nonwearer. The remaining member often can be taught to perform many of the functions of the missing hand. If this situation is allowed to persist for long, the amputee begins to feel that prosthetic replacement is unnecessary.</p> <h4>The Education of The Physician</h4> <p>To the end that all upper extremity amputees shall be properly fitted and trained, it is imperative that the education of all physicians and ancillary medical personnel be continued and expanded. Current knowledge and new techniques must be passed on not only to those physicians and technicians who, because they are specialists, see amputees regularly but also to all general practitioners, especially to the family doctors who usually are first to see the amputee. The general practitioner must be brought to realize that new skills and devices are available to help his patients, and he also must be made aware of the fact that the longer assistance is delayed the more unlikely is the amputee to wear and use a prosthesis. Education must be carried to every level, ideally down to the county medical society, which in many instances is the only group in which the general practitioner can participate regularly. Information relating to amputee management should appear in <i>all </i>medical literature, for technical assistants also are responsible for extending any educational program devoted to the amputee. If complete success in total rehabilitation is to be expected, an amputee must be presented to the various specialized centers or clinics with the least possible delay after amputation.</p> <h4>The Education of the Amputee</h4> <p>Equal stress must be placed upon educating the amputee. If, for example, he has a short stump or some other problem requiring that he be fitted with a more complicated and hence less efficient device, the limitations of the prosthesis must be explained in detail. Too many patients are given the benefit of excellent surgery and fit but are not prepared for the shock that comes when they discover that the prosthesis is, at best, only a device to assist the remaining hand. Such a disappointment often produces discouraging results and sometimes complete failure. Many specialists and technicians are prone to be overenthusi astic about a particular prosthesis. What to them appears to be an excellent prosthesis well may be to the patient a hideous collection of bolts and ropes. As a result of some specialists' enthusiasm, many amputees envision a prosthetic device far more functional than actually is possible.</p> <p>When a patient is counseled for the first time, therefore, every effort should be made to point out all the factors involved in total rehabilitation. The limitations of the prosthesis should be explained at once, so that no false concepts or hopes are allowed to exist or to be perpetuated. Even if nothing more than a photograph is available, the patient should be shown a prosthesis similar to the one he eventually will use, and the necessity for training must be outlined so that the patient realizes that wearing the prosthesis and using it efficiently are two distinct functions. Many patients are astonished to find that training is necessary, and many look upon it as just one more stumbling block in an already confused amputee existence. Each step in the program must be explained fully, and the possible complications also must be outlined. Only in this way can the amputee be spared the bitter disappointments that often attend rehabilitation.</p> <h4>Training and Checkout</h4> <p>Adequate checkout procedures should assure efficient mechanical function as well as correct fit.<a></a> An inefficient cable system may, for example, render an otherwise satisfactory prosthesis so difficult or clumsy to operate that even the patient with a great desire to learn may find it impossible to use the device. The disinterested patient who does not appreciate the true value of prosthetic replacement may seize upon such a situation as the final excuse to give up training completely.</p> <p>Prosthetic training and final checkout complete the patient's initial steps toward rehabilitation, but unfortunately training can be responsible for failure. Therapists must be sympathetic with the patient's initial efforts, but they also must be firm in developing adequate control before actual use of the prosthesis is attempted. The patient's first desire after receiving the prosthesis is "to do something with it," and time spent in learning control techniques may seem worthless to him. Here again explanation of the reasons for the training steps is essential.</p> <p>If the patient is unable to demonstrate adequate control skill in a reasonable time, it often is wise to postpone or slow the training process rather than to provoke marked frustration in both patient and therapist. In such instances it is important that the therapist keep the prosthesis until sufficient basic skills are developed by the patient. If the amputee is permitted to wear the device immediately, he is likely to develop inefficient and sometimes weird methods of operation, thus negating all of the valuable time expended in fabrication and fitting. It is essential, however, that the patient understand the reasons for his sometimes difficult and slow progress in training and why it is necessary for the therapist to retain the prosthesis until basic skills are achieved.</p> <p>In some clinics there are to be found a standard below elbow and a standard above elbow prosthesis with split and laced sockets to permit adaptation to many different kinds of stumps. These so called "standard" prostheses are used in early training to prepare the patient for efficient operation of his prescribed prosthesis. When used with proper care and reasonable patient selection, they serve a valuable purpose, but such a procedure may be unwise if the training arm cannot be adjusted readily to the individual patient or if it contains undesirable components. Attempts to use an ill fitting training arm may be so difficult that the patient becomes discouraged and anticipates the permanent prosthesis with misgivings. Accordingly, training arms should be used only on the advice of the clinic team. Too much training can be as harmful as too little. The higher the level of amputation the less functional usefulness can be derived even from the best prosthesis. Realization of this circumstance can prevent the hypertensive episodes that occur in patient and therapist alike when too much is demanded of the amputee prosthesis combination. There is no personal defeat when, as is often the case, it must be admitted that the prosthesis can serve only as a "helper" hand. Under such circumstances, training, to be effective, must be guided appropriately. Overtraining only discourages the patient whose level of amputation is a basic factor in determining the degree of prosthetic function. Achievement tests should be used to measure and record the patient's progress and final skills, but such tests vary from level to level and from patient to patient and can serve only as a crude measuring stick, not as the final criterion as to whether or not a patient has achieved the maximum benefit of training. The answer to that broad question can come only with careful observation of the patient during activities of daily living and of vocational pursuits.</p> <h3>Conclusion</h3> <p>From these considerations, it is possible to formulate certain basic rules for the management of the upper extremity amputee. It is important first to know as much as possible about the patient besides the fact that he is missing a hand. It is necessary to understand him and to understand his disability. Too much faith must not be placed in the absence of either a so called "dominant" or "subdomi nant" hand as the sole measure of disability. In addition, the patient must be made to understand what is in store for him. Above all, no questions about any phase of his problem should be left unanswered. In some instances the amputee is reluctant to discuss problems not relating directly to his amputation, and the physician should be certain that, aside from the amputation, there are no other physical or mental problems that may affect total rehabilitation.</p> <p>For psychological as well as physical reasons, the patient should be fitted as rapidly as possible. Early fitting allows the amputee to realize the advantages and limitations of his prosthesis. Moreover, early fitting often eliminates the danger of the patient's coming to think that he can get along with one hand a situation which can complicate and prolong total rehabilitation. Finally, because overtraining can be just as harmful as are all the other "don'ts" of amputee management, no attempt should be made to train the patient to do more things than the level of his amputation and the nature of his prosthesis permit.</p> <p>When all of these individual problems are considered systematically by the respective members of the clinic team, over all management of the upper extremity amputee becomes a synthesis of cooperative effort. In no other way can so much success and satisfaction be afforded both the patient and those charged with his care.</p> <p><b>References:</b></p> <ol> <li>Abt, Lawrence Edwin, <i>Psychological adjustment of the amputee</i>, Chapter 5 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Bechtol, Charles O., <i>The principles of prosthetic prescription</i>, Chapter 6 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Bechtol, Charles O., <i>The prosthetics clinic team</i>, Artificial Limbs, January 1954. p. 9.</li> <li>Carlyle, Lester,<i> Artificial arm checkout procedures</i>, Artificial Limbs, January 1954. p. 25.</li> <li>Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, <i>Experiments on pain referred from deep somatic tissues</i>, J. Bone and Joint Surg., 36A:981 (1954).</li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs</i>,Chapter 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Jampol, Hyman, and Jerry Leavy, <i>Training the upper extremity amputee</i>, Chapter 23 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw Hill, New York, 1954.</li> <li>Kuitert, J. H., and F. E. Vultee, <i>Prosthetic training for the upper extremity amputee with cineplasty</i>, Arch. Phys. Med. and Rehab., 34:367 (1953). </li> <li>University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Studies relating to pain in the amputee</i>, June 1952.</li> </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">Carlyle, Lester, Artificial arm checkout procedures, Artificial Limbs, January 1954. p. 25.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Jampol, Hyman, and Jerry Leavy, Training the upper extremity amputee, Chapter 23 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Kuitert, J. H., and F. E. Vultee, Prosthetic training for the upper extremity amputee with cineplasty, Arch. Phys. Med. and Rehab., 34:367 (1953). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The principles of prosthetic prescription, Chapter 6 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bechtol, Charles O., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Feinstein, Bertram, John N. K. Langton, R. M. Jameson, and Francis Schiller, Experiments on pain referred from deep somatic tissues, J. Bone and Joint Surg., 36A:981 (1954).</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs,Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Abt, Lawrence Edwin, Psychological adjustment of the amputee, Chapter 5 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">Bechtol, Charles O., The prosthetics clinic team, Artificial Limbs, January 1954. p. 9.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Frederick E. Vultee, Capt., USA (MC) </b></td></tr><tr><td class="clsTextSmall">Physical Medicine Service, Walter Reed Army Hospital, Washington, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_02_036/1955-MayOCRBatch-31.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_036/1955-MayOCRBatch-32.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_036/1955-MayOCRBatch-33.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 Problems in the Management of Upper Extremity Amputees Creator An entity primarily responsible for making the resource Frederick E. Vultee, Capt., USA (MC) * https://staging.drfop.org/files/original/1bfbe5548da1f1f787c5f9b69ac77ae4.pdf 11ca54b65800177402546316e1352c8c https://staging.drfop.org/files/original/802ddce4e368ab0f321e2bdc98173842.jpeg 69d07f495f9362b3076d7c0c53fec5da https://staging.drfop.org/files/original/d017fceacd06924dce3634293e3e615b.jpg 97c81669de828d6ffc77b59c510d05c2 https://staging.drfop.org/files/original/f23d96f97d854059d735a6faad5512bf.jpg c266c715736592a367b2d55d47b3a24d https://staging.drfop.org/files/original/96f6e7ec405077c1caca5aedbaa75f75.jpg 3f17afffe7cbfb411e498760677497e4 https://staging.drfop.org/files/original/a98c8f64d3c51b152bb32d0b1711eb89.jpg 867a3d79bedf809260590f74ce87e77e https://staging.drfop.org/files/original/116b9b3e583ae10ac88748d7f2091f23.jpg b664cf731070925b4db7aecacdf2b205 https://staging.drfop.org/files/original/8ce37ee8d1e152a826a64cddbff91402.jpg 13d16f86a53a7698aab3c0bf5c088144 https://staging.drfop.org/files/original/7f4d31c4953101fb3dac69063e9fd876.jpg d103dfa8fc9520418b1e36fdf51a7b1d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1979_01_004.pdf Text Any textual data included in the document <h2>Prosthetic principles in bilateral shoulder disarticulation or bilateral amelia</h2> <h5>G. Neff&nbsp;<a style="text-decoration: none;">*</a></h5> <blockquote> <p><i>The following article by Dr. Neff originally appeared in German in the November 1978 issue of Orthopaedie Technik. At the suggestion of Siegfried Paul we had the article translated for publication of the Newsletter because it seems to supplement the material on external power included in earlier issues of the Newsletters. As we were about to begin editing the rather literal translation provided by the commercial service, Volume 2, Number 3, of "Prosthetics and Orthotics International" arrived and we were pleased to see that it included an excellent English version of Dr. Neff's article. Accordingly with permission from the editors of both journals we are pleased to provide the readers of Newsletter the English version developed by the International Society for Prosthetics and Orthotics.</i></p> <p><i>This article is presented not with the idea that the hardware shown is available for use, but rather to provide the readers of this publication with the findings of a very experienced clinical team as given in the discussion.</i></p> <p><i>A. Bennett Wilson, Jr.</i></p> </blockquote> <p><i>Based on a paper presented at the Second World Congress, ISPO, New York, 1977.</i></p> <h3>Abstract</h3> <p>Following a brief survey of the historic development of pneumatic prostheses the actual principles of prosthetic management in bilateral shoulder disarticulation or bilateral amelia are explained.</p> <p>The active functions are restricted to active pronation and supination, active gripping of the terminal device "hook" or "hand", combined with pneumatic locking of free swinging shoulder and elbow joints in one artificial arm; the cosmetic arm provides only space for the power package in the resin socket of the upper arm. Both arms are suspended on a Simpson frame.</p> <p>Thus optical control is concentrated on the movements of the functional arm. The reduction of valve control makes prosthetic training and use easier.</p> <p>Recently hybrid systems came into use because electric power proved superior to pneumatic power for pronation and supination and gripping, whereas CO₂ is still necessary for locking the elbow and the shoulder joint. The accumulator can be recharged daily at a plug socket, the CO₂ container need only be refilled after one or two weeks ensuring more independence for the disabled. The advantage of such a prosthesis is the better appearance in public combined with a certain functional use.</p> <p>However only intensive foot training without prostheses provides independence in daily activities, because even sophisticated prosthetic systems cannot make up completely for body loss.</p> <h3>Introduction</h3> <p>Whereas an amputee with shoulder disarticulation and one healthy upper limb generally finds a cosmetic prosthesis without active functions adequate, there is an obvious problem in the fitting of cases of bilateral disarticulation or congenital absence of both upper extremities with functionally satisfactory prostheses. No unexplored possibilities remain for the body powered positioning of artificial arms and for opening and closing the terminal device "hook" or "active hand"; so external power for a functional prosthesis becomes indispensable.