8 20 371 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/d586b041111b65540684d82a6e22f061.pdf e776f2fafbdbd45711ced14b11af8203 https://staging.drfop.org/files/original/a6c4aeadeff6b0f8ec45aad1761417bc.jpg 0335be700fe81e4e50cc3fa690fb418f https://staging.drfop.org/files/original/9621cce0bb9d571026c1d68d6c3bfdea.jpg e4ea4687449f451e36041c2e86b31857 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_001.pdf Text Any textual data included in the document <h2>Plastics in Lower-Limb Orthotics</h2> <p>Our October 1976 Issue of the Newsletter discussed "Plastics in Lower-Limb Orthotics" and requested information from our readers as to their experiences and preferences. The following is the results of the questionnaire on this subject.</p> <p><a href="/files/original/a6c4aeadeff6b0f8ec45aad1761417bc.jpg"><b>Fig. 1: <span>Fitting the Molded Plastic AFO.</span></b></a></p> <h3>Results of the Questionnaire and a Discussion of the Results</h3> <ol> <ol> <li> <p><i>Does your clinic use custom made orthoses formed from sheet thermoplastic material?</i></p> <blockquote> <p>YES - 71<br />NO - 2</p> </blockquote> <p>One of the respondents who answered "NO" is an institution that treats only amputees. The other "NO" came from an orthotics facility in New England who gave as the reason "We use Ortholene blanks and laminated AFO's."</p> </li> <li> <p>If the answer is "Yes" please name the materials used and show opposite the types of appliances made from the particular material.</p> <p>The responses to this question are shown in this <b>Table</b>.</p> </li> </ol> </ol> <img src="https://staging.drfop.org/files/original/9621cce0bb9d571026c1d68d6c3bfdea.jpg" /> <ol> <li> <p><i>Do you use preformed "off-the-shelf" AFO's?</i></p> <p>Thirty-one used preformed or "off-the-shelf" AFO's. Thirty-six who also used molded AFO's did not use "off-the-shelf" AFO's. Most of the respondents who used the preformed AFO's stipulated that the use was limited to initial trials or to those relatively few patients that could be fitted adequately. Those that refused to use the preformed unit felt that the better results obtained by custom molding was worth any extra effort necessary.</p> </li> <li> <p><i>Please give the reasons for the answer you gave to question "3".</i></p> <p>Some typical responses were:</p> <blockquote> <p>"They (preformed) will work on some patients....."</p> <p>"Use (preformed) on easy to fit patients or those not needing the extra support."</p> <p>"If the doctor specifically prescribes (preformed), or if the patient insists after explaining the advantages and disadvantages."</p> <p>"I use preformed AFO's for pes equinus only. I use custom made for all other orthotic treatment."</p> <p>"Because (preformed are) no good; have to reheat and mold to have work properly, so may as well start from scratch and make your own."</p> <p>"Fitting difficulties - sizes do not fit many patients who are edematous, atrophied, or need support."</p> <p>"They don't fit."</p> <p>"Doctors prefer custom-made."</p> </blockquote> </li> <li> <p><i>If you provide molded plastic orthoses, what type of equipment do you use in fabrication?</i></p> <p>The answers given were not always clear but it appears that:</p> <blockquote> <p>35 used a vacuum machine of one type or another<br />19 used hand drape with vacuum<br />14 used hand drape without vacuum<br />8 used central fabrication</p> </blockquote> <p>Some facilities used more than one method, thus accounting for a total greater than the number of respondents that use custom formed orthoses. About the only conclusion that can be drawn from these figures is that vacuum machines are probably worth the investment.</p> </li> <li> <p><i>Please give your opinions about the usefulness of sheet thermoplastics in orthotics.</i></p> <p>Nearly every respondent answered this question in some detail. Most cited lightness and cosmetic benefits.</p> <p>Some typical comments:</p> <blockquote> <p>"We feel that this is the biggest advance in orthotics in the last few years, providing the patient with a lightweight, hygienic, orthotic system."</p> <p>"We feel that molded AFO's are far superior to conventional braces in every respect. Most of our orthoses are constructed using the materials and the patients and their physicians are most pleased."</p> <p>"I am able to obtain excellent fit and control with plastics that would not be possible with a leather-metal orthosis. Also, it is lighter and more cosmetic."</p> <p>"We find it has great adaptations to orthotics, with unlimited applications."</p> <p>"It's the only way."</p> <p>"These orthoses are useful for cosmesis, function, and light weight."</p> <p>"Unlimited potential, but discretion advised."</p> <p>"I feel we have uncovered a new dimension to orthotics and look forward to further developments in the future."</p> <p>"Enables orthotists to apply new ideas toward orthotics."</p> </blockquote> </li> <li> <p><i>Have you experienced problems with the quality of the sheet plastic material? If the answer is "Yes", please explain.</i></p> <p>Twenty five respondents indicated that they had experienced problems with the quality of sheet plastic, while 32 said that they have had no problems.</p> <p>Alan Finnieston of Miami, Florida, who has had a lot of experience in the use of the sheet plastics offers the following observations:</p> <blockquote> <p>"In answer to your question #7, we have had many difficulties with the quality of thermoplastic sheet material of various types. For example: Polypropylene, polyethylene, ABS, styrene, and polycarbonate to only mention a few. We have been involved with thermoplastics and the vacuum-forming field for approximately ten years.</p> <p>Orthotics and prosthetics cannot justify, by virtue of their volume, specific formulations of material to specifications. As an example, most Orthotists or Prosthetists are buying polypropylene on a local level through a distributor. The distributor has no means of controlling what material or formulation of polypropylene he is receiving. Polypropylene is available in homopolymer, copolymer, random or block, plus many variations of grades; extrusion, injection and film, with a multitude of modifiers which can vary specifications of the base material. One then must seek out the reputable extruder with high-quality equipment and technology. This eliminates the problem of the re-ground materials of unknown formulations plus regulation of the extrusion prices."</p> </blockquote> </li> <li> <p><i>Are special courses needed to provide orthotists and other members of the clinic team with training in the prescription, fabrication and fitting of molded plastic lower-limb orthoses? Please explain.</i></p> <p>Of the 73 respondents, only 2 said that they felt that special courses for orthotists and other members of the clinic team were not needed. One of these provided only "hard corsets" and "arch supports"; the other stated "No, not in lower limb orthotics, because the basic rationale is unchanged as is the function." An institution that provided only "hand splints" said "Registered occupational therapists who are trained in splinting in their academic and clinical education fabricate all splints in the clinic." One clinic and one orthotics facility <i>both of which provided molded AFO's</i> answered with a question mark, and another clinic did not respond to this question.</p> <p>However, the remaining 67 respondents felt quite strongly that special courses are needed if orthotists and other members of the clinic team are to make maximum use of the advantages afforded by sheet thermoplastics. The vast majority felt that all members of the clinic team should be offered training, but a few felt that formal training should be restricted to orthotists.</p> <p>Some of the responses are:</p> <blockquote> <p>"Yes, any further education is valuable to the entire team."</p> <p>"Yes - exchange of ideas would be very useful particularly concerning fabrication. I have been making vacuum formed molded orthoses for 2-1/2 years and I still find it useful to exchange ideas with others who do it; to get the bugs out."</p> <p>"Yes. It would be most help to attend a course in KAFO's."</p> <p>"Definitely. Many problems can be circumvented with previous training."</p> <p>"Yes, I believe this would be very helpful. I think this could be done in the curriculum of the schools already teaching Orthotics and Prosthetics. Seminars are helpful but only touch upon the surface. I think this area has already been covered in the last 5 years and needs more advance hands-on courses and experiences by physicians, therapists, orthotists and prosthetists."</p> <p>"Yes. So many doctors still want to use old methods."</p> <p>"Orthotists only should have courses, and then show the latest uses and methods. I feel that he should be the one to explain the advantages to the other team members."</p> <p>"I think courses stressing cast modification, preparation, hand layup, and fitting problems would be helpful to the whole team. Personally, I have seen all the vacuum layup films I can stand."</p> </blockquote> </li> </ol> <h3>Overall Conclusions</h3> <p>Thus, it seems obvious that sheet thermoplastics have a great potential in all aspects of orthotics and that appropriate education programs are needed and wanted.</p> <p>Alan Finnieston included in his reply an announcement that his firm intends to offer "a series of instructional programs on the correct use of plastics in contemporary orthotic practice" and suggests that those interested in attending contact him at 1901 N.W. 17th Avenue, Miami, Fla. 33125.</p> <p>The <i>results of this survey have been forwarded to the</i> formal education programs in this country and abroad with the hope that the faculties will be stimulated to initiate programs in this area.</p> Page Number(s) 1 - 4 Year 1977 Volume 1 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 1 http://www.oandplibrary.org/cpo/images/1977_02_001/1977_02_001-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Plastics in Lower-Limb Orthotics https://staging.drfop.org/files/original/cd2773276c38e31c5de8654b32560573.pdf 87b82fb3ff0928e5a56676a56b7cbdcf https://staging.drfop.org/files/original/a78493f4da7fe644e100ca7cd8f56d1e.jpg e073105d25ced27a5e34a054493e1b9b Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Fig. 1. Common type of fitting stool in use as early as 1915. https://staging.drfop.org/files/original/08467dd5927652e3f141a24cfd88006d.jpg 6b207b6637a053feab492dfd5671d043 https://staging.drfop.org/files/original/70ce2e00269500442488030867f39c27.jpg 89f554cdd092a9be038f0d15dd877649 https://staging.drfop.org/files/original/dccd360bb421f24a14130d0561616df2.jpg 80c4e525bbf609f14fb7e4a1ab680320 https://staging.drfop.org/files/original/7fb4c0a612ed285e0c2e9087a7e28b62.jpg 76427ad85f7535e83fe3bfd90e193887 https://staging.drfop.org/files/original/0d84a2e1a512d5f9cb9193668acd65ae.jpg bed71c0fb716d2bdf7f019f1e9eb4b37 https://staging.drfop.org/files/original/97791855ac3600156a68a12b7c972dd5.jpg 2b164807888f99334218d0f7f47b8f17 https://staging.drfop.org/files/original/da317ff46ffe02bafb48463f608f475d.jpg 6810da6531996bb2b6c2be42269f130d https://staging.drfop.org/files/original/963ad811431eb69af334aa267224b273.jpg 1e1a95fac1029fec7c7f718ecb7e4a94 https://staging.drfop.org/files/original/2841d434985c67fafb98c4d6d708fb1d.jpg 674642f0b1ea2c951c02a34b642778c3 https://staging.drfop.org/files/original/4f883a6fd1a5b6708ec59964f8f2a42b.jpg 9c29c06be2efb1a6f591ec3270228eb0 https://staging.drfop.org/files/original/c80c09227dc29bd5b10a5c5d39e6a560.jpg 44accb51743d8c7c84cfc4df44fbde0b https://staging.drfop.org/files/original/c6663fb4bff4e66ca21d755e4fd2bce7.jpg 496e66c530a145b0109ce9a5596bc33e https://staging.drfop.org/files/original/d4d6515876785c9dc32270fdd4c7af27.jpg 1a33a5ea6da53b83e55a91265fa656e3 https://staging.drfop.org/files/original/4f02159f1f7aefd8f42f385c1a097c7a.jpg 9e0b9a2c892c1167b0652e3e195a4a8c DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_020.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 20 - 28 Text Any textual data included in the document <h2>Mechanical Aids for Alignment of Lower-Extremity Prostheses</h2> <h5>Charles W. Radcliffe, M.S.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>If a prosthetic device is to give optimum service to the amputee, it must always be properly fitted, regardless of its mechanical excellence. This is especially true in the case of the lower extremity, where the prosthesis must function continually and where poor fit or alignment will lead quickly to rejection of the device by the wearer. Among prosthetists there seems to be general agreement that by far the most important factors in the success of any artificial leg relate to fit and alignment on the subject. Fit and alignment are usually considered together, since they are mutually interdependent.</p> <p>Over the years many different mechanical devices to aid in fitting and alignment of lower-extremity prostheses have been developed to help in the application of one or another particular set of alignment principles in use by individual fitters. Others of these devices are more general in application and are adaptable for use by any prosthetist regardless of the particular alignment principles he advocates. In every case, however, an attempt has been made to improve the fitting and alignment technique by adopting one definite set of principles and using a mechanical device to aid in the application of those principles.</p> <h3>Historical Background</h3> <p>In 1919 Franz Schede<a></a> wrote <i>Theoretische Grundlagen fiir den Bau von Kunstbeinen, </i>a work generally considered to be one of the first important contributions in the field of prosthetic devices. In this volume Professor Schede established for the alignment of lower-extremity prostheses a set of principles based on application of known laws of mechanics. He was particularly concerned with alignment of the joints in a lower-extremity prosthesis so as to provide sufficient stability during the stance phase. As a result of the interest in his work, there was developed the so-called "plumb-line" method of alignment, a method which, essentially, assumes that the prosthesis carries weight along a vertical plumb line, the elements of the prosthesis then being arranged using this line as a reference. Still in general use throughout Europe and the United States, this system involves the problem of determining the location of the plumb line in the socket so that it can be extended down to the foot and used as a reference. For this purpose, many mechanical devices have been used.</p> <h4>The Fitting Stool</h4> <p>One of the oldest devices to aid in the fitting of lower-extremity sockets is the common fitting stool (<b>Fig. 1</b>). This device was well known as early as 1915 and is still in general use. When it is used to aid in establishing a "weight line," wedges are employed to tilt the socket block until the desired orientation is achieved. The hydraulic fitting stool of Habermann (<b>Fig. 2</b>) is a recent refinement. It requires that the location of one point on the weight line be assumed, usually at the socket brim, and that the plumb line be drawn vertically downward from this point.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 1. Common type of fitting stool in use as early as 1915.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 2. Modern fitting stool with hydraulic height adjustment. Manufactured in Germany by Habermann.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p><i>Pivot-Point Balancing Devices</i></p> <p>In an attempt to eliminate the necessity for the assumption of one point on the weight line of the socket, various modifications of the standard fitting stool have been tried.<a></a> <b>Fig. 3</b> is a schematic diagram of a fitting stool which uses a fixed ball as the lower contact point. The point of contact of the ball locates one point on the plumb line, which is then extended upward through the socket.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 3. Point-balance fitting stool with a fixed ball as the supporting point</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>In a further refinement of this technique, introduced into this country in 1947, the plumb line is located at the intersection of two vertical planes (<b>Fig. 4</b>). The lower edge of each plane is determined by use of a triangular block giving a line contact along the bottom of the socket.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 4. Line-balance fitting stool with triangular block as a support.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>Another pivot-point balancing device (<b>Fig. 5</b>) locates a similar point near the top of the socket block by supporting the socket in a clamp which pivots about a fore-and-aft axis and allows the pivot point to be moved medially or laterally as desired. Weight is transmitted to the floor through a connecting pylon.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 5. Pylon-type fitting stand with support at a point near the top brim of the socket.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p><i>Vise-Type Fitting Stand</i></p> <p>Another school of thought in the alignment of the above-knee socket believes that establishment of a plumb line is not as important as is establishment of the proper inclination of the socket in space. In the vise-type fitting stand (<b>Fig. 6</b>) of Habermann<a></a>, the socket can be adjusted in inclination to any position desired. Once the proper inclination and height have been established, the socket is clamped rigidly in space, and the amputee "marks time" in the socket. If necessary, changes are made until the amputee is able to bear weight comfortably and to use his stump efficiently in the control of body movements. After an arbitrary plumb line has been assumed, the optimum socket orientation is incorporated into the final prosthesis.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 6. Vise-type fitting stand.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>All of these mechanical aids have helped in the so-called "static alignment" of the prosthesis, a condition which determines the stability of the artificial limb in the stance phase. The "dynamic" factors, which affect the swing phase of the prosthesis, and which account for the differences between the static and dynamic conditions in the stance phase, are adjusted as necessary after the amputee is walking on the rough leg.</p> <h4>Schneider's "Gehmaschine"</h4> <p>Hans Schneider<a></a> of Nuremberg, Germany, has long advocated the use of an adjustable leg or "walking machine." Essentially, his method is to allow the amputee to walk on a trial prosthesis (<b>Fig. 7</b>), changes being made empirically until the alignment is considered satisfactory. Then, as the optimum alignment is being duplicated in the final prosthesis, various measurements are read from the adjustable leg and a measuring stand (<b>Fig. 8</b>). It is claimed that from these measurements the fit and alignment can be duplicated in additional prostheses ordered later.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 7. Schneider's "Gehmaschine."</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 8. Schneider's alignment stand.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h3>The University of California Above-Knee Adjustable Leg</h3> <p>A study of methods for alignment of the above-knee suction-socket prosthesis was started at the University of California, Prosthetic Devices Research Project, in the autumn of 1946. As one of the first phases of investigation, two adjustable prostheses were designed and constructed. These experimental devices (<b>Fig. 9</b> and <b>Fig. 10</b>) allowed adjustment of a large number of variables, and data were collected having to do with the effect of a change in one of the many alignment variables upon the behavior of the prosthesis<a></a>. It soon became apparent that devices of this nature were not only useful as research instruments but that they might also have some practical use as limbshop tools. Accordingly, there was designed and constructed for limbshop purposes a series of models of a simplified device in- corporating only those adjustments found most important, as determined using the research devices.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 9. Experimental adjustable above-knee leg used for research at the University of California.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 10. Experimental adjustable below-knee leg (University of California).</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>The initial effort was to develop a device for alignment of the above-knee suction-socket prosthesis. Out of this work came the above-knee adjustable leg shown in <b>Fig. 11</b>. Several units of this design were used in the experimental program at the University of California and were given shop trials in the San Francisco Bay Area. They were found very useful in the alignment of above-knee prostheses in the shops and, in addition, were widely used for demonstration of alignment principles. But use of the above-knee adjustable leg was then limited because of the difficulty in transferring the optimum relationships from the adjustable trial prosthesis to the final setup.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 11. The UC adjustable leg.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h3>The UC Alignment Duplication Jig</h3> <p>To fill this need, the designers produced the Alignment Duplication Jig (<b>Fig. 12</b>), which is essentially a rather specialized set of clamps and an associated saw guide to maintain the socket, knee axis, ankle axis, and foot in a fixed position, thus permitting the temporary adjustable knee to be removed and replaced with wood, plastic, or metal structural members and joints. Three models of the alignment duplication jig were constructed and loaned, along with models of the above-knee adjustable leg, to the representatives of the Orthopedic Appliance and Limb Manufacturers Association who were then serving as the Technical Advisory Committee to the Lower-Extremity Technical Committee of ACAL. The representatives of the limb industry were unanimous in their conclusion that use of these devices offered considerable advantage to the prosthetist for alignment of all above-knee suction-socket prostheses.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 12. The alignment duplication jig.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>On the basis of the experience gained, the above-knee adjustable leg was redesigned, as shown in <b>Fig. 13</b>, and drawings for both the adjustable leg and the duplication jig were made available to the artificial-limb industry.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 13. Revised design of the adjustable leg as released to the artificial-limb industry.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>Devices similar to those shown in <b>Fig. 12</b> and <b>Fig. 13</b> are now being manufactured<a style="text-decoration: none;">*</a> and can be purchased by limbshops.</p> <h3>The UC Combination Adjustable Leg</h3> <p>Because of the acceptance of the above-knee adjustable leg during its trial period of limbshop use, the Technical Advisory Committee of OALMA recommended that a similar unit be developed for alignment of below-knee prostheses. As a result, the combination above-knee/below-knee adjustable leg (<b>Fig. 14</b>) was designed and constructed at the University of California. Its use as a below-knee alignment device is indicated in <b>Fig. 15</b>. The principal advantage of this unit over previous designs is that no tools are required in making adjustments.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 14. Combination above-knee/below-knee adjustable leg in use as a trial above-knee prosthesis</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 15. Combination above-knee/below-knee adjustable leg in use as a trial below-knee prosthesis.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h3>Use of the Adjustable Leg and Alignment Duplication Jig</h3> <p>The basic difference in the use of the University of California alignment devices, as compared with Schneider's apparatus, lies in the manner of duplication of the optimum alignment. The adjustable leg is used in much the same manner as is Schneider's device. A set of guiding principles for filling and alignment has been established, and the adjustable leg is used as a means of applying these principles to the conditions existing with a particular amputee. But the devices serve as shop tools only, and any set of principles can be applied by the prosthetist.</p> <p>In the use of the alignment duplication jig, the (assumption is made that the optimum alignment will be influenced considerably by the fit of the socket. Since subsequent sockets for a particular amputee are not apt to be exactly alike, it is considered unnecessary to try to duplicate in all later prostheses the alignment of the first. Each socket is considered as a separate alignment prob- lem, and the alignment duplication jig helps in the construction of the final prosthesis rather than as a measuring instrument.</p> <p>In the prior art of lower-extremity limb-fitting, there has naturally been the tendency to stop making adjustments as soon as the prosthesis is just "good enough," especially so when a further change would mean breaking a glued connection or resetting a joint. The principal advantage of the UC alignment equipment is that, since all adjustments in the trial prosthesis are easily and quickly made, the prosthetist can make very small changes until both he and the amputee are satisfied that the best job has been done. The alignment of a leg prosthesis is especially critical in the swing phase and during the periods of transition from stance to swing. Very small changes in alignment can have very noticeable effects upon the performance of the prosthesis at these times. Since small adjustments can be made accurately using the adjustable leg, the prosthetist is able to obtain optimum performance where that is difficult, if not impossible, to achieve by trial-and-error methods. Besides this, the adjustable leg has found considerable use as an educational aid in teaching prosthelisls the fundamentals of limb alignment in suction-socket schools and in demonstration of alignment principles before groups of orthopedic surgeons, physical therapists, and others.</p> <p><b>References:</b></p> <ol> <li>Habermann, Alfred, <i>Mechanische Hilfsmittel fur denstatischen Aufbau des Kunstbeines, </i>Medizinische-Technik, 4(3) :60 (March 1950).</li> <li>Schede, Franz, <i>Theorelische Grundlagen fur den Bauvon Kunstbeinen; Insbesondere fur den Oberschenkel-amputierten, </i>Ztschr. f. orthopad. chir., Supplement 39, Enke, Stuttgart, 1919.</li> <li>Schnur, Julius, <i>BeinbelasiungsUnie und Schwerlinie,</i>edizinische-Technik, 5(3):54 (March 1951).</li> <li>Schnur, Julius, <i>Die Aquilibral-Kontakt Prolhese,</i>rthopadie-Technik, 4(2) :36 (February 1952).</li> <li>University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Functional considerations in fitting and alignment of the suction socket prosthesis, </i>March 1952.</li> <li>War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, <i>Report on European observations, </i>Washington, 1946. <b>p.92.</b></li> </ol> <br /> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Footnote</b></td> </tr> <tr> <td class="clsTextSmall">By the Plastic Fibre Limb Company, Minneapolis Minnesota.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Reference</b></td> </tr> <tr> <td class="clsTextSmall"><b>5.</b></td> <td class="clsTextSmall">University of California (Berkeley), Prosthetic De-ices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, Functional considerations in fitting and alignment of the suction socket prosthesis, March 1952.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Reference</b></td> </tr> <tr> <td class="clsTextSmall"><b>6.</b></td> <td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946. p.92.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Reference</b></td> </tr> <tr> <td class="clsTextSmall"><b>1.</b></td> <td class="clsTextSmall">Habermann, Alfred, Mechanische Hilfsmittel fur denstatischen Aufbau des Kunstbeines, Medizinische-Technik, 4(3) :60 (March 1950).</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>References</b></td> </tr> <tr> <td class="clsTextSmall"><b>3.</b></td> <td class="clsTextSmall">Schnur, Julius, BeinbelasiungsUnie und Schwerlinie,edizinische-Technik, 5(3):54 (March 1951).</td> </tr> <tr> <td class="clsTextSmall"><b>4.</b></td> <td class="clsTextSmall">Schnur, Julius, Die Aquilibral-Kontakt Prolhese,rthopadie-Technik, 4(2) :36 (February 1952).</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Reference</b></td> </tr> <tr> <td class="clsTextSmall"><b>2.</b></td> <td class="clsTextSmall">Schede, Franz, Theorelische Grundlagen fur den Bauvon Kunstbeinen; Insbesondere fur den Oberschenkel-amputierten, Ztschr. f. orthopad. chir., Supplement 39, Enke, Stuttgart, 1919.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Charles W. Radcliffe, M.S. </b></td> </tr> <tr> <td class="clsTextSmall">Acting Assistant Professor of Engineering Design, University of California, Berkeley; member, Lower-Extremity Technical Committee, ACAL, NRC.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-10.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-11.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-12.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-13.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-14.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-15.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-16.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-17.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-18.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-19.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-20.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-21.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-22.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-23.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_02_020/May-1954OCRBatch1-24.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Mechanical Aids for Alignment of Lower-Extremity Prostheses Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S. * https://staging.drfop.org/files/original/ee61dd08d73b1cad17151d32ba21665a.pdf 00de1488d4f6818f709108234fc1fd5a https://staging.drfop.org/files/original/30c5fecef8a972c9d044dc4d99f003e8.jpg 51ba0ecca6e54631dcd919a2c26a692f https://staging.drfop.org/files/original/1ea58d09d331e165282d3da5cc9f227d.jpg bf16b3b914da6223c95f0a83bf29956b https://staging.drfop.org/files/original/4fd62f8f90674af658c40281e2d37b8a.jpg f7926bbf8fc79875b7a3224beafaffed 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_01_002.pdf Text Any textual data included in the document <h2>Plastics in Lower-Limb Orthotics</h2> <p>Polypropylene has been in use for lower-limb orthoses in various parts of the U.S. and Canada for more than 5 years. Although polypropylene itself was introduced and used in orthotics slightly before vacuum forming was introduced, most of the fabricators have used this technique in fabrication. Some AFO designs are being offered "off-the-shelf" in a series of sizes. Some suppliers stress that the purpose of these prefabricated units is to determine if the patient will benefit from a custom made device or devices.</p> <p>A partial bibliography on the use of plastics in orthotics is included on this page.</p> <p>We invite readers of the Newsletter to give us the benefit of their experiences with respect to both custom-made designs and off-the-shelf units by filling out the questionnaire on page 3 and returning it to AAOP, 1444 N Street, N.W., Washington, D.C. 20005. You are asked to be as complete as possible in the information you give so that meaningful conclusion can be obtained. If additional space is needed please use a blank piece of paper and attach it to the original.</p> <p><a href="/files/original/30c5fecef8a972c9d044dc4d99f003e8.jpg"><b>Fig. 1</b></a>, <a href="/files/original/1ea58d09d331e165282d3da5cc9f227d.jpg"><b>Fig. 2</b></a>, <a href="/files/original/4fd62f8f90674af658c40281e2d37b8a.jpg"><b>Fig. 3</b></a></p> <p><b>References:</b></p> <ol> <li>Artamonov, Alex, <i>Vacuum forming of sheet plastics</i>, ISPO Bulletin, No. 4, October 1972</li> <li>Casson, Jerry, <i>Advanced designs of plastic lower-limb orthoses</i>, Orth. and Pros. 26:3, September 1972</li> <li>Cohen, Samuel, and Warren Frisina, <i>Polypropylene spiral ankle-foot orthosis</i>, Orth. and Pros., 29:2, June 1975</li> <li>Demopoulos, James T. and Johne E. Eschen, <i>Experience with plastic patellar-tendon-bearing orthoses</i>, Orth, and Pros. 28:4, December 1974</li> <li>Dixon, Malcolm, and Robert Palumbo, <i>Polypropylene knee orthosis with suprapatellar latex strap</i>, Orth, and Pros., 29:3 September, 1975</li> <li>Engen, Thorkild J., <i>The TIRR poly-propylene orthoses</i>, Orth. and Pros. 26:4 December 1974</li> <li>Glancy, John and Richard E. Lindseth, <i>"The polypropylene solid-ankle orthosis,"</i> Orth and Pros. 26:1, March 1972</li> <li>La Torre, Richard R., Michael Richards, and Sooklall Ramcharran, <i>Ischial-thigh-knee-ankle orthosis</i>, Orth, and Pros. 27:4, December 1973</li> <li>Lehneis, H. R., <i>New concepts in lower-extremity orthotics</i>, Med. Clin, of NA.A. 53:3:585-592, May 1969</li> <li>Lehneis, Hans Richard, Warren Frisina, Herbert W. Marx, and Tamara T. Sowell, <i>Bioengineering design and development of lower-extremity orthotic devices</i>, Bull. Pros. Res., BPR 10-20, Fall 1973</li> <li>Lehneis, Hans Richard, <i>Plastic spiral ankle-foot orthoses</i>, Orth, and Pros. 28:2, June 1974</li> <li>Marx, Herbert W., <i>Lower-limb orthotic designs for the spastic hemiplegic patient</i>, Orth, and Pros. 28:2, June 1974</li> <li>Rice, Edward, <i>A new design for the drop-foot polypropylene orthosis</i>, ISPO Bulletin No. 12, October 1974</li> <li>Rubin, Gustav, and Michael Danisi, <i>A knee-stabilizing ankle-foot orthosis with adjustable spring-loaded ankle</i>, Orth, and Pros. 29:3, September 1975</li> <li>Rubin, Gustav and Michael Danisi, <i>A "slip" cuff for ankle-foot orthoses-a piston-action absorbing polypropylene orthotic cuff</i>, Orth, and Pros. 28:1, March 1974</li> <li>Simons, Bernard C, Robert H. Jebsen, and Louis E. Wildman, <i>Plastic short leg brace fabrication</i>, Orth, and Pros. 21:3, September 1967</li> <li>Rubin, Gustav, and Robert L. Palumbo, <i>A polypropylene knee-ankle orthosis</i>, ISPO Bulletin No. 8, October 1973</li> <li>Sarno, J. E., and H. R. Lehneis, <i>Prescription considerations for plastic below-knee orthoses</i>, Arch. Phys. Med. and Rehab., 52:11:503-510, November 1971</li> <li>Stills, Melvin, <i>Thermoformed ankle-foot orthoses</i>, Orth, and Pros. 29:4, December 1975</li> <li>Stills, Melvin, <i>Vacuum-formed orthoses for fracture of the tibia</i>, Orth, and Pros., 30:2 June 1976</li> <li>Titus, Bert R., <i>A patellar-tendon-bearing orthosis</i>, Orth, and Pros. 29:1, March 1975</li> <li>Wilson, A. Bennett, Jr., <i>Vacuum forming of plastics in prosthetics and orthotics</i>, Orth. and Pros. 28:1, March 1974</li> </ol> Page Number(s) 2 - 2 Year 1977 Volume 1 Issue 1 Figure 1 https://staging.drfop.org/files/original/30c5fecef8a972c9d044dc4d99f003e8.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1977_01_002/1977_01_002-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 3 http://www.oandplibrary.org/cpo/images/1977_01_002/1977_01_002-3.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 Plastics in Lower-Limb Orthotics https://staging.drfop.org/files/original/9e60ebed5692df9e5fe07e6d4cd87a96.pdf 77971953d21518efcd4221380ba3b8a3 https://staging.drfop.org/files/original/c2545799ce5601d736f2cd4f1463a521.jpg 16fbd70081beef02a934947a081b6280 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_01_001.pdf Text Any textual data included in the document <h2>Introduction</h2> <p>In December of 1969 the Committee on Prosthetic-Orthotic Education of the National Academy of Sciences initiated publication of "NEWSLETTER .... AMPUTEE CLINICS" in an effort to disseminate timely information to amputee clinic teams throughout the country and to provide a vehicle for the interchange of information among clinicians responsible for the care of amputees.