</p> <p>In 1948 the first experiments with CO₂ driven pneumatic prostheses were undertaken by Hafner and Weil; CO₂ was used as a safe, easily controllable, easily applied and at the same time cheap propellant. In 1957 Marquardt and Hafner first fitted a child with bilateral amelia of the upper limbs with pneumatic prostheses.</p> <p>The initial aim of the most extensive motorisation possible of both prostheses rapidly proved itself inexpedient. The absence of suitable body parts for operating the control valves and the limited capacity of coordination, even in the most intelligent patients, was opposed to the increasing number of necessary control signals. The insufficient sensory "feedback" necessitated an exclusively optical control over the actions of the terminal devices. The independent use of each prosthesis at the same time beyond a small, optically controllable area was bound to fail for this very reason. The heavy weight and increasing energy consumption required finally led to reflection on the practicability of such "fully motorised" prosthetic systems. As a consequence there was a step by step reduction to the necessary functions and the improvement or new development of better suitable fittings.</p> <h3>Present practice</h3> <p>Partly manufactured by the industry and partly handmade in our own workshops the following pneumatically driven modular parts are available today:</p> <ul> <li> <p>a hook for children,</p> </li> <li> <p>a hook for teenagers,</p> </li> <li> <p>the pneumatic Otto-Bock-system hand,</p> </li> <li> <p>joints for pronation and supination,</p> </li> <li> <p>an active pneumatic elbow joint with lock,</p> </li> <li> <p>a free mobile elbow joint with pneumatic lock,</p> </li> <li> <p>for children, a free swinging shoulder joint manufactured from a standard modular elbow joint with pneumatic lock and extremely small CO₂ consumption combined with a friction joint for abduction,</p> </li> <li> <p>for older children and teenagers a free swinging shoulder joint with pneumatically lock-able forearm linkage.</p> </li> </ul> <p>The philosophy of prosthetic fitting of such seriously disabled patients, as described by Marquardt, is based on the idea that the prosthesis is only to be prépositioned, that is, a rough adjustment is obtained and held. Fine coordination is achieved by body movements, for example by bringing the mouth to the cup or to the spoon, which is already prepositioned with the prosthesis within the range of the body movements (<b>Fig. 1</b>).</p> <strong><a href="/files/original/802ddce4e368ab0f321e2bdc98173842.jpeg">Fig. 1.</a> Prepositioned prosthesis permits the patient to bring the mouth to the spoon.</strong><br /> <p>Connected with this is the reduction of prosthetic technique to the minimal yet indispensable functions. The dominant side is provided with a functional arm for active use. The opposite side is fitted with a cosmetic arm without active functions; in the moulded resin socket of its upper arm the CO₂ storage cylinder is accommodated. The functional arm has at its disposal:</p> <ul> <li> <p>a free swinging, pneumatically lockable shoulder joint,</p> </li> <li> <p>either a free or pneumatically movable elbow joint, in both cases pneumatically lockable,</p> </li> <li> <p>a pneumatic joint for active pronation and supination,</p> </li> <li> <p>a pneumatic "hook" or a pneumatic "system hand" (if possible interchangeable) for active gripping.</p> </li> </ul> <p>The cosmetic arm of the opposite side has only a free swinging shoulder joint and a passively adjustable elbow friction joint. Occasionally the hand of the cosmetic arm may be additionally pneumatically activated to allow a certain amount of hand to hand coordination. Both artificial arms are suspended on a Simpson frame (<b>Fig. 2</b>), which has replaced our former frame constructions (<b>Fig. 3</b>) due to its reduced weight and superior confort in wearing.<br /><br /><strong><a href="/files/original/d017fceacd06924dce3634293e3e615b.jpg">Fig. 2</a>. Prosthetic system with active arm on the right side with pneumatically lockable shoulder and elbow joint, pneumatic pronation and supination and pneumatic hand; on the left side, a free swinging shoulder and elbow friction joint, and built-in CO₂ storage cylinder in the upper arm. Both arms are suspended on a Simpson frame.</strong></p> <strong><a href="/files/original/f23d96f97d854059d735a6faad5512bf.jpg">Fig. 3</a>. Former frame construction for pneumatic prostheses for a child with phocomelic upper limbs.</strong><br /> <p>The individual functions are controlled by means of valves. For locking or unlocking of the free swinging shoulder and the elbow joints, flip-flop valves have proved successful since in these the pressure points are clearly defined. The pronation and supination of the forearm is controlled by means of a doublepoint pressure valve, situated above the acromion, or by a doublepoint traction valve, operated by a shoulder strap while lifting the shoulder (<b>Fig. 4</b>). The opening and closing of the gripping device is effected by activation of a flip-flop valve in front of the shoulder.</p> <strong><a href="/files/original/96f6e7ec405077c1caca5aedbaa75f75.jpg">Fig. 4</a>. Detail of doublepoint pressure valve in front of the shoulder and doublepoint traction value fitted to the Simpson frame.</strong><br /> <p>The few active functions can be easily controlled and, in general, learning problems in prosthetic training do not occur. The optical control is directed exclusively towards the activity of the functional arm. Energy consumption is limited, the contents of a CO₂ container, corresponding to about 500 actions, is sufficient for a normal day's use, as shown by experience. The weight of such a complete prosthetic system for a 10 year old child is about 1750 g with a pneumatic hook and about 1950 g with an Otto-Bock-system hand.</p> <p>One thing which remains unsatisfactory, is the dependence on refilling the CO₂ storage container carried in the prosthesis from a stationary CO₂ pressure cylinder by means of a reduction valve and a special adaptor. With regard to this inconvenience electrical power from batteries or from rechargeable accumulators has proved superior to CO₂ pneumatics.</p> <p>On this account we changed over to electromechanical prostheses. The first patients were children with phocomelic upper limbs; their forearmlike prostheses were attached to a modified "Ring-bandage" instead of the uncomfortable stiff frame, permitting maximum freedom of movement (<b>Fig. 5</b>). The phocomelic limbs were fitted into the moulded resin sockets in such a way as to give the impression of an actively movable elbow joint and to enable the fingers to operate microswitches which in turn controlled the electromechanically driven hands (<b>Fig. 6</b>). The result was an improvement upon wearing comfort, cosmetic appearance and function.</p> <strong><a href="/files/original/a98c8f64d3c51b152bb32d0b1711eb89.jpg">Fig. 5</a>. Recent prosthetic fitting of a phocomelic girl with electromechanical prostheses and suspension on a modified "Ringband-age"; Hosmer outside locking for elbow joints. Extreme right, cosmetic result.</strong><br /><br /><strong><a href="/files/original/116b9b3e583ae10ac88748d7f2091f23.jpg">Fig. 6</a>. Microswitch which is operated by the movements of the one finger phocomelia.</strong><br /> <p>For the reasons mentioned above it seemed sensible to convert also the prostheses for patients without arms to electrical power. So far, however, no comparably efficient electromechanically lockable shoulder and elbow joints have been developed. Thus in the meantime, we are developing hybrid systems which exploit the advantages of the pneumatic as well as of the electrical external power (<b>Fig. 7</b>).</p> <strong><a href="/files/original/8ce37ee8d1e152a826a64cddbff91402.jpg">Fig. 7.</a> Hybrid prosthesis in bilateral amelia with pneumatically lockable shoulder joint (controlled by valves in the left side) and pressure and traction microswitches for gripping and forearm rotation. Built-in accumulators fitted to the frame of the right upper arm.</strong><br /> <p>The shoulder and elbow joint of the functional arm is pneumatically lockable as before. The CO₂ consumption for these actions is extremely small; the volume of the container carried in the prosthesis is now sufficient for one or two weeks, according to the amount of use, assuring greater independence from the stationary energy reservoir at home. The energy consuming functions, such as pronation and supination and gripping movements, are electrically driven. The accumulator can be recharged at the nearest, most convenient plug socket or, with little interruption in prosthetic use, it can be exchanged for a charged second accumulator. In our experience this hybrid system can be most recommended.</p> <h3>Discussion</h3> <p>In spite of these improvement excessive enthusiasm concerning the extent of functional use of such prostheses in daily life is out of place. Their actual value lies in the indisputable "normalization" of the patient's appearance in public (one should perhaps say: <i>for</i> the public), combined with an optimizing of the functional possibilities of such prostheses by exploiting the technical knowledge available today. Therefore an intensive training in daily activities without prostheses is also essential. Besides simple technical aids, as for example, an eating aid attached to and moved by the leg, foot training is of the utmost importance, especially for overcoming daily recurring problems not only in toilet use, dressing and undressing, washing (<b>Fig. 8</b>), combing hair, teeth cleaning, but also in eating, drinking and in writing (with or without typewriter). Not only can many things be <i>handled</i> better with the feet but functional independence of (meaning freedom <i>from</i>) the prosthesis-at least at home in privacy-releases the patient from the unpleasant feeling to be capable of living only as a "perfect operator of a sophisticated prosthetic robot". This consideration should be uppermost in the mind while prescribing such a costly AID: it protects against the over-evaluation of technology and the concomitant under-evaluation of the individual, whom the technology should serve.</p> <strong><a href="/files/original/7f4d31c4953101fb3dac69063e9fd876.jpg">Fig. 8.</a> Result of self-care foot training, independence from prostheses in daily activities at hom</strong>e.<br /> <p><em>*Developed by H. Kramer, Research Lab. of the Dept. for Dysmelia and Technical Orthopaedics, Heidelberg University</em>.</p> <p><b>References:</b></p> <ol> <li>Marquardt, E. and Hafner, O. (1956). Technische Bewahrung und prakhische. Anwendung der Heidelberger pneumatische Prosthese. <em>Archiv fur Orthopadische und Unfallchirurgie</em> 48,115-135.</li> <li>Marquardt, E. (1957). Muskelsteuerung von pneumatischen Unter-und Oberarmprothesen. <em>Archiv fur Orthopadische und Unfallchirurgie</em>, 49,419-426.</li> <li>Marquardt, E. (1965). Erfahrungen mit pneumatischen Prothesen. <em>Verh. Dtsch. Orthop. Ges.</em>, 52, 346-352.</li> <li>Marquardt, E. (1974). Pneumatische Prothesen, Eigenkraftprothesen und technische Hilfen fur schwere Armfehlbildungen in:¹⁰<em>Jahre Entwicklung und Erprobung von Hilfen und Hilfmitteln fur behinderte Kinder</em>. Hrsg.: AG Technische Orthopadie und Rehabilitation, R. Schunk Verlag, Konigshofen.</li> <li>Neff, G. Marquardt, E. (1977). Stand der Versorgung mit pneumatischen Prothesen in: <em>Amputation und Prothesenversorgung bein King</em>. Ed.: R. Baumgartner, F. Enke Verlag, Stuttgart.</li> <li>Neff, G. (1978). <em>Prinzipien der prothetischen Versorgung nach beidseitiger Schulterexartikulation oder bei beidseitiger Amelie Orthopadie-Technik</em>, (In press.).</li> <li>Simpson, D.C. and Kenworthy, G. (1973). Entwurf eines voll-stangigen Amersatzes (Teil 2) <em>Orthopadie-Technik</em>, Feb. 41-44.</li> </ol> <em><b>G. Neff<br /></b>Orthopädische Universitätsklinik, Tubingen</em><br /> <div style="width: 400px;"></div> Page Number(s) 4 - 7 Year 1979 Volume 3 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1979_01_004/1979_01_004-8.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prosthetic principles in bilateral shoulder disarticulation or bilateral amelia Creator An entity primarily responsible for making the resource G. Neff * 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/f705a88b62579919ebd280734cc87c01.pdf b9eacb74fddcfd81decdd065a6705fdd https://staging.drfop.org/files/original/e05b257845dff7213c7f075b57cf5fcc.jpg bd523911342105f9a2128e78a1aeb6cb https://staging.drfop.org/files/original/11cd3f8a84385221430f3e8c6b68d7a8.jpg b96e00d451e355e664197cf1f6c096b8 https://staging.drfop.org/files/original/81be0b0e594f36536b95cc888ea0798a.jpg 23da1b6dc1872b1b5797b235a956b7c7 https://staging.drfop.org/files/original/3791a0eb792a4d25c7f40b60c75e5b2d.jpg bad29a39e144a9990815beb05f7bbdc6 https://staging.drfop.org/files/original/a2c4d5480f72caa73d1807874cb70fce.jpg 8a15ca8c6b8342bd3cf706868a599486 https://staging.drfop.org/files/original/6f0562d37d37b957ceba489c2e2ca39b.jpg 96e365de47b09be1e0e2dd80223633ac https://staging.drfop.org/files/original/b01cfe724a87500df31cadb5038854e7.jpg bddf845abdebf1a394bf9fd15257f9db https://staging.drfop.org/files/original/3de6676506062bef75f71a38287a7578.jpg 2445d12e95b2289f26c3cbd6f2a18c05 https://staging.drfop.org/files/original/74f77a4af134297887250161d208c62c.jpg 8c549b1b71dbc8c982018a1cee1545fb https://staging.drfop.org/files/original/070812cad4152c89454a35f884e2e3e9.jpg 2a7a6bb1dd1ed4f8098878287bc3d4e8 https://staging.drfop.org/files/original/a2fe1d3281087c6ce407dd3a40dd4c21.jpg f1f8ea956fc5d035040e0eefd468e990 https://staging.drfop.org/files/original/5cab3bf9dca0d59b832e1adb6cb078dd.jpg b7419f891e57061df0c34997b04d0bd5 https://staging.drfop.org/files/original/70128bff2c284b7089ab9d7941dd8170.jpg 3cf6e7ffb74689f5ef7610709e4932dd https://staging.drfop.org/files/original/35d21b8cabb98a340036e5d94c747608.jpg 4372e34ed61e9169c31341fc400b42d2 https://staging.drfop.org/files/original/8e48f7a2f951dd4704f7f69bc1d7c09c.jpg e1364dfabd6d579d4acd84dc43569812 https://staging.drfop.org/files/original/53aa38977adfa885dd4446a080079bea.jpg 047c02beb59db92227b8a507b687614f https://staging.drfop.org/files/original/680e550c3416ad1257bf7172cd07a96b.jpg 0dbe82e84dd46cc9172de94cf4cb754c https://staging.drfop.org/files/original/0018b73701a2a03adb1202951eb9890e.jpg 2bd534a213d889b949b9f5e556cdf482 https://staging.drfop.org/files/original/341143f786b503326091116f2cafa449.jpg af22ca80378e8cdccdf571b5f1d5e0ad DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_01_065.pdf Year 1970 Volume 14 Issue 1 Page Number(s) 65 - 72 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1970_01_065.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_01_065.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Direct Forming of Below-Elbow Sockets</h2> <h5>Gennaro Labate <a style="text-decoration:none;">*</a><br />Thomas Pirrello <br /></h5> <p>The following equipment and materials are required for this direct-forming procedure:</p> <ul> <li> Polysar<a style="text-decoration:none;">*</a> X-414 tubing</li> <li> Hot plate (thermostatic control optional)</li> <li> Tote pail and cover (height 22 in.; diameter 10 in.)</li> <li> Rubber casting sleeves</li> <li> Silicone spray</li> <li> Manila folders</li> <li> Pressure-sensitive tape</li> <li> Trichloroethylene</li> <li> Heat gun and adapter</li> <li> Cosmetic covers</li> </ul> <p>All the prosthetics information required to fabricate a conventional socket is necessary for forming a socket with Polysar synthetic rubber.</p> <p> 1. A rubber sleeve that will best conform to the stump is selected. (The three sizes which will accommodate most below-el-bow stumps are 3 in. x 6 in. x 14 in., 3 1/2 in. x 6 in. x 14 in., and 4 in. x 6 in. x 14 in.) The rubber sleeve is pulled snugly over the stump, and the proximal end is fastened with Yates clamps to a figure-eight harness. The sleeve is lubricated generously with silicone spray. <b>Fig. 1</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 2. Tubing whose circumference 2 in. from the distal end is closest to <i>but less than</i> the circumference of the stump is selected. (The three tube sizes which accommodate most below-elbow stumps are 4 3/4 in., 5 1/2 <i></i> in. and 6 1/4 in.) The tubing is cut 3 in. longer than the measurement from the lateral epicondyle to the stump end. The inner surface of the tube is cleaned to remove loose particles. <b>Fig. 2</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 3. The tube is immersed in water heated to approximately 180 deg F. (The tube may float when it is completely soft and ductile.) <b>Fig. 3</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 4. The softened tube is removed from the water and the entire inner surface is lubricated with silicone spray. <b>Fig. 4</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 5. After the tube has cooled to skin tolerance, it is drawn up on the stump to a point where the proximal brim is about 1 in. above the olecranon. <b>Fig. 5</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 6. The tube is encircled at the distal end of the stump with nylon cord, and the cord is gently pulled until the tubing conforms to the end of the stump and is completely sealed. <b>Fig. 6</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 7. The excess tubing is cut off close to the cord. <b>Fig. 7</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 7.