</p> <p>The Newsletter met with immediate success and was published every two months until 1975 when policy changes at the National Academy of Sciences precluded publication of the Newsletter .... Amputee Clinics. The final issue, Vol. VIII No. 1 has been published with a date of July 1976 after a hiatus of nearly a year.</p> <p>Because so many members of the American Academy of Orthotists and Prosthetists and their colleagues on the clinic teams that they work with have voiced regret that the forum provided by the Newsletter, no longer exists the Board of AAOP, after a study, determined that the majority of the membership were in favor of assuming responsibility for continuation of this type of publication. Therefore, the board of the AAOP has made the decision to proceed on the basis of four issues per year, initially, and to expand the coverage to include orthotics.</p> <p>It was hoped that an announcement concerning the plans of the AAOP would be made in the final edition published by the NAS, but since such could not be effected this abbreviated edition is being sent to those who in the past have received the "Newsletter-Amputee Clinics" to determine the size of the circulation that can be expected.</p> <p>Our editor for the new publication will be Mr. A. Bennett Wilson, Jr. who helped formulate the original newsletter while in his previous position as Executive Director of CPRD. Mr. Wilson is now acting Director of Training at the Krusen Research Center of the Moss Rehabilitation Hospital in Philadelphia, Pa. The editorial board will be headed by Charles H. Epps, Jr., M.D. of Washington, D.C. Dr. Epps is chief of the Juvenile Amputee Clinic at D.C. General Hospital. Mr. Robert B. Peterson, R.P.T., Supervising Physical Therapist for Hospital Services, Maryland Department of Health and Mental Hygiene and the undersigned will also reside on the board. This group plans to seek technical consultation with representatives of the Veterans Administration Prosthetic Center and the Rehabilitation Services Administration of Health, Education and Welfare on all applicable subject matter.</p> <p>We would also like to thank Mr. Anthony Staros, Director of the Veterans Administration Prosthetic Center for his assistance and guidance in planning this new publication.</p> <p>To begin, four issues per year are contemplated. The initial subscription rate will be $8.00 per year. Each issue will contain short articles on both Prosthetics and Orthotics. AAOP members will receive their copies as a service to members. Prices will be adjusted to reflect costs without profit to the AAOP.</p> <p>A subscription order blank is included in this issue for the use of those who are not members of AAOP. Your participation will help us in assuring the long term success of this publication.</p> <p><a href="/files/original/c2545799ce5601d736f2cd4f1463a521.jpg"><b>Joseph M. Cestaro: AAOP President</b></a></p> Page Number(s) 1 - 1 Year 1977 Volume 1 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1977_01_001/1977_01_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Introduction https://staging.drfop.org/files/original/eadb68192d9b2fd8666172557a83275b.pdf 8628bf8a26a7358be776d63ecd50ba6b https://staging.drfop.org/files/original/683a272758a01a47d6dd619c491baf61.jpg 7ea1b0286f3578fec1cf44dd5a141b9e https://staging.drfop.org/files/original/daa86023b71672f0a988e985dd93a419.jpg 5eb13779da4b535642b8ac5e1a5c5226 https://staging.drfop.org/files/original/cac34132ec07e39e8a9063fc6f68b271.jpg 9bef4a8ac31752e52b0f209b8931e0c7 https://staging.drfop.org/files/original/407678256598a48985a5feb419cc10d5.jpg a2ec8084e42fc4e0b67846e1a2bba35a https://staging.drfop.org/files/original/c93608737f30dfd643676d669a794a64.jpg 2ed98b712bd84d285f960a725db0fcf7 https://staging.drfop.org/files/original/22027ce38ca9febc705ae68ae2d16d29.jpg d0562d55da5fc853efdff575c4b3b3a4 https://staging.drfop.org/files/original/14871e7f9a505732ae822f2edbca77f7.jpg 43818bdcb8084b609ccc5bf9c32af638 https://staging.drfop.org/files/original/ddc66f3e4c72ff82e42e8f893269b9bd.jpg 669fc27dd0a2411e77fc9fcbf0a70eff https://staging.drfop.org/files/original/0cec4ba5780fb4f35866dc6af5c54369.jpg 6aecaf5252c3c3574490ef7a65c71e61 https://staging.drfop.org/files/original/345253512930834516888667968141f5.jpg 257a926d196f4a06d609e70a91762ed0 https://staging.drfop.org/files/original/abff7786ca0707d90e783c3c76bbdd31.jpg 9a00399a1136593653b1fd885778d8b5 https://staging.drfop.org/files/original/8b502451ff1f3d43c09d55eb60739c97.jpg 5df759b91e24e21517cafeee940aaebe https://staging.drfop.org/files/original/0210b549389d0d1b7535a201fae94c59.jpg efb4ea591ef51d962f2784a5b9be02ca https://staging.drfop.org/files/original/d5875f021ebf8d742348602b3a498be5.jpg 1ff76c735ab9211f0bb7ac2323c571b0 https://staging.drfop.org/files/original/592e7093372ede7dc18e9aba9afdc43a.jpg 26778cea8e1db5412ea480d941294dd3 https://staging.drfop.org/files/original/2c4da75e6ccb1c8871d09849b20b2ccc.jpg b9e1e2ba106d0e7a9a3ffd6c9ed5d4cd https://staging.drfop.org/files/original/550140a7e8d57308f9dcee01377b0e5f.jpg e28e9978a9f3891ea1c3cc360c261c4a https://staging.drfop.org/files/original/9791acd3b4bc1ea260a21ef4f3386641.jpg 7d78e1beb99b5ec8d612e7e97a9d6982 https://staging.drfop.org/files/original/19341294a016736c920b22eb3d7c6c29.jpg 7e6bc6f995213c9adcf5f7fa316d613e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_03_004.pdf Year 1954 Volume 1 Issue 3 Page Number(s) 4 - 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/1954_03_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_03_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Prosthetics Research and the Amputation Surgeon</h2> <h5>Rufus H. Alldredge, M.D. <a style="text-decoration:none;">*</a><br />Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Except in abnormal circumstances, man is born into his world with four mobile members which extend from his trunk like branches from a tree. These so-called "limbs" he uses in manifold complex patterns, first to serve his immediate personal needs and second to shape his own environment as best he can. Although in early life man reveals the history of the race by crawling about on all fours, he shortly assigns to two of the limbs chiefly, but not exclusively, the functions of supporting the body and of moving it from place to place. The "legs" thus become the principal weight-bearing members and the generally accepted means of locomotion.<a style="text-decoration:none;">*</a> To the more versatile "arms" man assigns most of the more complex functions of daily living and of creative activity. No doubt to this "division of labor" can largely be attributed the rather remarkable development of art and science and literature and industry and most of the other creative manifestations of human life.</p> <p>Because, however, the limbs extend from the body proper, they are particularly susceptible to damage, either from lack of nutrition and disease or by external forces of one kind or another. Since the limbs are not "vital" organs in the same sense as, say, the heart or the liver, it is possible under favorable conditions to remove one or more without loss of the whole living organism, especially since the advent of modern surgery, anesthesia, and the newer drugs and blood substitutes. That is to say, a man has a chance of living on, though a natural member be discarded. We thus have as a result of war, accident, and disease a sizable number of individuals lacking part or all of one or more limbs, and to these must be added those persons born with malformed or missing limbs. All these people, now known generally as "amputees," are obviously handicapped, to greater or lesser degree, in the performance of all those functions ordinarily carried out by the arms and legs, and in extreme cases there may be no residual function at all. To restore lost functions in as great a measure as possible has long presented a challenge to certain people, mostly, as might have been expected, to amputees themselves.</p> <h4>The Background</h4> <p>Early amputations undoubtedly were more often than not traumatic events leading to a prompt death. Occasionally, however, history records amputees who survived their bloody and painful experiences. One famous example was Hegesistratus, who, captured and chained by the Spartans, amputated his own foot in order to escape.<a></a> With the slow development, over the centuries, of surgery in general, amputations came to be performed more frequently. Typically they were desperate efforts to save life. Such works as those of Pare,<a></a> of the sixteenth century, described the techniques. In some cases, a tight tourniquet was applied and left intact until the distal portion was lost by spontaneous amputation. In others, the amputation was conducted with knife and saw, and bleeding was controlled by cauterization.</p> <p>From the beginning it seemed obvious that the amputation should be as distal as feasible in order to conserve the maximum bony lever. Many surgeons, however, preferred a disarticulation at a joint whenever that was possible. For they had found that infection was relatively unlikely to enter the bone through the normal surfaces which could be retained with disarticulation, whereas, in the days before aseptic surgery, osteomyelitis was all too common when the marrow cavity was opened by amputation through the shaft of a bone.</p> <p>Roughly a century ago the introduction of anesthetics made prolonged surgery possible, and not long after that the germ theory and antiseptic and aseptic surgery greatly increased the chances of surviving either accidental wounds or surgery. These factors made possible the comparatively long and complicated amputations now taken for granted, the revision of otherwise unsuitable stumps, and the elective amputations in cases of serious disease or deformity.</p> <p>At about the same time, wars involving European powers, and especially the American Civil War, led to large numbers of surviving amputees. Also, and again more or less simultaneously, the rapid development of heavy industry and of railroading resulted in many traumatic amputations in civilian life, especially in the United States. All these factors increased interest in amputation surgery and in limb-making for the large numbers of surviving amputees.</p> <h4>Amputation Surgery and the Art of Prosthetics</h4> <p>Artificial limbs of one kind or another date from antiquity. Particularly during the fifteenth, sixteenth, and seventeenth centuries, crudely functional artificial arms came to be made, chiefly by armorers, who were already experienced in a related field. Of many known examples, the arm and hand made about 1509 for Goetz von Berlichingen <a></a> is by far the best known (<b>Fig. 1</b>), numerous copies having been constructed for museums. In this and others of the period, joints were flexed by the other hand and locked by ratchets. Springs returned the joints when the ratchets were released by pressure on a projecting knob. In all such armorlike arms and hands, iron was used, sometimes with holes punched to reduce weight. Leather doublets or sockets, often with laces, commonly were used for several centuries.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> <p class="clsTextCaption"><br /> Fig. 1. Typical "sites of election" for amputation in the upper extremity, from well-known texts, by permission of the respective publishers. In general the sites became progressively less restricted. <i>A, </i>Recommendations of zur Verth,<a></a> as reproduced by Vasconcelos<a></a> reporting to the 3rd Brazilian and American Surgical Congress, Rio de Janeiro, November 1943. Original caption labels left drawing as representing functional values for an "intellectual," right drawing as for a "workman." Note that zur Verth favors more lever for a "working man." <i>B, </i>Recommendations of Langdale-Kelham and Perkins.<a></a> They state, ". . . but limb-makers are unable to fit a limb that allows the patient to pronate and supinate, for the circumference of the forearm changes its shape during rotation and the socket is either too tight to permit the change of shape or too loose to secure a firm hold on the stump. . . ." C, Recommendations of Kirk .<a></a> Note increasing emphasis on saving all length possible. Kirk's text suggests that wrist disarticulation is rather unsatisfactory and that few if any prostheses make use of pronation. The elbow disarticulation is tolerated but criticized. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Near the end of the eighteenth century, Klingert<a></a> introduced an above-elbow arm with most of the natural motions controlled by ten catgut cords fastened to a vestlike garment and moved individually by the sound hand. Since in most cases the sound hand might better have performed the intended action, this impractical prosthesis was a classic pioneer in exceeding what some nowadays call the "hardware tolerance" of the amputee. In 1818, Peter Ballif<a></a> of Berlin developed the first voluntary control by use of trunk and shoulder muscles. His hand was of the voluntary-opening type<a></a> with springs to close the fingers and thumb. To the Dutch sculptor, Van Peeterssen, is attributed the first above-elbow prosthesis with harness control permitting voluntary flexion of the artificial elbow joint.<a></a> </p> <p>As the art of armormaking declined, limb-making on the Continent came to be carried on usually in conjunction with the making of braces, and consequently the artificial legs produced there typically evidenced steel sidebars and molded leather corsets similar to those used in braces. At the time of the Napoleonic Wars, the wooden leg, used from earliest times, was provided, for example, by Potts of London for the Marquis of Anglesey and others.<a></a> Wood reinforced by rawhide was used customarily in the United States, although a variety of other structural materials has been suggested in the journal literature and in patents.</p> <p>Comte de Beaufort<a></a> invented a number of artificial arms as well as legs, some of which were approved for French veterans of the Crimean and Italian campaigns. In 1858, he presented to the French Academy of Medicine a hand with an alternator mechanism and a double-spring hook.<a></a> Dorrance<a></a> introduced in America the well-known voluntary-opening split hook with rubber bands to close a movable finger against a rigid one. He and others rapidly produced a variety of hook shapes intended for specific trades.</p> <h4>World War I</h4> <p>World War I led to a revival of interest in amputations and in artificial limbs, notably in Germany, Belgium, and England. All these countries had rather extensive programs involving the cooperation of surgeons, limb-fitters, and engineers. Publications based on World War I experience<a></a> indicated considerable progress in understanding of amputation techniques, of the need for prompt rehabilitation of amputees, and of the importance of fit and alignment of the prosthesis. The development of many new devices and components for artificial limbs for both upper and lower extremity was described perhaps most impressively in Ersatzglieder und Arbeitshilfen.<a></a> Martin's second book <a></a>, prepared for the International Labour Office, and Little's text <a></a> were particularly useful because they offered critical analyses following impartial descriptions of prostheses and mechanisms.</p> <p>The wooden leg came to be used widely throughout the Continent as well as in England and in the United States. Aluminum, introduced by Desoutter<a></a> in England in 1912, was used particularly in England and to a lesser extent elsewhere. The fiber leg was used by a substantial number of limbmakers, particularly in the United States. Despite the large number of knee locks and ankle joints permitting lateral motion, described in patents and in medical and technical literature, most above-knee amputees used a simple uniaxial hinge for the knee joint and a single-axis ankle joint. Rubber bumpers were used widely in place of the tendons popular in the nineteenth century. It is interesting to note that in 1922 Little remarked<a></a> that most leg amputees had to use at least one stick.</p> <p>For the upper extremity, a great many artificial arms, hands, and working tools were developed during World War I, as can be seen from the major books on prostheses of the period .<a></a> American designers generally used the split mechanical hook closed by rubber bands and separated from the forearm by a rubber washer which provided stability by friction but which at the same time permitted pronation-supination by means of the other hand. Europeans generally preferred passively operated clamps and special tools so designed as to be interchangeable by a disconnect at the wrist. Either a clamp, as on a machine tool, or a locking bolt engaging any one of a series of holes in a disc was used to fasten the tool in the selected position of pronation or supination. For working purposes, the attachment for the tool was often placed at the end of the socket, far above the normal hand level, so as to decrease the leverage of the load on the stump. For dress wear, a cosmetic forearm and terminal device could be attached in place of the tool.</p> <p>Various wooden hands, usually with spring-loaded or voluntarily controlled thumbs, were shown in the literature of many countries. Generally, it was assumed that such hands were for dress and for light office use only, either bare or covered with a leather or fabric glove. Often the fingers were curved permanently to carry a briefcase. The Carnes arms and hands,<a></a> patented in 1912, 1922, and subsequently, were widely sold in the United States for many years. During World War I they were widely admired abroad and were described in detail by Schlesinger<a></a> and to a lesser extent by Martin<a></a> and by Little.<a></a> </p> <p>Similar devices, under the general name "Germania," were built in Germany after entrance of the United States into hostilities. Most authors admired the dexterity achieved by the Carnes devices-particularly because of their ingenious construction, the passively adjustable wrist flexion, and the possibility of coordinating supination with elbow flexion to assist in eating-but criticism was leveled at complexity, relatively heavy weight, lost motion, and the restriction against interchange of a hook for the hand.</p> <h4>World War II</h4> <p>Surgical authorities during World War II advocated<a></a> typical "sites of election" <b>Fig. 1</b> and <b>Fig. 2</b>) based upon the extensive practical experience of the surgeons as well as on the advice of many of the more active limb-fitters, who were notably successful in fitting good stumps at these "sites of election" but who had encountered serious difficulty in fitting such stumps as the wrist disarticulation, the very short below-elbow stump, the knee disarticulation, or the Syme stump. Typical prostheses for the so-called "sites of election" are shown in <b>Fig. 3</b>, <b>Fig. 4</b>, <b>Fig. 5</b>, and <b>Fig. 6</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Typical "sites of election" for amputation in the lower extremity, from well-known texts, by permission of the respective publishers. <i>A</i>, Recommendations of Langdale-Kelham and Perkins.<a></a> These authors condemn the Syme. <i>B, </i>Recommendations of Kirk <i>. </i><a></a> Although Kirk does not show a Syme, he agrees with the Canadians that a properly fitted Syme's amputation is ideal for the "laboring man." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Typical prosthesis for amputation below the elbow, made about 1945-47. Note modled leather socket, steel sidebars and single-axis joints permitting elbow flexion only, full upper-arm cuff with two straps, heavy leather shoulder saddle and webbing cheststrap, and double leather thong passing over pulleys at the elbow joint to open the voluntary-opening hook. Rubber bands closed the hook and determined the gripping force. Changing the number of rubber bands to vary the gripping force was possible but inconvenient. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans A administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Conventional prosthesis for amputation above the elbow, made about 1945-47. Note the molded leather socket (with the unusual rear opening and laces), wooden elbow shell and forearm, and push button projecting from lower surface of forearm to control elbow locking by pressure on table top through the sleeve or by use of the opposite hand. Such elbows provided a maximum of five locking positions. A relatively complex harness of cotton webbing supported the prosthesis on the stump and controlled a helically wound rawhide thong sliding through short lengths of stiff housing rigidly mounted above and below the elbow. Tension in the thong flexed the elbow when it was unlocked. When the elbow was locked, tension was transmitted to close the hand, which could be locked by means of the button projecting from the volar portion near the wrist. A desirable disconnect in the thong and a screw thread at the wrist permitted substitution of a hook for the hand. The harnessing pattern for a given level of amputation varied markedly among different limb-makers. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Conventional wooden prosthesis for amputation below the knee, made about 1947. Note the usual leather thigh corset, leather thong or lace, leather back-check to prevent hyperextension of the knee, single-axis mechanical knee and ankle joints, and wooden toe fastened to wooden foot by a belting hinge. Usually a webbing waist belt was connected by an elastic strap to an inverted Y-strap straddling the patella and attaching near the front brim of the shank to help suspend the prosthesis and to extend the knee. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Conventional wooden prosthesis for amputation above the knee, made about 1947. Note reinforced pelvic band and single-axis hip, knee, and ankle joints. Elastic straps from front and rear of pelvic band are joined by a leather strap passing under a roller ahead of the knee bolt so as to extend the knee from a flexed position. In other prostheses of the same type, refinements of workmanship included inlaying the hip joint into the wood and reinforcing it with rawhide, covering the metal pelvic-band reinforcement with leather, and providing a continuous leather-covered sponge-rubber layer on the sole of the foot. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It will be noted, for example, that all levels of forearm amputation, from the wrist disarticulation to the short below-elbow, were fitted with the same type of forearm composed of a molded leather socket, usually laced, extending into a cosmetic shell and reinforced by volar and dorsal metal sidebars which formed a crosspiece at the wrist supporting a screw thread or bayonet-type attachment for the hook or artificial hand. Typically, the terminal device could be rotated passively by the opposite hand against the friction of a rubber washer but could not be pronated or supinated actively. The metal sidebars were hinged in line with the humeral epicondyles to permit elbow flexion in relation to a buckled or laced cuff about the upper arm. Usually the terminal device was operated by a leather thong which passed over a pulley or through a short length of helical wire housing at the elbow joint so as to be independent of elbow flexion. Since the prosthesis did not provide for pronation-supination, whatever of this function was originally available in a stump amputated at the "site of election" soon disappeared owing to muscular atrophy.</p> <p>The elbow lock for above-elbow arms generally was operated, in the case of a unilateral amputee, by the opposite hand, or, in the bilateral arm amputee, by pressure against the body or against a table. It usually consisted of a sliding bolt engaging one of three or four holes in a metal strap surrounding the carved wooden elbow portion below the molded leather or fiber humeral socket. Cotton webbing and rather heavy leather shoulder saddles were commonly used in the arm harness, and leather thongs transmitted forces to flex the elbow and to operate the terminal device.</p> <p>During the period of World War II, the typical unilateral leg amputee in the United States, including many hip-disarticulation cases, walked without the aid of a cane, although the above-knee amputee usually walked with the relatively fixed cadence for which the fixed friction about the knee bolt was adjusted. Any attempt to walk faster or slower led to excessive heel rise or to a tendency to drag the toe. The below-knee artificial leg was often carved from a wooden block by trial-and-error fitting. Alternatively, a leather socket, molded over a modified plaster replica of the stump, was inserted into a fiber, metal, or occasionally a wooden shank. Sometimes, in an effort to increase conformity to the stump, a certain degree of softness or of ability to flow plastically was imparted by a thin lining of felt, wax, or relatively pliable leather.</p> <p>The above-knee leg was occasionally held to the body by suspenders, but by 1945 a large percentage of above-knee amputees used a pelvic band and metal hip joint. Usually the hip joint permitted the leg to swing in one plane only, although in some designs an additional axis permitted abduction and adduction. In England, and rarely in the United States, a third axis, substantially vertical, also permitted a limited amount of rotation, although about an axis outside the body several inches from the ball and socket of the natural hip joint.</p> <h4>Era of Antobacterial Techniques</h4> <p>During World War II, blood, plasma, and antibiotics came to be used widely to increase the chances of survival at the time of injury as well as to permit more extensive surgery. The Surgeon General of the U.S. Army ordered open amputation exclusively, to be followed by skin traction until a revision operation could be performed. This flat order unquestionably reduced the incidence of infection and gangrene<a></a> from combat injuries to U.S. Servicemen in World War II, as compared to experience in previous wars or to the experience of certain other military forces. It undoubtedly led also to the conservation of many stumps which, under other circumstances, would have been reamputated at the "site of election" above the next joint in order to avoid rapid spread of infection and gangrene. According to Veterans Administration records, for example, the U.S. forces had over two thirds of their lower-extremity amputations below the knee, whereas during the American Civil War and among the Filipino Scouts and guerrillas<a></a> and the Yugoslavian guerrillas<a></a> in World War II, it was estimated that at least half of all lower-extremity amputations were above the knee. Little, <a></a> in a sample of 1030 amputations among the English forces in World War I, found only 219 "leg" (below-knee) and 441 "thigh" (above-knee) stumps in a total of 723 lower-extremity amputations.</p> <p>On the other hand, there is no question that the order for open amputation, followed by traction and a second, or revision, operation, led to prolonged hospitalization for some cases which safely could have been performed primarily as closed amputations, particularly as antibiotics became available late in World War II. Furthermore, many of these "military" amputations, performed as they were far behind the lines, were really essentially civilian in nature. It seems very questionable that there would be a need for performing as many open amputations in civilian practice where risk of infection and gas gangrene is relatively low. The surgeon has a responsibility to use open amputation and traction when there is a clear risk, yet to consider prudently the much shorter care which will be needed with a primary closed amputation when it is feasible medically.</p> <h4>New Concepts in Rehabilitation</h4> <p>The large military amputation centers in World War II provided an excellent opportunity to study the entire problem of amputee rehabilitation.<a></a> Although civilian surgeons generally had been in the habit of dismissing the patient when the amputation scar had healed, leaving him to search for limbfitting services with only the guidance of the classified telephone directory and the perplexing visits of amputee salesmen and demonstrators, the military Services reawakened the responsibility of the surgeon for more complete rehabilitation through the stages of prosthetic fitting, training, and subsequent follow-up. Similarly, the Services assumed responsibility for the necessary vocational guidance and counseling.</p> <h4>Wartime Problems</h4> <p>Because of the dramatic concentration of hundreds of amputees in a single hospital, however, the large military amputation centers drew considerable public attention-both favorable and unfavorable and generally over-dramatic. In operating their limbshops, they encountered difficulties because of the scarcity of experienced personnel (P). This problem was partially corrected, though never completely solved, by diligent effort to locate limbfitters who had been drafted and to see that they were reassigned to limbshops at amputation centers. In every case, however, the bulk of the limb-shop staff was necessarily made up of men who perhaps had mechanical aptitude but who were without previous training or experience in the limb industry.</p> <p>At the same lime the commercial artificial-limb industry was kept very busy with its private cases from civilian life and with the veterans from previous wars, while some of its younger men were drafted into the Services. Besides this, the generally good business conditions during and immediately following World War II, together with the manpower shortage, led to the employment or advancement of a great many amputees who, during the previous depression, had had great difficulty in finding and holding jobs. Many of these people wished to procure new limbs, thus further overloading the commercial limb industry.</p> <p>To add to the difficulties, the industry was then neither certified nor licensed, and it consisted, as it does today, of several hundred relatively small workshops. While some of its members had had formal education in other fields, there had never existed in this country any means for formal training in the arts and sciences basic to limbmaking and limbfitting. The sudden release, within a limited number of months, of some 21,000 veterans from military amputation centers imposed upon the industry an exceptional burden. These men had been fitted in the military centers with a serviceable, adequate, but admittedly "temporary" prosthesis, with the understanding that soon after their release the Veterans Administration, through civilian contractors, would provide a permanent prosthesis. Indeed, an additional or spare permanent prosthesis also was provided as a matter of policy.</p> <p>The confused state of affairs about the end of World War II, and during the year or so immediately thereafter, was further complicated by a series of sensational stories in some of the newspapers concerning difficulties with the limbs provided by the military centers and covering a series of indictments and trials of certain members of the commercial limb industry for alleged violation of the Antitrust Acts. The rather emotional atmosphere then prevailing in regard to amputees led to dramatic stories but in many cases to neglect of the basic difficulties.</p> <h4>Casualities From Korea</h4> <p>Substantially all factors concerned have since been greatly improved, so much so in fact that there were no difficulties of this type over the treatment of amputees returning from the Korean conflict. The relatively calm and orderly handling of these casualties, with the close cooperation of all concerned, was a tribute to the progress which had been made since 1945 in both technical and administrative aspects. Much of this change has been due to the fine cooperation of the commercial limb industry, now emerging into a prosthetics profession. It also has been influenced by the greater interest of surgeons in amputations and amputee rehabilitation, by the development of the team concept in this area as in so many other areas of medicine (and indeed in science generally), by the contributions of many sound administrators, and by the results of much hard work in the research and development laboratories.</p> <p>Some of the major changes which have influenced the amputation surgeon have been proven clinically by experience with casualties from Korea. Concepts of level of amputation and certain of the techniques of surgery have been affected. Perhaps most important, there is now a greater interest in postoperative care and in the rehabilitation responsibilities of the medical profession.</p> <h4>Level of Amputation and Modern Prosthetic Replacement</h4> <p>The surgeon's first decision in amputating is the selection of the site. Perhaps the influence of the Artificial Limb Program, sponsored by the Government and coordinated by the Committee on Artificial Limbs of the National Research Council, can be shown most dramatically by a review of the changes in recommended level. From a few definite "sites of election," the development of new principles and devices has made possible reaffirmation of the policy<a></a> of "save all possible length." Every level, with the possible exception of the below-knee amputation, has benefited, particularly in the upper extremity, where it is now possible to define at least nine amputee types (<b>Fig. 7</b>), all of which can be fitted successfully. In many cases the new devices not only permit satisfactory fitting of longer stumps but often replace additional functions beyond the important increase in bony lever.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Definitions of upper-extremity amputee types. Lengths above elbow are measured as percentages of distance from acromion to epicondyles; lengths below elbow are measured as percentages of distance from epi-condyles to styloid. From <i>Manual of Upper Extremity Prosthetics.</i><a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Upper Extremity</h4> <h4><i>The Below-Elbow Cases</i></h4> <p><i>The Wrist-Disarticulation Case. </i><br /> The wrist-disarticulation prosthesis is a good example of the development of a simpler appliance which yet permits better appearance and additional function than did the conventional prosthesis of 1945. At the end of World War II, the wrist disarticulation, if retained at all and not later reamputated at a higher level, was fitted with a laced, molded leather socket supported by steel sidebars jointed at the elbow, quite similar to that shown in <b>Fig. 3</b>, with rather bulky harness and a leather thong for power transmission. Elbow flexion and terminal-device operation were the only functions provided, pronation-supination being prohibited by the single plane in which the elbow hinge operated. The entire appliance was bulky, the uncoated leather soon absorbed perspiration and became objectionable, and the almost complete encasing of the forearm made the prosthesis uncomfortable in warm weather. Because of the screw thread attaching it to the wrist, the terminal device, whether hook or mechanical hand, projected appreciably beyond the opposite natural hand, resulting both in limited function and in undesirable appearance. No cosmetic covering faired the gap between the mechanical hand and the wrist.</p> <p>In contrast, there has been developed under the program of the Advisory Committee on Artificial Limbs a light and sanitary plastic-laminate prosthesis (<b>Fig. 8</b>) which covers only the distal portion of the stump and extends only a short distance up the radial side to support tipping loads while still permitting pronation and supination. <a></a> Extending farther up the ulnar aspect, the socket provides adequate leverage and bearing area to permit comfortable resistance to large loads on the terminal device which tend to tip the socket about the stump when the forearm is in the horizontal position. The snug, "screw-driver" fit of the bony prominences at the wrist into the terminal portion ensures rotation of the socket and terminal device as the radius glides around the ulna. Since this rotation decreases progressively up the forearm until, at the elbow, there is no relative displacement, it is necessary to cut away as much as possible of the radial aspect from the socket. But removal of socket material decreases both the weight of the prosthesis and discomfort in warm weather. The plastic-laminate socket and nylon coating of any leather<a></a> used in this or any other prosthetic or orthopedic appliance will prevent absorption of perspiration and the consequent development of odors.