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 8. The tube is molded on the stump to produce the desired contours. The working time is approximately 5 minutes. <b>Fig. 8</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 9. While the tubing is still soft, a trim line is marked according to the socket plan and the tube is trimmed. The socket is cooled before removing it from the stump: the covered stump is immersed in cold water, and hand and finger pressure are used to maintain the socket contours while it is immersed. <b>Fig. 9</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>10. The socket is removed from the stump and trimmed to its final shape. Large areas requiring reshaping may be resoftened by immersion in hot water. Smaller areas may be softened by use of a heat gun and reshaped on the stump. (When using a heat gun on Polysar X-414, it is advisable to use a conical adapter.)</p> <p> 11. The forearm extension is made over a manila folder formed into a conical tube, incorporating the desired wrist fitting. The length of the tube is equal to the epicon-dyle-to-ulnar-styloid measurement. The tube is adjusted so that the proximal end flares into the socket approximately 3 in. over the distal end. <b>Fig. 10</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 12. A length of Polysar tubing is cut approximately 2 in. longer than the manila tube and immersed in hot water until soft. <b>Fig. 11</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 13. A section of 2-in. stockinet which is twice the length of the Polysar tube is pulled through the softened tube. <b>Fig. 12</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 14. With the stockinet used as a "pull sleeve," the softened tube is pulled down until the proximal edge overlaps the proximal end of the manila tube by 1 in. The tube extension is cooled by immersion of the entire assembly in cold water. <b>Fig. 13</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>15. Realignment reference lines are marked on both the socket and the extension, and the extension, manila tube, and wrist fitting are removed.</p> <p>16. The socket surface covered by the extension is sanded lightly, and the socket and the extension are wiped with trichlo-roethylene.</p> <p> 17. The extension tube is replaced on the socket and realigned according to the reference lines. The proximal 3 in. of the extension are heated until soft. <i>(The socket is not allowed to become soft.)</i> The softened end of the extension is compressed until it adheres evenly to the socket, then the socket and extension are immersed in cold water. <b>Fig. 14</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 18. The epicondyle-to-ulnar-styloid measurement is checked, and the extension is trimmed if necessary. <b>Fig. 15</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 15.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 19. One inch of the distal end of the extension is immersed in hot water until soft. The wrist fitting is inserted into the softened extension and the tube compressed around the wrist fitting with pressure-sensitive tape. The alignment is again checked and adjusted if necessary, and the tube is cooled in cold water. <b>Fig. 16</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 16.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 20. The extension and socket are flared by sanding. The wrist fitting is secured with four 3/8-in. #6 self-tapping pan-head sheet-metal screws. <b>Fig. 17</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 17.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>21. The proximal socket brim is buffed with a felt wheel and wiped with trichlo-roethylene to produce a smooth surface.</p> <h4> <i>Finishing</i> </h4> <p> Below-elbow prostheses fabricated with synthetic-rubber sockets are best finished with prefabricated flexible cosmetic covers. Although the sockets may also be finished by conventional laminating procedures, laminates tend to reduce the yielding property of Polysar X-414, and therefore are not recommended. Three cosmetic coverings are illustrated: contoured vinyl sleeve, armlet stockinet, and tubular rubber sleeve. <b>Fig. 18</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 18.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The contoured vinyl sleeve (A) is pulled over the arm after softening in hot water. The cover is trimmed approximately 1/4 in. above the proximal socket brim. </p> <p> The armlet stockinet <i>(B)</i> is sewn closed at the unfinished end. A small opening in the sewn end is made to accommodate the threaded stud of the terminal device. The armlet is pulled over the prosthesis. (The proximal end is not cut.) </p> <p>The tubular rubber sleeve (C) must be bonded to the prosthesis, as follows.</p> <p> 1. A length of 3-in. stockinet is used as a "pull sleeve." The stockinet is inserted into a rubber sleeve cut one and one-half times the length of the prosthesis. <b>Fig. 19</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 19.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 2. The stockinet is pulled over the prosthesis until the rubber sleeve extends 1 in. past the proximal socket edge. <b>Fig. 20</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 20.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 3. Approximately half of the rubber sleeve is rolled back, and the stockinet is trimmed. <b>Fig. 21</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 21.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 4. The exposed portion of the socket is coated with rubber cement, and the rubber sleeve is unrolled while the cement is still wet. <b>Fig. 22</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 22.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> 5. The cementing procedure is repeated at the proximal end after removal of the remaining stockinet. When the cement is completely dry, the excess rubber sleeve is trimmed. <b>Fig. 23</b> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 23.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> <i>Hinges and Transmission System</i> </h4> <p>Metal or leather joints are aligned and fastened with Speed rivets. All other components are installed in the conventional manner.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Registered trademark of th ePolymer Corporation Limited.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Gennaro Labate </b></td></tr><tr><td class="clsTextSmall">Veterans Administration Prosthetics Center, New York, N.Y.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1970_01_065/tmp39B-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Direct Forming of Below-Elbow Sockets Creator An entity primarily responsible for making the resource Gennaro Labate * Thomas Pirrello  https://staging.drfop.org/files/original/4699d64d3df5994ef8f7e1b85cd99959.pdf b3917f4e00ca2ab8d8c25b3f49862b6e https://staging.drfop.org/files/original/e5ce76adfd45dd6f57b618d54dde10ad.jpg 73269599a0739d162dabc155d43ed468 https://staging.drfop.org/files/original/743b5e834a6bd64136a8729f21c07d13.jpg 94ba2e4204849d17989659f400598a78 https://staging.drfop.org/files/original/36ae3ca908bc73b7f24e244440dda104.jpg f928a27eaaee312841c942cf30496ae1 https://staging.drfop.org/files/original/b65a0390d93c0160d55cc411ff05f1d9.jpg a2f12631b5934dca4d2cffbe177994eb https://staging.drfop.org/files/original/a366ac4453ec47ff2c58896dcaaeed9f.jpg 4d4b69bb9323ba6d1e82d72ee69e7b11 https://staging.drfop.org/files/original/404e9dfeeaf0ddf28ee6cc9724a164be.jpg b7cf2d1829b06c77f60ad53a56ea1532 https://staging.drfop.org/files/original/1b6b21650828332a841575640ebd49c2.jpg b97764b21b3f5e2eb36440de368b7a9e https://staging.drfop.org/files/original/69921ae973886707c7f19d0b0ad8d958.jpg 11567fa8743e3ca28c329197914c2b13 https://staging.drfop.org/files/original/cb3f332ee038c22ea975988c0684ce58.jpg 069149801aa269a87db508949da51d8f https://staging.drfop.org/files/original/924b2334c44029327c1b7924cb3fe7ac.jpg ffebb08a2dd20782db4a706e97eb0c18 https://staging.drfop.org/files/original/667fb5c153d80c36866d27fd5fd55700.jpg 6682288306bc4940fe68f83b9b600f51 https://staging.drfop.org/files/original/f078c25d734e44df7cc68fc2991aaa1e.jpg a46a3f90736de24584111c8e3b4dd414 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_027.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 27 - 36 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1969_01_027.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_027.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Causes of Death in a Series of 4738 Finnish War Amputees</h2> <h5>Georg Bakalim <a style="text-decoration:none;">*</a><br /></h5> <p>The loss of a limb and its replacement by a prosthesis create conditions deviating from the normal. Walking is always more difficult. Loon <a></a> found that the energy consumption of amputees increases with the level of amputation. In the case of an above-knee amputation the effort of walking is greater than in a be-low-knee amputation and, in cases of hemipelvectomy and disarticulation of the hip, energy requirements are still greater. In the same investigation, it was found that walking with crutches, without a prosthesis, requires more energy than walking with a prosthesis. In addition, it appeared that in the presence of disturbances in the stump that affect walking, the consumption of energy increases. A poorly fitted prosthesis has the same effect. During walking, the center of gravity should shift smoothly, not in a jerky way that makes it more difficult to maintain balance. Almost all amputees experience excessive sweating not only of the stump but in general. The tightly fitted socket and the thigh corset used in connection with the old, conventional type of below-knee prosthesis are contributory causes of sweating.</p> <p>Owing to the loss of the weight and accompanying movements of the amputated limb, upper-extremity amputees find it more difficult to keep their balance in walking after amputation. Similarly, the strain on the remaining upper limb in lifting and carrying is greater than before. The increased consumption of energy taxes the circulation and the heart. In this connection, no further attention will be paid to the secondary changes in the weight-bearing structures, particularly the joints and spine, that result from the altered static conditions due to the loss of a limb <a></a>.</p> <p>The health of amputees has been the subject of many previous studies, <i>e.g., </i>those of Rausche, <a></a> Schneider, <a></a> Schulze, <a></a> and Bodechtel <a></a>. Meyer-ingh, Stefani, and Cimbal <a></a> reported a higher rate of hypertension in obese amputees than in amputees of average weight. In an electrocardiographic investigation of 1033 amputees, performed by the same authors, no differences were observed as compared with a normal series. Likewise, in a series of 1128 amputees obesity was not more frequent than in a corresponding group of the general population. <a></a> Loos <a></a> reported similar findings in a series of 647 cases. Solonen, Rinne, Viikeri, and Karvinen <a></a> observed no noteworthy increase in cardiac and vascular diseases in amputees.</p> <p>The purpose of this study was to find out whether death from degenerative cardiac and vascular diseases is more common among amputees than in the general population. At the same time tuberculosis, cancer, accidents, suicide, and miscellaneous causes of death were surveyed from the same standpoint.</p> <h3>Material</h3> <p>The series consists of 4782 war amputees. Data was collected from the files of the State Insurance Department. Finger, hand, toe, and foot amputations have been omitted since these cause no major problems. Before the end of 1944, <i>i.e., </i>during the war, 44 amputees died. These cases are also considered in this study. The age distribution in this group was the same as in the remaining 4738 cases which have been followed up from 1945 till the end of 1965. The causes of death were obtained from the death certificates. During the last 10 years a steadily increasing number of cases have been examined postmortem. In case of a casualty, or when the cause of death is unknown, autopsy is invariably performed. As a rule, the autopsy records contain more than one diagnosis, but in this study only the main diagnoses have been utilized. Although many of the second diagnoses might have been of interest, taking them into account would have implied considerable technical problems and would have rendered the statistical treatment more difficult. Since 1945, 643 subjects have died. During the period 1940-1965 the total mortality was thus 687/4782 (14.4 per cent). The number of mortalities during each year is shown in <b>Fig. 1</b>. A steady rise is seen from 1960 onward. This increased mortality is not surprising, considering that more than 20 years have elapsed since the war and the mean age of the war veterans is about 50. However, this curve alone permits no conclusions to be drawn. In order to form an opinion concerning the mortality of the war amputees, the figures have to be compared to the death rates for the corresponding age groups of the general population.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Annual mortality of war amputees in 1940-1965. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Age And Occupation</h4> <p>For the main causes of death the distribution of the dead war amputees by 5-year age groups is given in <b>Table 1</b>. Mostly, the age groups 40-50 years show the highest mortality. However, for conclusions to be drawn concerning the health of the group under review, comparable data for a "normal" group is required. The occupations of the dead, differentiated mainly on the basis of training, are given in <b>Table 2</b>. In this connection the main interest attaches to the proportion of heavy laborers.</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>Farmers (177) and unskilled workers (230) constitute the largest groups. Heavy labor is represented by 72.6 per cent, light occupations by 27.4 per cent. The handicraftsmen number 74 (10.8 per cent). There are as many as 31 shoemakers, which is accounted for by the fact that training for this occupation was offered after the war.</p> <h4>Level Of Amputation</h4> <p>The level of amputation appears in <b>Table 3</b>. Finger, hand, toe, and foot amputations were not included in this series because the trouble caused by them is considered to be so slight that it cannot lead to vascular disease. Two amputees in the present series had Chopart stumps, one had a Pirogoff stump, and in six cases disarticulation of the wrist had been performed. The ratio of above-knee to be-low-knee amputations is 1:2.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Method of Comparison</h3> <p>The age distribution of the series followed up, exclusive of those who died before 1945, and the percentage figures for the corresponding age groups of the general Finnish male population are shown in <b>Table 4</b>. As may be seen in the table, the age distribution of the amputees differs widely from the age distribution of the general Finnish male population as obtained from the Statistical Yearbook of Finland. <a></a> For this reason, the death rates for the general Finnish male population could not be used as such for comparison with the mortality rate of amputees. It was necessary therefore to construct an equivalent, theoretical population with an age distribution corresponding to that of the amputees. The data required was obtained in part directly from the Statistical Yearbook, and in part by calculation based on the death rates for men and women and the sex ratio, or for the earlier years, on the total mortality and the age distribution of the dead, as indicated in the Statistical Yearbook. In the comparisons, it was deemed most appropriate to consider only the period from 1945 till the end of 1964. The amputees who died before 1945 numbered 44, and 71 died in 1965. When these 115 cases were subtracted from the total number of dead in the present series (687), 572 cases remained for the comparative analysis of mortality.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Mortality</h4> <p>As mentioned above, the total mortality for the period under review was 687/ 4782 (14.4 per cent). The causes of death are listed in detail in <b>Table 5</b>. The distribution according to the cause of death has been given in summary form in <b>Table 1</b>. Degenerative vascular diseases of the central nervous system and degenerative cardiac and vascular diseases have the same etiology but each forms a separate entity, and the Statistical Yearbook of Finland provides figures for comparison precisely on this basis. In addition, death rates were available for pulmonary tuberculosis, malignant diseases, accidents, and suicide, other causes falling into a miscellaneous group consisting of cases for which no comparative figures were found in the Statistical Yearbook. Many cases of poisoning and drowning were recorded under accidents. Alcohol abuse was a major etiological factor. It was sometimes difficult to decide whether the cause of death was an accident or suicide.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Comparison of Mortality of the Amputees and the General Population</h3> <p>In what follows, the total mortality is analyzed first and then the mortality in the various groups listed above is analyzed, except for the miscellaneous group for which no comparable data was available.</p> <h4>Total Mortality</h4> <p>On comparing the total number of deaths during the period January 1, 1945, to December 31, 1964, <i>i.e., </i>572, to the mortality of the general Finnish male population, the age distribution was taken into account in two different ways. In both methods, consideration was given to the fact that during the period under review the subjects passed into age groups with a lower expectation of life.</p> <p><i>Method I</i></p> <p>For each 5-year age group of amputees in <b>Table 4</b> (age distribution at the beginning of 1945), the expected losses for the 5-year periods 1945-1949, etc., until the beginning of 1965, were calculated on the basis of the expectations of life indicated in the Statistical Yearbook of Finland, that figure being used which pertains to the mean age of the age group during the period in question. To exemplify, for those who were aged 20-24 years at the beginning of 1945, the expectation of life at 25 years was considered as the relevant figure for the period 1945-1949, since the youngest in the group had survived for 20-24 years and the oldest for 24-29 years. Correspondingly, the expectation of life at 30 years was applied to the period 1950-1955, etc. The 5-year losses were calculated on the basis of the total number of survivors. In <b>Fig. 2</b>, the cumulative curve for the calculated losses from the level of 1945 is compared to the cumulative curve for the actual losses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Cumulative death rates-calculated for 5-year periods compared to cumulative expected death rates. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The recorded death rates for the <i>5-year age groups </i>are slightly lower than the expected figures, but the difference is statistically insignificant. The same obtains to the death rates as expressed by <i>5-year periods </i>(<b>Table 6</b>). The differences between the recorded and the expected figures are of the order of 10 per cent. The greatest differences relate to the periods 1950-1954 and 1955-1959, while for the periods 1945-1949 and 1960-1964, the recorded figures fall below the expected ones by about 2 per cent only.</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>Method II</i></p> <p>In the Statistical Yearbook of Finland, the number of survivors among 100,000 men of the same age is indicated. On the basis of these figures, the numbers of expected survivors in all age classes represented in this series at the beginning of 1945 were calculated for the end of the age periods 20-24 years, 25-29 years, etc., and the expected death rates in the various age groups were expressed as percentages. The expected total mortality by the end of 1964, <i>i.e., </i>549, is in very good agreement with the actual figure of 572. All the 687 deaths considered, the percentile distribution between the age groups corresponds fairly well to the expected distribution (<b>Table 7</b>, <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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Death rates for the different age groups compared to the expected death rates. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If the causes of death are disregarded, it may be stated that the mortality in the present series corresponds very closely to the mortality in the corresponding general population. This obtains to the figures for the various 5-year periods and the total mortality as well as to the figures for the age groups. There seems to be a tendency toward a lower mortality for amputees than in the general population, and, with regard to the age at death, it appears that among the amputees there may be a trend toward a lower age, though only by one or two years at the most.</p> <h4>Degenerative Egenerative Vascular Diseases of the Central Nervous System</h4> <p>The mortality in degenerative vascular diseases of the central nervous system was 64/687 (9.3 per cent). Traumatic cerebral hemorrhages of course do not belong to this group. Comparable data relating to the general population was obtained from the Statistical Yearbook of Finland, and expected figures were calculated for the period 1945-1964 in the same way with respect to the total mortality. The expected number of deaths in this group of disease was 37.4. The actual number (64) was 71.2 per cent higher. In the age groups 25-44 years the actual number of deaths was 130.9 per cent higher than the expected number; in the age groups 45-64 years it was 49.6 per cent higher; and in the age groups 65-74 it was 42.6 per cent higher (<b>Table 8</b>). No consistent trend is discernible with regard to the age at death.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Degenerative Cardiac And Vascular Diseases</h4> <p>This group includes cardiac infarction, pulmonary infarction, peripheral embolism, myodegeneration, cardiac insufficiency, and arteriosclerosis. The mortality in this group was 219/687 (31.9 per cent). The expected number of deaths in the general population was 134.3. The actual mortality was 63.1 per cent higher. As regards the different age groups, the actual mortality was 193.2 per cent higher than the expected in the group aged 25-44 years at death, 38.9 per cent higher in the group aged 45-64 years, and 28.6 per cent higher in the group aged 65-74 years (<b>Table 8</b>). One hundred and four amputees (47.5 per cent) died at an age of 45-54 years, 51 (23.3 per cent) at an age of 35-44 years, and 44 (20.1 per cent) at 55-64 years. The remaining 20 deaths (9.1 per cent) were evenly distributed between the age groups 25-34 and 65-84 years (<b>Table 1</b>).</p> <h4>Pulmonary Tuberculosis</h4> <p>The mortality in pulmonary tuberculosis was 70/687 (10.2 per cent). The actual mortality was found to be 24.9 per cent lower than the expected mortality (93.2 cases). In the group under 24 years of age the mortality was 172.7 per cent higher than the expected, while in the age groups 25-44 and 45-64 the actual mortality was 10.5 and 70.9 per cent lower, respectively, than the expected (<b>Table 8</b>).</p> <h4>Malignant Diseases</h4> <p>The mortality in malignant disease was 96/687 (14.0 per cent). The mortality was 19.6 per cent lower than the expected. In the age group 45-64 years the mortality was 21.1 per cent lower, and in the age group 65-74 it was also 21.1 per cent lower than the expected mortality. The frequency of malignant disease in different organs appears in <b>Table 5</b>. In none of the present cases was the disease a result of the amputation (<b>Table 8</b>).</p> <h4>Accidents</h4> <p>Accidents were the cause of death in 72/687 cases (10.5 per cent). The actual figures were in all age groups lower than the expected. In the age group under 24, the recorded number of deaths was 78.3 per cent lower than the expected mortality; in the group 25-44 years it was 36.2 per cent lower; in the group 45-64 years it was 24.1 per cent lower. The actual total mortality was 34.2 per cent lower than the expected. This group includes 17 (2.5 per cent) traffic accidents, but these could not be separately analyzed, because traffic accidents are not treated as a separate group in the Statistical Yearbook (<b>Table 8</b>).</p> <p>It thus appears that the mortality from accidents was markedly lower among the amputees than in the general population. It might have been expected that amputees would be more accident-prone both at work and in the traffic, owing to their poorer mobility. The small proportion of traffic accidents among the total number of cases is also striking. Obviously, the amputees move about less than the general population, work at less dangerous places, and are, perhaps, employed to a lesser extent owing to their reduced working capacity.</p> <h4>Suicides</h4> <p>Since about 80 per cent of the suicides are committed by men, it seemed reasonable to use this age distribution as a basis when the expected mortality was calculated in the same way as for the other causes of death. The actual figures for the periods 1955-1959 and 1960-1964 are 68.1 and 36.0 per cent higher than the expected figures. The total number of suicides (63) for the period 1945-1964 is 37.3 per cent greater than the expected number. The greatest difference is noted for the period 1945-1949, the recorded frequency of suicides being 3.6 times higher (260.0 per cent) than the expected (<b>Table 8</b>). By contrast, the figure for 1950-1954 is 73.4 per cent lower than the expected mortality. If these two 5-year groups are added together the difference by which the actual frequency of suicides exceeds the expected has changed to a decrease (-13.8 per cent).</p> <p>It appears that among amputees under 25 years of age, suicides were 300.0 per cent higher, and in the age group 25-44 years 53.8 per cent higher than was to be expected on the basis of the statistics for the general population. By contrast, the number of suicides committed by amputees aged 65-74 years was within 0.2 per cent of the expected figure. The total actual number of suicides exceeds the expected figure by a difference of 37.3 per cent (<b>Table 8</b>).</p> <p>In addition, the rate of suicides among the dead amputees with the same occupation has been calculated. In this respect there is no major difference between heavy labor and other occupations. Technicians have the lowest rate of suicide, those with unknown occupations the highest. With regard to the former, it may be pointed out that their occupation is highly suitable for amputees, while the latter group includes subjects without regular employment, who lived in poor social conditions.</p> <p>The possible relationship between the rate of suicides and the level and site of the amputation is analyzed in <b>Table 9</b>. Among lower-limb amputees the frequency of suicide was twice the frequency among upper-limb amputees. However, when the whole series is taken into account, the difference is not very great, the number of lower-limb amputees being double the number of upper-limb amputees.</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 methods of suicide appear in <b>Table 5</b>. Alcohol abuse was known to have played a part in 11 cases, and 6 subjects had used barbiturates in addition. This group of 63 consists of only sure cases of suicide. In the group of accidents, at least a slight suspicion of suicide was present in many cases.</p> <h3>Summary and Discussion</h3> <p>In a series of 4782 war amputees, the total mortality was 687 (14.4 per cent). The period covered by the present study is from 1945 till the end of 1965. In 1960, the mortality of the war amputees began to rise abruptly, and was one of the causes for undertaking this study. This mortality was compared to the mortality in the general Finnish male population. A theoretical, equivalent male population was constructed on the basis of data obtained from the Statistical Yearbook of Finland.</p> <p>When the causes of death were not differentiated, the mortality of the amputees was found to be in good agreement with the mortality of the general population. This obtains to both the whole series and the different 5-year periods. There was even a tendency towards slightly lower figures for the amputees.</p> <p>On the other hand, when the causes of death were differentiated, certain features of interest emerged. The recorded death rates were higher than the expected figures with regard to degenerative diseases of the central nervous system ( + 71.2 per cent), degenerative cardiac and vascular diseases ( + 63.1 per cent), and suicide (+37.3 per cent). These were the causes of death in half the cases. One-fourth of the deaths were due to pulmonary tuberculosis or malignant disease. In both these groups the actual death rate was lower than the expected ( - 24.9 per cent and - 19.6 per cent). In the age group under 25, the mortality in pulmonary tuberculosis was 2.7 times higher than in the corresponding group of the general population, but in all other age groups it was lower than the expected death rate. The number of deaths due to accidents (72) fell below the expected mortality by 34.2 per cent. Obviously, amputees move about considerably less than the general population, and they are less exposed to accidents owing to their limited working capacity.</p> <p>In order to give a general survey of the findings, the main causes of death are listed in <b>Table 8</b>. In addition to the number of deaths, the mortality in each group is expressed as a percentage. Likewise, the expected mortality is given both in absolute figures and as percentages, and the differences between the actual and expected figures are indicated in percentages. In this connection, it has been assumed that the total expected mortality is the same as the actual mortality, as was also suggested by the analysis of the total mortality carried out at the beginning of this study. The amputees seem to be more afflicted with fatal degenerative diseases of the central nervous system and fatal degenerative cardiac and vascular diseases, and suicides seem to be more common among them, as compared with the general population. On the other hand, the mortality from pulmonary tuberculosis, accidents, and a large group of miscellaneous diseases <i>(e.g., </i>various diseases of the lungs and abdominal disorders), was lower among the amputees than in the general population.</p> <p>It may be assumed that the higher frequency of suicides among the amputees is due in part to psychological causes connected with the loss of a limb. Also, a postwar depression may have become more pronounced with the lapse of time. Economic problems and poor social conditions may be regarded as contributory causes.</p> <p>In the care of amputees, the factors of importance are: a satisfactory prosthesis, good condition of the stump, rehabilitation, suitable employment, and judiciously administered subvention. The question arises as to whether all that could have been done for the war amputees was done. Perhaps something had been neglected that could have prolonged the lives in some cases.</p> <p><b>References:</b></p> <ol> <li>Bodechtel, G., <i>Klinik des veget</i>. Nervensystems, Verh. Deutsch. Ges. Inn. Med., 57: 1948.</li> <li>Loon, H. E., <i>Biological and biomechanical principles in amputation surgery</i>, Prosthetics international, Copenhagen, 1960.</li> <li>Loos, H. M., <i>Klinische und statistiche Ergebnesse des Blutdruckuerhaltens bei Amputierten</i>, Medizinische, 29:1050, 1957.</li> <li>Meyeringh, H., and H. Stefani, <i>Besteht nach einer Amputation des Oberschenkels eine Neigung zur Adipositas und zur Hyperextension</i>? Deutsch. Med. Wschr., 81:10, 1956.</li> <li>Meyeringh, H., H. Stefani, and G. Cimbal, <i>Herz und Amputation: Eine klinische EKG Studie</i>, Deutsch. Med. Wschr., 85:9, 1960.</li> <li>Rausche, C, <i>Uber den Zusammenhang zwischen Amputation und arteriellem Hochdruck</i>, Med. Klin., 35:1418, 1939.</li> <li>Schneider, K. W., according to G. Schletter, in A. W. Fischer, R. Herget, and G. Molineus, <i>Das artzliche Gutachten im Versicherungs-wesen</i>, Johann Ambrosius Barth, Munchen, 1955.</li> <li>Schulze, K., according to G. Schletter, in A. W. Fischer, R. Herget, and G. Molineus, <i>Das drtzliche Gutachten im Versicherungswesen</i>, Johann Ambrosius Barth, Munchen, 1955.</li> <li>Solonen, K. A., H. J. Rinne, M. Viikeri, and E. Karvinen, <i>Late sequelae of amputation: The health of Finnish war veterans</i>. Ann. Chir. Gynaec. Fenn., Supplementum 138, 1965.