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Cutaway views of light and simple plastic prosthesis for wrist disarticulation, with APRL hand attached to plate embedded in end of forearm to conserve length. The plastic cosmetic glove drapes neatly over the junction. A separate socket similarly attached to a hook (as in Figure 9) is easily substituted to avoid disconnecting the terminal device, as is customary in the usual forearm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Very simple harness is adequate. For the rare amputee requiring only an extremely light-duty prosthesis, the socket can be held on the bulbous stump by a strap like that for a wrist watch to close a keyhole slot so as to clamp the socket firmly just above the bulging styloids. In this case, the only harness necessary is the cable and loop about the opposite shoulder. Practically all amputees, however, require a somewhat more secure, yet still minimum harness, as shown in <b>Fig. 9</b>, with a light triceps pad held by an inverted Y-strap whose fork is higher than the fully tensed biceps. A very simple figure-eight harness is used, and the steel Bowden cable transmits energy quite efficiently without stretching and without catching the shirt sleeve.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Prosthesis and harness for wrist disarticulation or long below-elbow stump. Note simple figure-eight webbing entirely across back, with no cheststraps. A steel Bowden cable transmits energy to the hook with improved efficiency. An open upper-arm harness, consisting of triceps pad and inverted Y-strap, leaves biceps free from pressure. Flexible leather straps as elbow hinges, suggested years ago but seldom used, permit pronation and supination as well as elbow flexion. The APRL hook case may be laminated into the forearm to conserve length. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To shorten the prosthesis markedly in order to match the length of the opposite arm, the proximal wall of the APRL No. 4C hand<a></a> may be fastened to a plate built into the distal wall of the plastic-laminate socket, as shown in <b>Fig. 8</b>. Thus the plastic cosmetic glove can readily bridge the gap between the hand and the prosthesis and extend up under the shirt or coat sleeve of the wearer. A similar plan can be followed with the APRL hook<a></a> by removal of the stainless-steel stud and plate by which the hook case is normally fastened to the wrist disconnect. On other types of hooks, the stainless-steel stud can be removed or shortened and a suitable fastening plate added by welding or brazing. For wrist friction, thin rubber 0-rings may sometimes be used instead of thicker rubber washers, thus further decreasing length.</p> <p>In many cases, it has been found entirely feasible, both technically and economically, to supply two sockets, one laminated to a hand and the other to a hook, to be worn interchangeably. The added length due to a conventional wrist disconnect and stud is thus avoided. Snap fasteners between the flexible leather elbow hinges and the forearm socket, plus the disconnect feature of the control-cable attachment post, permit interchange of prosthesis without changing the harness. Thus the amputee can make the interchange from hand to hook simply by rolling up his sleeve, it being unnecessary for him to remove his shirt.</p> <p><i>The Long Below-Elbow Case. </i><br />In many shorter below-elbow stumps, a similar type of prosthesis, but without the bulges for the styloids, can be applied to permit the amputee to use his remaining pronation and supination. The key factors are flexible elbow hinges and the "screw-driver" fit of the end portion of the stump in the socket with increasingly loose fit proximally. The fact that pronation and supination may be retained encourages the surgeon to make every effort to avoid fusion of the radius and ulna owing to bone spurs or similar causes and to instruct the amputee to participate in physical therapy designed to redevelop muscular control.</p> <p><i>The Medium Below-Elbow Case. </i><br />In the medium below-elbow stump, the limited amount of pronation and supination is worth retaining, yet it is inadequate to permit direct control of the prosthesis. Accordingly, the step-up type of rotation device (<b>Fig. 10</b>) has been developed. Early attempts at an automatic lock were frequently disappointing, particularly if the amputee tended to snap the prosthesis when used with a wrist-flexion unit, because the high inertia forces jammed the locking surfaces and caused permanent dents which thereafter caused chattering or even failure to lock. Instead, a simple lock has been supplied on an experimental basis, some mechanical problems remaining to be solved. A simple bolt in the stabilized outer socket engages one of a series of holes in the rotating portion of the wrist whenever the elbow is flexed more than a few degrees but is withdrawn at maximum elbow extension (<b>Fig. 10</b>, detail). This device is particularly desirable even with a short, almost conical below-elbow stump which, with elbow extended, participates in humeral rotation from the shoulder. The entire extremity rotates within the triceps pad and outer socket, which are stabilized by the harness. With the socket and terminal device rotated to the desired position, the amputee returns his stump to its normal position with the elbow axis parallel to the mechanical elbow hinges, flexes the stump, and thus locks the wrist in the desired position.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. APRL-Sierra wrist-rotation step-up unit showing details of locking mechanism and of hinges used in control of lock. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In such applications, step-up gears are normally provided to increase the rotation of the terminal device in relation to that of the socket. A lock is desirable partially to transmit torsional loads on the terminal device through the elbow hinges to the open humeral cuff, but it is particularly desirable with outside Bowden-cable control of the terminal device to permit the torsional component of tension in the cable, when it spirals about the forearm, to be transmitted to the upper arm without stress upon the stump. The mechanical advantage of torque at the terminal device or control cable over the stump is due, of course, to the step-up gearing used to increase rotation of the terminal device.</p> <p><i>The Short Below-Elbow Case. </i><br />For rather short below-elbow amputations, a geared poly-centric hinge (<b>Fig. 11</b>) has been developed. In some cases, it permits easier fitting of the socket and may hold the socket more firmly on the stump. For still shorter stumps, the socket may be attached to the link connecting the two axes of rotation, while the forearm is attached to the lower geared segment (<b>Fig. 12</b>), thus providing a <i>fixed </i>ratio of 2:1 between degree of flexion of the artificial forearm and degree of flexion of the below-elbow stump and socket. It has been found, however, that this fixed ratio has only limited application.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Hosmer PC-100 polycentric hinge, particularly suited for medium to short below-elbow stumps. By virtue of the mechanical linkage, it sometimes aids in permitting extreme flexion in cases where the stump retains a full range of motion so that step-up hinges are unnecessary. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Geared step-up hinge (Hosmer MA-100) for very short below-elbow stumps of limited range of motion. The stump socket is fastened to the center link connecting the two geared links, which in turn are fastened to the upper-arm cuff and the forearm shell. The ratio of flexion of the forearm shell to that of the short stump is thus 2:1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The short below-elbow stump is another example of the new principle of saving all possible length. Formerly, most surgeons and limbmakers would have agreed that such short below-elbow stumps could not be fitted satisfactorily. Such a stump tends to slip out of the conventional socket and also may exhibit no useful control of the elbow joint. Frequently, it was advised that such cases be reamputated at the "site of election" in the humerus. Late in World War II, however, both in Canada and in at least one U.S. Army amputation center, hinges were developed, similar to those shown in <b>Fig. 13</b>, which permitted a step-up of forearm movement as compared to stump movement, a <i>variable </i>ratio compensating roughly for the resistance encountered and the strength of the stump at various positions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical occupational-aid terminal devices, all European. The screened boxes indicate the devices recommended for the various activities. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As seen in <b>Fig. 14</b>, the short below elbow, biceps are feasible.<a style="text-decoration:none;">*</a> Since there is no appreciable pronation-supination at this level, the biceps tendon remains in a fixed position rather than tending to migrate from medial toward lateral as it does when a longer stump moves from pronation to supination. The posterior rim of the socket is carried as high as possible, substantially to the olecranon. In some cases it is possible to hook the socket brim over the olecranon to help pull the stump into the socket during flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Prosthesis with variable-ratio step-up hinges for short below-elbow stumps. An above-elbow type of cable control assists in flexing the forearm shell. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The middle pivot of the step-up hinges is substantially opposite the humeral epicondyles, which define the anatomical elbow axis. The lower hinge moves in its slot during elbow flexion, as indicated in <b>Fig. 13</b>. The lower proximal end of the forearm shell must be cut out in order to clear the short stump at extreme elbow flexion. But since this type is used on short below-elbow stumps, there is no serious protrusion of the stump beyond the general line of the forearm socket and, therefore, no appreciable bulge in the coat sleeve.</p> <p>Customarily, an auxiliary lift for the forearm is provided by an above-elbow type of harness, with two separate pieces of cable housing attached to the forearm and to the triceps cuff but bare cable running from a space between the two separated pieces of housing, as shown in <b>Fig. 14</b>. By voluntarily controlling the position of the stump, the amputee can effectively "lock" the forearm as if by a mechanical elbow lock and can thus operate the terminal device by increased tension on the control cable without causing further flexion of the forearm. By means of stump action, he also can press downward firmly enough on the forearm to perform functions such as holding papers on a table or holding a fork to stabilize a piece of meat while it is cut by a knife held in the opposite hand.</p> <p><i>The Elbow-Disarticulation Case</i><br /> The elbow disarticulation was for many years frowned upon because of the difficulties of fitting it with a conventional prosthesis with laced molded-leather socket and elbow lock and joint requiring a bolt extending the full width of the elbow. In such a design, of course, the mechanical lock was necessarily fitted below the end of the stump, thus making an overly long humeral section and a correspondingly short forearm section, usually preventing the amputee from reaching his mouth with the terminal device, as well as creating an awkward appearance and difficulty in using the amputated elbow as a support on the desk top, and the like. Capable of end-weight-bearing, the elbow-disarticulation stump, however, is useful as a support without the prosthesis, as in rolling over in bed. Its bulbous and irregular shape serves as a key to stabilize the prosthesis against rotation about the long axis of the humerus.</p> <p>To conserve these functions, therefore, the external lock shown in <b>Fig. 15</b> and <b>Fig. 16</b> was developed to fit on the <i>outside </i>of the socket in line with the humeral epicondyles and the anatomical axis. The artificial forearm can thus be of a conventional length, and the terminal device can be brought to the mouth readily. The locking circle is, however, necessarily of a smaller diameter than would be available in a conventional above-elbow type of prosthesis, so that in the present model the number of locking positions is reduced to five (<b>Fig. 16</b>). Although numbering more than in the earlier conventional above-elbow or brace locks, the five positions are less than the 11 or even infinite number of positions provided by above-elbow locks which have been developed in the ACAL research program.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Prosthesis for elbow disarticulation, with APRL-Sierra external elbow lock (Figure 16) and same dual control as used on above-elbow prostheses. To accommodate bulbous humeral condyles, a channel may be left in the socket, a lacer may be used, or a slotted, flexible, plastic-laminate socket and clamping strap may be loosened and expanded enough to permit entry and withdrawal and yet provide adequate control during use. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Schematic diagram of APRL-Sierra external elbow lock, intended for elbow disarticulation but also useful with very short below-elbow stumps or with paralyzed arms. Top, locked position. Next pull on lock-operating cable in upper right withdraws locking plunger from the wedge-shaped notch in forearm piece and raises the alternator crosshead, thereby compressing the two helical springs. Pin on the thin leaf spring follows right side of inverted heart-shaped cam until it slips into notch at bottom of cam. Relaxing cable drops the alternator cross-head slightly until the pin and leaf spring hold the cam and locking plunger in the unlocked position (middle). Subsequent tension on the cable raises the alternator crosshead enough so that the leaf spring can straighten until its pin follows the left side of the heart-shaped cam back to original position. Meanwhile the helical springs force the crosshead down and push the locking plunger into a tooth in the lower portion attached to the forearm (bottom). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The APRL-Sierra outside-locking elbow hinge has another special application in the very short below-elbow stump where range of motion is insufficient to operate a forearm through a step-up elbow hinge but where a small residual motion is adequate to operate the locking mechanism diagrammed in <b>Fig. 16</b>. In the arrangement shown in <b>Fig. 17</b>, elbow locking is effected by stump motion rather than by motion of the shoulder, thus giving a more natural appearance and more freedom than could be obtained with an elbow disarticulation or an above-elbow stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Prosthesis for very short below-elbow stumps of such limited motion that step-up hinges are inadequate. The external elbow lock is controlled by a convenient cam, lever, or cable system triggered by the limited stump motion, and the forearm shell is flexed by an above-elbow type of harness. By this system the elbow lock is more easily operated than in a conventional above-elbow type of control. The Northrop-Sierra voluntary-opening two-load hook <a></a>shown here is usually considered to be a left hook, that is, as used on a right arm the operating lever is in the little-finger position rather than in the thumb position. This arrangement results in <i>a. </i>more nearly straight control cable of higher efficiency than is possible when the operating lever is on the medial side, in which case the cable must spiral over the forearm. More often, particularly in the case of bilateral arm amputees, voluntary-opening hooks are fitted with the operating lever, and also the control button for changing the load, located on the medial side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The external elbow lock has already been used occasionally for applying artificial-arm principles to arm braces. The situation in that entire field should improve rapidly in the near future. Occasionally, patients have requested, or surgeons have recommended, amputation of an arm when disease or injury have left a flail elbow. It has seemed that improved artificial arms would actually provide the patient with more function. It must be remembered, however, that the damaged arm provides at least some support and perhaps sensation, and consequently every effort should be made to replace the lost functions of stability, control, and voluntary movement by suitable bracing. Polio cases, retaining sensation and an erratic distribution of muscle activity, offer a special challenge.</p> <p>The outside-locking hinge of <b>Fig. 16</b> is normally fitted as shown in <b>Fig. 15</b> and <b>Fig. 17</b> for control from the proximal joint. Presumably, though, it could be inverted and controlled from the distal end of the arm if some portion capable of even a little voluntarily controlled movement with very nominal forces were available in the hand or wrist. A ring on a finger or extreme hyperextension of the wrist could, for example, be used to trigger the elbow lock, thus simplifying the harnessing, particularly if the shoulder were also weakened.</p> <p>It may be noted parenthetically that some work has been done<a></a> both by rehabilitation centers and by prosthetists and orthotists to drive paralyzed fingers with mechanisms adapted from the artificial-hand field or to hyperextend a paralyzed hand on a "cock-up" wrist splint and substitute a hook on a rotary or even on a ball-and-socket mounting on the volar aspect of the wrist. Even with a quadriplegic there has been enough control of shoulder movement to provide the necessary voluntary control for the hook, supplementing at least a weak biceps action for forearm flexion and supination. The relatively heavy hook extending from the volar aspect of the wrist will provide by gravity forearm extension and a tendency toward pronation. Since the degree of paralysis and of loss of sensation may be so variable, in the entire field of arm bracing the role of the doctor is even more important than it is in rehabilitation after amputation. Correspondingly, there is an even greater challenge to the ingenuity of the prosthetist, the engineer specializing in prosthetics, and the manufacturer in adapting or developing special appliances for the individual case and to the patience of the therapist in redeveloping even faint voluntary movements which might control triggers for locking mechanisms.</p> <h4><i>The Above-Elbow Cases</i></h4> <p>In the above-elbow stump, as much as possible should be saved consistent with the nature of the injury or disease. Even a very short above-elbow stump may be useful as an anchor point, and in experimental work on electric arms<a></a> such a stump has been used to control the necessary switches and clutches (<b>Fig. 18</b>). A stump of nothing more than the head of the humerus helps to round out the shoulder and to provide a much more secure stabilization of the "shoulder-disarticulation" socket.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Shoulder cap for electric control by shoulder motion or by short humeral stump or both. From Alderson .<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Nevertheless there remains a challenge to the engineer and prosthetist in providing improved shoulder-disarticulation and very high-above-elbow arms with passive or voluntarily controlled humeral flexion and abduction. A number of designs were shown in the literature<a></a> after World War I, but none appears to have been practical. The sectional plates<a></a> used in the ACAL research program have facilitated independent construction of the socket and remainder of the prosthesis and their subsequent alignment. Sometimes they have been provided with rotation to facilitate donning of clothing with the humeral section flexed, followed by return of the humerus to a vertical position. Such joints of the humeral section to the shoulder cap have not permitted abduction, however, and have not normally permitted voluntary or passive forward flexion of the humeral section about the shoulder joint to bring the elbow forward and permit the terminal device to reach the mouth.</p> <p>The conventional sectional plates have been solid and thus have been suited only for a true shoulder disarticulation, but it should be feasible to leave an opening through which a very short stump, such as the head of the humerus and its surrounding socket, could protrude into the hollow humeral section. Provision of a sector of a complete circular track, rather than the elongated D-shape which has been used, would also result in better cosmetic appearance when the artificial humeral section is flexed forward. Possibly a simple lock to stabilize such humeral flexion could be controlled by a very short above-elbow stump, even if passive adjustment with the other hand, or by gravity in connection with torso movement, were necessary because of the weakness of the stump.</p> <p>Attempts to provide voluntary control of humeral abduction and rotation have been reported in the literature. Alderson <a></a> developed an experimental arm of the shoulder-disarticulation type in which shoulder lift against the anchorage of a groin strap generated either elbow flexion followed by humeral abduction or humeral abduction alone, depending on whether the elbow were free or locked. At least one commercial limb manufacturer recently has experimented with a "universal shoulder joint" permitting a combination of actively and passively controlled motions including upper-arm rotation by means of a turntable located in the humeral section.</p> <h4>The Lower Extremity</h4> <p>In the lower extremity, although there have been definite changes in techniques and devices, the influence of the Artificial Limb Program has not as yet markedly changed the levels of amputation. Work is, however, going forward rapidly, particularly at the Lower-Extremity Clinical Study operated at the University of California using facilities of the U.S. Naval Hospital at Oakland. It is to be expected that in the next few years more definite changes can be recommended.<a></a> Meanwhile, the principal effects of wartime experience and of the ACAL research program have been increased emphasis on the Syme and knee disarticulation and a better understanding of muscle functions, particularly in relation to the suction socket for above-knee amputees.</p> <h4><i>The Below-Knee Cases</i></h4> <p><i>The Syme Amputation. </i><br />While the Syme amputation is more than a century old, it has until recently been considered controversial, with firm advocates and bitter opponents. In some cases, criticism has rightly been directed toward very long below-knee stumps which, however, were not true Syme amputations with the normal heel flap and capable of full end-weight-bearing. Experience at military amputation centers during World War II seems to have confirmed the successful results which have been reported by the Canadians ever since World War I<a></a>. A recent Canadian report<a></a> on the Syme amputation describes surgical precautions, conventional and experimental Syme prostheses, and clinical experience.</p> <p>Although the Syme amputation requires meticulous surgery, in the absence of sepsis, and careful attention to all details, a successful result provides much greater freedom of action for the amputee and enables him to remain on his feet for long periods. The broad surface of tissues anatomically adapted to weight-bearing offers the Syme amputee a great advantage over the below-knee amputee with limited areas offering a wedgelike support for the stump and pressing upon tissue which has not been accustomed to weight-bearing.</p> <p>The prosthesis for the Syme has been improved, on an experimental basis, by the Canadians (<b>Fig. 19</b>) and, more recently, by the Prosthetic Testing and Development Laboratory of the Veterans Administration (<b>Fig. 20</b>). Both types use a plastic laminate in place of molded leather for greater sanitation as well as for greater strength with decreased weight and bulk. Both use Fiberglas extensively for high strength.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Prostheses for Syria's amputation. Above, conventional Syme prosthesis with typical bulky and unattractive design at ankle and with bothersome shank lacer. Below, Syme prosthesis developed by the Canadian.<a></a> Same stump in the two cases. Note improved cosmetic appearance and simplified method of donning. The Canadian model consists ol a perforated plastic-laminate shell with thin, cellular-rubber lining, the whole considerably lighter than the conventional design above. Rear portion can be opened to admit bulbous stump. yet material is effectively distributed to withstand large bending loads. No ankle joint is used, but the foot is formed of cemented layers of cellular rubber around a reinforcing tongue projecting from the socket to the ball of the foot. Pressure on heel compresses the rubber to give the equivalent of plantar flexion. <i>Photos courtesy Canadian Department of Veterans Affairs.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Experimental Syme prosthesis designed and tested at the VA's Prosthetic Testing and Development Laboratory on request of the Orthopedic and Prosthetic Appliance Clinic Team, New York. It combines a molded plastic-laminate shell with rear opening, thin sponge-rubber lining, and an adaptation of the U.S. Navy functional ankle <a></a> using two-durometer rubber block. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Considerable success has attended efforts to reduce the bulk at the ankle by eliminating the steel sidebars which, in earlier prostheses, projected beyond the malleoli on the medial and lateral aspects, thus adding thickness to a zone already the broadest portion of the ankle. The steel sidebars had, in any case, been mechanically rather ineffective in sustaining bending loads, as when the weight of the amputee is supported on the ball of the foot, because the material was close to the neutral axis or central portion of the bars.<a></a> In the newer designs, this portion over the malleoli is relatively thin, but bending moment is resisted more effectively by the most anterior portion, ahead of the tibial crest, and by the posterior portion at a greater lever arm than was available in the older, narrow, metal bars. To avoid fatigue failures, special care must be taken to achieve a smooth posterior cut in the shell-like prosthesis. The bulbous malleoli are introduced into the prosthesis by opening a posterior portion, which may then be closed either in trap-door fashion by a hinged portion of the shell or by a fabric- or nylon-coated leather portion held by a slide fastener, laces, or adjustable straps.</p> <p>The shell-like combination socket and shank section, with the end-bearing pad, is molded over a plaster model of the stump to attain uniform fit. A slightly soft lining may be used throughout the socket. Relief is provided along the sharpest portion of the tibial crest so as to maintain comfort when weight is carried on the ball of the artificial foot and there is a tendency for the socket to press sharply on the upper portion of the tibia. Under such conditions, firm counterpressure, distributed comfortably, is also required just above the malleoli on the posterior portion of the tibia and fibula. Ankle action may be provided by a laminated sponge-rubber heel which is compressed at heel contact, giving the equivalent of plantar flexion, or by a rubber-block ankle joint with a shallow V-shaped section removed to accommodate the long stump.</p> <p><i>The Short Below-Knee Case. </i><br />Short, badly scarred, below-knee stumps have heretofore sometimes been reamputated above the knee or have been used in a permanently flexed position in the so-called "bent-knee" or "kneeling-knee" prosthesis reminiscent of pirate tales. In either case, the advantages of voluntary control of knee-joint movement are lost.</p> <p>The U.S. Navy below-knee "soft" socket, <a></a> an outcome of recent research, consists of a plastic lining backed by a thin layer of sponge rubber and a rigid or, recently, a rather flexible shell (<b>Fig. 21</b>). An improvement on earlier commercial sockets with felt or wax lining, it may be fitted to any below-knee stump, but particularly it has permitted conservation of short, sensitive, badly scarred stumps. The weight-bearing impression of the stump dipped in plaster yields a much more accurate replica than do most wrapped plaster-bandage impressions. In general, it seems reasonable to believe that any technique for making a socket from a cast is likely to produce a more accurate fit more rapidly and with less discomfort than is a trial-and-error carving process.<a></a> The thin sponge-rubber lining giving the "soft" socket its name seems to be only one of several factors contributing to its usefulness.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. U.S. Navy "soft" socket for below-knee amputation, cut to show plastic sheet lining rolled over brim, thin (1/8-inch) sponge-rubber lining, and flexible plastic-laminate outer shell, all formed over male plaster model of the stump. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Careful location of the mechanical knee joints is always important. The work of the University of Denver<a></a> indicated the possibilities, for below-knee amputees in general, of improved fitting of conventional legs with single-axis knee joints by more careful location of the knee joints. Particularly recommended were fixtures and tools to ensure that the mechanical joints on opposite sides of the prosthesis are on a common axis. Poly-centric joints did not seem necessary. The report considered, however, the possibility of a mechanical joint of the single-axis type at the knee, but mounted high up on the thigh corset by a pivoting joint of limited angular range, in place of rigidly riveting the upper joint bar to virtually the full length of the corset. This idea has been proposed in the German literature.<a></a> In such a case, probably a reinforcing band should be mounted in the thigh corset to ensure that the upper joints are kept on a common axis.</p> <p>The very short below-knee stump, with the tibia amputated in the broad condylar area and with trabecular bone structure, is often suited to take a high fraction of weight-bearing on the distal end, in contrast to the usual below-knee stump of much smaller diameter, limited bearing area, and with thick, hard cortex surrounding a medullary canal. If the thickness of pads at the end of the stump is gradually increased, particularly if the pad in contact with the stump end is carefully molded to the irregularities of the stump, an increasing fraction of end-weight-bearing may often be tolerated.</p> <p>These circumstances deserve careful investigation before any thought is given to re-amputation above the knee, which in the past has often been suggested for such stumps. End-weight-bearing is both more nearly normal with respect to mechanical characteristics, promoting calcification, and is desirable in avoiding any tendency toward lordosis. The very short below-knee stump often can be fitted successfully by very careful forming of the socket. Special care is needed in shaping the posterior brim to accommodate the hamstring tendons, yet to rise into the popliteal space as much as possible without cutting off circulation. The "slip" socket, elastically supported to stay in contact with the stump during the swing phase, is an old idea often indicated for short stumps.</p> <p>Even if a very short below-knee stump cannot take appreciable weight-bearing on its end and on the flaring tibial condyles, it may be fitted with a long, ischial-supporting thigh corset and the sturdy external mechanical joints which would be used in a knee-disarticulation prosthesis. In this case the below-knee amputee, like the above-knee amputee, must rely upon mechanical stability of the prosthesis during the stance phase with the knee in full extension, but at a minimum he has proprioceptive sense of knee position and usually some limited ability to control slight knee flexion to return the knee to full extension, thus saving himself from some falls. Partial control of heel rise at the beginning of the swing phase and of knee extension at the end of the swing phase permit a more graceful gait and a better range of cadence than generally can be attained with above-knee prostheses.</p> <h4><i>The Knee-Disarliculation Case</i></h4> <p>The knee disarticulation, an old type of amputation, typically has been fitted with a molded leather socket provided with a lacer to permit the entry of the bulbous end of the stump. This type of prosthesis has mechanical joints and sturdy metal sidebars similar to those in the below-knee prosthesis. Normally, no mechanical friction has been used, and consequently gait tends to be limited to a single cadence. Any attempt to walk more rapidly leads to excessive heel rise and to "slamming" of the artificial shank into full extension just before heel contact.<a></a> Normally, extension is limited by thongs similar to the back-check in a below-knee artificial leg. Since the knee cannot be extended or stabilized voluntarily, the joints are arranged to give mechanical stability at full extension, as in an above-knee leg.<a></a> </p> <p>Many prosthetists have objected to the knee disarticulation as a level of amputation because of discomfort of the long, molded, leather socket, tendency toward breakage of the sidebars, and the lack of mechanical friction. Amputation at a higher level has frequently been advocated. The knee disarticulation, however, provides definite advantages over the above-knee amputation. If the end of the stump is properly fitted, a broad weight-bearing area is available. Normal transmission of weight through the shaft of the femur minimizes the tendency toward the lordosis often developed in above-knee amputees as the result of weight-bearing on an ischial support located back of the normal hip joint. <a></a> Clearly, disarticulation offers the maximum bony lever of any amputation at or above the knee.</p> <p>A recent informal survey of some of the knee-disarticulation cases performed under supervision of one of the authors (R.H.A.) at Thomas England General Hospital during World War II has indicated satisfaction of the patient with this type of amputation and prosthesis. In spite of the gait deficiencies noted, these knee-disarticulation amputees feel that they walk well, continue to prefer this level of amputation, and refuse any consideration of reamputation above the condyles to become more conventional above-knee amputees. Although some knee-disarticulation prostheses providing knee friction are reported in the literature, <a></a> much more needs to be done in this respect.</p> <h4><i>The Above-Knee Cases</i></h4> <p>In the above-knee amputation, at all locations as much length as possible should be conserved. Gritti-Stokes and similar end-bearing stumps have in many cases been fitted successfully with the suction socket,<a></a> although attachment of the muscles is then particularly important to avoid development of excessive negative pressure owing to displacement of muscle bulk in the necessarily limited clearance volumes available with long stumps and end-bearing pads. Some have found difficulties in fitting such cases with the suction socket and have preferred to rely on a conventional pelvic-band suspension, perhaps with a second hinge permitting abduction. In either case, the longer the above-knee stump the better.