</li> <li>Statistical Yearbook of Finland, 1945-1965, Central statistical office.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Statistical Yearbook of Finland, 1945-1965, Central statistical office.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Solonen, K. A., H. J. Rinne, M. Viikeri, and E. Karvinen, Late sequelae of amputation: The health of Finnish war veterans. Ann. Chir. Gynaec. Fenn., Supplementum 138, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Loos, H. M., Klinische und statistiche Ergebnesse des Blutdruckuerhaltens bei Amputierten, Medizinische, 29:1050, 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>5.</b> </td><td class="clsTextSmall">Meyeringh, H., H. Stefani, and G. Cimbal, Herz und Amputation: Eine klinische EKG Studie, Deutsch. Med. Wschr., 85:9, 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>5.</b> </td><td class="clsTextSmall">Meyeringh, H., H. Stefani, and G. Cimbal, Herz und Amputation: Eine klinische EKG Studie, Deutsch. Med. Wschr., 85:9, 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>1.</b> </td><td class="clsTextSmall">Bodechtel, G., Klinik des veget. Nervensystems, Verh. Deutsch. Ges. Inn. Med., 57: 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>8.</b> </td><td class="clsTextSmall">Schulze, K., according to G. Schletter, in A. W. Fischer, R. Herget, and G. Molineus, Das drtzliche Gutachten im Versicherungswesen, Johann Ambrosius Barth, Munchen, 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>7.</b> </td><td class="clsTextSmall">Schneider, K. W., according to G. Schletter, in A. W. Fischer, R. Herget, and G. Molineus, Das artzliche Gutachten im Versicherungs-wesen, Johann Ambrosius Barth, Munchen, 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>6.</b> </td><td class="clsTextSmall">Rausche, C, Uber den Zusammenhang zwischen Amputation und arteriellem Hochdruck, Med. Klin., 35:1418, 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Solonen, K. A., H. J. Rinne, M. Viikeri, and E. Karvinen, Late sequelae of amputation: The health of Finnish war veterans. Ann. Chir. Gynaec. Fenn., Supplementum 138, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Loon, H. E., Biological and biomechanical principles in amputation surgery, Prosthetics international, Copenhagen, 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>Georg Bakalim </b></td></tr><tr><td class="clsTextSmall">State Supervisor of Prosthetic Services, Ministry of Social Affairs, Helsinki, Finland.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_027/spring69-21.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_027/spring69-22.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_027/spring69-23.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_027/spring69-24.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_027/spring69-25.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_027/spring69-26.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_027/spring69-27.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_027/spring69-28.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_01_027/spring69-29.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_01_027/spring69-30.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_01_027/spring69-31.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_01_027/spring69-32.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Causes of Death in a Series of 4738 Finnish War Amputees Creator An entity primarily responsible for making the resource Georg Bakalim * https://staging.drfop.org/files/original/300fec58bb900f1c7824dd89bd4bbaae.pdf 76815d70cedf1bca701b131c7ff7e1e3 https://staging.drfop.org/files/original/900377a01eea06be7f175e196b90925d.jpg f2357efa66a29ce5c62e4d968a6ccfa9 https://staging.drfop.org/files/original/9f83d9cea044e7f3c97f76b921831c78.jpg 7eebd4fbeda2d03e63a1e5aa08d4ee8c https://staging.drfop.org/files/original/210a566f2d7906636a17a4da061ba64f.jpg a9a6af01b0842bab00a8484934d9b946 https://staging.drfop.org/files/original/1576a7cdca5985ca39b8dfd73643a26d.jpg cd929d3b6f4cf06461d5d6085b38b978 https://staging.drfop.org/files/original/7f40b03606f628d72d01f42ac743588c.jpg 7d7945a45ce4611bc7826c5b4eb56bac https://staging.drfop.org/files/original/60fd60e81e861bcade3d43e96948c6ed.jpg 616e1eafc83246f42671d97fe4d7cb35 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_014.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 14 - 22 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/1965_01_014.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_014.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>Experiences with the PTB Prosthesis</h2> <h5>Georg Bakalim, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The original patellar-tendon-bearing (PTB) prosthesis was constructed at the Biomechanics Laboratory of the University of California. For details regarding the anatomical and physiological considerations<a></a>, the biomechanics<a></a>, and the construction<a></a>, the reader is referred to the June 1962 issue of <i>Artificial Limbs.</i></p> <p>In Finland about 1,000 PTB prostheses have been manufactured since 1959. Although the name of these prostheses and the main principle of their construction imply that weight is borne on the lower patellar ligament (<b>Fig. 1</b>), this is not the only weight-bearing area. Both tibial condyles and, to some extent, the distal end of the stump share the weight. The distribution of weight in these areas necessitates truly individual fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Vertical cross section of anterior portion of PTB socket. The supporting force, as shown by the arrow, acts on the lower patellar ligament. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For technical details of fabrication of PTB prostheses, the reader is referred to the issue of <i>Artificial Limbs </i>which has been cited. Here it is sufficient to say that a plaster cast of the stump is taken first. Then an intimately fitting, distally closed socket of hard plastic and a socket insert of sponge rubber are made. Distally, the socket is joined to a wooden shank, to which a SACH foot is attached (see <b>Fig. 2</b> for views of a finished prosthesis). It is not essential that the socket be made of plastic, but at present this seems to be the best material available. It is relatively easy to laminate a plastic shell from a plaster model. The plastic socket withstands moisture and is, therefore, relatively resistant to perspiration, and it is readily cleaned. The drawbacks are the airtightness of the material, the risk of its causing allergic reactions, and, perhaps, the poorer heat insulation in cold weather compared with materials previously used. These points will be discussed later.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Finished PTB prosthesis using supracondylar cuff as only means of suspension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the Department of the State Supervisor of Prosthetic Services of the Ministry of Social Affairs, a follow-up study has been made of amputees fitted with PTB prostheses. Initially, the amputees are given, for trial, prostheses which are not quite finished, although fit for wear. After three weeks the patients and their prostheses are examined at the Department of the State Supervisor, where either the prostheses are approved, or some modification, correction, or repair is prescribed. Only after this examination are the prostheses given their final finish. This applies to all prostheses paid for by the state. Six months after the patients have been fitted with their PTB prostheses a questionnaire is sent to them. At the Department of the State Supervisor, record cards are kept for all amputees, on which are entered notations concerning modifications and repairs. Thus it is easy to check on what happens to the various prostheses.</p> <p>This article is based on the examinations of the amputees and their prostheses three weeks after the initial issue, data obtained from the questionnaires distributed to the amputees when they have worn their prostheses for six months, and data obtained from the record cards.</p> <p>The study covers 228 amputees fitted with PTB prostheses. Prostheses from different workshops differ somewhat from each other, since standardization of the products is a problem in Finland, as it is elsewhere, perhaps. Therefore, only genuine PTB prostheses have been included in this study.</p> <p><b>Fig. 3</b> shows the ages of the amputees, disclosing that the age group of 40-54 years is the largest. The youngest patient was 20, while the oldest was 75. Ex-servicemen account for 94.3 per cent of the series. The remainder are insured civilians. Only one of the cases in the series was a recent amputee whose initial fitting was with a PTB prosthesis. This does not imply that recent amputees are fitted for theoretical reasons with so-called "conventional" prostheses. On the contrary, it should be an advantage to be fitted from the outset with a PTB prosthesis, although it goes without saying that recent amputees offer special problems because of the longer duration of stump changes.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Ages of the amputees when they were fitted with PTB prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 1</b> shows the occupations of the patients in the series. From the standpoint of prescription, it is of major interest to ascertain whether the PTB prosthesis can be worn while performing heavy labor, considering the absence of a thigh corset and the greater stress on the knee joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 1</b> discloses that the series includes 59 farmers or smallholders, 21 industrial workers, two lumbermen, and 7 painters. It stands to reason that amputees, whenever possible, choose labor that is not very heavy. Many farmers admitted that they had abandoned the heaviest tasks. However, others in the series mentioned lumbering as a part-time occupation. It was learned that some amputees had worn the PTB prosthesis without a thigh corset while walking on soft, uneven ground and on snow; in other cases, a short above-knee corset had been added almost immediately or when the PTB prosthesis had been worn for some time. It is apparent that stump length and the stability of the knee are important factors.</p> <p><b>Fig. 4</b> shows the lengths of the stumps in the series. In general, cases with a stump length of less than 12 cm. required a thigh corset, the length of which was about one-half or one-third the length of the thigh corset of a conventional prosthesis. The shortest stump in the series measured 6 cm., and the longest 35 cm. The series includes nine bilateral amputees (3.9 per cent).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Lengths of the amputation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Replies to the questionnaire are presented below:</p> <ol> <li><i>Have you worn your prosthesis regularly; if not, for how long have you worn it? </i>According to the replies, 210 amputees (92.1 per cent) had worn their prostheses regularly from the outset.</li><li><i>Why have you not been able to wear your prosthesis regularly? </i>When the replies were compared with the record cards, it appeared that 18 (7.9 per cent) had not been able to wear their prostheses regularly. In three cases the cause could not be elicited. In 15 cases the causes were as follows:</li></ol> <ul> <li>The skin became irritated in three cases, and in one case an allergy set in.</li> <li>In two cases the socket became too loose.</li> <li>The stump did not tolerate the pressure; it became tender.</li> <li>There was pressure on the stump when the patient drove his car.</li> <li>Ulceration of the stump occurred in three cases.</li> <li>The prosthesis was cold in the winter, and it slipped off when the patient walked in the snow.</li> <li>The stump swelled when the patient was riding a bicycle.</li> <li>Stairs were a problem.</li> <li>The closed socket caused excessive perspiration of the stump.</li> </ul> <p>3. <i>Have you worn your prosthesis </i>(a) <i>when working indoors, (b) when working outdoors, (c) when working outdoors in very cold weather? </i>A total of 223 (97.8 per cent) had worn their prostheses while working indoors; 208 (91.2 per cent), while working outdoors; and 140 (61.4 per cent), while working outdoors in very cold weather.</p> <p>4. <i>Have you worn your prosthesis in some additional</i>- <i>part-time</i>-<i>occupation? </i>(The intention was to elicit data regarding incidental jobs, recreation, and hobbies.) Only 21 replies were obtained on this point. One patient was a chauffeur, two were building their own houses, one was building a summer cottage, two fished, five were doing agricultural work, three did lumbering, six did gardening, and one was a night watchman.</p> <p>5. <i>Have you previously used a prosthesis of some other material (wood, leather, or light metal)? </i>The majority had used conventional prostheses of wood or leather. Only a few had worn prostheses of light metal. Some amputees had had prostheses of all three materials in the course of years.</p> <p>6. <i>Have you been satisfied with your prosthesis? </i>There were 206 (90.4 per cent) satisfied wearers. Only 22 (9.6 per cent) complained.</p> <p>7. <i>Do you think this prosthesis is {a) better than, (b) just as good as, (c) not as good as your previous limb? </i>The replies were as follows:</p> <table> <tbody><tr> <td> <p>Better than previous prostheses</p> </td> <td> <p>   207 ( 90.8 per cent)</p> </td> </tr> <tr> <td> <p>Just as good as previous prostheses</p> </td> <td> <p>   8 ( 3.5 per cent)</p> </td> </tr> <tr> <td> <p>Not as good as previous prostheses</p> </td> <td> <p>   12 ( 5.3 per cent)</p> </td> </tr> <tr> <td> <p>First prosthesis (recent amputee)</p> </td> <td> <p>   1 ( 0.4 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p>   <b>228 (100.0 per cent)</b></p> </td> </tr> </tbody></table> <p>The great majority were satisfied with the PTB prosthesis. What appealed to them most was its lightness and the freedom from a thigh corset. This enabled the development of the thigh muscles in a short time. However, not all the amputees were able to manage without a thigh corset.</p> <p>8. <i>What defects or drawbacks have you observed in your PTB prosthesis? </i>Listed below are the complaints of 26 amputees (12.3 per cent). In eight cases the complaints apply mainly to the stump, and in 18 to the prosthesis, but it is not always possible to distinguish sharply between the two.</p> <table> <tbody><tr> <td> <p><b>Amputation stump</b></p> </td> <td> <p><b>Prosthesis</b></p> </td> </tr> <tr> <td> <p>Allergic reaction</p> </td> <td> <p>Cold in the winter (two cases)</p> </td> </tr> <tr> <td> <p>Circulatory disturbance</p> </td> <td> <p>Socket closed and too warm (three cases)</p> </td> </tr> <tr> <td> <p>Ulceration</p> </td> <td> <p>Socket became too loose (two cases)</p> </td> </tr> <tr> <td> <p>Itching</p> </td> <td> <p>Socket pressed on the stump</p> </td> </tr> <tr> <td> <p>Stump shrinkage</p> </td> <td> <p>Flexion of the knee during work impossible because socket extends above knee</p> </td> </tr> <tr> <td> <p>Perspiration</p> </td> <td> <p>Unstable on slippery ground and without a thigh corset</p> </td> </tr> <tr> <td> <p>Edema</p> </td> <td> <p>Unstable in soft snow</p> </td> </tr> <tr> <td> <p>Fatigue</p> </td> <td> <p>Unstable on soft ground </p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Excessive strain on the knee without a thigh corset</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Insert wears out too rapidly </p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Heel of the SACH foot is too soft</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Toe of the SACH foot gradually bends upward</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Toe wears out too rapidly</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Difficult to ski</p> </td> </tr> </tbody></table> <p>9. <i>Has perspiration in the amputation stump constituted a problem? </i>The replies were as follows:</p> <table> <tbody><tr> <td> <p>Perspiration a problem</p> </td> <td> <p>   161 (70.6 per cent)</p> </td> </tr> <tr> <td> <p>Perspiration not a problem</p> </td> <td> <p>   39 (17.1 per cent)</p> </td> </tr> <tr> <td> <p>Initially excessive perspiration, later not</p> </td> <td> <p>   19 (8.3 percent)</p> </td> </tr> <tr> <td> <p>Less perspiration than with other prostheses</p> </td> <td> <p>   9 (4.0 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p>   <b>228 (100.0 per cent)</b></p> </td> </tr> </tbody></table> <p>Owing to the closed, air-tight socket, perspiration was a major problem, particularly in the summer. It should be borne in mind, however, that this problem also occurs with conventional prostheses, although perhaps not to the same degree. The possibilities for reducing the perspiration problem are discussed later.