</p> <p>As regards the above-knee case, the principal development thus far of the Artificial Limb Program has been the reintroduction of the suction socket, with many far-reaching effects on stump shape, muscle conservation, socket fit, and alignment, accompanied by increased need for the cooperation of many disciplines and the launching of a program of education and certification. As for the first of these, the suction-socket program shifted emphasis from the excessively flabby, conical stump (<b>Fig. 22</b>) desired for the so-called "plug" fit to a more nearly cylindrical stump with firm muscles stoutly attached to the bone. In the suction socket, the muscles are needed both to control the newly found freedom about the hip join and to provide a gripping action by bulging against the walls of the socket, thereby decreasing the negative pressure required to carry the weight of the prosthesis. Similarly, introduction of the suction socket led to replacement of the typical conical socket of triangular or circular cross section (<b>Fig. 23</b>) by a more nearly rectangular socket (<b>Fig. 24</b>). The latter, developed in Germany within the last generation, has a better basis in physiological and anatomical fact, appears to be a necessity with the suction socket, and has, of course, also been used successfully with an increasing number of pelvic-band conventional limbs without use of suction.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. An above-knee socket with nearly circular cross section and steeply conical form intended to support a conical, atrophied stump by side-bearing. Typically, a substantial roll of flesh developed over the rim around most of the circumference. The straps were used with suspenders. Adjustment for atrophy and shrinkage of the stump was easily made by additional stump socks, since the stump was regarded as a jellylike mass whose shape was easily distorted, with little definite relation between socket shape and stump shape. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Conventional socket for "plug" fit of above-knee stumps, showing rounded, triangular top portion of prosthesis for right thigh (looking forward and laterally). Note shelving flare below gluteal crease and ischium and broad, horizontal flare through perineum and adductor region. A considerable roll of flesh develops over this flare also, as in Figure 22. Socket shown here is made of metal and perforated, but the style often was used in wooden sockets as well. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Substantially rectangular or quadrilateral plan of top of socket for left above-knee prosthesis (seen from the rear), typically used for the suction socket but also applicable with soft belt or mechanical hip joint and pelvic band. Note the definite but narrow ischial support, slightly sloping forward and down and well rounded on its forward edge. The medial wall is thinner than the flare in a "plug" fit, since it should <i>not </i>provide a shelf or support against vertical load but should, in order to provide horizontal support during the stance phase, reach into the perineum as high as feasible without striking the pelvis. A nearly square anteromedial corner provides relief for the prominent adductor tendons. A high forward wall keeps the ischium on its support. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As for alignment, introduction of the suction socket has forced the prosthetist to pay more attention to details, since, unlike the case of the conventional above-knee leg, errors in alignment cannot here be concealed by trial-and-error bending of the pelvic band and metal, single-axis hip joint which forced conventional legs to swing in a single plane regardless of their inertia and the gait of the amputee. With the suction socket in correct alignment, the amputee balances his weight completely on the leg, since he has no pelvic band and hip joint to lean against for support. Conversely, however, attention to better alignment has led to decreased stress in the hip joints and pelvic bands of those legs which, for one reason or another, are still fitted with pelvic bands. If one thinks of the suction socket as being fitted with an imaginary hip joint carrying zero stress, it is apparent that a comparable alignment will result in minimum stress in a real hip joint and pelvic band of a conventional leg and, therefore, to greatly reduced risk of breakage.</p> <p>In a very short above-knee leg, the suction socket <i>plus </i>auxiliary suspension, either the Silesian bandage (<b>Fig. 25</b>) or the conventional hip joint and pelvic band (<b>Fig. 6</b>), has permitted conservation of greater <i>effective </i>stump length than would be possible with the same stump in a conventional leg with hip joint and pelvic band but with a "plug" fit. In donning the suction socket, the flesh is pulled into the socket with stockinet, in contrast to the tendency of the conventional stump sock and "plug" fit to push the soft tissues upward and out of the socket. The auxiliary suspension provides greater control and stability than would be available in a pure suction socket. The more logical anatomical fit of the quadrilateral shape, including some ischial support, avoids the roll of flesh in the adductor region and the skin irritations and furuncles so commonly seen with the "plug" fit. Thus, some very short above-knee stumps fitted with this combination of suction socket and auxiliary suspension can function as if with a conventional above-knee leg without the necessity of flexing the stump permanently in a tilting-table type of socket such as would be used for a hip disarticulation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Model of German suction-socket prosthesis with Silesian bandage, or trochanteric belt, with padded horseshoe encircling the trochanter, soft leather belt posteriorly around the pelvis, and V-shaped strap from anterior of socket through ring of the belt. The pelvic belt aims to assure vertical support during the swing phase, while the V-strap provides support against unwanted abduction and external rotation. <i>Courtesy Prosthetic Testing and Development Laboratory, U.S. Veterans Administration.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Extremely short above-knee stumps, with little more than the neck of the femur, can be fitted in some cases with the "saucer" type of socket<a></a> in place of the tilting-table type generally used throughout the world with a true hip disarticulation.<a></a> Often the knee joint is locked during standing and walking, so that the amputee walks stiff-legged. In this case the prosthesis is often built shorter than the sound leg. Sometimes, however, adequate alignment stability can be obtained to permit a free knee joint. The thigh section is sometimes locked to the tilting-table socket so that the back muscle can function to stabilize a free knee as do the hip extensors in the above-knee amputee.</p> <p>Hiyeda, <a></a> in 1942, and independently the Canadian Department of Veterans Affairs<a></a> have used free joints at both hip and knee, with the hip joint farther forward and the knee farther to the rear than usual (<b>Fig. 26</b>). A posterior elastic strap helps to extend the hip joint. Either the saucer socket or the tilting-table type may be built of plastic laminate instead of from the older, molded leather, but if for some reason leather is used, the nylon coating developed at the Army Prosthetics Research Laboratory<a></a> will make it much more sanitary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Hip-disarticulation prosthesis developed by the Canadian Department of Veterans Affairs. Anterior view-shows three points of suspension© and full width of hip joint. Lateral view shows standing and sitting positions. From McLaurin.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Partial Amputations</h4> <p>Wherever possible, of course, partial hand or foot amputations should be performed in preference to major amputations.<a style="text-decoration:none;">*</a> Much work was done during and immediately following World War II on the surgery of the hand,<a></a> and interest has been lively since the formation of the American Society for Surgery of the Hand. In the recent Korean conflict, a great many partial hand and partial foot amputations were performed safely, whereas in previous times many of these cases would have required major amputations, probably as below-elbow or below-knee amputations at the former "sites of election."</p> <p>In recent years, satisfactory cosmetic gloves have been developed by the commercial prosthetics industry<a></a>, at the Army Prosthetics Research Laboratory, <a></a> in the Navy,<a></a> and in the Veterans Administration's Plastic Artificial Eye and Restorations Clinics. These have made possible adequate cosmetic fitting of many partial hand amputations while retaining some function. Moreover, various operable terminal devices for partial hand amputations have been developed both commercially and on an experimental basis in the ACAL program. Sometimes a small hook is mounted on a molded socket and controlled by a conventional cable or by wrist movement. On an experimental basis, the mechanism and wrist plate of an APRL hand have been removed, the transmetacarpal stump allowed to fit within the hand shell, and the side frames of the mechanical hand hinged opposite the anatomical wrist joint to a light forearm cuff. Thus wrist flexion and forearm rotation are preserved. Such cases clearly present individual challenges to the prosthetics clinic team <a></a> and to the designer and manufacturer.</p> <h4>Recapitulation</h4> <p>Decision as to the level of amputation, then, can be recapitulated in terms of saving all length possible.<a style="text-decoration:none;">*</a> This policy is justified not only by new devices, developed predominantly in the Artificial Limb Program, but also by the spectacular advances in recent years in many fields of medicine and related sciences. Blood, plasma, and antibiotics have helped to control shock and infection and have made possible prolonged and precise operations. Medical schools and residency training programs are only beginning to give more attention to education in the broad field of prosthetics to make the new findings available to the practitioner. The various medical societies are now devoting to this broad field more and more time on their programs and more space in their exhibits. Special courses, such as those on the suction socket held at various locations throughout the country, and the Institutes on Upper-Extremity Prosthetics at UCLA,<a></a> are bringing specialized knowledge to the doctor, the prosthetist, and the therapist. More attention is given to individual prescription rather than to "sites of election," with increasing cooperation and expert consultation from the prosthetist as to devices available but without dictation of sites merely because they might be more convenient. Best of all, there is now greater interest in over-all rehabilitation and continued follow-up on the part of the medical profession to see that every amputee, regardless of level of amputation, achieves the greatest possible restoration to normal life.</p> <h4>New Techniques in Amputation Surgery</h4> <p>There is no need here to describe in detail the techniques of amputation surgery, since they are all so well presented in numerous other sources, for example, by Slocum.<a></a> Certain points reflecting the experience of the Artificial Limb Program<a></a> may, however, be worthwhile. These may first be illustrated in terms of a typical amputation with primary closure, chiefly that producing an above-knee stump for which suction socket is intended, followed by notes on some of the special conditions at other levels of amputation.</p> <h4>The General Case</h4> <p><i>Skin Flaps and Subcutaneous Tissue</i></p> <p>In general, the skin flaps are approximately equal on the anterior and posterior sides and are so curved as to meet neatly without undue skin tension but without leaving "dog ears." The usual amputation has a central scar, although in some of the special cases of weight-bearing stumps there is usually a longer flap on one aspect so as to move the scar out of the end-weight-bearing zone. Even for the belowknee amputation without end-weight-bearing, a longer posterior flap has sometimes been advocated to take advantage of the presumably richer blood supply and more liberal muscle and fascia, but the advisability of this technique has not yet been sufficiently evaluated for it to be recommended here. Since when divided the skin and other soft tissues retract, the skin flaps are initially outlined distal to the intended level for sawing the bone, thus compensating for the successive retraction of the various layers and permitting the bone eventually to be sawed through at the edge of spontaneously but temporarily retracted tissues.</p> <p>The subcutaneous tissue may be regarded as a gliding mechanism, enabling the skin to move freely over the deeper fascia and achieving the goal of freely movable skin without an adherent scar. The subcutaneous tissue is cut perpendicularly to the skin, without beveling, and both are allowed to retract as they are cut, without undermining.</p> <p><i>Fascia</i></p> <p>A complete fascial envelope is very desirable, primarily to secure the severed muscles to each other and to the bony lever. Besides this, as Lawrence<a></a> has suggested, piston action of the bone within the soft tissues of the stump may help to pump fluid from the stump. Presumably this action is more effective if the fascial envelope is completely closed in order to force fluid displacement upward through the veins and lymphatic channels. In contrast, an opening in the fascial envelope may permit a compensating pulsation of the soft tissues through the defect, thus failing to generate effective pumping action. Although as yet there is little direct evidence to support such views, the reasoning seems logical.</p> <p>A further advantage of the fascial envelope is to avoid bulging of muscle through a defect in the deep fascia. Accordingly, it is also desirable, when feasible, to repair traumatic defects in the fascia and to refrain from removal of fascia during any plastic operations intended to remove bad scars.</p> <p>The tough fascia lata plays a special role while the above-knee amputee is on the artificial leg during the stance phase. Acting as a guy wire at the most favorable leverage to balance body weight falling medial to the ischial support, it helps to support the pelvis in a substantially horizontal position with minimal expenditure of muscular energy. Hence every reasonable effort should be made to secure firm attachment of the severed end of the fascia lata to the bony lever and to the fascia on the medial side of the stump in order to replace its former anchorage below the knee, as in the intact leg.</p> <p>The incision through the fascia is parallel to the initial skin incision but at the level of the retracted superficial tissues. Like all aspects of amputation surgery, it should be clean and precise.</p> <p><i>Muscles</i></p> <p>The importance of muscles has been emphasized by the Artificial Limb Program in connection with the suction socket <a></a>as a vital part of the cineplasty studies<a></a> and in analysis of the forces, motions, and hence the energy costs of both normal and pathological gait.<a></a> Only from reattachment of the severed ends of the muscles is it possible to attain control of the stump, particularly when greater freedom of action is made possible by improved devices, as, for example, by the suction socket. Moreover, the muscles must be held at substantially their original "rest length" in order to attain the greatest force during contraction.<a></a> Appreciation of this fact was brought out especially in connection with the cineplasty program, but of course the principle applies to all other muscles. A brief review of muscle physiology, mostly of features known for over 50 years but re-emphasized by recent research, is in order.</p> <p><i>The Nature of Muscle Forces. </i></p> <p>The muscle studies at the University of California in connection with cineplasty <a></a> have re-emphasized the importance of the early studies by Blix <a></a> of force-length characteristics. Briefly, as shown in <b>Fig. 27</b>, the force developed by a muscle is related to the length of the muscle at the time the force is exerted. Any attempt to stretch a relaxed muscle beyond its rest length results in an increasing resisting force, as shown by the "passive-tension" curve. If the muscle is restrained at its rest length and then stimulated as vigorously as possible, a certain maximum force can be generated. Full excitation of all the fibers, as by electrical stimulation, yields this maximum force for isometric contraction, although in practical voluntary use only part of the muscle fibers are activated at a given instant, so that a much lower value is attained when the subject "tries as hard as possible."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Idealized length-tension curves for a typical muscle. Note that the passive-tension curve rises sharply when the relaxed muscle is stretched beyond rest length and that maximum voluntary force with isometric contraction is available at or near rest length. Clearly, use of a muscle in a contracted position yields both lower force and less available energy. From Inman and Ralston.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>If now the muscle is allowed to shorten, that is, to move toward the left of the rest length in <b>Fig. 27</b>, stimulation results in some maximum isometric muscle force less than the value attained at rest length. Continued shortening results in decreasing forces measured isometrically until, at some value of contraction varying somewhat in different muscles but roughly 60 percent of the original length of the muscle, no force can be exerted.</p> <p>Beyond rest length, an increased total tension may be developed upon isometric contraction. The exact shape of the curve varies with the nature of the muscle, its past history of stretching or contraction <i>over </i>prolonged periods (especially noticeable in muscles in which the cineplastic operation has been performed), and with the individual case. When the passive-stretch force is subtracted from the total tension attained by isometric contraction, the resulting <i>net </i>force available voluntarily tends in general to decrease again as the muscle is elongated beyond the rest length. Thus the curve of the <i>net </i>force is roughly an inverted parabola with its maximum at or slightly beyond rest length. Since this curve varies with individuals and with training and exercise (which affect both the cross-sectional area of a muscle and the shape of the passive-stretch curve), examples can be found which depart markedly from this schematic pattern. Nevertheless, the general principle leads to a number of interesting conclusions relating to the surgery of both upper and lower extremities.</p> <p><i>Applications of Muscle Mechanics. </i></p> <p>It is immediately apparent from <b>Fig. 27</b> that, if a muscle is allowed to retract, temporarily or permanently, it cannot attain a voluntary force as great as would be possible at or near the original rest length. Prosthetic devices should be utilized, as far as practicable, with the appropriate muscles near, perhaps slightly beyond, the rest length. A cineplastic tunnel, for example, should be so harnessed that most objects will be picked up with the tunnel near the rest length.<a></a> As is well known, the hamstrings, if reattached to the end of the femur in an above-knee amputee, can serve as hip extensors. On the basis of known muscle mechanics, they will be most effective when the hip is somewhat flexed but will be considerably less effective when the hip is fully extended or when it is hyperextended just at the end of push-off. The amputee may then attempt to supplement hip extension by using his back muscles, thus producing lumbar lordosis. Alignment of the socket bore and condition of the back-check controlling extension of the thigh socket relative to the shank will both affect the length of the hamstrings and hence the ability of the amputee to stand securely and to push off forcefully.<a></a> Permanent contracture of a muscle will result in a movement of the passive-tension curve toward the left in <b>Fig. 27</b> and, in general, in a steeper shape of the curve, thus resulting in greater passive tension with only little stretching of the muscle. Thus the maximum force which can be attained voluntarily will be reduced substantially, and the effect may be more serious than the simple reduction in range of motion. Avoidance of contractures is thus mandatory.</p> <p>Workers at the University of California have studied the moment (or force X leverage) available about the hip joint in relation to the angle of adduction or abduction of the stump. Since the gluteus medius and tensor fasciae latae are at their rest length when the stump is in its normal position, under slight passive stretch with an adducted stump, but allowed to contract when the stump is abducted, it is not surprising to find that the available moment about the hip joint decreases markedly from the adducted into the abducted region. Forcible abduction of the stump against the socket wall is essential to keep the pelvis level during the stance phase ,<a></a> and consequently maximum available abduction moment about the hip is desirable to avoid an apparent gluteus medius limp. Therefore, workers at the University of California have reasoned, it is highly desirable to maintain as much adduction as feasible of the socket bore in space and in relation to the remainder of the prosthesis. Experiments with controlled fitting and alignment on the University of California adjustable leg<a></a> have indeed shown this reasoning to be valid. In contrast, fitting of the socket to an abducted stump and "straight" alignment of the shank to the socket result in an appreciable limp.</p> <p><i>Stump Muscles in Prosthetic Control. </i></p> <p>Muscles may have within a socket several actions particularly favorable in the above-knee suction-socket leg. General bulging of the muscle belly during contraction increases the diameter of the stump in the zone of the maximum muscle belly, thus helping to grip the walls of the socket and producing frictional forces which help to support the prosthesis. Muscle bulging and even the contour of the relaxed muscles help to key the correspondingly irregular socket against rotation about its longitudinal axis and thus aid in voluntary control of rotation of the prosthesis.</p> <p>Conversely, the muscles of the thigh sometimes become detached from the cut end of the bone and the overlying fascia but by some mischance become attached to the superficial tissues, as through the scar. Contraction of such muscles causes a pistonlike retraction of the end of the stump, a condition that may cause discomfort in any case, especially if simultaneous contraction of opposing muscles tends to stretch the scar, and one that is particularly undesirable in a suction socket. Pistonlike retraction of the stump end, analogous to withdrawal of the plunger from a hypodermic syringe, develops additional negative pressure in the space between the end of the stump and the floor of the socket. Such excessive negative pressure, far beyond that necessarily created by the weight of the prosthesis, may tend to cause edema.</p> <p>If stump retraction seems apt to occur, the physician should consider all factors carefully before prescribing a suction socket and, if he decides to proceed with one, should caution the limbmaker to leave adequate clearance volume between the end of the stump and the sealing floor. In that case, the change of volume owing to movement of the soft tissue will be only a small percentage of the original volume, so that the resulting negative pressure will be only a correspondingly small fraction of the barometric pressure. But with long above-knee stumps, because of the problem of locating the mechanical knee joint, it may not be feasible to allow adequate clearance volume, in which case the suction socket may be contraindicated.</p> <p>Movements of muscle bellies also may create a wedging action within a relatively conical socket, thus tending to force the socket off the stump and to increase negative pressure in a suction socket, but this effect is not likely to prove serious in the relatively cylindrical, well-muscled stump recommended.<a></a> Wedging action may, however, be desirable in the thigh muscles of a below-knee amputee so as to provide additional support on the somewhat conical thigh corset, thus relieving the below-knee stump of some of the pressure to which it would otherwise be subjected.</p> <p>Muscles or tendons passing over the brim of the socket may also tend to force the prosthesis from the stump when the muscles are tensed, again tending to increase negative pressure in a suction socket. This effect can be minimized by careful fitting of the socket.</p> <p>Muscle tissue acts as a pump to promote return circulation of blood and lymph, as is well known. Obviously, this effect is particularly important in the suction socket to reduce tendency toward edema, and hence vigorous muscle activity is doubly desirable.</p> <p><i>Securing Muscles at Rest Length. </i></p> <p>For all these reasons, it is highly desirable that the muscles be secured to the end of the stump at their rest lengths. Accordingly, the muscles are cut at the levels of the spontaneously retracted superficial tissue and fascia. If necessary, the cut muscles may be sutured to their overlying fascia. Later, when the fascia is closed and sutured over the end of the stump, the muscles will be carried back from their spontaneously retracted position substantially to their rest lengths. It is desirable to have not a mass of loose muscle tissue over the end of the stump but rather a neatly tailored muscle and fascial closure with the muscles restored to their rest length, that is, simply pulled back against the natural tone.</p> <p>To suture muscles to each other at the end of the stump, as has sometimes been recommended in the past, is unnecessary. In fact, the sutures would probably pull out of muscle alone. Suturing of the tough fascia is much more effective, so that it is unnecessary, as well as undesirable, to suture muscles to holes drilled in the bone.</p> <p>In a few special cases, the tendons of the muscles may be sutured together. For example, in the case of knee disarticulation, the tendons of the hamstrings and quadriceps may be sutured in the patellar notch. Generally, the intention is to secure, by healing and scarring processes, the cut ends of the opposing muscles to each other, to their overlying fascia, and to the bone.</p> <p><i>Bone</i></p> <p>With the possible exception of the below-knee amputation (see footnote, page 30), the surgeon will plan to save the maximum practicable length of bony lever. The saw line is made at the level of the naturally retracted soft tissues. Before the bone is sawed, the periosteum is cut cleanly around with a sharp scalpel, taking special care to avoid loose flaps of periosteum, which may later form bone spurs. The bone is then sawed off squarely. There is no need to remove a periosteal cuff, and there should be no attempt to elevate the periosteum.</p> <p>In general, it is not necessary to bevel the bone cortex.<a style="text-decoration:none;">*</a> Preliminary anatomical studies of bone ends at the U.S. Naval Hospital at Oakland, California, and at the University of California Prosthetic Devices Project have shown that the bone end, when treated as already described, may round over spontaneously within a few months so that the medullary cavity tends to become sealed <a></a>. This simply confirms clinical observations already made from amputation of long duration.</p> <p><i>Nerves</i></p> <p>The aim of the surgeon is to sever the nerves in such a manner that the inevitable neuroma will be embedded in soft tissue at a point where it will not be stimulated. Thus, it should not be permitted to reattach to scar or bone in such a manner that the fibrils of the neuroma become stretched at every step owing to piston action of the bone within the tissues or to movement of the scar as a result of muscular action. The neuroma should also be far enough up the stump so that it is not subjected to unusual pressure from use of the prosthesis.</p> <p>The most desirable technique, it has been realized for some years, is to dissect the nerve carefully from the neurovascular bundle, pull it gently from its sheath, and cut it cleanly with a sharp instrument. The severed nerve is then allowed to retract up its nerve sheath into soft tissue. The major cutaneous sensory nerves, which are less obvious, deserve the same careful attention given to the major nerve trunks.</p> <p>Contrary to the advice in some earlier texts, experience of the past decade has shown clearly that no injections of alcohol or other chemicals should be given. Rather, the nerve should be left entirely alone after it has retracted into the tissue. Much clinical experience, and recently the studies of the Pain Project at the University of California <a></a>have indicated that formation of a neuroma must be expected at every cut nerve. Resection of a neuroma once formed will therefore merely lead to development of another neuroma at a higher level. Difficulties are encountered from a neuroma only if it is stretched or compressed. Although phantom pain is sometimes triggered by the stimulation of a neuroma, there are so many other possible causes that repeated surgery to remove a neuroma each time one forms generally is not justified.</p> <h4>The Special Cases</h4> <h4><i>The Upper Extremity</i></h4> <p><i>The Wrist-Disarticulation Case. </i><br />In the wrist disarticulation, the distal joint between the radius and ulna must carefully be preserved to permit free motion of the radius over the ulna during pronation and supination. Occasionally it may be wise to round off any exceptionally sharp surfaces on the styloids, but in general the styloids can be accommodated by careful fitting of the molded plastic-laminate socket (<b>Fig. 8</b> and <b>Fig. 9</b>).</p> <p><i>The Long Below-Elbow Case </i><br /> Similarly, in the long below-elbow stump, every effort should be made to preserve free motion of the radius over the ulna to retain pronation and supination. Cutting of the bones permits the radius to approach the ulna, resulting in shortening, and hence weakening, of the pronator teres. Although with training the weakness can be overcome, the proximity of the radius to the ulna makes bone spurs or actual bony bridging between the two bones much more of a hazard to adequate pronation-supination. Thus careful, clean cutting of the periosteum is of particular importance.</p> <p><i>The Short Below-Elbow Case </i><br />Where there is the possibility of a very short below-elbow amputation, the short stump always should be preserved if at all medically feasible, in preference to amputation at or above the elbow. In some cases, for example where rolling and notching of the socket brim (<b>Fig. 14</b>) might be inadequate to prevent an intact biceps from pushing the socket from the stump during elbow flexion, the surgeon may consider cutting the biceps tendon to permit fitting the socket brim higher than usual. If biceps cineplasty is performed for such cases, the biceps tendon will, of course, be resected and the cut end carefully covered over or imbricated to prevent reattachment. In this case severing the biceps tendon may in some instances permit higher fitting of the socket while simultaneously preserving a useful function for the biceps muscle.</p> <p><i>The Elbow-Disarticulation Case </i><br />The elbow-disarticulation prosthesis with the new external lock (<b>Fig. 15</b>) has encouraged the preservation of the elbow-disarticulation stump whenever feasible medically. As with any end-bearing stump, it is probably desirable to place the scar line away from the weight-bearing area. The irregular shape of the humeral condyles may be retained to assist in anchoring the socket against rotation. Careful attention to the nerves is desirable to prevent formation of sensitive neuromata in the areas which will be subject to load during end-weight-bearing or as a result of bending loads upon the prosthesis when the elbow is locked.</p> <p><i>The Short Above-Elbow Case </i><br />The very short above-elbow stump should be preserved so far as medically feasible in preference to a true shoulder disarticulation or, worse, forequarter amputation. Even the short stump will serve to key the socket and provide greater stability. In some cases the short stump can be used for control of a lock. In experimental work on an electric arm, a very short above-elbow stump has been used to operate a keyboard of switches and clutches (<b>Fig. 18</b>) for control of the electrically driven motions as well as to control an electric elbow lock while a turntable lock above the elbow joint was controlled by a button pressed by the pectoral muscle.<a></a> </p> <p><i>Cineplasty Cases </i><br />In general, upper-extremity candidates for later cineplasty operations<a></a> can undergo the original amputation in the same manner as do those amputees who will use conventional prostheses. Thus far ACAL has accepted cineplasty in the intact biceps of a below-elbow amputee only (<b>Fig. 28</b>; see also <b>Fig. 12</b>, page 61), and in the case of a veteran prior approval from the VA Central Office is required. For many years cineplasty has been performed in a variety of locations and by many different techniques. In the Artificial Limb Program, it has been performed experimentally in a number of locations in various individuals, including the biceps in above-elbow amputees and the pectoralis major for short above-elbow and shoulder-disarticulation cases.<a></a> But before such procedures can be recommended, problems remain to be solved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Typical biceps muscle tunnel in below-elbow case, six months postoperative. <i>Courtesy Army Prosthetics Research Laboratory.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The general principle is to preserve muscle length and attachment at the time of the original amputation so as to prevent permanent contraction. The distal end of the muscle is released only at the time of the cineplasty operation so as to permit prompt exercise and stretching of the muscle soon after the tunnel has healed. Special attention should, of course, be given to repair of any injuries proximal to the intended saw line in order to assure full innervation and blood supply and to avoid serious scarring of the remaining stump.</p> <h4><i>The Lower Extremity</i></h4> <p><i>The Syme Amputation. </i><br />In the Syme amputation, in contrast to amputation at many other levels, preservation of the normal heel flap permits weight-bearing on tissue normally accustomed to full body weight and impact. The incision has a special shape across the instep so as to permit the shelling out of the calcaneus from the heel flap and the later formation of a suture line across the anterior aspect of the stump. <a></a>To provide good bearing, the bones are sawed just above the articular cartilage and in such a plane that the cut surfaces will be parallel to the floor when the amputee stands (not necessarily perpendicular to the long axes, as, for example, in the case of a bowlegged or knock-kneed patient).</p> <p>To ensure preservation of circulation in the heel flap, little if any tailoring is performed. Dog ears left at each side of the heel flap will disappear with proper postoperative wrapping. Contrary to the usual rule, the tendons are simply cut and permitted to retract without attempting to suture the tendons in place or to attain fascial closure. If a good Syme stump cannot be obtained, the surgeon should perform a conventional below-knee amputation, since a very long below-knee stump extending to the lower third of the shank frequently breaks down from poor circulation.</p> <p> <i>The Knee-Disarticulation Case</i><br />In the knee disarticulation, an exceptionally long anterior flap is necessary for closure of the stump and so that the suture line may be posterior and out of the end-weight-bearing zone. In general, the cartilage is simply left in place. The patella, although routinely left in place, may be removed to give extra length to the anterior flap when needed for adequate closure. The patellar tendon is sutured to the hamstring tendons in the patellar notch between the femoral condyles, but no attempt is made to prevent the tendons from gliding.</p> <h3>Summary</h3> <p>Techniques advocated, partly as a result of World War II and subsequent experience and partly as a result of the ACAL program, may be summarized as follows:</p> <ol> <li>With the possible exception of the below-knec amputation, save all length of stump considered surgically feasible.</li><li>Preserve the muscles at their rest length.</li><li>Attempt to secure attachment of opposing muscles to each other and to the bony lever during the healing process through suturing of the opposing fasciae, without attempting to suture the muscles to each other or to the bone.</li><li>Avoid attachment of the muscles to the scar.</li><li>Secure a complete fascial envelope.</li><li>Secure a smooth and freely movable scar, usually central but displaced in the case of end-weight-bearing stumps (or possibly where skin on one side of the stump has a much better blood supply and gliding fascia than that on the other).</li><li>Sever a nerve cleanly and allow it to retract into soft tissue, without injection and with as gentle treatment as possible.</li></ol> <h4>Postoperative Care</h4> <p>The doctor should in every case maintain continuing supervision and responsibility for the postoperative care of the amputee. Just what are the relative responsibilities of the surgeon and of the doctor of physical medicine, where the latter is available, is subject to discussion and, in the present state of knowledge, will necessarily vary from place to place depending upon their respective interests, training, and available time for both professional and administrative duties. But it is important for the patient's welfare that there always be available some single physician who is familiar with the case and who can take responsibility for seeing that the patient receives maximum cooperative service from the nurses, therapists, prosthetist, vocational counselors, and others concerned.</p> <h4>Bandaging</h4> <p>Although the extremely shrunken, conical stump of former days is no longer desired, it is obvious that some muscles (such as the vastus group of the thigh in an above-knee amputation or the soleus in a below-knee case) will no longer have as important functions as before and can be expected to atrophy. It is desired that these muscles atrophy slowly without deposition of an equivalent amount of fat. Careful application of an adequately wide elastic bandage, in accordance with well-known techniques <a></a> will hasten the desired shrinkage.</p> <p>Immediately after the amputation, therefore, the wound is dressed and the stump wrapped with broad elastic bandage. But the bandage will become loose in a few hours and should be replaced by a fresh one, usually every four hours during the day. The used bandage is washed and dried, the usual precautions being taken to restore its elasticity. After a suitable interval, usually 10 to 14 days, sutures are removed, the wound re-dressed, and elastic bandage again applied. Meanwhile, the patient should be taught to cooperate in the application of the elastic bandage so that, when dressings are no longer needed, he may himself learn to reapply fresh elastic bandage several times a day as needed to prevent edema and to encourage shrinkage of tissues no longer functional.</p> <p>The bandage is made snug at the distal end, with no constriction at a higher point on the stump, and it must be carried above the next intact joint, for example up to the thigh in the case of a below-knee amputation or above the hip and around the waist as a hip spica in the case of the above-knee amputation. To avoid rolls of flesh, all parts of the stump must be bandaged, notably the adductor region high into the crotch in the case of the above-knee amputation. The patient must be cautioned against developing above the stump a local constriction which would lead to poor circulation. Likewise, bandaging should avoid a bulbous mass of soft tissue at the end of the stump, which would interfere with later fitting.</p> <h4>Bed Posture</h4> <p>Every effort should be made to restore full range of motion of the stump as early as possible without risk of tearing the muscles from their newly organizing attachments to the bone. The patient should be discouraged from remaining in a fixed position, such as sitting in a wheelchair with the hip and knee flexed, or lying in bed with the stump propped up on a pillow.<a></a> It should be carefully explained to him that some temporary discomfort and inconvenience will be necessary to ensure subsequent full range of motion and effective use of a prosthesis. The leg amputee should lie in bed with his legs parallel, without abduction and external rotation of a thigh stump or flexion of a below-knee stump.</p> <h4>Traction</h4> <p>In the event of a preliminary open amputation, the line of skin traction should be toward the center of the bed, and the patient should be checked frequently to be certain that he is lying with his pelvis parallel to the bottom of the bed. In no case should he be permitted to slant the pelvis and thus, in effect, to abduct the stump. In the more common closed amputation in civilian life, traction is seldom necessary unless, in an attempt to conserve greater bone length, exceptionally short skin flaps have been used and it is desired temporarily to remove tension from the suture line.</p> <h4>Exercises</h4> <p>Restoration of strength and of full range of stump motion can begin when the muscles have become adequately attached to the bone, with gentle voluntary exercises at first to prevent detachment. Restoration of strength will depend both upon developing maximum size of the cross section of the muscle and upon stretching of the muscle stump so that it operates near the amputation rest length, as already discussed. The role of a low passive-tension curve is particularly important, and of course exercises should be prescribed with due regard to the patient's general condition.</p> <p>Home exercises, conducted by the amputee first merely by setting the muscles and later by using simple and readily available apparatus, are particularly important. Much can be done with a flatiron, a pail filled with increasing amounts of water or sand, or other convenient weights attached by a piece of sash cord over a pulley or doorknob to a towel about the stump. Elaborate gymnasium equipment or exercise tables obviously are not essential, convenient as they may be for the well-equipped rehabilitation center. The amputee and his family should be convinced of the importance of sensible home exercises, not only immediately postoperatively but whenever indicated throughout the rest of the amputee's life to maintain good stump condition and to avoid the flabby, weak, and contracted stump so often seen in an amputee of long duration. The amputee should be convinced of the need for maintaining adequate range of motion and strength in order that he may use his prosthesis effectively, gracefully, and with minimum effort. But of course he should be discouraged from intermittent extremes leading only to exhaustion.</p> <h4>General Health</h4> <p>Finally, general body tone is important both for good health and good spirits as well as for effective use of a prosthesis. The leg amputee, for example, must have good triceps to use crutches when necessary and good abdominal muscles to minimize the risk of lordosis. The arm amputee will use muscles of the trunk and opposite shoulder in supporting, positioning, and operating his prosthesis. All young, healthy amputees should be encouraged to take part in swimming, skating, bowling, table tennis, or other sports as appropriate.</p> <p>Every amputee should be cautioned against obesity, which in the lower extremity increases the load on the stump and in any case increases the difficulties facing the prosthetist. Because of the difficulties encountered from alternate tightness and looseness of the socket, all wearers of prostheses, and especially those using the suction socket, should be cautioned against violent fluctuations of body weight. Where indicated, all possible conditions causing obesity should be corrected, and patients should be supervised by a physician to stabilize body weight at normal for the individual.</p> <h4>Rehabilitation Responsibilities</h4> <p>An important result of World War II military experience, of subsequent work under the ACAL program, and of the increasing numbers of amputation clinics both in the Veterans Administration and in private institutions has been the increased interest by the medical profession in its responsibilities for lifetime rehabilitation for amputees. These include not only the obvious medical responsibilities but also psychological aspects; pain and phantom sensations; teamwork with others concerned in the prescription, fitting, training, and checkout of the prosthesis; and referral for any necessary vocational counseling and retraining.</p> <p>Psychological aspects of amputation are particularly important.<a></a> In many cases the doctor can provide appropriate psychological services, but in other cases referral to a clinical psychologist or to a psychiatrist may be desirable. Sometimes preoperative discussion and psychological preparation may be possible, especially if the amputation is elective or if the need for amputation can be foreseen. The prospective amputee himself should, when possible, decide realistically that amputation is preferable to other alternatives and that it is not "the end of the road."</p> <p>In many cases the patient can be helped preoperatively or postoperatively to accept amputation and to begin a realistic estimate of the possibilities of worthwhile rehabilitation through discussion with other amputees of the same level who have been rehabilitated successfully. Clubs of amputees<a></a> are beginning more and more to provide, on request of doctors and hospitals, levelheaded, rehabilitated amputees for just this purpose. Such amputees are not to be confused with the overenthusiastic salesman type or with the psychologically disturbed exhibitionist, who so often has demonstrated his remarkable prowess without making the patient aware of the nature of his stump, the differences between his condition and that of the patient, and the fact that so much depends upon the general physical condition and the will power of the patient. Just as there are professional golfers, there are also professional amputees. These persons can often perform remarkable feats not ordinarily desirable in or to be expected of the average amputee and one, as is usually the case, unwilling to make a career of stunts with a prosthetic device. Realistic discussions of the responsibilities of the patient, yet of the many important and fascinating things which remain possible, will be most effective.</p> <p>A matter of great importance is attention to the attitudes of those associated with the patient. Members of the family will wish to help in every way, yet their efforts must be guided intelligently toward help in the real difficulties while avoiding overprotectiveness generated by pity, which all too soon might turn into rejection. The employer can be helped to realize that the amputee may again return to useful work, whether at his former job or at some other and perhaps better and more skilled job after suitable vocational guidance and retraining.</p> <p>Sometimes the handicapped person, perhaps for the first time receiving professional guidance and being forced to think carefully about his future, will aim at more education and a much higher economic level than before the amputation. After all, much of the heavy labor of industrial countries is being taken over by machines. Unaffected by the amputation, the patient's brain power and ability to make decisions and to control the machines will command a higher value.</p> <p>Friends and acquaintances too must learn to accept the amputee for the many qualities he has left and to admire his demonstrated fortitude and cheerfulness rather than to pity him or even to shrink from him because of past memories of an amputee beggar. Finally, society as a whole must learn to accept not only amputees but all handicapped and disabled persons on the basis of their inherent dignity, ability, and worth as human beings, not on the superficial basis of individual differences in physical condition due to crippling disease, congenital defects, or mutilating injuries. In the past, amputees, like members of other minority groups, have encountered unreasoning psychological prejudices unworthy of the brotherhood of man.</p> <h4>Pain and Phantom Sensation</h4> <p>The amputee will need counseling, both in the acute stage and perhaps occasionally throughout his life, about the nature of pain in the stump, phantom sensation, and phantom pain. Postoperatively, pain is handled as in the case of any other operation. But the amputee may be puzzled that he still has a sensation of the missing member, perhaps in some bizarre position. He can be assured that at least 85 percent of other amputees, and perhaps practically all amputees other than congenital, retain such feelings. Phantom sensations have long interested neurologists and psychologists and recently have come in for study in considerably more detail at the University of California.<a></a> It appears that such sensations are related to the continued activity of the cortex on which the missing limb was originally projected but which no longer receives the normal bombardment of constant new sensations of position, temperature, pressure, and so on.</p> <p>Phantom <i>pain </i>is rare. It occurs only in a small fraction of amputees. Sometimes it appears to be related to specific physical difficulties in the stump or in the remainder of the body, such as pressure on a neuroma or traction upon a neuroma which has, unfortunately, become caught in scar tissue and is stimulated by muscular movement or piston action of the stump in the socket. In other cases, it may be related to some cause further up the body which might have been sought immediately in a normal individual but which might be neglected in the amputee. For example, a ruptured disc in the spine immediately would be sought from certain classic patterns of pain radiating down the leg, but the same might be overlooked in an amputee who complains that pain radiates into his missing phantom limb.</p> <p>Studies at the University of California involved injecting salt solution, as a stimulant, into the various vertebral segments of both normal volunteers and amputees in order to produce radiation of pain which could be mapped systematically.<a></a> In some cases, radiation of the pain into the phantom limb of an amputee resulted in disappearance of the phantom sensation itself after a short period, concurrently with disappearance of pain in the rest of the body (<b>Fig. 29</b>). In other cases, distribution of phantom pain was altered, and in a few cases the phantom pain became worse. In general, however, workers at the University of California believed that phantom pain could be alleviated by one or more of a series of systematic attacks. No single remedy was found that applied to all cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Typical patterns of pain radiation in the phantom limbs of two subjects. <i>Courtesy University of California Medical School</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Prosthetics Clinic Teamwork</h4> <p>The duties of the physician on the prosthetics clinic team have been well outlined by Bechtol. <a></a>The increasing success of prosthetics clinic teams in overcoming the problems of the amputee, as well as those of the wearers of braces and orthopedic shoes, has brought a rapid expansion of amputee clinics in both government and private circles. Indeed, the teamwork concept has been utilized increasingly at many levels of rehabilitation for many kinds of disabilities and throughout scientific research generally. Each member of the team needs humble realization of his own limitations,<a style="text-decoration:none;">*</a> appreciation of the contributions to be made by each of the other members, and, of course, an understanding of the participation of the patient himself as a member of the team created in his behalf. Thus only can there be created a realistic basis for self-confidence in the total effectiveness of the team as an integrated unit. In the Veterans Administration's Orthopedic and Prosthetic Appliance Clinic Teams, the Chief of the Prosthetic and Sensory Aids Unit is the administrative "key" to the success of the individual clinic.</p> <h4>Lifetime Responsibility</h4> <p>The surgical responsibilities immediately after operation have, of course, long been obvious. But no more can the doctor dismiss the patient when the scar is healed-with advice to "look in the classified telephone book for a limbmaker." Rather, the doctor should serve as captain of the prescription team in its efforts to see that the amputee is provided with the best current prosthesis suited to the individual and with adequate training in its use, and he should assume continuing responsibility throughout the lifetime of the amputee.</p> <p>The doctor should, for example, have the clinic administrator arrange for periodic checkup examinations at proper intervals, perhaps once a year. Thus the amputee can be checked for adequate fitting and can be informed of new improvements as they become available, both from the commercial industry's own developments and from the Artificial Limb Program as it makes tested devices available to the industry. The gait of lower-extremity amputees can be observed, facility in the use of upper-extremity prostheses can be noted, and, if necessary, further periods of training may be prescribed. Other problems, such as obesity, spinal curvatures, skin difficulties, and so on can be detected and corrected before they become serious. Frequently, all the amputee needs is a reminder for encouragement to brush up on his old skills. Reassurance and renewed encouragement are of important psychological value to the amputee patient.</p> <p>Finally, the experienced patient, returning for his routine checkup, serves as an example to improve the morale of the more recent patients sitting in the waiting room. The successfully placed and well-rehabilitated patient, grateful for his own return to active life, will be glad to assist by visiting more recent patients in the hospital. He may be called upon whenever his unique physical condition, type of work, or hobby makes him especially suitable to help a person of similar circumstances.</p> <h4>The New Knowledge and the Medicla Profession</h4> <p>The challenge to the medical profession will thus be clear. There has been a rapid increase in knowledge of prosthetic devices themselves, in methods of performing amputations, and in the philosophy of amputee management. Medical education must somehow fit into the medical curricula and into the crowded training programs for interns and residents the new knowledge and changing viewpoint in amputee rehabilitation.<a></a> Exhibits at medical meetings and papers in the medical journals offer some of this new knowledge. The new 800-page collaboration, <i>Human Limbs and Their Substitutes </i>(see <i>Digest, </i>this issue, page 77) presents a much more extensive range of knowledge and broader point of view than is possible in a single article. The busy practitioner, especially the general surgeon to whom amputation is only a rather incidental part of practice, must somehow find time to keep abreast of new knowledge and philosophy while conserving the best principles he has learned in the past.</p> <p>Finally, there is a growing need for geographically spaced centers for performing amputations and to serve as bases for orthopedic and prosthetics clinic teams serving civilians as well as veterans. Perhaps only thus can those with specialized knowledge best serve the patients, especially those with unusual problems. Indeed, such centers could serve as agencies of the Artificial Limb Program, pointing out needs and priorities based on clinical experience and providing facilities for field tests and educational activities.</p> <h3>Conclusion</h3> <p>Thus, it can be seen that marked changes have taken place from the days of the few sharply delimited "sites of election" and the few types of prosthetic appliances available for them. The changes thus far have perhaps been most marked in the upper extremity, where a whole new armamentarium of appliances has been developed and rigorously tested both in the laboratory and in clinical studies. The findings have been made available to physicians, therapists, and prosthetists through a series of Institutes on Upper-Extremity Prosthetics at the University of California at Los Angeles. Even so, the present <i>Manual </i><a></a> shows interim devices which should be greatly improved in years to come. Improved function and appearance are certain, and perhaps there will be some limited sensibility of position, contact, and gripping force.</p> <p>In the meantime, however, a great deal of work also has been done on the lower extremity. Although relatively few new devices, such as the U.S. Navy above-knee artificial leg<a></a> and the suction socket have been accepted, a great many new devices and many changes in practice are being tested at the laboratory and clinical levels. It is to be expected that, in the next few years, <a></a> an equivalent to the upper-extremity armamentarium will be released in an array of new devices for the lower extremity, such as stable knees, means for preventing stumbling, and perhaps forcible ankle push-off. Current inventors' designs and test models eventually will be tested through a systematic transition procedure and released for routine use.</p> <p>To those close to the heart of the ACAL program for nearly a decade, the changes noted herein have occurred so slowly and so imperceptibly in the pressure of daily emergencies that they have not been realized fully. Until brought out by a systematic review or by a chance conversation with someone untouched by the genuine progress which has been made, the alterations lie buried in the seeming monotony of obvious "good practice." Yet all these little modified details in technique, new or revived appliances, and perhaps more profound changes in points of view and philosophy add up strikingly to benefit the individual amputee.</p> <h4>Acknowledgments</h4> <p>It is a pleasure to acknowledge the contributions received through past discussions with a host of associates in military amputation centers, Veterans Administration Orthopedic and Prosthetic Appliance Clinic Teams, the Artificial Limb Program, and private life. Some of the concepts described may be attributed particularly to Jerome Lawrence, of the Veterans Administration Clinic Team in New York; to Verne T. Inman, of the University of California; and to Herman Gladstone, Surgical Consultant to the Prosthetic and Sensory Aids Service of the Veterans Administration. Thanks are due George Rybczynski, who provided most of the line drawings. Photographs were supplied through the courtesy of the VA's Prosthetic Testing and Development Laboratory, the Army Prosthetics Research Laboratory, and the Canadian Department of Veterans Affairs.</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, in press 1954.</li> <li>Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on <i>Research and development of electric arms and electric arm components, </i>1954. Fig. 11 and p. 40.</li> <li>Alderson Research Laboratories, Inc., <i>op. cit.</i> p. 20, Fig. 5</li> <li>Alldredge, Rufus H., <i>The management of war amputations in a general hospital, </i>N. Y. State J. Med., 44:1763 (1944).</li> <li>Alldredge, Rufus H., and T. Campbell Thompson,<i>The technique of the Syme amputation, </i>J. Bone &amp; Joint Surg., 28A:415 (1946).</li> <li>Alldredge, Rufus H., <i>Major amputations, </i>Surg.Gyn. &amp; Obstet., 84:759 (1947).</li> <li>Alldredge, Rufus H., <i>The cineplastic method in upper-extremity amputations, </i>J. Bone &amp; Joint Surg., 30A:359 (1948).</li> <li>Alldredge, Rufus H., <i>Amputations and prostheses,</i>Chapter XII in Christopher's <i>Textbook of surgery, </i>5th ed., Saunders, Philadelphia, 1949.</li> <li>Alldredge, Rufus H., <i>Recent developments and future trends in the field of orthopedic appliances, </i>Southern Med. J., 46:7 (1953).</li> <li>Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, <i>The techniques of cineplasty, </i>Chapter 3 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Alldredge, Rufus H., and Eugene F. Murphy,<i>The influence of new developments on amputation surgery, </i>Chapter 2 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Anderson, Miles H., <i>UCLA prosthetic course to open January 12, </i>Orthop. &amp; Pros. Appl. J., September 1952. p. 14.</li> <li>Anderson, Miles H, <i>A report on the prosthetics training center at the University of California, Los Angeles, </i>Orthop. &amp; Pros. Appl. J., December 1953. p. 27.</li> <li>Bechtol, Charles 0., <i>The prosthetics clinic team.</i> Artificial Limbs, January 1954. pp. 9-14.</li> <li>Bechtol, C. O., and E. F. Murphy, <i>The clinical applications of engineering principles to the problems of fractures and fracture fixation, </i>American Academy of Orthopaedic Surgeons, Instructional Course Lectures, Vol. IX, pp. 272-275, Edwards, Ann Arbor, Mich., 1952.</li> <li>Blix, M., Skandinav. Arch. f. Physiol., 5:150(1894).</li> <li>Borchardt, M., <i>el al., </i>eds., <i>Ersatzglieder und Arbeitshilfen, </i>Springer, Berlin, 1919.</li> <li>Borchardt, <i>op. cit. </i>pp. 397, 425, 509.</li> <li>Borchardt, <i>op. cit. </i>pp. 404-405.</li> <li>Borchardt, <i>op. cit. </i>pp. 523-528.</li> <li>Brunnstrom, Signe, <i>Physical therapy in aftercare of amputations of lower extremity, </i>U.S. Nav. Med. Bull., 43:634 (1944).</li> <li>Brunnstrom, Signe, <i>The lower-extremity amputee,</i>Chapter XIX in Bierman and Licht's <i>Physical medicine in general practice,</i>3rd ed., Hoeber, New York, 1952.</li> <li>Bunnell, Sterling, <i>Surgery of the hand, </i>2nd ed.,Lippincott, Philadelphia, 1949.</li> <li>Canty, Thomas J., <i>Construction, fitting and alignment manual for the U.S. Navy soft socket below knee prosthesis, </i>United States Naval Hospital (Amputation Center), Oakland, Calif., printer's date 9-29-53.</li> <li>Carnes, W. T., U.S. Patent 1,046,966, December, 1912.</li> <li>Carnes, W. T , U S. Patent 1,046,967, December, 1912.</li> <li>Carnes, W. T., U.S. Patent 1,402.476, January 3, 1912.</li> <li>Catranis, Inc., Syracuse, N. Y., Subcontractor'sFinal Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>Improved artificial limbs for lower extremity amputations, </i>June 1954.</li> <li>Committee on Artificial Limbs, National Research Council, Washington, D. C, <i>Terminal research reports on artificial limbs </i>[to the Office of the Surgeon General and the Veterans Administration] covering the period from 1 April 1945 through 30 June 1947. See especially pp. 34-35.</li> <li>Denver Research Institute, University of Denver,Denver, Colo., Contractor's Final Report (Contract No. V-100-LM-4089) to the Advisory Committee on Artificial Limbs, National Research Council, <i>A program for the improvement of the below knee prosthesis with emphasis on problems of the joint, </i>24 August 1953.</li> <li>Department of Veterans Affairs, ProstheticServices, Toronto, Canada, <i>Syme's amputation and prosthesis, </i>January 1, 1954.</li> <li>Desoutter, E. R., <i>Back to activity, </i>DesoutterBrothers, Ltd., 73 Baker St., London W1, 1938.</li> <li>Dorrance, D. W., U.S. Patent </li> <li>1,042,413, October, 1912.</li> <li>Eberhart, Howard D., Verne T. Inman, and BorisBresler, <i>The principal elements in human locomotion, </i>Chapter 15 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Eberhart, Howard D., and Jim C. McKennon,<i>Suction-socket suspension of the above-knee prosthesis, </i>Chapter 20 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Feinstein, Bertram, John N. K. Langton, R. M.Jameson, and Francis Schiller, <i>Experiments on pain referred from deep somatic tissues, </i>J. Bone &amp; Joint Surg., A, in press 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, in press 1954.</li> <li>Fletcher, Maurice J., <i>New developments in hands and hooks, </i>Chapter 8 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Fletcher, Maurice J., <i>The upper-extremity prosthetics armamentarium, </i>Artificial Limbs, January 1954. p. 15.</li> <li>Gray, Frederick, <i>Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, </i>2nd ed., R. Renshaw, London, 1857.</li> <li>Haddan, Chester C, and Atha Thomas, <i>Status of the above-knee suction socket in the United States, </i>Artificial Limbs, May 1954. pp 29-39, especially p. 34, Fig. 4; p. 36; and p. 37, Fig.7. </li> <li>Hiyeda, Masatora, <i>Work leg for the hip exarticulation, </i>J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary muscle, </i>Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Kirk, Norman T., <i>Amputations, </i>a monograph from Vol. III of Lewis' <i>Practice of surgery, </i>W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</li> <li>Langdale-Kelham, R. D , and George Perkins,<i>Amputations and artificial limbs, </i>Oxford University Press, London: Humphrey Milford, 1944. Fig. 3, p. 9.</li> <li>Lawrence, Jerome, unpublished lecture, 34th Suction-Socket School, New York, May 7, 1954. </li> <li>Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, <i>Nylon-coated leather, </i>Ind. Eng. Chem., 45:773 (1953).</li> <li>Leonard, Fred, and Clare L. Milton, Jr., <i>Cosmetic gloves, </i>Chapter 9 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Little, E Muirhead, <i>A lecture on a new material (duralumin) for surgical appliances, </i>Brit. Med. J., 1:236 (1912).</li> <li>Little, E. Muirhead, <i>Artificial limbs and amputation stumps, </i>H. K. Lewis and Co., Ltd., London, and Blakiston, Philadelphia, 1922.</li> <li>Little, <i>op. cit. </i>pp. 6-7.</li> <li>Little, <i>op. cit. </i>pp. 7-8.</li> <li>Little, <i>op. cit. </i>p. 8.</li> <li>Little, <i>op. cit. </i>p. 10</li> <li>Little, <i>op. cit. </i>p. 24.</li> <li>Little, <i>op. cit. </i>pp. 110-113.</li> <li>Little, <i>op. cit. </i>p. 249.</li> <li>Martin, Florent, <i>La prothese du membre inferieur,</i>Masson et cie., Paris, 1918.</li> <li>Martin, Florent, <i>Artificial limbs, </i>International Labour Office, Geneva, 1925.</li> <li>Martin, <i>op. cit. </i>pp. 260-279.</li> <li>McLaurin, C. A., <i>Hip disarticulation prosthesis,</i>Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, 19 March 1954.</li> <li>Mommsen, F., and K Buchert, <i>Kunstliche Glieder, Heft 1, </i>Enke, Stuttgart, 1932. pp 4-5.</li> <li>Mommsen and Biichert, <i>op. cit </i>pp. 86-97.</li> <li>Murphy, Eugene F., <i>The role of an amputee club,</i>summary in Bulletin of Amputees Alliance, Inc., Vol. 3, No. 5, New York, December 1952.</li> <li>Murphy, Eugene F., <i>The fitting of below-knee prostheses, </i>Chapter 22 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Naval Medical Research Institute, NationalNaval Medical Center, Report No. 1, Project NM-009003, <i>Description of a prosthetic hand appliance, </i>March 1, 1948.</li> <li>New York University, Prosthetic Devices Study,[Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Shakedown test of the Navy above-knee prosthesis, </i>May 1951.</li> <li>Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, </i>1947. pp. 1.33-1.36.</li> <li>Pare, Ambroise, <i>Ouevres completes, </i>J.-F. Malgaigne, ed., G.-B. Balliere, Paris, 1840. Vol. 2, Pt. 2.</li> <li>Personal communication from Verne T. Inman,University of California.</li> <li>Personal communication from representatives ofUNRRA, 1946.</li> <li>Possibilities Unlimited, Inc., Cleveland, Ohio, <i>Possibilities unlimited, </i>Vol. II, Issue 2, 1950.</li> <li>Putti, Vittorio, <i>Historic artificial limbs, </i>Hoeber, New York, 1930. p. 7.</li> <li>Putti, <i>op. cit. </i>pp. 1-3.</li> <li>Radcliffe, Charles W., <i>Alignment of the above-knee artificial leg, </i>Chapter 21 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Radcliffe, Charles W., <i>Mechanical aids for alignment of lower-extremity prostheses, </i>Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</li> <li>Ralston, H. J., V. T. Inman, L. A. Strait, andM. D. Shaffrath, <i>Mechanics of human isolated voluntary muscle, </i>Am. J. Physiol., 151:612 (1947).</li> <li>Renfro, Clarence A., U.S. Patent 2,563,618,August 7, 1951.</li> <li>Saunders, J. B., V. T. Inman, and H. D. Eberhart,<i>The major determinants in normal and pathological gait, </i>J. Bone &amp; Joint Surg., <b>35A(3) </b>:543 (1953).</li> <li>Schede, Franz, <i>Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fiir den Oberschenkelamputierten, </i>Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</li> <li>Slocum, D. B., <i>An atlas of amputations, </i>Mosby,St. Louis, 1949.</li> <li>Spittler, A. W., and I. E. Rosen, <i>Cineplastic muscle motors for prostheses of arm amputees, </i>J. Bone &amp; Joint surg., 33A:601 (1951).</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasty, </i>Chapter 12 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Taylor, Craig L., <i>The objectives of the upper-extremity prosthetics program, </i>Artificial Limbs, January 1954. pp. 4-8, especially p. 7.</li> <li>Tenenbaum, Milton, and Adele Tenenbaum, U.S.Patent 2,453,604, November 9, 1948.</li> <li>Thomas, A., and C. C. Haddan, <i>Amputation prosthesis, </i>Lippincott, Philadelphia, 1945.</li> <li>Thompson, T. Campbell, and Rufus H. Alldredge,<i>Amputations: surgery and plastic repair, </i>J. Bone &amp; Joint Surg., 26A:639 (1944).</li> <li>United States Army, Office of the SurgeonGeneral, Report 9940 TSU-SGO, <i>Philippine amputation and prosthetic unit, </i>n.d.</li> <li>University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies on human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</li> <li>University of California (Berkeley), ProstheticDevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Studies relating to pain in the amputee, </i>June 1952.</li> <li>University of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>R. Deane Aylesworth, ed., 1952. Section 7.3, Fig. 7.3-B.</li> <li>Upper-Extremity Technical Committee, ACAL,minutes of meeting at University of California, Los Angeles, February 5, 1953.</li> <li>Vard, Inc., Pasadena, Calif., Subcontractor'sFinal Report [to the] Committee on Artificial Limbs, National Research Council, <i>The development of artificial arms for amputees who have had the cineplaslic operation, </i>1947.</li> <li>Vasconcelos, Edmundo, <i>Modern methods of amputation, </i>Philosophical Library, New York, 1945.</li> <li>Wagner, Edmond M , <i>Contributions of the lower-extremity prosthetics program, </i>Artificial Limbs, May 1954. p. 16.</li> <li>Wagner, Edmond M., and John G. Catranis,<i>New developments in lower-extremity prostheses, </i>Chapter 17 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954. See especially pp. 484, 485, and 605 ff.</li> <li>War Department, Washington, D. C, TrainingManual 8-293, <i>Physical therapy for lower extremity amputees, </i>June 1946.</li> <li>Wilson, A. Bennett, Jr., <i>The APRL terminal</i><i>devices, </i>Orthop. &amp; Pros. Appl. J , March 1952.</li> <li>Wilson, A. Bennett, Jr., and Robert J. Pursley,<i>Fitting the wrist-disarticulation case, </i>Orthop. &amp; Pros. Appl. J., September 1952. p. 17. 100. zur Verth, M., <i>Die biologische Absetzung der menschlichenGliedmassen, </i>Muench. Med. Wschr., 82:525 (1935).</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>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>67.</b> </td><td class="clsTextSmall">Naval Medical Research Institute, NationalNaval Medical Center, Report No. 1, Project NM-009003, Description of a prosthetic hand appliance, March 1, 1948.</td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices 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>9.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Recent developments and future trends in the field of orthopedic appliances, Southern Med. J., 46:7 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Websters definition of teamwork reads in part as follows: Work done by a number of associates, usually each doing a clearly defined portion, but all subordinating personal prominence to the efficiency of the whole!