</p> <p><i>10. Has the skin on the stump tolerated the prosthesis? </i>The skin tolerated the prosthesis well in <b>190 </b>cases (83.9 per cent), better than with other types of prostheses in 14 cases (6.5 per cent), and not so well as with others in 24 cases (9.2 per cent).</p> <p><i>11. Have reddening of the skin and eczema occurred? </i>A total of 75 amputees complained of reddening and eczema, while 153 had no such symptoms.</p> <p><i>12. Did reddening, eczema, or ulceration of the stump occur before you started using a PTB prosthesis, and, if so, for how long? </i>In 157 cases (68.9 per cent) such symptoms had arisen from the use of conventional prostheses of wood, leather, or light metal.</p> <p><i>13. What are your experiences with the new prosthesis outdoors in cold weather? </i>A total of 142 amputees had worn their prostheses outdoors during the winter, and temperatures of -20 to -40 deg. C had caused no problem. Many had skied as much as 30 km. Only five (3.5 per cent) had found the new prosthesis too cold. Replies were as follows:</p> <table> <tbody><tr> <td> <p>No complaints</p> </td> <td> <p>   111 ( 78.2 per cent)</p> </td> </tr> <tr> <td> <p>Better than previous prostheses</p> </td> <td> <p>   5 (3.5 per cent)</p> </td> </tr> <tr> <td> <p>Somewhat colder than previous prostheses</p> </td> <td> <p>   21 (14.8 per cent)</p> </td> </tr> <tr> <td> <p>Very cold</p> </td> <td> <p>   5 (3.5 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p><b>   142 (100.0 per cent)</b></p> </td> </tr> </tbody></table> <p>It developed from the replies that the vast majority of the patients had been able to wear their PTB prostheses regularly from the outset. Eighteen amputees had experienced discomfort of various kinds. In many cases there were only minor complaints, and the source of the trouble was readily dealt with. Sometimes the complaints related to phenomena always associated with the manufacture and fitting of prostheses.</p> <p>It is noteworthy, too, that the patients wore their prostheses while performing hard labor.</p> <p>The vast majority of the patients were satisfied. The dissatisfied wearers numbered 22 (9.6 per cent). The causes for complaint are specified in <b>Table 2</b>. The ages and stump lengths of these patients are indicated in the tabulation to permit evaluation of their possible influence. Data regarding all the modifications needed to make the prostheses fit for use, even the smallest repairs, were obtainable from the amputee cards.</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 is a characteristic feature of the PTB prosthesis that it immediately starts remodeling the stump, because of the intimate fit of the socket. During the first few weeks the stump shrinks, so that the socket becomes too loose. It can be seen in <b>Table 2</b> that this occurred in 11 cases, or 50 per cent of the dissatisfied wearers. These patients were fitted with a new socket insert, and occasionally also with a new socket shell, which implies that a large part of the prosthesis had to be rebuilt. In many cases the insert had to be modified several times. These possibilities must be reckoned with when this type of prosthesis is prescribed.</p> <p>The regeneration of the thigh muscles in those who managed without a thigh corset has already been mentioned. This phenomenon results from the greater muscular activity required to control the movements and the stability of the knee with the PTB prosthesis. After three weeks none of the wearers was able to use his old prosthesis with a thigh corset, because the corset had become too tight.</p> <p>The genuine PTB prosthesis is furnished with only a narrow strap fixing it above the knee. In six cases it was necessary later to provide a thigh corset with sidebars, but the length of the corset was one-third to one-half of what is usual for conventional prostheses. These amputees had stumps which measured 12,13,15,19, 22, and 25 cm., respectively. Only half of these can be said to be particularly short. Obviously, the need for a thigh corset depends not only upon the length and shape of the stump, but also upon the stability of the knee. In three of the cases the knee had been strained. In one case the PTB prosthesis, even after being furnished with a thigh corset and sidebars, had to be replaced with a conventional prosthesis, but this was an exceptional case.</p> <p>Excessive perspiration in the stump, particularly during the summer, constituted a major problem. The closed socket insert and the airtight material are its main causes, but the muscular atrophy because of inactivity and the resultant poor circulation contribute. A gradual decrease in perspiration might be expected to occur, considering the development of the musculature and improved circulation resulting in all amputees who manage without a thigh corset, and considering also the pump effect exerted on the stump by the tight-fitting socket. A similar effect has been observed as a result of placing a sponge-rubber pad at the bottom of conventional prostheses of patients with chronic eczema and ulceration of the stump (<i>1</i>). In the present series, however, a later decrease of perspiration was observed in only 8.3 per cent of the cases. In addition, four per cent reported that perspiration has all the time been less of a problem with the new prostheses.</p> <p>When perspiration of the stump is excessive, skin complications-eczema and ulceration- are likely to occur. Data on skin symptoms in the present series were compared with corresponding data relating to the use of conventional prostheses. The comparison is hampered by the fact that the observation time is shorter for the PTB prostheses than for the older types. Results of the comparison were as follows:</p> <table> <tbody><tr> <th><p></p> </th> <th><p>PTB</p> </th> <th><p>Conventional Prostheses</p> </th> </tr> <tr> <td> <p>Reddening, eczema, ulceration</p> </td> <td> <p>   75 (32.9 percent)</p> </td> <td> <p>   157 (68.9 percent)</p> </td> </tr> <tr> <td> <p>No complications</p> </td> <td> <p>   153 (67.1 per cent)</p> </td> <td> <p>   71 (31.1 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p>   228 (100.0 per cent)</p> </td> <td> <p>   228 (100.0 per cent)</p> </td> </tr> </tbody></table> <p>It appears that with the PTB prosthesis skin complications were about half as common as with conventional prostheses.</p> <p>In cold winter weather, the PTB prosthesis is somewhat colder than prostheses made of leather or wood, but nonetheless satisfactory and fit for use.</p> <p>In general, the difficulties arising in the present series were due mainly to reduction in the volume of the amputation stump, instability of the knee, and, in some cases, shortness of the stump, which necessitated the construction of a thigh corset. Also, skin complications sometimes occurred as a result of the excessive perspiration caused by the closed-socket insert. The first-mentioned circumstances were easy to cope with, while the skin changes constituted a real problem. In some cases, an opening was made in the distal end of the socket insert, or a number of small holes were drilled in the socket. In certain cases, a sponge-rubber pad was utilized, partly to exert a continuous light pressure on the stump and partly to absorb the moisture accumulating in the bottom of the socket insert.</p> <p>When the PTB prosthesis was first introduced into Finland, we hesitated to prescribe it to amputees who move about much outdoors on soft ground; for instance, on fields and meadows, in the forest, and on snow. This group of persons consists mainly of farmers and lumbermen and the population of northernmost Finland. Our apprehensions have been confirmed only in occasional cases, and the general impression of the PTB prosthesis is favorable. The advantages far outweigh the drawbacks. In particular, the lightness of this prosthesis, the hygienic properties of the plastic material, and the regeneration of the thigh muscles should be emphasized.</p> <p>Reference to the literature shows that others have encountered the same problems that are described here. Frank A. Witteck <a></a>, writing in the June 1962 issue of <i>Artificial Limbs, </i>warned against prescribing the PTB prosthesis in cases with instability of the knee, to very heavy amputees, and in bilateral cases. However, if the stumps have been satisfactory, we have even fitted bilateral cases with PTB prostheses, and no special problems have occurred.</p> <p>In our experience, the PTB prosthesis is con-traindicated only in cases with instability of the knee and with very short stumps or with stumps of unsatisfactory shape.</p> <p>Because numerous, careful fittings are required in these cases, it is desirable that a prosthetist's shop be within easy reach. The PTB prosthesis makes heavy demands on the skill of the manufacturer.</p> <h3>Summary</h3> <p>This study was carried out on 228 amputees fitted with PTB prostheses. It is based on personal follow-up examinations, replies to questionnaires, and data obtained from record cards kept on the amputees.</p> <p>The age group 40 through 54 years is the largest. War veterans comprise 94.3 per cent of the series, the remainder being insured civilians. In some cases the prostheses were worn by amputees engaged in heavy labor under difficult conditions. Of the amputees, 92.1 per cent were able to wear their prostheses regularly from the outset, and 90.4 per cent were very satisfied. In particular, they emphasized the lightness of the prostheses and the absence of tight thigh corsets, resulting in a sense of ease and freedom.</p> <p>In some cases, complications were caused by a decrease in stump volume, a result of the intimate fit of the socket. This necessitated a change of socket insert, which is readily accomplished, and sometimes of the socket shell as well, which in effect amounts to making a new prosthesis. In certain cases, instability of the knee, the shape of the stump, and a stump length less than the optimum gave rise to symptoms which could be alleviated only by giving the amputee a thigh corset. The series includes four such cases (1.8 per cent).</p> <p>PTB prostheses were also prescribed in bilateral cases, of which there were nine (3.9 per cent).</p> <p>The study shows that the PTB prosthesis has been successfully worn in cold winter weather, although it is somewhat colder than prostheses made of wood or leather.</p> <p>In all the amputees the thigh muscles developed enormously within a few weeks.</p> <p>Excessive perspiration in the stump was a problem in many cases. This phenomenon is due to the intimate fit of the plastic socket. A gradual decrease of the perspiration was noted in 8.3 per cent. However, four per cent stated that, from the outset, perspiration had been less of a problem than with their previous prostheses. It should be borne in mind that during the warm season perspiration tends to be a problem with all prostheses.</p> <p>The PTB prosthesis without a thigh corset is contraindicated in cases with instability of the knee and in cases with a very short stump or with a stump of unsatisfactory shape. Furthermore, caution is indicated in the prescription of this prosthesis to farmers, lumbermen, and others who move on soft and slippery ground.</p> <p>The PTB prosthesis requires very careful fitting, and extreme care must be exercised in its manufacture. In cases where there is a long distance between the place of residence and the prosthetics facility, this is not perhaps the most appropriate type of prosthesis.</p> <p><b>References:</b></p> <ol> <li>Bakalim, Georg, Sponge rubber pad in the prosthesis in cases of chronic dermatitis and ulceration in the stump, Acta orthop. scandinav., 1:117, 1964.</li> <li>Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, Artificial Limbs, June 1962, pp. 25-73.</li> <li>Murphy, Eugene F., and A. Bennett Wilson, Jr., Anatomical and physiological considerations in below-knee prosthetics, Artificial Limbs, June 1962, pp. 4-15.</li> <li>Radcliffe, Charles W., The biomechanics of below-knee prostheses in normal, level, bipedal walking, Artificial Limbs, June 1962, pp. 16-24.</li> <li>Witteck, Frank A., Some experience with patellar-tendon-bearing below-knee prostheses, Artificial Limbs, June 1962, pp. 74-85.</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">Witteck, Frank A., Some experience with patellar-tendon-bearing below-knee prostheses, Artificial Limbs, June 1962, pp. 74-85.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, Artificial Limbs, June 1962, pp. 25-73.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., The biomechanics of below-knee prostheses in normal, level, bipedal walking, Artificial Limbs, June 1962, pp. 16-24.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Murphy, Eugene F., and A. Bennett Wilson, Jr., Anatomical and physiological considerations in below-knee prosthetics, Artificial Limbs, June 1962, pp. 4-15.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Georg Bakalim, M.D. </b></td></tr><tr><td class="clsTextSmall">State Supervisor of Prosthetic Services, Ministry of Social Affairs, Helsinki, Finland.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-12.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-13.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-14.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-15.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-16.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-17.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 Experiences with the PTB Prosthesis Creator An entity primarily responsible for making the resource Georg Bakalim, M.D. * https://staging.drfop.org/files/original/7904e0df9f82ca12c7c4e5cd88f6db97.pdf 28eeacacfe9b1b5e4ac2b081f46ce305 https://staging.drfop.org/files/original/82e7e39858aab0ffb26247e4ac66f8ff.jpg 9f927c763f3c0a435205f628539e33fd https://staging.drfop.org/files/original/959f68367f7cae905c928c179c005a3f.jpg 53b45497795ecaf6b411058791a39c7b https://staging.drfop.org/files/original/7b0e5455441dc18eff98d48d86415fb7.jpg bd46345d3be76766394dec62eb977ef7 https://staging.drfop.org/files/original/6c178a7d49b2ae565c5fdd88f9b45441.jpg dca58414c4ca42c275c9827d838c88d0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_01_051.pdf Year 1967 Volume 11 Issue 1 Page Number(s) 51 - 57 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1967_01_051.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_01_051.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>Experiences with the Total-Contact Prosthesis</h2> <h5>Georg Bakalim, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>At the request of the Finnish Disabled Ex-Servicemen's Association, New York University arranged for a series of lectures on the fabrication of total-contact, above-knee sockets to be given in Helsinki in 1963. The lectures were intended for prosthetists and other interested persons. Since then some 300 prostheses of this type have been fabricated in Finland.</p> <p>The total-contact socket <a></a> is a further development of the conventional open-end socket. The proximal portion of a total-contact socket has the same contours as the corresponding portion of an open-end socket. The ischial seat, the relatively high anterior and lateral walls, the bulge into the femoral triangle, and the reliefs for the rectus femoris, for the adductor longus, and for the hamstring tendons are similar in both the open-end socket and the total-contact socket. The main difference is that the total-contact socket completely encases the stump, while the open-end socket, as its name implies, is open distally.</p> <p>This means that, in the total-contact socket, the stump end is surrounded by a vacuum which keeps the prosthesis in position without a pelvic joint and belt. The total-contact socket is kept in place by its intimate fit around the stump. There is a moderate vacuum during swing phase. The intimate fit of the total-contact socket, which is made of plastic, has been designed with a view toward imitating the mechanism of the physiological pumping action performed by the muscles while walking. the patellar-tendon-bearing (PTB) prosthesis acts in a similar fashion. The pumping effect is accomplished by the amputee as he walks. In fact, a principal advantage of the total-contact socket is the mild, gentle counterpressure on the distal end of the stump during the stance phase. This positive pressure, alternating with the negative during the swing phase, improves circulation and reduces edema in the stump.</p> <p>The total-contact socket is designed to reduce pressure on the stump proximally and increase the pressure distally. In cases where the diaphysis has been cut, the stump end never tolerates strong pressure. Therefore, pressure must be very carefully modified in each case.