</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Bechtol, Charles 0., The prosthetics clinic team. Artificial Limbs, January 1954. pp. 9-14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>36.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon,Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>37.</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 &amp;Joint Surg., A, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies on human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Mommsen and Biichert, op. cit pp. 86-97.</td></tr><tr><td class="clsTextSmall"><b>72.</b> </td><td class="clsTextSmall">Personal communication from representatives ofUNRRA, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>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, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Brunnstrom, Signe, Physical therapy in aftercare of amputations of lower extremity, U.S. Nav. Med. Bull., 43:634 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Brunnstrom, Signe, The lower-extremity amputee,Chapter XIX in Bierman and Licht's Physical medicine in general practice,3rd ed., Hoeber, New York, 1952.</td></tr><tr><td class="clsTextSmall"><b>97.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis,New developments in lower-extremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954. See especially pp. 484, 485, and 605 ff.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Alldredge, Rufus H., and T. Campbell Thompson,The technique of the Syme amputation, J. Bone &amp;Joint Surg., 28A:415 (1946).</td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, ProstheticServices, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Schede, Franz, Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fiir den Oberschenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Slocum, D. B., An atlas of amputations, Mosby,St. Louis, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The cineplastic method in upper-extremity amputations, J. Bone &amp;Joint Surg., 30A:359 (1948).</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>82.</b> </td><td class="clsTextSmall">Slocum, D. B., An atlas of amputations, Mosby,St. Louis, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., op. cit. p. 20, Fig. 5</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>36.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon,Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>37.</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 &amp;Joint Surg., A, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>90.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies on human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Pare, Ambroise, Ouevres completes, J.-F. Malgaigne, ed., G.-B. Balliere, Paris, 1840. Vol. 2, Pt. 2.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The single exception is the anterior tibial crest in the below-knee amputation, where beveling is desirable but without extending the beveled surface to the medullary cavity. In special cases, such as the Syme, there will be modifications of the general surgical technique. See page 36.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Putti, op. cit. pp. 1-3.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Spittler, A. W., and I. E. Rosen, Cineplastic muscle motors for prostheses of arm amputees, J. Bone &amp;Joint surg., 33A:601 (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>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Blix, M., Skandinav. Arch. f. Physiol., 5:150(1894).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr><tr><td class="clsTextSmall"><b>77.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>34.</b> </td><td class="clsTextSmall">1,042,413, October, 1912.</td></tr><tr><td class="clsTextSmall"><b>79.</b> </td><td class="clsTextSmall">Renfro, Clarence A., U.S. Patent 2,563,618,August 7, 1951.</td></tr><tr><td class="clsTextSmall"><b>89.</b> </td><td class="clsTextSmall">United States Army, Office of the SurgeonGeneral, Report 9940 TSU-SGO, Philippine amputation and prosthetic unit, n.d.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Hiyeda, Masatora, Work leg for the hip exarticulation, J. Japanese Orthop. Surg. Soc, 17:935 (1942). In Japanese, with German abstract.</td></tr><tr><td class="clsTextSmall"><b> 77.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. pp. 20-28, especially p. 24,Fig. 11, and p. 26, Fig. 14.</td></tr><tr><td class="clsTextSmall"><b>83.</b> </td><td class="clsTextSmall">Spittler, A. W., and I. E. Rosen, Cineplastic muscle motors for prostheses of arm amputees, J. Bone &amp;Joint surg., 33A:601 (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>35.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and BorisBresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Langdale-Kelham, R. D , and George Perkins,Amputations and artificial limbs, Oxford University Press, London: Humphrey Milford, 1944. Fig. 3, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,The influence of new developments on amputation surgery, Chapter 2 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>81.</b> </td><td class="clsTextSmall">Schede, Franz, Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fiir den Oberschenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Anderson, Miles H., UCLA prosthetic course to open January 12, Orthop. &amp;Pros. Appl. J., September 1952. p. 14.</td></tr><tr><td class="clsTextSmall"><b> 13.</b> </td><td class="clsTextSmall">Anderson, Miles H, A report on the prosthetics training center at the University of California, Los Angeles, Orthop. &amp;Pros. Appl. J., December 1953. p. 27.</td></tr><tr><td class="clsTextSmall"><b>84.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">An exception may be the below-knee amputation. At the present time, and until further information is available, the below-knee stump should not extend more than 6 in. below the tibial plateau.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Bechtol, Charles 0., The prosthetics clinic team. Artificial Limbs, January 1954. pp. 9-14.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>66.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The fitting of below-knee prostheses, Chapter 22 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, Nylon-coated leather, Ind. Eng. Chem., 45:773 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>85.</b> </td><td class="clsTextSmall">Taylor, Craig L., The objectives of the upper-extremity prosthetics program, Artificial Limbs, January 1954. pp. 4-8, especially p. 7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Bunnell, Sterling, Surgery of the hand, 2nd ed.,Lippincott, Philadelphia, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In general, partial amputations should be considered only when normal sensation and good blood supply can be retained.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Martin, op. cit. pp. 260-279.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Lawrence, Jerome, unpublished lecture, 34th Suction-Socket School, New York, May 7, 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>61.</b> </td><td class="clsTextSmall">Martin, op. cit. pp. 260-279.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artificial Limbs, May 1954. pp 29-39, especially p. 34, Fig. 4; p. 36; and p. 37, Fig.7. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artificial Limbs, May 1954. pp 29-39, especially p. 34, Fig. 4; p. 36; and p. 37, Fig.7. </td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Mommsen, F., and K Buchert, Kunstliche Glieder, Heft 1, Enke, Stuttgart, 1932. pp 4-5.</td></tr><tr><td class="clsTextSmall"><b>68.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,[Report to the] Advisory Committee on Artificial Limbs, National Research Council, Shakedown test of the Navy above-knee prosthesis, May 1951.</td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart,The major determinants in normal and pathological gait, J. Bone &amp;Joint Surg., 35A(3) :543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Washington, D. C, Terminal research reports on artificial limbs [to the Office of the Surgeon General and the Veterans Administration] covering the period from 1 April 1945 through 30 June 1947. See especially pp. 34-35.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>35.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and BorisBresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Gray, Frederick, Automatic mechanism as applied in the construction of artificial limbs in cases of amputation, 2nd ed., R. Renshaw, London, 1857.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>78.</b> </td><td class="clsTextSmall">Ralston, H. J., V. T. Inman, L. A. Strait, andM. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>35.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and BorisBresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>75.</b> </td><td class="clsTextSmall">Putti, op. cit. pp. 1-3.</td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Wagner, Edmond M , Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>28.</b> </td><td class="clsTextSmall">Catranis, Inc., Syracuse, N. Y., Subcontractor'sFinal Report to the Advisory Committee on Artificial Limbs, National Research Council, Improved artificial limbs for lower extremity amputations, June 1954.</td></tr><tr><td class="clsTextSmall"><b>96.</b> </td><td class="clsTextSmall">Wagner, Edmond M , Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954. p. 16.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">McLaurin, C. A., Hip disarticulation prosthesis,Department of Veterans Affairs, Prosthetic Services, Toronto, Canada, 19 March 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>30.</b> </td><td class="clsTextSmall">Denver Research Institute, University of Denver,Denver, Colo., Contractor's Final Report (Contract No. V-100-LM-4089) to the Advisory Committee on Artificial Limbs, National Research Council, A program for the improvement of the below knee prosthesis with emphasis on problems of the joint, 24 August 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>65.</b> </td><td class="clsTextSmall">Murphy, Eugene F., The role of an amputee club,summary in Bulletin of Amputees Alliance, Inc., Vol. 3, No. 5, New York, December 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>24.</b> </td><td class="clsTextSmall">Canty, Thomas J., Construction, fitting and alignment manual for the U.S. Navy soft socket below knee prosthesis, United States Naval Hospital (Amputation Center), Oakland, Calif., printer's date 9-29-53.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Bechtol, C. O., and E. F. Murphy, The clinical applications of engineering principles to the problems of fractures and fracture fixation, American Academy of Orthopaedic Surgeons, Instructional Course Lectures, Vol. IX, pp. 272-275, Edwards, Ann Arbor, Mich., 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>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, ProstheticServices, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Department of Veterans Affairs, ProstheticServices, Toronto, Canada, Syme's amputation and prosthesis, January 1, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and T. Campbell Thompson,The technique of the Syme amputation, J. Bone &amp;Joint Surg., 28A:415 (1946).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>95.</b> </td><td class="clsTextSmall">Vasconcelos, Edmundo, Modern methods of amputation, Philosophical Library, New York, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954. Fig. 11 and p. 40.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., op. cit. p. 20, Fig. 5</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices 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>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954. Fig. 11 and p. 40.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Alderson Research Laboratories, Inc., New York City, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954. Fig. 11 and p. 40.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., op. cit. p. 20, Fig. 5</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>92.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952. Section 7.3, Fig. 7.3-B.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>38.</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, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In only apparent contradiction, Shallenberger, from experience in 1946-47 with two short-below-elbow amputees on whom the cineplastic operation had been performed, with consequent severing of the biceps tendon, recommended a high and almost horizontal front brim with adequate corners on the medial and lateral sides. He found that the flesh was thus restrained at the top and front of the stump and was instead forced out at the sides, where it could not interfere with elbow flexion. He thus found the bearing area to be much greater, with consequent relief of pressure on the stump. In general the same situation would not prevail in the ordinary below-elbow amputee whose biceps tendon is intact.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>38.</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, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">War Department, Washington, D. C, TrainingManual 8-293, Physical therapy for lower extremity amputees, June 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</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, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">War Department, Washington, D. C, TrainingManual 8-293, Physical therapy for lower extremity amputees, June 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Lawrence, Jerome, unpublished lecture, 34th Suction-Socket School, New York, May 7, 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>99.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., The APRL terminaldevices, Orthop. &amp;Pros. Appl. J , March 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>91.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Major amputations, Surg.Gyn. &amp;Obstet., 84:759 (1947).</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Amputations and prostheses,Chapter XII in Christopher's Textbook of surgery, 5th ed., Saunders, Philadelphia, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., The management of war amputations in a general hospital, N. Y. State J. Med., 44:1763 (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>55.</b> </td><td class="clsTextSmall">Little, op. cit. p. 10</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Personal communication from Verne T. Inman,University of California.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>88.</b> </td><td class="clsTextSmall">Thompson, T. Campbell, and Rufus H. Alldredge,Amputations: surgery and plastic repair, J. Bone &amp;Joint Surg., 26A:639 (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>87.</b> </td><td class="clsTextSmall">Thomas, A., and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">Little, op. cit. p. 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>60.</b> </td><td class="clsTextSmall">Martin, Florent, Artificial limbs, International Labour Office, Geneva, 1925.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Borchardt, op. cit. pp. 523-528.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>25.</b> </td><td class="clsTextSmall">Carnes, W. T., U.S. Patent 1,046,966, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Carnes, W. T , U S. Patent 1,046,967, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Carnes, W. T., U.S. Patent 1,402.476, January 3, 1912.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Little, op. cit. p. 249.</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart,The major determinants in normal and pathological gait, J. Bone &amp;Joint Surg., 35A(3) :543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 110-113.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Desoutter, E. R., Back to activity, DesoutterBrothers, Ltd., 73 Baker St., London W1, 1938.</td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">Tenenbaum, Milton, and Adele Tenenbaum, U.S.Patent 2,453,604, November 9, 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>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Borchardt, M., el al., eds., Ersatzglieder und Arbeitshilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Little, E Muirhead, A lecture on a new material (duralumin) for surgical appliances, Brit. Med. J., 1:236 (1912).</td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Little, op. cit. p. 249.</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Martin, Florent, La prothese du membre inferieur,Masson et cie., Paris, 1918.</td></tr><tr><td class="clsTextSmall"><b>80.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart,The major determinants in normal and pathological gait, J. Bone &amp;Joint Surg., 35A(3) :543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Dorrance, D. W., U.S. Patent </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Little, op. cit. p. 8.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 7-8.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>40.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, January 1954. p. 15.</td></tr><tr><td class="clsTextSmall"><b>86.</b> </td><td class="clsTextSmall">Tenenbaum, Milton, and Adele Tenenbaum, U.S.Patent 2,453,604, November 9, 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>52.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 6-7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>38.</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, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>98.</b> </td><td class="clsTextSmall">War Department, Washington, D. C, TrainingManual 8-293, Physical therapy for lower extremity amputees, June 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Borchardt, op. cit. pp. 397, 425, 509.</td></tr><tr><td class="clsTextSmall"><b>51.</b> </td><td class="clsTextSmall">Little, E. Muirhead, Artificial limbs and amputation stumps, H. K. Lewis and Co., Ltd., London, and Blakiston, Philadelphia, 1922.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Borchardt, op. cit. pp. 404-405.</td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Little, op. cit. pp. 6-7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Kirk, Norman T., Amputations, a monograph from Vol. III of Lewis' Practice of surgery, W. F. Prior Company, Inc., Hagerstown, Md.,1944. Fig . 7, p. 22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>94.</b> </td><td class="clsTextSmall">Vard, Inc., Pasadena, Calif., Subcontractor'sFinal Report [to the] Committee on Artificial Limbs, National Research Council, The development of artificial arms for amputees who have had the cineplaslic operation, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>100.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., and Robert J. Pursley,Fitting the wrist-disarticulation case, Orthop. &amp;Pros. Appl. J., September 1952. p. 17. 100. zur Verth, M., Die biologische Absetzung der menschlichenGliedmassen, Muench. Med. Wschr., 82:525 (1935).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>74.</b> </td><td class="clsTextSmall">Putti, Vittorio, Historic artificial limbs, Hoeber, New York, 1930. p. 7.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, 1947. pp. 1.33-1.36.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">Possibilities Unlimited, Inc., Cleveland, Ohio, Possibilities unlimited, Vol. II, Issue 2, 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be recalled that with a little practice man can walk on his hands, but it is not a very comfortable behavior or one that can long be continued.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service (Central Office), Veterans Administration, 252 Seventh Avenue, New York City; member, Upper- and Lower-Extremity Technical Committees, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Rufus H. Alldredge, M.D. </b></td></tr><tr><td class="clsTextSmall">Formerly Chief, Orthopedic and Prosthetic Appliance Clinic Team, Veterans Administration Regional Office, New Orleans, Louisiana; member, Advisory Committee on Artificial Limbs, National Research Council.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_03_004/fig1A.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_03_004/fig2.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1954_03_004/tmp1C6-19.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 Prosthetics Research and the Amputation Surgeon Creator An entity primarily responsible for making the resource Rufus H. Alldredge, M.D. * Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/557e23aa1d087b7c2f923c835fba0ffc.pdf ad1cf6296e80bdb87d62d1953933265f 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_04_004.pdf Text Any textual data included in the document <h2>Phantom Limb Pain</h2> <h5>Gustav Rubin, M.D., FACS&nbsp;<a style="text-decoration: none;">*</a></h5> <p>This article is reprinted with authors permission from the Feb. 1979 issue of "The Amp." Doctor Rubin discusses Phantom Limb Pain on a basic and objective level that is easily understandable, especially to the amputee.</p> <p>This column was prompted by a letter from John Riegel, N.S.O., of Cleveland, Ohio. Let me expand on some of the points he wanted discussed.</p> <p><i>First</i>: A definition of terms. <i>Phantom Sensation</i> is the feeling that the absent limb is still there but not necessarily painful. <i>Phantom pain</i> is the same feeling but the absent limb (or part of it) is painful. Almost every amputee experiences phantom sensation but statistically only five to ten percent have varying degrees of phantom pain.</p> <p><i>Second</i>: Some of my medical colleagues still think that this type of pain is imagined by the amputee. It is not. It is a very real pain and can sometimes be so severe and continuous as to be disabling. However, in the great majority of instances it is intermittent, although it may last for days (and nights) at a time.</p> <p><i>Third</i>: The cause and cure are unknown, just as the cause and cure of the common cold, and even cancer, are unknown. We have difficulty satisfactorily treating such ordinary conditions as chronic arthritis and severe flat feet, so the difficulty in adequately treating phantom limb pain should not be surprising.</p> <p><i>Fourth</i>: The Cause. There are many theories about the cause. None is completely explanatory. As a working basis, the theory most acceptable to me is based on the fact that there is an area in the central nervous system which is a sort of way-station for messages on the way to our consciousness where they can be interpreted, in this specific case, as pain. Signals can either go up from the absent limb, or down from the conscious part of the brain (cortex) and affect the way-station. Sometimes if an amputee talks about or thinks about phantom pain he will trigger an episode. The signals that go up can be described as either "excitatory" or "inhibitory." These terms require no explanation. The inhibitory effect is partly <i>maintained</i> by messages from the skin. If a leg is amputated then a large part of the inhibitory messages that would ordinarily come from the skin of that part will be absent. The excitation messages will dominate and pain could be experienced. A way of thinking about the effect of inhibitory messages from the skin could be exemplified by the instance of the person who bumps his shin and then <i>rubs the skin</i> over a broad area to relieve the pain. He sends skin inhibitory messages to the brain to relieve the pain.</p> <p><i>Fifth</i>: Treatments. Many different methods of treatment have been used. It is a simple fact that, when there are many ways to treat a condition, not one of them is much good. If there was one good way that would be the method used.</p> <p>Treatments attempted have ranged from the use of a freezing spray, to injections of novocaine, either locally or into the lower spine, cutting the nerves to the stump, cutting the roots of the nerves near the spinal cord, cutting the nerve pathways in the spinal cord itself, and even cutting out parts of the brain. Drugs, acupuncture, biofeedback, hypnosis, electrically stimulated implants around the nerve or in relation to the spinal cord; and even reamputation have been employed as methods of treatment.</p> <p>The most recent, and, at this writing, the most popular approach has been the use of transcutaneous electrical nerve stimulation (TNS or TENS). In contrast to many of the other previously mentioned methods it is harmless to the amputee. It is not destructive. Sometimes wrapping the stump tightly with an Ace bandage or percussing the stump will help. Putting the leg back on will often help. As one amputee said he wraps the stump and just "lies there and curses."</p> <p>If the pain in unrelieved by simple, non-destructive, non-damaging techniques, the amputee should be referred to one of the highly specialized pain centers. There are now many of these throughout the country.</p> <em><b>*Gustav Rubin, M.D., FACS <br /></b> V.A. Prosthetics Center<br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 4 - 5 Year 1979 Volume 3 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Phantom Limb Pain Creator An entity primarily responsible for making the resource Gustav Rubin, M.D., FACS * 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 * 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>Building A Positive Self Image In Patients</h2> <h5>Mary Point Novotny, RN., MS.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>"Poems are made by fools like me, but only God can make a tree. "</i></p> <p>Momentary reflection on this literary work brings into perspective the complex task of rebuilding the image of one who has lost a limb. It is a task which requires not merely the professional and technical abilities of the prosthetist, but also a personal concern for the self image of the patient.</p> <p>Body image is the constantly changing mental picture one has of his individual, body appearance. It develops through reflected perceptions about one's body and sensations originating from internal and external stimuli as the individual adapts to a kaleidoscopic variety of living activities. All too frequently body image is overlooked in the rehabilitation plans for a patient with chronic disease, disability, or surgical intervention, because physical diagnosis and mechanical advances have become paramount in our fast-paced acute care settings. The concept is so basic, it is not hard to see why it is overlooked; yet, if one begins to examine the personal effect of alterations, such as mastectomy, amputation, colostomy or stroke, we can begin to identify with the grief, anxiety and fear accompanying the loss of a body part and the ensuing alteration in functional ability.</p> <p>Research of Schilder and others has shown that since body image is primarily a psychological entity, alterations in it are extremely subjective experiences which vary in intensity, dependent on the unique characteristics of each individual, in three distinct categories. These sources of self image include:</p> <ol> <li> <p>Past experiences which are gradually built up through the years from physiologic, psychologic, and social components, organized and integrated by the central nervous system.</p> </li> <li> <p>Social interactions which include the reaction of significant others and of society to the person's body, as well as his own interpretation of that reaction.</p> </li> <li> <p>Current sensations, such as perceptions of physical appearance, alterations incurred, and images, attitudes and emotions regarding the body.</p> </li> </ol> <p>Because these components are subject to constant revision, the body image of any individual is constantly changing. Survival of a healthy self image is determined by the amount of flexibility available to adapt to new situations and one's ability to realize that the image he projects to others is the one others see.</p> <p>The loss or absence of a limb, therefore, has varying consequences dependent on the individual and his stage in the life cycle. Studies have shown that an individual is capable of incorporating a firmly-attached object, such as a prosthesis, cane, etc., into his self image. This seems to be particularly evident with congenitals fitted very early in life, before developing unilateral coordination and functional abilities. Of the acquired amputees, early fitting and functional use of the prosthesis also increases the chances of reconstructing a complete image of one's self. A juvenile amputee, up to 3 years old, is not able to consciously deal with "loss," and congenitals, up to 6 years old, generally do not perceive themselves as "different." Yet amputation in later years results in the patient undergoing the process of grief, which includes feelings ranging from denial, anger and hopelessness, to reorganization and adaptation.</p> <p>Schilder places a positive emphasis on the necessity for communication of these feelings. He believes we constantly construct, dissolve, and reconstruct our own body image as well as the body images of others. He points out that the tendency to destroy a previous body image is essential to acceptance of a new, altered image.</p> <p>This appears to be a critical area in successful care of any patient. Because most amputees and their families have limited, if any, exposure to others with similar problems, their greatest fears are of the unknown. Will amputation ruin my personal life? End my career? Leave my child handicapped and dependent? With little factual information in the areas of prosthetics and a body image distortion that has not been reconciled, the patient frequently arrives at the professional door seeking an opportunity to communicate his fears and frustrations to an individual who will, hopefully, aid in the design of a prosthesis and promise for the future. While personal style and approach vary with the needs of individual patients, certain factors should be considered in dealing with an amputee: personality type, expectations, stage of adjustment, support system, and medical conditions.</p> <p>Recent amputees, for example, would benefit from an opportunity to see and touch a prosthesis, with a complete explanation of the stages of fitting and fabrication to limb completion. Be open and honest with patients, keeping in mind that cosmesis may be a priority for some while function and durability are essential for others. While no prosthesis will ever replicate human functioning, once you determine what a patient expects to achieve through prosthetic usage, you can then fulfill his needs and likewise increase his acceptance of an artificial limb.</p> <p>Parents of a congenital amputee frequently need much more support than the child who can learn to lead a "normal" life if allowed to develop and achieve, unhampered by "concerned" adults who would treat him "special/different."</p> <p>Meeting with another amputee who has mastered life with a prosthesis can have a very positive effect on the older child or adult who is attempting to re-adjust his self image. Family members or significant others should be encouraged to be present at such meetings, as the fear of new amputees is generally in direct proportion to the acceptance reaction of those whose opinion he values most. Seeing is believing!, and once normal functioning in everyday living is explained, there will be less chance of the amputee being treated as a "handicapped" individual, which he is not.</p> <p>Lastly, bear in mind that you are a very important person in the eyes of your patient. This is because you are now the professional most heavily relied on for advice, support and adjustment in the initial period of building a new self image. So grin and bear those minor repairs, etc., keeping in mind that a well-worn prosthesis is your best measure of success. Function and form go hand-in-hand in establishing a sense of completeness in self image.</p> <p>While you may not have the power of our creator, you can surely have a part in the final design of his creations.</p> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, "Behavioral and Psychological Reactions of Juvenile Amputees." Reprinted from <i>Limb Development and Deformity: Problems of Evaluation and Rehabilitation</i>, Charles C. Thomas, Publisher, 400-407.</li> <li>La Fleur, Jean and Novotny, Mary, "A Study of Human Figure Drawings by Amputee Children and Verbalization of their General Adjustment," Masters' thesis, De Paul University, 1978.</li> <li>Schilder, Paul, <i>The Image and Appearance of the Human Body</i>, International Universities Press, Inc., New York, 1950.</li> <li>Schilder, Paul "Symposium on the Concept of Body-Image," Nursing Clinics of North America, VII (December, 1972).</li> </ol> <em><b>*Mary Point Novotny, RN., MS. <br /></b>Nurse-educator for health professionals; Consultant, University of Illinois at the Medical Center, Amputee Clinic, Chicago, Illinois; has lectured across the country on body image alterations and the role of professionals in assisting patients with adjustment.</em> Page Number(s) 1 - 2 Year 1979 Volume 3 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Building A Positive Self Image In Patients Creator An entity primarily responsible for making the resource Mary Point Novotny, RN., MS. * https://staging.drfop.org/files/original/7821ac6162abe595c2139897f396fecc.pdf 0bcce967fcfd627030a029c02594ff9c https://staging.drfop.org/files/original/a66e029293ca734565f6b91200071432.jpg e0ab811142f0169b690b4e8859ef14b6 https://staging.drfop.org/files/original/345a8f6d88787fb5569177c99ca4d7f7.jpg d29c0ac6eb59475dc22409206e69c298 https://staging.drfop.org/files/original/12ca9adaacb8c06c5eb20427ab64f46d.jpg 8363fe5120fc99ac33a0eb179ae273ed https://staging.drfop.org/files/original/e9d94ea851ebdbb5e0a81ae9d61b845f.jpg a108f96e990025c40ff36607bc770296 https://staging.drfop.org/files/original/27ad3e7aadc5e665c134b448e33340c5.jpg ce9577ae574f7e521bf0a6dee646d735 https://staging.drfop.org/files/original/5bc094ab41ace0120e8ba8896408edb8.jpg 8d8a73eceb72ffa43d8d319a3dfd8f8d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1979_03_005.pdf Text Any textual data included in the document <h2>Bilateral Knee Disarticulation, Immediate Post-Surgical Fitting: An Unusual Case Study</h2> <h5>William Susman&nbsp;</h5> <p>There are certain specific indications for utilizing immediate Post-Surgical Fitting (IPSF) in the postoperative management of the amputee. Clinical observations have substantiated that the constant even pressure provided by the immediate application of a rigid dressing to the residual limb helps control edema, supports circulation, and immobilizes tissue, subsequently minimizing the inflammatory process within the traumatized tissues, promoting wound healing, aiding good shaping of the limb and decreasing intrinsic pain and phantom sensations.</p> <p>The attachment of a pylon and prosthetic foot to the rigid dressing either immediately after the residual limb is wrapped or within a short post-operative period has been shown to enhance the positive effects of the rigid dressing and provide additional functional and psychological benefits. The gentle compression of residual limb tissue provided by closely monitored weight-bearing promotes wound healing by further decreasing edema. Ambulation resumes with a prosthesis sooner than with more conventional post-operative management approaches. Hospital stay is shortened, resulting in a more rapid return to previous personal, social and vocational activities. The amputee experiences an almost immediate resumption of function and although he or she will most likely undergo mourning for the lost limb, the actual commencement of rehabilitation is also experienced. In addition, the patient may be told pre-surgically the sequence of post-operative events so that the immediate introduction of functional prosthetic restoration can be hopefully, although cautiously, anticipated.</p> <p>It is readily acknowledged that IPSF is not appropriate for all circumstances. Cooperation among the rehabilitation team members from prosthetics, physical therapy, surgery, physiatry, and nursing, and a shared understanding of the technical aspects and goals of treatment, as well as individual proficiency in treatment procedures are necessary. The patient's understanding of the treatment approach and a willingness to adhere to treatment protocol are also essential. Lowered standards in any one of these areas may lead to injury of residual limb tissue, pressure sores, wound infection, hematoma, or necrosis and ultimately failure of the procedure and a real physical and psychological set-back for the patient. In addition, such complications are more difficult to perceive since the wound cannot be directly observed without disruption of the rigid dressing.</p> <h3>Patient History</h3> <p>With the above general review of the clinical advantages and precautions of IPSF in mind, it may be illustrative to present a case which is representative of these aspects of this treatment approach and yet extraordinary in view of the history and personal motivation for seeking treatment. The patient was a 28 year old woman who had contracted anterior poliomyelitis at the age of 16 months. She presented with stunted lower limbs, and muscle power at both hips was below functional levels except for the ability of the Sartorious muscle to withstand moderate resistance bilaterally. The knees and ankles were essentially flaccid. Sensation throughout the lower limbs was within normal limits. No contractures were evident and upper body strength was above normal.</p> <p>The patient wore bilateral, conventional KAFO's with knee locks and both ankles set in plantarflexion. Her feet rested on approximately nine-inch cork lifts set inside the calf sections of tall leather boots. (See <a href="/files/original/a66e029293ca734565f6b91200071432.jpg"><b>Fig. 1</b></a>) The patient related that as an adolescent she increased the lift height periodically to compensate for the lack of normal lower limb growth. She displayed excellent balance and body awareness, ambulated and climbed stairs and curbs independently with axillary crutches, and was able to negotiate sitting and rising from most types of seating. She led an active life as a college instructor and graduate student.</p> <p>The patient had a history of multiple surgical procedures during her teen-age years including a spinal fusion for scoliosis, subtalar arthrodeses, transplantation of hamstring tendons to the quadriceps mechanisms, and Achille's tendon releases bilaterally. She also had a history of left patella and right tibial fractures because of falls.</p> <p>The patient had been interested in seeking elective amputation of her legs for some time. Her chief reasons were of both a physical and a psychological nature. Pain in her feet resulting from the prolonged standing teaching required, and concern over the vulnerability of her legs to fractures from falling were related. Nevertheless, her foremost concern was for her appearance. Due to the devices she used to provide height and function she always felt compelled to wear floor-length dresses and was unable to interchange footwear (see <a href="/files/original/a66e029293ca734565f6b91200071432.jpg"><b>Fig. 1</b></a> &amp; <a href="/files/original/345a8f6d88787fb5569177c99ca4d7f7.jpg"><b>Fig. 2</b></a>). She wanted greater freedom in dress and to be able to have her legs seen without embarrassment over their appearance. She also found the braces and boots cumbersome and loose on her legs. Therefore, the patient came to the clinic seeking amputation primarily for reasons of cos-mesis and self-image.</p> <h3>Pre-Surgical Management</h3> <p>The rehabilitation team's decision to recommend bilateral knee disarticulation amputations was based upon the less traumatic nature of the surgical procedure, the good weight-bearing tolerance that has been demonstrated at this level, and another factor unique to this case. Due to the diminished growth of the patient's femurs, knee disarticulations would leave the amputation level proportional in length to long above-knee amputations. This level would provide a long lever arm for prosthetic control, yet not disturb anthropometric placement of the prosthetic knee and, consequently, proportional thigh and shank length.</p> <p>The IPSF approach was selected due to the patient's psychosocial background and to avoid the abrupt prolonged change in function that can result from bilateral surgery. With IPSF the patient would have a shorter period of disruption of her social and vocational success and her proud independence in activities of daily living. It would limit her experience as a wheelchair-dependent individual since two-legged function would never be completely interrupted.</p> <p>To determine whether or not knee disarticulation prostheses would provide function comparable to her presenting situation, temporary prostheses were fabricated to simulate post-surgical restoration. Plaster quadrilateral sockets with polyvinyl chloride (PVC) thermoplastic pylons, SACH feet and shoes were used. A cut-out in the posterior wall of each socket allowed the patient's shanks to protrude in the flexed-knee position, thus mimicking knee-disarticulation amputations (see <a href="/files/original/12ca9adaacb8c06c5eb20427ab64f46d.jpg"><b>Fig. 3</b></a>). A full functional evaluation showed no deficit in the patient's function from that previously demonstrated. Her ambulation pattern remained unchanged.</p> <p>From a psychological standpoint the patient was instructed to seek psychiatric consultation to closely examine her motivations for electing this treatment and to investigate her feelings regarding the possible failure of adequate functional prosthetic restoration. In addition, the patient discussed at length with team members the pros and cons of her decision and the possible sequela of amputation surgery such as wound-healing difficulty, residual limb pain, phantom sensations, less than optimal function, and prosthetic maintenance.</p> <h3>Post-Surgical Management</h3> <p>After closure of the amputation wounds and placement of drains, stump socks were applied over the surgical dressings on both limbs. A distal pad was held in place while a plaster wrap of each residual limb was done. Each plaster socket was hand-molded to provide a quadrilateral shape and ischial seat. Supracondylar purchase and belts over the iliac crests provided suspension. Pylons were not added at this time since the PVC tubing to be used requires heating before application.</p> <p>On post-operative day (POD) #2 the surgical drains were removed. On POD #5, PVC pylons and SACH feet with shoes were applied. To control and monitor the degree of weight-bearing, a tilt table and two scales were used (see <a href="/files/original/e9d94ea851ebdbb5e0a81ae9d61b845f.jpg"><b>Fig. 4</b></a>). Two five minute-periods at ten pounds of weight-bearing were allowed initially. On POD #6 the patient was seen twice during the day and stood on scales in the parallel bars (see <a href="/files/original/27ad3e7aadc5e665c134b448e33340c5.jpg"><b>Fig. 5</b></a>). Two daily sessions were continued and weight-bearing was increased to 20 pounds on the right limb and 15 pounds on the left, being limited due to pain. Throughout this period the patient complained of phantom sensations and residual limb pain which increased markedly at night. The first cast change was done on POD #12 at which time the stitches were removed. The following day the patient began ambulation in the parallel bars with weight-bearing to tolerance. On POD #15 the patient was given a walker for bedside use and on the following day was able to ambulate independently outside the parallel bars with axillary crutches and a four-point gait, testimony to her longstanding adaptation to her physical deficits and her determination to succeed. At this time the patient was transferred from the acute care setting to an inpatient rehabilitation bed.</p> <p>Four weeks after surgery the patient was casted for her definitive prostheses. At five weeks she was fitted with the sockets and locked knees and returned to the parallel bars for ambulation training. During the sixth week, first one and then both prostheses had safety knees added. By the ninth post-operative week the patient had returned to the use of crutches and had received training in elevation activities and ambulation on different terrains.</p> <p>The prostheses were delivered at the end of the ninth post-operative week and consisted of quadrilateral total contact sockets with semi-suction and supracondylar suspension. Windows were not cut in the sockets for donning but rather a soft insert was fabricated which was compressed during donning and re-expanded within the socket to grip the femoral condyles. The patient rejected the use of any suspension belts as uncosmetic. Otto-Bock's modular endoskeletal safety knees and components, and SACH feet were used. (See <a href="/files/original/5bc094ab41ace0120e8ba8896408edb8.jpg"><b>Fig. 6</b></a>).</p> <h3>Follow-Up</h3> <p>The patient returned to her former daily interests and activities and maintained her ambulatory status. Having worn the prostheses for approximately a year and a half she returned for re-evaluation. Changes in residual limb shape due to shrinkage necessitated the fabrication of a second pair of prostheses which she currently uses.</p> <h3>Summary</h3> <p>This case well illustrates the advantages and appropriate application of the IPSF approach to amputee management. The patient was able to have both limbs amputated at once and yet hasten the rehabilitation process. The physical debilitation and psychological shock associated with such a radical intervention was minimized by her youth, determination, and cooperation with the rehabilitation team. A deeply felt desire to improve her quality of life was satisfied with minimal disruption of what was an already successful life style in the face of life-long physical difficulties.</p> Page Number(s) 5 - 7 Year 1979 Volume 3 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1979_03_005/1979_03_005-6.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Bilateral Knee Disarticulation, Immediate Post-Surgical Fitting: An Unusual Case Study Creator An entity primarily responsible for making the resource William Susman  https://staging.drfop.org/files/original/8c7a6970296e60cde98fb2b926104479.pdf e0922ee3443a9fb4e8fe43481878f21c https://staging.drfop.org/files/original/683dddbeabe8a01b0c8e7067bc596ecf.jpg 271073242017918d8370a864251ad0eb https://staging.drfop.org/files/original/373393b245d73849895b4181a127430b.jpg ff274eca7b23aa261109f9258b2e7c0e https://staging.drfop.org/files/original/32cd3103345077afd83b7af5dc7abc05.jpg 6f53d9444bd5c4976b690cd3cdf3bf39 https://staging.drfop.org/files/original/326f0da3a571622d5e2f89a4f1fbf8f7.jpg 3a46e2005501e0890e80e9d19c88297b https://staging.drfop.org/files/original/6c37ae42905af01a9e9460d43bd3553f.jpg 8ee9df44430899e5ec2be193ff06157c https://staging.drfop.org/files/original/5a8831a6307c5d66cdbc2c2d334b473e.jpg b8b6d65bc61c774c998c966b4b8d9776 https://staging.drfop.org/files/original/65a169d989d02cea39b0c321f258efa3.jpg cd8f75e9cfe0960fb6bf27afce0ba348 https://staging.drfop.org/files/original/70bcb435ec1c123bf2b535fb68b27738.jpg c78dfaf4d86b2f73a6a2a70f5a64a7d7 https://staging.drfop.org/files/original/161398ae7cc34eeac4871900abe93df6.jpg eff0bd44c9f395dd53ae74ecc0ba4242 https://staging.drfop.org/files/original/7d80433608eed4a89c5fc22dd07055ef.jpg 35b33774ed1a270b804361dc81f05bff https://staging.drfop.org/files/original/a0ca2656198d3d989f5e474a37b95dcf.jpg 5b4d98e6150520153b45e30d3431bfd4 https://staging.drfop.org/files/original/d36951552083714c2c80fb0e9b8d7005.jpg 4842a3d61f9e2e5c58c5c7946f2da9ff https://staging.drfop.org/files/original/f174327fa60278c7a99afa8d8f592ac1.jpg ae8b6b1631695f54693e660a689337b2 https://staging.drfop.org/files/original/fc107ec87d21c63b7439534a3f554f07.jpg 53c791fbf64feffd8cab5c141c9f8606 https://staging.drfop.org/files/original/0b1833b99f21a9bef0babbe75f155aa2.jpg e95fdcb37adc9e7a6f249f62be244e39 https://staging.drfop.org/files/original/f68c9b3da10bd6494c265eebd460e66a.jpg a16093ae85b8381722948051554431eb https://staging.drfop.org/files/original/20291c2668b999b54c80a68aba5da376.jpg f24be81cd11ca69b05949e0d02eedc9c https://staging.drfop.org/files/original/b6606c9f4e7dceb4aa02b5b6dd8582e0.jpg 3df58f3eed4f318cf1971b56f5d402c4 https://staging.drfop.org/files/original/91e23f3a95ec0103ee52beb7c5d5eb14.jpg 965674dd0925c9b4d2a55098c963a7f7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_03_047.pdf Year 1954 Volume 1 Issue 3 Page Number(s) 47 - 76 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_03_047.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_03_047.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>Prosthetics Research and the Engineering Profession</h2> <h5>Renato Contini, B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>In the establishment of any program in prosthetics,<a style="text-decoration:none;">*</a> whether it be a program devoted to research on and development of new and improved devices, or whether it be a program for the dissemination of knowledge in the application of these devices, guidance must come primarily from the medical sciences. In any such program, one can appreciate the role of the physician, either the surgeon involved in the amputation or the physiatrist concerned with the physical rehabilitation of the patient. To a lesser extent perhaps, the role of the physical and occupational therapist, in implementation of the prescription established by the physician for medical rehabilitation or re-education, also is generally appreciated.</p> <p>Since there can be no prostheses without a limbmaker, the role of the prosthetist cannot be underestimated. Certain attempts at the fabrication of artificial limbs may be traced back to the time of the Roman Empire. Several ingenious devices made during the sixteenth century (<b>Fig. 1</b> and <b>Fig. 2</b>) still are in existence. The major impetus, however, was received as a result of the Napoleonic Wars, of the War between the States, and of the Franco-Prussian War. Improvements in medical practice had by then made it possible to save a much larger number of men who had lost limbs than had been possible earlier. There thus developed a well-defined craft which reached its peak during World Wars I and II and which established with the medical profession a working relationship directed toward the fabrication of acceptable prosthetic devices.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Iron hand of Goetz von Berlichingen, a.d. 1509. From Faries,<a></a> by permission. See also Thomas and Haddan.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Leg of Ambroise Pare, a.d. 1561. From Faries,<a></a> by permission. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To the efforts of these three professional groups - medicine, therapy, and limbmaking - there have been added in more recent rehabilitation programs the efforts of the social worker, of the psychologist, of the psychiatrist, and of the counselor in vocational guidance, the over-all purpose being to return the amputee to a more successful and better-adjusted position in society. The organization and functions of a modern prosthetics clinic team, as most usually accepted, have been fully and ably described by Bechtol.<a></a> </p> <p>Important as is the role of each of these disciplines, the progress that has been made in prosthetics in recent years may be attributed, in large measure, to the interest the problem has aroused in a substantial number of engineers. The role of engineering in a prosthetics program is not as yet well understood or fully appreciated by the general public. We speak of the role of engineering, rather than of the role of the engineer, because we are concerned more with the application of certain basic physical principles than with the particular individual who applies them. When these principles are well understood and applied by the physician, therapist, or prosthetist, each will function better in his own role. Unfortunately, in our present system of education no provision is made for imparting the basic principles of engineering in courses of instruction for any of these other disciplines. As a consequence, until recently such advances as were made in prosthetic devices came about primarily as a result of much trial and error rather than as the outcome of a planned approach.</p> <p>Any program directed to the development of new prosthetic devices may be divided into three major stages. The first is concerned with basic research. Second is the translation of knowledge gained in the basic research stage into a specific design for a particular device. And third is the application of the device to the amputee and the evaluation of functional gain. But of course a program does not necessarily proceed in such an orderly fashion. Before a device is finally accepted for general application, it may be necessary, and in fact it often is, to retrace the sequence not once but many times in order to gain additional information and understanding. We shall consider later the role of engineering in each of these stages.</p> <h4>The Background</h4> <p>Man performs activities in a variety of ways controlled by physical law. The manner in which he does so has thus interested scientists since the time of Leonardo da Vinci (1452-1519), who made the first systematic study of human movements and described them in his <i>Note on the Human Body.</i> <a></a> In 1679-1680, Borelli,<a></a> a pupil of Galileo, published <i>De Motu Animalium, </i>the first treatise which applied the sciences of physics and mathematics to human and animal activity. The mathematicians and physicists of the eighteenth century - Bernoulli, Euler, and Coulomb - tried to develop rational mathematical formulae for determination of the capacity of human work.</p> <p>The number of investigators increased greatly in the nineteenth and early twentieth centuries, and the two World Wars gave still greater impetus to research in the general field of human locomotion and activity. In Germany, France, England, Russia, and the United States, with different objectives perhaps but directed toward the same general problems, Fischer,<a></a> Fick,<a></a> Gilbreth,<a></a> Amar<a></a>, Martin,<a></a> Schlesinger,<a></a> Schede,<a></a> Bernshtein <a></a>, Steindler,<a></a> Elftman,<a></a> Henschke and Mauch ,<a></a> and the groups at the University of California<a></a> and at New York University<a></a> have studied human performance. Each, individually or as groups, contributed to the increasing knowledge both in the general areas of human activity and in the specific application of this knowledge to prosthetics.</p> <p>From the time of Leonardo, almost every investigator in this field either was primarily a physical scientist, or, if not, had a very intimate knowledge of physics and mathematics. In the later period particularly, the major contributors to the increasing knowledge of human performance have been engineers, physical scientists, or anatomists and physiologists with training in the physical sciences. A more comprehensive review of the investigators in this field is that of Contini and Drillis .<a></a> </p> <h4>Basic Research in Human Motions</h4> <p>In the design of any structure or mechanism, for whatever purpose, the engineer usually proceeds from a set of established specifications. These specifications may describe the function of the device, the space it may occupy, the activity it must perform, the forces which may be applied to it and which it must withstand, the chemical and physical damage to which it may be subjected, the working life expected of it, how often it should be overhauled or maintained, and what it may cost. To design a prosthetic device properly, similar specifications should be prepared. Some of the requirements for a satisfactory prosthesis may be developed from known data, that is, from information obtained empirically over extended periods of time and from the experience of countless amputees. Other information, however, and perhaps the more important in the design of prostheses, can come only after systematic experimentation. To supply this information, then, is the purpose of the program in basic research.</p> <p>Every human movement takes place in time and space and is controlled by external and internal forces and by the mass of the parts involved. The internal forces are generated in the muscles and transmitted through the limbs to tools, controls, instruments, or other objects. The external forces are those of gravity, inertia, ground reaction, and air resistance. When the body is at rest, the external and internal forces are in equilibrium; when it is in motion, the resultant of these forces has some value other than zero.</p> <p>Of course human movements may be observed and the pattern of movement described subjectively. But unless these movements can be recorded and measured precisely, no true understanding of the movement can be had, nor can repeated movements be compared objectively in the same individual or between different individuals. As technology has moved ahead, engineering knowledge has made it possible to develop instruments and techniques for recording and measuring movements and the forces which affect these movements. Although it would be interesting, as an historical aside, to review the methods used by earlier investigators, it is more profitable to describe some of the recent developments.</p> <h4>Methods of Measurement</h4> <p>The invention of photography in the middle of the nineteenth century, and the subsequent improvements in photographic techniques, have made it possible to record motions and displacements exactly (<b>Fig. 3</b>). The development of motion-picture photography, of interrupted-light photographic techniques, and of a combination of the two as obtained in the gliding cyclogram has made it possible to measure not only displacement but also the rate and change in rate at which movements occur. By these techniques, then, we can obtain displacement, velocity, and acceleration. Once these quantities are known, and when the mass of the total moving body or of its segments can be obtained by other measures, the forces acting on the body, the energy costs, and the power requirements can all be computed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Walking with 75-lb. load. Subject photographed synchronously from three points of view. Time intervals: 0.075 sec. From Muybridge<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Motion-Picture Photography</i></p> <p>Of the photographic techniques mentioned, motion-picture photography is used perhaps most universally. By mechanical or electromechanical means, a light-sensitive film is transported at a known, fixed rate past a lens and shutter. The film-transport mechanism is synchronized with the shutter so that a picture is taken each time the film is advanced one frame. The speed at which pictures are taken may be varied between sequences to suit the particular need, and the shutter speed may be varied to stop the action down to the smallest fraction of time consistent with the particular apparatus and with the object being photographed.</p> <p>With conventional motion-picture equipment, frequencies of up to 128 frames per second have been photographed, action being stopped down to the order of one five-hundredth of a second. Within these limits most human activities may be photographed adequately. A timing device - in effect a large clock, driven by a synchronous motor, and with the dial subdivided into hundredths of a second - permits measurement of the variability in time between frames and in exposure time (<b>Fig. 4</b>). Sometimes x-ray and motion-picture photography have been combined. By this means it is possible not only to record the motion of a limb but also to observe any relative motion between the activating skeletal structure and the external surfaces.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Typical motion picture of walking. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although this method of motion recording has been used extensively, and even though it may be quite adequate for some measurements, it has certain disadvantages which detract from its general usefulness. In the reduction of data, for example, each frame must be registered in two of the three major coordinate axes, some point being maintained as a control. The location of each moving segment must be determined from a constant frame of reference, a matter which introduces possible sources for error. And it has been found that the transport mechanism does not always respond at the same rate, so that the interval of time between frames, on which the computations depend, may not always be constant.</p> <p><i>Interrupted-Light Photography</i></p> <p>When the activity to be recorded is not a repetitive one, as in jumping, or is repetitive but progresses along a linear axis, as is the case with the walking pattern of a leg amputee, interrupted-light photography can be used. In this system the film is stationary in the camera. The lens shutter is kept open, while a slotted disc, driven at the desired speed by a synchronous motor through a gear or pulley system, rotates before the shutter in such a way as to admit and exclude light alternately. The speed at which the disc rotates and the number of slits in the disc together determine the time increment between exposures. The width of the slit (that is, the size of the angle included in the slit) and the rotation speed of the disc determine the time of exposure. In the studies conducted at New York University in conjunction with the Veterans Administration's Prosthetic Testing and Development Laboratory, the disc rotates 20 revolutions per second and the slit is 14 degrees wide, so that the exposure time is of the order of one five-hundredth of a second and each revolution results in one exposure (<b>Fig. 5</b>). These conditions are optimum for the particular application, but they can be modified for other applications. In the system developed by the Prosthetic Devices Study, Research Division, New York University, working with the VA's PTDL, the light is supplied by a single photoflood bulb and is returned by reflective tape, such as <i>Scotch-lite, </i>which marks the points to be photographed. Similar results might be achieved with an open lens and a strobe-flash source of light.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Typical stick diagram of walking. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The obvious advantage of this system is that it provides a complete pattern of a total movement, such as the forward progression of an amputee for two or three strides, all of which may be recorded on one film. Reduction of data is greatly simplified, since the measures of vertical and horizontal displacement are taken directly from a single set of axes. The error then is only that which the operator may make in measuring. The time increment is as constant as permitted by the variation in speed of a synchronous motor.</p> <p><i>The Gliding Cyclogram</i></p> <p>When the motion to be recorded is repetitive in limited space, the interrupted-light method cannot readily be employed, for the pattern of points cannot then be distinguished as to occurrence in time. To overcome this difficulty, Bernshtein<a></a> in Russia and Drillis<a></a> in Latvia developed the gliding cyclogram. This method is similar to that previously described except that here the film is transported across the field at a constant rate but at one that may be varied to suit the particular activity being recorded. Under these circumstances, the position of any point can be identified both in space and time. Even if, in a repetitive motion, a point on a moving segment is returned to an original position, the image in the initial and succeeding instances will be displaced on the film by the distance the film has been transported in the elapsed time increment. If, for example, a point were moving in a circular path, its locus would appear on the film as a cycloid. Although this method increases the amount of work to be done in data reduction,<a style="text-decoration:none;">*</a> suitable graphic shortcuts reduce this work differential to a minimum. As will be apparent (<b>Fig. 6</b>), the gliding cyclogram has special advantages in recording the motion of arm activities, many of which are repetitive and overlapping.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Gliding cyclogram of the axe stroke in woodcutting. From Drillis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The Tachograph</i></p> <p>Although each of these methods permits the measurement of displacement, velocity, and acceleration, other methods of instrumentation give direct measurement of velocity and acceleration in certain situations. Velocities along one axis may be measured with a tachograph, a device consisting of a fine cable connected to a moving body, continuing in a closed loop, and driving the rotor of a generator (<b>Fig. 7</b>). Since the voltage is proportional to the angular velocity of the rotor, which in turn is proportional to the velocity of the body, the voltage generated is a direct measure of the linear velocity.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The tachograph - a system for recording linear velocity. From an NYU report.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The Accelerometer</i></p> <p>Another electrodynamic device, the accelerometer, measures accelerations directly. Essentially, this instrument consists of a small, compact mass supported by a spring device. When the mass is suddenly accelerated, its inertia deflects the spring by an amount dependent upon the acceleration and the spring constant. By suitable means, such as by differential transformers, the deflection is converted into a change in voltage proportional to the displacement and thus proportional to the acceleration imparted to the accelerometer. More recently, accelerometers have been devised employing strain gauges (see below).</p> <p><i>Direct-Recording Force-Measuring Devices</i></p> <p>Displacement and velocity permit us to describe a motion; acceleration and mass permit us to compute the forces which affect the motions. Sometimes it is possible and desirable to measure forces directly. A number of such force-recording devices have been made possible by technological advancement in the past 20 years.</p> <p><i>The Strain Gauge. </i>The strain gauge, which has been used in innumerable applications, is such a device. Essentially, it consists of a fine wire of known cross-sectional diameter and electrical resistance, arranged in a packet (not unlike a <i>Band-Aid</i>) so that it may be attached directly to some structural element. When the structural element is stressed, it either elongates or shortens, depending upon whether it is in tension or in compression. The filament of the strain gauge follows the structural element to which it is attached, and its cross-sectional area is reduced or increased, with consequent stretching or compression along its length. The electrical resistance is thus increased or decreased from the normal or zero-load position. By suitable electrical magnification and instrumentation, and with proper initial calibration, instantaneous changes in load can be measured and recorded.</p> <p><i>The Capacitor. </i>Another device for measuring loads or forces directly is the capacitor, a small capsule consisting of a dielectric material between two layers of electrical conducting material. When a voltage is applied across a capacitor, an electric charge is stored. The capacitance of the unit varies directly as the area of the surface plates and inversely as the thickness of the dielectric. When pressure is applied across the faces of the capacitor, the thickness of the dielectric is reduced and the capacitance is changed.</p> <p>Pressure gauges based on this principle have been developed at the Franklin Institute.<a></a> In these instruments, the construction is loose so that appreciable changes in spacing between the plates, and hence in capacitance, occur with changes in loading. Springiness is achieved by impressing a waffle pattern of indentations into the steel discs which serve as the plates of the capacitors. The gauge is used as one arm of a bridge circuit in which a high-frequency signal is supplied and the unbalance is amplified and recorded on an oscillograph. The degree of unbalance is calibrated in terms of load on the gauge.</p> <p><i>Other Force-Recording Devices. </i>Still other techniques for the measurement of loads have been used widely. For example, the principle of equal distribution of pressure in pneumatic and hydraulic systems has resulted in the development of various types of pressure gauges. The property of springs - leaf, helical, or torsion types - in maintaining, within certain limits, a direct ratio of load to deflection has been used in other force-measuring units. Still other devices have been developed making use of other known physical phenomena to obtain data desired in specific problems.</p> <h4>Experimental Adaptations</h4> <p>Many of these principles, techniques, or devices have been applied in the basic research program to obtain the data needed to develop new and better prostheses. The same applications also have been used to evaluate the prostheses on the amputee, and in some instances special adaptations of certain of these principles have been used as aids in amputee training. Some of the more important experimental units merit further elaboration.</p> <p><i>The Lower Extremity</i></p> <p>In 1945 the Prosthetic Devices Research Project at the University of California, Berkeley, initiated a program of basic research directed toward the gathering of information on locomotion, both in normal subjects and in leg amputees. It was desired to obtain data on the individual factors which contribute to the pattern of human gait - the displacements of the head, arms, and torso; the displacements and rates of displacement of the thigh, shank, and foot; the moments at the hip, knee, and ankle joints; the pressure at the point of ground contact; and the shift in apparent point of pressure application. Using the techniques already described, the engineers participating in this program developed a variety of ingenious devices.<a></a> </p> <p>To record the displacements of the segments of the body, motion-picture techniques were adopted. The appropriate control points on the body were identified by targets, in some instances the motions of small magnitude were magnified by target extensions, and in other instances the pattern of locomotion was photographed at intervals varying up to 3000 per second. To obtain the components of motion along the three axes of space, a glass walkway and tilted mirror were used. By this expedient, side and plan pictures were taken simultaneously on one film, thus minimizing the time required for reduction of data and also reducing the possibility of error as compared to the use of two synchronized cameras. From these photographs the motions of the leg segments, heel and toe rise, degree of knee flexion, phasing of the step, and all other desired details could be analyzed. Forces during the swing phase could be determined, as could also the moments at the joints.</p> <p>To measure ground reaction, two force plates were designed using strain gauges in various combinations to measure vertical, fore-and-aft, and lateral components of foot pressure at ground contact. Through appropriate electronic combinations, the strain pickup also could give the apparent instantaneous center of pressure and the torsional moments exerted by the rotation of the foot at ground contact. In a similar study conducted by the Research Division, College of Engineering, New York University, the same elements, strain gauges, and structural beams were combined in another variation of the force plate.<a></a> Both the UC and the NYU force plates represented a refinement of those conceived and used by Elftman,<a></a> who, in his earlier studies in human locomotion, had used springs and dial gauges to record components of forces.</p> <p><i>The Upper Extremity</i></p> <p>The University of California at Los Angeles, through its Engineering School, was entrusted with basic research in the upper extremity. To study the range of movement required by arm prostheses in the performance of selected daily activities, a photographic procedure was established. A subject was placed within an enclosure composed of vertical, horizontal, and lateral grids. Two mirrors permitted views in the horizontal and lateral planes (<b>Fig. 8</b>). When the subject was photographed, the motion of the targets on the joints could be pictured simultaneously in all three planes, together with the coordinate grids, thus permitting rapid data reduction. An ingenious mannikin enabled the duplication of motions photographed for further study of particular combinations of angular displacement of segments.