</p> <p>Distally, the plastic socket is joined to a wooden knee. The shank, too, is made of wood, to which a SACH foot is attached. Plastic has certain advantages over other materials. It is readily washed with soap and water. The surface can be made very smooth and free from pores. The chief drawback is airtightness. Plastic does not permit an exchange of air. The result is perspiration, particularly in the summer. Sweat gradually breaks down the plastic. In winter plastic is cold. Sometimes there are allergic reactions to plastic.</p> <p>In the Department of the State Supervisor of Prosthetic Services of the Ministry of Social Affairs, a follow-up study has been made of amputees fitted with total-contact prostheses. Initially, the amputees are given, for trial, prostheses which are not quite finished, although fit for wear. Some four to six weeks later the patients and their prostheses are examined at the Department of the State Supervisor, where the prostheses are approved or some modification or correction is prescribed. Only after this examination are the prostheses given their final finish. This applies to all prostheses paid for by the state. Six months after the patients have been fitted with their prostheses a questionnaire is sent to them, which they accomplish and return.</p> <p>Record cards are kept for all amputees on which are entered notations concerning new prostheses, repairs, and modifications.</p> <p>The present study covers 150 amputees fitted with total-contact prostheses. Of the amputees, 143 (95.3 per cent) were ex-servicemen and 7 (4.7 per cent) were insured civilians.</p> <p><b>Fig. 1</b>, which shows the ages of the amputees, indicates that the age group of 40 to 54 years is the largest. The high mean age of the ex-servicemen is accounted for by the time that has elapsed since World War II. The series includes two cases from the Finnish civil war of 1918. The youngest amputee was 24, the oldest 67. Only one was a recent amputee. In principle, every above-knee amputee should be fitted with a total-contact prosthesis from the outset in order to become used to it as soon as possible. This would accelerate the remodeling of the stump. Still, the stump of a recent amputee is often tender and swollen for some time. The total-contact prosthesis demands much of the stump. Consequently, a recent amputee may need a new socket at frequent intervals.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Ages of the amputees when they were fitted with total-contact prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 1</b> shows the occupations of the patients in the series. It is of major interest to ascertain whether the total-contact prosthesis can be worn while performing heavy labor of different kinds, particularly outdoors and at low temperatures. In northern Finland temperatures may be as low as -40 deg. C. Therefore, the occupations have been precisely specified. Whenever possible, amputees will usually choose labor that is not too heavy. The series includes 23 farmers (15.3 per cent), 1 lumberman, and 11 fitters. After World War II, retraining of invalids was arranged in the form of courses for watchmakers, storekeepers, fitters, shoemakers, etc. These occupations appear in the table.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 2</b> shows the lengths of the amputation stumps. The total-contact prosthesis has been worn successfully by amputees whose stumps measured only 10 cm to 15 cm. This series includes 10 such cases, but in two of these cases it became necessary to abandon the total-contact prosthesis. One of these patients received a conventional, wooden, open-end prosthesis; the other was fitted with a leather prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Lengths of the amputation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These cases (No. 8 and No. 9 in <b>Table 2</b>) will be discussed later.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. Amputees Who Could Not Wear the Total-Contact Prosthesis </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Replies to the questionnaire are presented below:</p> <ol> <li><i>Have you worn your prosthesis regularly; if not, for how long have you worn itf </i>According to the replies, 108 (72 per cent) had worn their prostheses regularly, while 42 (28 per cent) had not been able to do so for a variety of reasons.</li><li><i>Why have you not been able to wear your prosthesis regularly? </i>The replies were compared with the record cards, and causes were elicited as follows: <ul> <li>The knee joint in the prosthesis was too stiff.</li> <li>In eight cases there was profuse perspiration and a repulsive odor.</li> <li>In one case the prosthesis was too warm in the summer and too cold in the winter.</li> <li>In one case the prosthesis was too cold in the winter.</li> <li>In five cases the socket did not fit.</li> <li>The amputee put on weight and the socket became too tight.</li> <li>The inner surface of the socket became granular.</li> <li>The stump swelled.</li> <li>There were pains in the stump.</li> <li>Walking was difficult because of a heart condition.</li> <li>In two cases the socket split.</li> <li>There was a jarring sound from the knee joint of the prosthesis.</li> <li>In one case the amputee was so used to his old prosthesis that he preferred it.</li> <li>The SACH foot became loose, the socket was tight, and the knee mechanism functioned differently from what it did in the old prosthesis.</li> <li>In three cases the skin became irritated.</li> <li>In one case the stump was operated upon after the prosthesis had been finished.</li> <li>The socket became too wide.</li> <li>The stiffness of the knee mechanism was a hindrance while fishing.</li> <li>The socket became too tight.</li> <li>In many cases modification and repair of the prosthesis put an end to the trouble.</li> </ul></li><li><i>Have you worn your prosthesis (a) when working indoors, </i>(b) <i>when working outdoors, (c) when working outdoors in very cold weather? </i>Of those replying to the questionnaire, 128 (85.3 per cent) had worn their prostheses while working indoors, 100 (66.7 per cent) had worn their prostheses while working outdoors, and 72 (48.0 per cent) had worn them outdoors in very cold weather. Some amputees had been in a position to wear the prosthesis only during the warm season at the time of the questionnaire.</li><li><i>Have you worn your prosthesis in some additional</i>-<i>part-time</i>-<i>occupation? </i>(The intention was to elicit data regarding incidental jobs, recreation, and hobbies.) Only eight amputees indicated that they had such activities: fishing in one case, gardening in one case, agricultural work and lumbering in two, work as a doorkeeper in one case, two cases in which the patients had built their own cottages, and one case in which the amputee participated in ball games.</li><li><i>Have you previously used a prosthesis of some other material (wood, leather, or light metal)? </i>Conventional prostheses of wood had been worn by 147 amputees (98 per cent), one (0.7 per cent) had worn a leather prosthesis, and one (0.7 per cent) had worn a prosthesis of light metal. One patient (0.7 per cent) was a recent amputee and had been fitted with his first prosthesis.</li><li><i>Have you been satisfied with your prosthesis? </i>There were 112 (74.5 per cent) satisfied wearers and 38 (25.5 per cent) who were dissatisfied.</li><li><i>Do you think this prosthesis is (a) better than, (b) just as good as, </i>(<i>c</i>) <i>not as good as your previous limb? </i>The replies were as follows: <br /> <table> <tbody><tr><td> <p>Better</p> </td> <td> <p>   81 (54.0 per cent)</p> </td> </tr> <tr><td> <p>Just as good</p> </td> <td> <p>   36 (24.0 per cent)</p> </td> </tr> <tr><td> <p>Not as good</p> </td> <td> <p>   33 (22.0 per cent)</p> </td> </tr> </tbody></table><br /></li><li><i>What defects or drawbacks have you observed in your total-contact prosthesis? </i>Listed below are the complaints of 39 patients (26 per cent). In 32 cases the stump had caused trouble and in seven cases there was something wrong with the prosthesis. But no sharp distinction can be drawn between these two groups. Quite frequently, the prosthesis is the ultimate source of the discomfort.<br /> <table> <tbody><tr> <td> <p><b>Amputation stump</b></p> </td> <td> <p></p> </td> </tr> <tr> <td> <p>The skin did not tolerate the prosthesis</p> </td> <td> <p>   12</p> </td> </tr> <tr> <td> <p>Perspiration from the stump and an unpleasant odor</p> </td> <td> <p>   15</p> </td> </tr> <tr> <td> <p>Cold in winter</p> </td> <td> <p>   2</p> </td> </tr> <tr> <td> <p>Stump end became discolored</p> </td> <td> <p>   1</p> </td> </tr> <tr> <td> <p>Warm in summer, cold in winter</p> </td> <td> <p>   2</p> </td> </tr> <tr> <td> <p>Totals</p> </td> <td> <p>   32</p> </td> </tr> </tbody></table><br /> <table> <tbody><tr> <td> <p><b>Prosthesis</b></p> </td> <td> <p></p> </td> </tr> <tr><td> <p>Plastic socket split</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p>Socket was too closed</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p>Socket did not fit</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p>Socket too tight</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p>Totals</p> </td> <td> <p>   7</p> </td> </tr> </tbody></table><br /> </li><li><i>Has perspiration of the stump constituted a problem? </i>In 33 cases (22 per cent) perspiration had been profuse, in 99 cases (66 per cent) moderate, and in 17 (11.3 per cent) it had caused no trouble. Only one patient (0.7 per cent) stated that perspiration gradually became less of a problem. As a rule, summer was the worst season from this standpoint.</li><li><i>Has perspiration caused any repulsive odorf </i>The replies of 113 amputees (74.7 per cent) were in the affirmative, while 37 patients (25.3 per cent) replied in the negative. When the odor of the sweat in the closed socket mingled with the odor of the plastic, which is particularly strong in new sockets still containing traces of the solvents used in the fabrication, the effect is extremely disagreeable to both the amputee and his environment. The plastic socket can be washed with soap and water, but personal hygiene varies widely. Many patients have stated that perspiration is not a major problem, if the stump and the prosthesis are washed regularly.</li><li><i>Has the skin on the stump tolerated the total-contact prosthesis? </i>In 118 cases (79.0 per cent) the skin on the stump had shown no symptoms, while in 32 cases (21.0 per cent) it had not tolerated the strain of the intimate fit of the socket.</li><li><i>Have reddening of the skin and eczema occurred? </i>In 51 cases (34 per cent) there had been reddening, which may be a transient phenomenon of no significance, but 23 amputees (15.3 per cent) had had eczema, and ulceration had occurred in 18 cases (12 per cent).</li><li><i>Has the end of the stump become discolored after adoption of the new prosthesis? </i>Discoloration of the end of the stump had occurred in 34 cases (22.7 per cent). This phenomenon is the result of circulatory disturbances in the end of the stump. The most frequent cause is that pressure on the blood vessels is too strong.</li><li><i>Did reddening, eczema, or ulceration of the stump occur before you started wearing a total-contact prosthesis? </i>Reddening had occurred in 60 cases (40 per cent), eczema in 45 (20 per cent), and ulceration in 5 <i>(3.3 </i>per cent). These replies do not differ greatly from those to question No. 12. But it must be remembered that the previous, conventional prosthesis of wood, leather, or light metal had been worn for a long time, while the total-contact prosthesis had been worn only one-half year to one year. Therefore, the two groups cannot be directly compared.</li><li><i>What are your experiences with the new prosthesis outdoors in cold weather? </i>Thirty-two patients (35.1 per cent) had not experienced discomfort during the winter, while 61 (64.9 per cent) had found their prostheses very cold.</li><li><i>Have you skied with the new prosthesis? </i>Only 23 (15.3 per cent) patients answered in the affirmative. As a rule, above-knee amputees are not likely to participate in this sport. The below-knee amputees found on skis are much more numerous.</li><li><i>If you experienced phantom pains previously, have they been aggravated or alleviated after adoption of the new prosthesis? </i>The replies were as follows:<br /> <table> <tbody><tr> <td> <p>No previous phantom pains</p> </td> <td> <p>   32 (22 per cent)</p> </td> </tr> <tr> <td> <p>Phantom pains aggravated</p> </td> <td> <p>   15 (10 per cent)</p> </td> </tr> <tr> <td> <p>Phantom pains unchanged</p> </td> <td> <p>   94 (62.3 per cent)</p> </td> </tr> <tr> <td> <p>Phantom pains alleviated</p> </td> <td> <p>   8 (5.3 per cent)</p> </td> </tr> <tr> <td> <p>Total</p> </td> <td> <p>   149 (99.6 per cent)</p> </td> </tr> </tbody></table><br /></li><li><i>Have you had pains in the amputation stump (a) after adoption of the new prosthesis, (b) with the old prosthesis? </i>Sixty-six patients (44 per cent) had experienced pain after adoption of the new prosthesis, and 66 (44 per cent) had had pains while wearing their old limb. In this respect the type of prosthesis seemed to make no difference. But it should be noted that no direct comparison is possible because the total-contact prosthesis had been worn for a shorter period than the old one. In nine cases the total-contact prosthesis was abandoned in favor of the open-end prosthesis previously worn. These cases were subjected to a more detailed study, presented in <b>Table 2</b>.</li></ol> <p>The table discloses that the occupations of the patients had little to do with the failure. The ages of the patients did not differ from the mean age of the series as a whole. In two cases the stump was short, 12 cm and 15 cm, respectively. In the entire series there were 10 stumps measuring 10 cm to 15 cm, three measuring 16 cm, six measuring 17 cm, and five measuring 18 cm. In all cases except the two mentioned at first, fitting with a total-contact prosthesis proved successful. In general, short stumps constitute a problem to the prosthetist. No. 8 in <b>Table 2</b> was one of a number of amputees who had not been able to wear any prosthesis without complications. No. 9 was the only patient who was tested for allergy.</p> <p>As appears from the replies to the questionnaire, perspiration and skin changes constituted problems in the wearing of total-contact prostheses. These troubles arose from the properties of the socket: its intimate fit around the stump, and the airtightness of the plastic material. Partly because of the solvents used in the fabrication, the plastic socket sometimes has an irritating effect on the skin, especially when it is new. This irritation is increased by the decomposition of the sweat caused by the heat of the closed socket. In a considerable number of cases, however, the difficulties may have been caused by inadequate curing of the plastic laminate. Also, prostheses made of wood or leather are not free from perspiration.</p> <p>The possible occurrence of allergic reactions is another problem. In Finland, amputees suspected of allergy are remitted to the Dermatological Department of the Helsinki University Central Hospital. The present series includes only one such case. Perhaps the question of allergy has not been sufficiently taken into account.</p> <p>The majority of the remaining troubles were readily dealt with in the prosthetist's shop.</p> <p>It should be emphasized, however, that the view of the total-contact prosthesis derived from the replies that have been reported may be too unfavorable. To the amputee, it is a great advantage to be able to walk with greater ease than with a conventional prosthesis, because of the firm adherence of the total-contact socket to the stump. No pelvic joint and belt are needed. As mentioned earlier in this article, a principal advantage of the total-contact socket is the mild, gentle counterpressure on the distal end of the stump during the stance phase. This positive pressure, alternating with the negative during the swing phase, assists circulation. Some of the cases with derma-tologic problems had poor fits, usually as the result of stump changes. In a number of cases, the difficulties may well have been caused by inadequate curing of the plastic laminate. Also, a number of the problems did not relate to the principle of the total-contact socket as such but would have occurred with other designs.</p> <h3>Summary</h3> <p>This study was performed on 150 amputees fitted with total-contact prostheses. It is based on personal follow-up examinations, replies to questionnaires, and data obtained from record cards kept on the amputees.</p> <p>The age group 40 through 54 years is the largest. War veterans constitute the majority (96.3 per cent of the series).</p> <p>Seventy-two per cent had worn their prostheses regularly from the outset, and 74.5 per cent were satisfied with them. The airtightness of the socket elicited unfavorable reactions from the skin of a number of the patients (21 per cent). Twenty-two per cent of the amputees complained of profuse, and 66 per cent of moderate, perspiration of the stump. Some of the cases with dermatological problems had poorly fitting sockets, usually as the result of stump changes. In a considerable number of the cases, the difficulties may well have resulted from inadequate curing of the plastic laminate. The majority of the problems were readily dealt with in the prosthetist's shop.</p> <p>The skin requires meticulous hygiene. In contrast to leather and wood, the plastic socket is readily washed. Conventional prostheses are not free from dermatological problems.</p> <p>The total-contact prosthesis has been used in the performance of heavy labor and while outdoors in cold weather.</p> <p>Some of the problems of the patients did not relate to the principle of the total-contact socket and would have occurred with other designs.</p> <p>The gentle, alternating, positive and negative pressure afforded by the total-contact socket to the patient as he walks improves the circulation of the stump and constitutes one of the socket's main advantages.</p> <p><b>References:</b></p> <ol> <li>Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1963.</li> <li>Foort, J., and N. C. Johnson, Edema in lower-extremity amputees, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1962.</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">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1963.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Foort, J., and N. C. Johnson, Edema in lower-extremity amputees, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Georg Bakalim, M.D. </b></td></tr><tr><td class="clsTextSmall">State Supervisor of Prosthetic Services, Ministry of Social Affairs, Helsinki, Finland.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-4.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 Experiences with the Total-Contact Prosthesis Creator An entity primarily responsible for making the resource Georg Bakalim, M.D. * https://staging.drfop.org/files/original/3ffbae347395bd6358c27cde8e640cb0.pdf 3c1e43504bc5fe368e6d0b52b9ee3f23 https://staging.drfop.org/files/original/9ac99d90904964fbf707150717e8a50d.jpg e8ed5e738c54bbb55d742a611ae695ee https://staging.drfop.org/files/original/ae0d69cc03a931e61faf1371e769a573.jpg d2fbffa8ce932cf04e3bbdd2c30ac089 https://staging.drfop.org/files/original/d14a435b32caa77db0a8b81558fc2602.jpg 7ce6b179856dd2279ee95f246865d131 https://staging.drfop.org/files/original/ae0b927d201ab181204f175621d042cd.jpg 83325cd779700fe7327eb2b2a9fe16c2 https://staging.drfop.org/files/original/579595b2c3c9b825d4166f0f46b2ddcb.jpg b4f9c82d3f4974e187d4f4d785cde9cb https://staging.drfop.org/files/original/5ec23f79cd46fa212e8306f193030545.jpg e405e2a5b3e94e3baf1ae65b44e6f8c6 https://staging.drfop.org/files/original/b0762e6b36e5df9b2a7e8c7426c8d107.jpg 2c44ad68219084068c067bd70e3bf532 https://staging.drfop.org/files/original/9cfc6bce48e4a77f4899bd6853abaaca.jpg 7559251e1534b6a37a9dafafac9208f5 https://staging.drfop.org/files/original/f0f4b6501a67d0595fce6cd598f39cdb.jpg b7c470836998260c1b30dccb65f3d5e6 https://staging.drfop.org/files/original/b5efb724727d5b4455261299add09b51.jpg 7cbd41bff0429cfb9b1ca402ec264ca7 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_049.pdf Text Any textual data included in the document <h2>Modular Seat-Shells and Standardized Manufacture of Individually Shaped Seats for the Severely Disabled: The Tubingen Experience</h2> <h5>George Neff&nbsp;<a style="text-decoration: none;">*</a><br />Klaus Fischer&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>From the Editor: This article was received too late for inclusion in the Fall, 1986 issue devoted to seating and thus is presented in this issue. The authors' effort in submitting it is greatly appreciated.</i></p> <p>Over the years, proper seating for the severely disabled has been neglected. Often, an approximate position of the patient in commercially available "grandfather-chair" seats, upholstered with cushions, seemed to be sufficient for the needs of these individuals. Custom shaped seats manufactured in the usual manner to taking a plaster cast, and molding the seat-shell of plastic material on this plaster model, after rectification, have proven to be helpful at least for limited periods, especially for growing children. However, often, during the time of plaster taking, an unfavorable position of a child, especially in cerebral palsy children, could be achieved, causing a permanently defective position for the child in such a seat. Moreover the entire process was time consuming, requiring the presence and active participation of an experienced and, therefore, expensive orthotic specialist. Also, the presence of the patient for a long period was necessary in comparison to our present procedure.</p> <p>In 1978, we started a program for the improved manufacture of seats, using prefabricated seat shells and standardized patterns for the manufacture of individually shaped and adjusted seats for patients with seating problems, due mainly to neuromuscular diseases like cerebral palsy, muscle dystrophy, multiple sclerosis, and so on.</p> <p>The idea was to improve the seating comfort of our patients and to increase the adjustability for growth and clothing. At the same time we wanted to reduce the amount of work necessary, especially for the orthotist.</p> <p>Presently, there are six different sizes of prefabricated seat shells made from glassfiber-reinforced polyester resin. These are divided in the seat and the back section and are connected with strong hinges integrated into the laminated resin (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-01.jpg"><b>Fig. 1</b></a>). For each size of these seat shells, standardized inserts of polyethylene are necessary to form a second, innershell. The inner shells consist of one seat, one back, two upper and lower lateral parts (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-02.jpg"><b>Fig. 2</b></a>). The parts of the innershell are fixed to the outer seat-shell with screws. The holes are drilled with the use of a permanent pattern or die (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-03.jpg"><b>Fig. 3</b></a>). This allows for the quick exchange of one or the other part of the seat. They can also be removed for easy cleaning, reshaping, or for the addition of spacers between the inner and outer wall for proper fit with respect to clothing and climate (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-04.jpg"><b>Fig. 4</b></a>). Foot-rests, headsupports, handles, quick-exchange boards are also prefabricated in standardized sizes and on stock in the workshop. By this means, the orthotist gains more time to devote attention to the needs of the patient and to optimize his position, because he does not need to devote time to the production of these items.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-01.jpg"><strong>Figure 1. Four of six sizes of the modular seatshell. Two hinges connect the back and seat sections.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-02.jpg"><strong>Figure 2. Seat, back, two upper side, and two lower side inner sections to be mounted in the seatshell.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-03.jpg"><strong>Figure 3. Use of the permanent pattern, or die, for drilling of screw holes, in a standardized array, in the seatshell for mounting of the inner sections.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-04.jpg"><strong>Figure 4. In the foreground, spacers for insertion between seatshell and inner shell to allow for seasonal variation in clothing. In the background can be seen foam rubber pieces to be glued to the inner shell.</strong></a><br /> <p>Prior to the initiation of this fitting procedure, the responsible physician, physiotherapist, occupational therapist, and the orthotist have to decide what they want and how the patient is to be best positioned with respect to his daily living and physical abilities.</p> <p>The individual fitting of the module is achieved by optimal positioning of the patient in a seat shell of appropriate size and by positioning roughly cut foam rubber pieces between the patient's body and the sidewalls, seat, and back of the seat shell.</p> <p>After having made a rough alignment of the foam rubber pieces, they are glued to the inner parts of the seat. Then they are removed entirely and ground down to the proper shape until each of the six pieces fit properly (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-05.jpg"><b>Fig. 5</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-05.jpg"><strong>Figure 5. Foam rubber pieces have been glued in place and ground to proper contour and fit.</strong></a><br /> <p>Another solution is used for children with extensive spasticity. After selection of the proper size seat shell and inner-liner, the child is covered completely, including legs, arms and head, with layer of foam rubber and isolated by a piece of plastic foil or film. This is to prevent polyurethane foam from coming into direct contact with the patient's clothing or skin and to prevent burns. The patient is then positioned as well as possible in the modular seat shell. This is preferably done by the therapist or the mother of the child so as to prevent spasticity as much as possible and to optimize the posture of the child.</p> <p>If necessary, a foam rubber wedge is placed between the knees to create slight abduction of the legs. Then, the free space between the body and the seatshell module is filled with polyurethane foam (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-06.jpg"><b>Fig. 6</b></a>). After the foam hardens, the child is removed from the seat and the foam is cut along the borderlines of the six parts of the insert, including the lengthened backpart for a headsupport if its use is necessary (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-07.jpg"><b>Fig. 7</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-06.jpg"><strong>Figure 6. The child is held in place while the void between him and the seat is filled with polyurethane foam. Child is protected against exposure to foam with a layer of plastic film and against thermal burns with a layer of foam rubber. This also allows for the layer of foam rubber to be subsequently added for comfort.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-07.jpg"><strong>Figure 7. Seat following completion of the foaming procedure.</strong></a><br /> <p>Each piece of foam is then ground to the proper fit and covered with a layer of foam rubber to prevent pressure sores and for sitting comfort.</p> <p>The same procedure is carried out for those seats for which polyurethane foam was not used. By adding more foam rubber and grinding the six different parts to proper fit, an individually optimized shape of the interior of the modular seat shell is achieved.</p> <p>A headrest may be made from a separate piece of polyethylene padded with foam rubber and shaped to properly fit the individual patient. It is fixed with adjustable metal bars on the backside of the seatshell. Another solution is the so-called integrated headsupport which is not removable, in contrast to the above-mentioned type. It is made from a sheet of polyethylene as an elongation of the polyester inner-layer of the back (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-08.jpg"><b>Fig. 8</b></a>) on which foam rubber is glued and shaped to size. An additional pillow for the neck and head is easily removed and attached to the headrest by means of Velcro® fasteners.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-08.jpg"><strong>Figure 8. Section of polyethylene added to the top of the innershell to serve as the foundation upon which an integrated headrest will be built.</strong></a><br /> <p>In most cases, additional fixation of the patient is necessary to prevent him from falling out of the seat, e.g. during a sudden spastic convulsion. In moderate cases, safety belts adapted to the seat may be sufficient. If a more secure purchase is necessary, the lateral parts of the backrest are elongated at the level of the sternum and closed in around the front of the chest by an additional belt (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-09.jpg"><b>Fig. 9</b></a>); or, an entire thoracic pad, made of a sheet of polyethylene, covered with foam rubber and ground to a snug fit, is fixed firmly to the seat by a hinge on one side and a clasp on the other to provide proper hold of the body. In severe cases, for example in athetoid spasticity, we use a kind of apron with a belt-system (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-10.jpg"><b>Fig. 10</b></a>) to keep the pelvis and the trunk in proper position within the seat.</p> <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-09.jpg"><strong>Figure 9. Completed seat showing restraint system and anterior thoracic extension.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-10.jpg"><strong>Figure 10. Completed seat showing apron and belt arrangement for restraint.</strong></a><br /> <p>It is essential to provide enough free space for the bent knee joints. If necessary, the module and the seat part have to be cut out to allow for comfortable sitting. The abduction wedge must fit correctly too; otherwise it may increase spastic adduction patterns.</p> <p>Due to the hinges between the seat and the backpart, and a stop on either side of the seat module, the patient can be leaned back in his seat, if desired.</p> <p>In patients with limited movement in the hip joints, the seat part may be divided longitudinally. Then, each half can be adjusted independently to the individual position of either leg.</p> <p>Additional armrests are used to prevent injuries to hands and arms if they are uncontrollable. For children and wheel-chair-bound adults a removable table may be added to the seat within the range of motion of both arms and the body, providing enough space for playing with toys, eating, paper work, and so on.</p> <p>Finally, prefabricated footrests make sure that the entire body is in a proper and comfortable position. Our footrest is adjustable to height and inclination as dictated by the patients' needs.</p> <p>The quick-exchange board system allows for easy removal of the entire seat from the wheel chair, normal chair, or the regular seat of a car. The wooden board of the seat is fixed with one or two special clasps and a "U" shaped metal stop to a second board which is screwed to the wheel chair or another chassis. This disconnecting device provides stable and safe fixation of the seat and the patient to the respective underlying surface.</p> <p>If it seems preferable to first try the unfinished seat before finishing, the patient uses the seat at home for one or two weeks. After a final check and correction, the different parts of the insert are removed once more and covered with a strong and long lasting colored nylon-velour. This gives the entire assembly a lively appearance, quite different from the ordinary "medical" wheelchair design.</p> <p>Since we started this seating program, approximately 500 patients have been fit with this device. Each was provided with an individually shaped seat by using modular seat shells and pre-fabricated componentry to the largest extent possible. Only a few severely handicapped individuals had to be fit in the conventional manner by taking an individual plaster of Paris cast to create a mold for a seat. Thus, we recommend the use of prefabricated modular seat shells and componentry for satisfying the seating needs of the physically disabled.</p> <p><em><b>*Klaus Fischer </b> Klaus Fischer, Orthopadie-Mechanikermeister, can be contacted c/o Fa. Brillinger at Orthopadie-Technik, Rhein-landstraBe 18, D-7400 Tubingen, Federal Republic of Germany.</em></p> <p><em><b>*George Neff </b> Priv. Doz. Dr. Med. Georg Neff is with the Department Technical Orthopaedics at the Orthopaedic University Hospital, Calwer Straße 7, D-7400 Tubingen, Federal Republic of Germany.<br /><br /><br /></em></p> Page Number(s) 49 - 54 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Modular Seat-Shells and Standardized Manufacture of Individually Shaped Seats for the Severely Disabled: The Tubingen Experience Creator An entity primarily responsible for making the resource George Neff * Klaus Fischer *