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Three-dimensional grid system for analyzing motions in the upper extremity. From an NRC report.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Adaptations to Evaluation</i></p> <p>It is difficult to indicate clear boundaries between the basic research and the evaluation stages in the Artificial Limb Program, for many of the tools used to obtain basic data also are useful to the group at New York University engaged in the evaluation of prostheses. These techniques and others now being used in the evaluation program are discussed later (page 65). As the measuring and recording instruments become more generally applied, scientists other than engineers will become equally proficient in their use. When the need arises, the engineering profession undoubtedly will produce even more refined devices for measuring more complex performances.</p> <h4>Prosthetics Design</h4> <p>Important as is the role of engineering in the development of instrumentation and equipment for basic research in human motion, it is in the second stage of any prosthetics program - the design of the prosthetic device - that the engineer is pre-eminent. Among the many factors he must consider in the design of a prosthetic device we may include safety, function, control, efficiency, appearance, comfort, simplicity, and durability. These features can scarcely be assigned any order of importance; since they are all interdependent, the design usually must end up as a compromise.</p> <p>Safety, function, control, efficiency, and appearance require a knowledge of the means - mechanical, pneumatic, hydraulic, or electrical - by which the desired performance can be accomplished and also a knowledge of the forces available, of the forces applied, and of the proper distribution of masses in the device. Comfort requires a knowledge of the limits and distribution of pressure that can be tolerated by body tissues and vessels without damage and without distress to the amputee. Simplicity and durability, both important in the cost and maintenance of the device, require a knowledge of the breakdown that may occur owing to perspiration and body acids, continuous use, temperature changes, and abrasion and chemicals from external sources and, in addition, knowledge as to what materials and combinations of materials may be used to minimize such deterioration.<a style="text-decoration:none;">*</a></p> <p>This kind of problem is the true test of engineering. All the physical sciences which contribute to the substance of engineering may be called upon in evolving the final product. The mechanical engineer contributes his knowledge of mechanisms - cams and gears and linkages, which together may reproduce a motion. With the hydraulic and electrical engineer, he devises means for the operation or control of the prosthesis, for damping a swing, or for magnifying the power available within the amputee. The metallurgical engineer develops the alloys which go into the joints and prescribes methods of treatment to bring out the maximum qualities desired - strength or ductility or resilience or wear. The chemical engineer makes available the new synthetic substances which so handsomely replace the natural substances heretofore the only materials available. Plastics, whether they be the strong, structural resins used in the lamination of shanks and arms,<a></a> or whether they be the plastics used for cosmetic purposes,<a></a> have radically changed the appearance, weight, and sanitary properties of prostheses.</p> <p>The design engineer must combine all this knowledge into the most effective whole. He must bring to the job all of the experience and ingenuity he possesses so that the ultimate product will not only produce the desired function, be strong enough, and last an adequate period but will also be relatively inexpensive and simple enough to be maintained locally with a minimum of special tools. The making of artificial limbs can now be based on well-established scientific principles; it can cease to be empirical and can become a branch of engineering and medical activity. But without the necessary technical skills, progress in prostheses will return to the trial-and-error system from which it has so recently emerged. Some of the specific problems to be solved, and the methods for their solution, which have occurred in the design of upper- and lower-extremity prostheses, deserve to be discussed in some detail.</p> <h4>The Lower Extremity</h4> <p>The scientific basis for lower-extremity prostheses is provided by biomechanical investigation of the functions of the lower limb in human locomotion. Man is an erect biped, that is, he has two supporting limbs and the mass of his body is carried in a vertical plane. The human body, then, may be represented as an upper mass upheld by two supporting columns. The upper mass consists of the head, arms, and trunk. The supporting columns are the two lower limbs. Of complex character, they each consist of three segments, superposed and movable on each other. To meet the needs of standing, the three movable segments form a quasi-rigid column by virtue of their superposition.</p> <p>The standing position includes standing on both feet and standing on one foot, as in the stance phase during locomotion when the weight is borne on one foot only. The vertical line passing through the center of gravity of the body passes behind the line connecting the centers of the two hip joints and in front of the axes of the knee joints. Extension of the trunk relative to the thigh and of the thigh relative to the shank is thus maintained by gravity and limited by powerful ligaments. The two lower limbs therefore remain rigid with a minimum use of active muscle groups. But locomotion demands that the lower limbs be composed of movable, superposed segments. This requirement appears irreconcilable with the demands imposed by the standing position, but the natural arrangement of the lower limbs meets both requirements. Mobility of the hip and knee joints is essential in performing a normal step, a motion which can be divided into four alternating phases, two phases of support on both feet and two phases on each foot alternately.</p> <p>During single support on one foot, the supporting leg bears the weight of the body while the other swings in the sagittal plane like a pendulum suspended from the trunk. Since the two lower limbs are of precisely the same length, the swinging leg must become shorter than the supporting one, or else the swinging foot would drag on the ground. Shortening of the swing leg is effected by flexion of the thigh on the trunk, of the shank on the thigh, and of the foot on the shank.</p> <p>The geometry of the hip joint, and particularly that of the knee and ankle joints, is very complex. Not all authorities are in agreement as to the movements of the segments of the lower limb in flexion and extension, but enough is known to provide information as to how stability and mobility are provided both in standing and in walking. In the manufacture of artificial legs, it is desirable to reproduce insofar as possible the static and dynamic characteristics of the sound limb.</p> <p><i>The Above-Knee Case</i></p> <p>With notably rare exceptions, the design of artificial legs proceeded along a fairly well-defined pattern. Generally, until the middle of the nineteenth century, and now still so in many underprivileged countries, it was considered adequate to supply the leg amputee with a peg-leg. For above-knee amputations, it consisted of a pylon supported below a pad, corset, or socket, which in some fashion was attached to the stump or suspended from the shoulders. For below-knee amputees, the stump was flexed and the peg-leg attached below the flexed knee.</p> <p>Such an artificial leg satisfied completely one of the two functions of the normal leg. It provided a column which, together with the sound leg, allowed the individual to stand erect. It also enabled the wearer to walk, although, since there was no knee joint, it affected the amputee's gait considerably. In the swing phase, the wearer was required to raise the hip on the amputated side in order to swing through; in the stance phase he necessarily had to vault over the pylon. Although such a device is simple, strong, inexpensive, and quite serviceable, the amputee is subjected to excessive stress during walking, his gait is asymmetric and unnatural, his performance in walking is inefficient, and his physical appearance is far from cosmetic.</p> <p>Next in order of development was the so-called "conventional" leg (<b>Fig. 6</b>, page 11). In general, this prosthesis was made to look like the sound leg, that is, it possessed some cosmetic appearance. The knee was hinged and could be flexed, although in the earlier devices a knee lock was provided to assure stability in standing. The foot was attached to the shank with either a rigid or a jointed ankle.</p> <p>This order of devices had many advantages over the peg-leg, but it introduced other problems. Because of the knee hinge, it was possible to sit or kneel or to perform in a more natural manner other activities requiring knee flexion. Moreover, because of the knee joint, when not provided with a knee lock, the amputee was able to walk with a better gait. Knee flexion permitted a certain amount of leg shortening in the swing phase, thus reducing the amount of hip elevation required to clear the ground. But the knee and ankle joints introduced instability in the stance phase, particularly at heel contact. The free-swinging leg resulted in an exaggerated back swing and forward swing with a pronounced shock at each stop. Later compromises were effected by setting the knee bolt forward of the weight line of the body, by addition of check straps to decelerate the shank at toe-off and to provide some assistance at the beginning of the forward swing, by introducing friction devices at the knee bolt, by a combination of both, and by limiting ankle motion through the use of bumper blocks.</p> <p>With minor and individual exceptions, this was the general state of development at which the above-knee prosthesis had remained until the end of World War II. As a result of the research initiated thereafter, engineers began to devote time to the application of old and new knowledge to the design of lower-extremity prostheses. Among the features which had been demonstrated as desirable were flexion at the knee but with some stabilizing control at the time of heel contact and immediately thereafter, some measure of support in an emergency situation such as in stubbing the toe, a controlled swing of the leg, an ankle joint which would permit rotation in a horizontal plane as well as in the sagittal and transverse planes and yet not be so flexible as to increase instability, and a toe-lift device for ground clearance in the swing phase. All this was to be accomplished without substantially increasing weight, sacrificing durability, or increasing initial and maintenance costs of the device. By combining known engineering principles with newly developed materials, a substantial gain was achieved in the above-knee prosthesis, with consequent improvement in the performance of many leg amputees.</p> <p>The U.S. Navy above-knee leg <a></a> developed at the U.S. Naval Hospital, Oakland, California, is an example of such an improved prosthesis. Controlled swing with terminal deceleration was achieved by the use of friction devices which come into operation in the last portion only of the forward and backward swings. New plastics and molding techniques provide a much more natural appearance. New methods of bonding rubber and a new method of attaching the foot to the shank allow for greater flexibility at the ankle without serious problems of instability.</p> <p>Proper application of mechanical and hydraulic engineering principles have resulted in two improved devices, the Stewart-Vickers and the Henschke-Mauch hydraulic legs, both for above-knee amputees. The Stewart-Vickers leg (<b>Fig. 9</b>) provides some resistance to knee flexion and hydraulic damping or deceleration at the terminal portion of the forward and backward swings. By a controlled cycle of operation of valves and cylinders, it provides coordinated hip-knee-ankle flexion in the swing phase so that adequate ground clearance is obtained, gives to the gait a more natural appearance, and apparently results in less effort on the part of the amputee. Whenever it has been tried by an amputee, it has generally resulted in favorable acceptance.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The Stewart-Vickers hydraulic leg incorporating knee lock, swing-phase control, and coordinated motion between ankle, shank, and thigh. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Henschke-Mauch leg,<a></a> which most nearly duplicates the swing pattern of the sound limb, has been designed to provide stability at heel contact, both at the beginning of the stance phase or in the event of a sudden forward acceleration as in stumbling. A carefully designed, pendulum-type valve controls the passage of hydraulic fluid within a cylinder, the added stability being maintained long enough for the amputee to regain his balance but not long enough to impede knee flexion in the stance phase or to increase the risk of a fall. By other valving arrangements the hydraulic cylinder also controls the leg in the swing phase by providing adjustable constant friction in the full cycle plus terminal deceleration.</p> <p>The human knee joint flexes by a combination of rotation and sliding, so that a simple, single-axis joint cannot duplicate the relative positioning of the tibia and femur. A number of attempts have therefore been made to duplicate this articulation in so-called "anatomical" knees by means of various complex mechanical devices, of which one is the four-bar linkage. In <b>Fig. 10</b>, links <i>AD </i>and <i>BC </i>attach thigh to shank. Links <i>AB </i>and <i>CD </i>are formed by the shank piece and the thigh piece, respectively. <i>A </i>is the center of rotation of the ankle; <i>K </i>is the center of rotation of the knee; <i>H </i>is the center of rotation of the hip joint. The locus of the instantaneous center of rotation of the knee is 0-5-10-20-30-45-90, the centers being at the point of intersection of projections of the links <i>AD </i>and <i>EC. </i>Each number indicates the angle of knee flexion which places the instantaneous center at the point shown. As extension takes place, the effect is as if the shank were lengthened and the thigh shortened, a feature which aids stability in the stance phase and reduces the force required to start flexion at the beginning of the swing phase.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Polycentric knee based on a four-bar linkage. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the design shown, maximum elevation of the center of knee rotation occurs prior to full extension, so that initial knee flexion at toe-off is difficult. An improved design, with maximum knee elevation at full extension, is to be found in the University of California four-bar-linkage knee <a></a>. It attempts to simulate the path of the instantaneous centers of rotation of the knee joint so as to provide maximum stability and maximum flexibility at the proper times in the walking cycle.</p> <p><i>The Below-Knee Case</i></p> <p>It is this complex articulation of the knee joint that poses a major problem in the design of an adequate below-knee prosthesis. Since the below-knee amputee retains his natural knee, and since each individual knee follows an individual pattern in flexion, it has thus far been impossible to provide between the thigh corset and the below-knee socket an articulation that will not introduce some displacement between the stump and the socket.</p> <p><i>Methods of Suspension</i></p> <p>The suspension of the above- or below-knee prosthesis has been another area for research and design. Above-knee prostheses had been suspended either by shoulder harness or by some sort of pelvic band. The former did not maintain an adequate positioning between the stump and the socket, since by its very nature it could not adjust to the varying relationship between the shoulder and the leg in different activities. Although the pelvic band retained the leg more securely, it in turn imposed an artificial restriction on possible thigh movements, especially rotation and abduction.</p> <p>A novel method of suspension by suction was patented by Parmelee<a></a> in 1863, but the idea apparently was abandoned in this country although it continued to be used occasionally in Europe. Increasing experience with the suction socket in Germany after 1933 brought it to the attention of medical and engineering scientists in other countries, including the United States. After World War II, in a coordinated program sponsored by the Veterans Administration and directed by the Advisory Committee on Artificial Limbs of the National Research Council, all aspects of suction-socket suspension were studied carefully. The results of this study proved the merits of the suction-socket method of suspension, and it is gradually being adopted for all above-knee prostheses<a></a> where the limbmaker is certified to make such a socket and where there are no medical contraindications. A similar method of suspension is being worked out for below-knee prostheses with increasing evidence of success.</p> <h4>The Upper Extremity</h4> <p>The upper limb is the limb of contact. It consists of three segments - the hand, the forearm, and the arm. Of these, the hand is the most highly differentiated and the most important, since the essential upper-extremity function is grasp, which is mobile and variable in quality, power, and duration. Although its primary function is that of prehension, the hand is also one of our major sense organs. Through it we sense temperature, pressure, surface quality, and the shape of objects. For the blind it serves as substitute for the eyes by providing a sense for discriminating form and texture and, together with the forearm and arm, for determining spatial relationships. The forearm and arm serve merely as mobile attachment for positioning the hand in space. Since most of the hand movements and its different articulations are dependent on arm and forearm muscles, they provide a reserve of active power for hand activation. A detailed analysis of the functional mechanism of grasp <a></a> furnishes the basis for construction of the more scientifically conceived artificial hands.</p> <p><i>The Mechanism of Prehension</i></p> <p>The natural grasp and manipulation are wholly dependent upon the muscular action controlling movement of the fingers. The nature of muscular action therefore determines the nature of the grasp, and the two properties governing the mechanical phenomena of muscular function are contractility and elasticity. Contractility of the muscle is controlled at will. It can be graduated voluntarily in power, extent, and duration, so that the fingers can be closed firmly or gently, as in holding a tool or an egg, or partially or wholly, as in holding a book or a sheet of paper (<b>Fig. 11.</b>). Similarly, the fingers can be moved or closed for very short or very long increments of time, as in fingering the violin or in holding a telephone receiver. Muscle normally is in a state of tone, which may be defined as the property possessed by muscle of preserving, either by voluntary or by reflex action, a state of contractility. This contractility may be long or short in duration, greater or less in extent, strong or weak in power. By means of muscle tone, the hand can be kept in a convenient position for long periods of time.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Twelve basic types of grasp. After Schlesinger.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the hand is so important in everyday activities, and since its functioning is so complex and so dependent for mobility on the two other segments of the upper limb, surgical and orthopedic treatment of the upper-extremity amputee is extremely important in restoration of functional loss. It should be directed toward preservation of the maximum amount of natural mobility. Since it is not yet possible to create artificial muscle, it is necessary to reproduce as well as possible by indirect processes the effects of normal muscle action on the fingers. Prostheses for this purpose are successful in such proportion as the mechanical effects produced approximate those of the natural limb.</p> <p><i>Substitute Power Sources</i></p> <p>Until the present, and even now with all the currently available technology, the most adequate substitutes for the lost muscle activators are muscular substitutes, self-powered agents which induce the movement of the artificial fingers by means of artificial tendons, that is, by control cords. The latter are, as a rule, attached by some appropriate means to the shoulder on the amputated side or on the normal side or both. The movement produced by them is thus entirely dependent upon the shoulder group of muscles. Improvements in surgical techniques<a></a> and extensive research in muscle physiology<a></a> recently have reawakened interest in the use of cineplastic procedures to provide other muscle motors (<b>Fig. 12</b>). Both the biceps and pectoral muscle groups have been used for this purpose.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Below-elbow biceps cineplasty control system. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the action of the controlling muscles must continue for such periods as required for the particular grasp function concerned, the muscular substitute can become heavily burdened. It is therefore absolutely necessary to arrange for release of the muscular substitute once the fingers have been placed in the appropriate position. This is achieved by mechanisms which produce in the artificial fingers the same effect as that produced by muscle tone in the natural fingers.</p> <p><i>Prior Art in Upper-Extremity Prosthetics</i></p> <p>Although the basic concept of an artificial arm and its terminal device has not changed materially from that of the first arms made many years ago, recent technological developments in materials of construction and a better application of known mechanical principles have together resulted in arms of improved appearance and greatly improved function. As in the artificial leg, the materials most commonly used for the artificial arm and forearm have been wood and leather. Control was achieved by shoulder harness operating through control cords, usually leather, connected to the terminal device, which was usually a split hook, that is, a pair of iron or steel fingers bent in the shape of a hook and so hinged as to close on each other. For different applications the shape of the hook was modified as appropriate. Since in general the closed position required for grasping an object is of longer duration than is the open position for approaching the object, opening was effected by the shoulder muscles and closing was brought about by some spring or elastic medium. Cosmetic appearance was neglected or, in those few cases where it was attempted, a passive hand was the usual result.</p> <p>To return to the arm amputee some measure of productive capacity, there were devised a great many one-function terminal devices, each intended for some particular occupational need (<b>Fig. 13</b>). Such "tools" could be inserted and attached to the distal end of the artificial arm. The practice was predominantly European, and we see in their "armamentaria" hooks, rings, hammers, knives, brushes, and a multiplicity of other designs intended to enable the amputee to function in his customary occupation as smith or carpenter or metal worker .<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical occupational-aid terminal devices, all European. The screened boxes indicate the devices recommended for the various activities. From a German report.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Present-day technology and a formal approach to the design of both arms and terminal devices has since effected vast improvements in upper-extremity prostheses. Although most of the newer designs have been described in detail in available literature,<a></a> it is appropriate here to review these developments in a very general way as they relate to engineering practice.</p> <p><i>New Arm Substitutes</i></p> <p>The developments in plastics and in methods of fabrication have resulted in greatly improved arms. By proper lamination, molding, and coloring, arms and forearms can be made lighter, stronger, and with much better cosmetic value.<a></a> Shoulder caps for high above-elbow amputations and for shoulder disarticulations (<b>Fig. 14</b>) can be molded successfully to provide a good base for attachment of the prosthesis. Similarly, plastics of a different character and with other molding methods produce the flexible artificial gloves which cover the active hand to provide natural appearance.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Shoulder-disarticulation harness. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With regard to elbow and wrist articulation, basic research had indicated the desirability of certain ranges of arm motions.<a></a> To provide the necessary mobility, multipositioning elbows and wrists have been devised. The use of ratchet mechanisms, friction clutches, and alternator devices enable the above-elbow amputee to position the forearm by voluntary control through the shoulder harness. Wrist units have been designed both for positioning the terminal device in flexion and rotation and for quick disengagement of the terminal device.</p> <p><i>New Hand Substitutes</i></p> <p>The improvements effected by sound engineering approach are particularly evident in the terminal device (<b>Fig. 15</b>). Since control resides in the shoulder muscles, it appears logical that voluntary control should be available for closing the fingers rather than for opening the device. Such an arrangement, characteristic both of the APRL hook and of the APRL hand,<a></a> permits some measure of control of the force applied. An alternator mechanism provides for alternate opening and closing of the fingers, locks the fingers in the closed position with the desired pressure, and thus relieves stress on the shoulder muscles while an object is held. The extent of opening of the fingers can be set in either of two positions, depending upon the particular operation being performed, and in repetitive operations the lock can be eliminated, thus reducing the amount of work to be done by the shoulder muscles. The development of these voluntary-closing devices has, moreover, permitted the more successful fitting of cineplasty cases.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Types of grasp possible with the natural hand and those available in various designs of artificial hands. After Schlesinger.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For other situations, where an amputee may prefer a voluntary-opening hook, the Northrop two-load hook<a></a> is available. Using springs rather than elastic bands, it permits the fingers to close with either one of two available spring loads. The hook fingers of this terminal device as well as of the APRL hook were shaped in accordance with the findings of basic research into the frequency of hand prehension patterns.<a></a> </p> <p><i>Harnessing</i></p> <p>The whole technique of harnessing has undergone extensive revision as a result of applied engineering principles.<a></a> One feature concerns the fact that the power available at the shoulder should be transmitted to the terminal device with a minimum of loss, that is, with maximum efficiency. Replacing the older leather thongs is the Bowden cable adapted from the aircraft industry. The cable is attached to the harness, directed along the arm by an appropriate number of suitably located cable-housing retainers, and ends at the terminal device. In this circuitous path are friction losses owing to passage of the cable through its housing, especially at points of flexion around joints. Proper selection of points of load application, however, and judicious design of various components make it possible to reduce frictional losses to a minimum (<b>Fig. 14</b> and <b>Fig. 16</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Below-elbow figure-eight harness. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The successful harnessing of cineplasty cases requires the intelligent use of applied mechanics and biomechanics.<a></a> The terminal device and the control system by which it is operated must be adapted both to the end-uses desired by the amputee and to the physiological characteristics of his muscle motor.</p> <p><i>External Power Sources</i></p> <p>A more or less radical departure in the design of upper-extremity prostheses has been the application of engineering science to the utilization of external power sources for activation of arms and terminal devices. Although pneumatic and hydraulic applications have been attended with little success, the development of miniature, compact, and powerful electrical components has made it possible to develop an electrically actuated arm.<a></a> Elbow flexion, wrist rotation, and prehension can all be operated electrically, but thus far it has not been possible to develop completely suitable methods of control. The individual components, such as the electric elbow lock, may, nevertheless, have useful application in more conventional arms.<a></a> Study of such possible applications is now under way. There can be little doubt that, in some future study, with even newer materials and more advanced methods, externally powered arms, discretely controlled and respondent to the will of the amputee, may be developed.</p> <h4>Techniques of Evaluation</h4> <p>The real merit of a prosthesis cannot be judged solely on the basis of mechanical and cosmetic elegance of the design or by the number of functions it incorporates. It can be evaluated in true perspective only when it is fitted to the amputee and when his over-all performance with and acceptance of the device is appraised. In the Artificial Limb Program, the Prosthetic Devices Study, Research Division, College of Engineering, New York University, has been charged with the evaluation of prosthetic devices. To conduct this work, the roster of personnel includes physicians, psychologists, physiologists, therapists, and engineers, and the evaluations consider both the subjective and objective aspects of the biomechanical relationship.</p> <p>Although in much of ordinary engineering practice the objective evaluation of a mechanism is the only valid criterion, in prosthetics practice, because of the close relationship between the human and mechanical elements, the importance of subjective evaluations cannot be discounted.<a></a> As has been demonstrated repeatedly, what appears to be a very distinct and sound advance in a prosthesis may not in fact be acceptable to the amputee. A proper understanding of the attitudes of amputees, how they are affected by their own experience and by the characteristics of a device, and how these factors can be translated into the design is altogether necessary. The psychologist therefore has an important role in the evaluation process. So, too, the therapist, trained to observe human performance, and with a knowledge of the physiology and function of the human organism, can render a sound opinion with respect to the relative merits of various amputee-prosthesis combinations.</p> <p>But these methods of evaluation are subject to all the limitations of personal judgment. The experience and acuity of the particular observer, the relationship between the observer and the amputee, and other individual factors will in some way affect the evaluation. To a certain extent these variables are controlled by a comparison and correlation of judgments of different observers, but even under the most favorable conditions there may always be areas of disagreement as to what has been observed.</p> <p>When positive criteria of performance with a prosthetic device can be established, it becomes very important to be able to measure and record accurately those factors which constitute the criteria. Instrumentation and methods developed on the basis of engineering knowledge provide the tools for obtaining objective data. They enable the investigator to compare the performance of a particular amputee with different prostheses, of a given amputee with the same prosthesis at different times, or of different amputees wearing identical prostheses. The recording instruments and techniques available can record more rapidly, more accurately, and more permanently than can any human observer. All the devices useful in the basic research program are equally useful in the evaluation program.</p> <h4>The Lower Extremity</h4> <p><i>Symmetry in the Walking Pattern</i></p> <p>In establishing criteria for the evaluation of lower-extremity prostheses, it has been postulated that the pattern of normal locomotion is symmetrical and, therefore, that the behavior of the normal side may be the legitimate measure of performance of the affected side. That is to say, the more nearly the amputee achieves a symmetrical pattern of locomotion the better the prosthetic device and the better the adjustment to it. Further, it is assumed that, in the performance of activity, the human organism adjusts itself to perform at a minimal level of stress. The measure of performance of normals, then, can be a guide to the relative merits of amputee-prosthesis combinations. Such criteria as stability in the erect position, variability of stride time, and other biomechanical factors may be used as indices of performance. Lacking proper instrumentation, no objective evaluations of this character could be made.</p> <p><i>Energy Costs</i></p> <p>The investigations of Hettinger and Muller<a></a> indicate that the walking cadence favored by a normal human being is usually that which requires the minimum expenditure of energy. Deviations from this optimum cadence require increasing amounts of energy. Psychologists indicate that, in a repetitive operation which may be performed at varying tempos, the average person will perform the operation with least deviation at some one tempo best suited to him. On the strength of these two premises, the variations in stride time at different cadences were recorded and curves plotted (<b>Fig. 17</b>). The assumption is made that the nearer the curve of the affected leg approaches that of the normal leg, and the nearer the two curves approach those of a normal subject, the better the prosthetic device. Such data can be taken with the tachograph (<b>Fig. 18</b>), force plates, and interrupted-light photography.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. Variability in stride time. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Velocities in level walking at normal speed (from tachograph records). <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 19</b> represents a typical plot of vertical load versus time during ground contact from heel contact to toe push-off. By means of stick diagrams and force-plate records, this over-all curve may be resolved into one for heel-contact impact and another for toe push-off momentum. When the separation is correct, the area C should be equal to the area <i>D. </i>Used in conjunction with other criteria, these curves give useful information regarding the effect of a prosthesis on the amputee's gait.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Components of vertical force. Normal speed, level walking, mean of eight subjects.<i>Double-Support Time (delta t)</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Marey and Demeny<a></a> determined that the time of double support in the walking cycle is inversely proportional to cadence. The NYU studies indicate that it is also related to the ratio of swing-phase time to stance-phase time <i>r </i>and that, moreover, at optimum cadence the stance-phase time in normals is approximately twice the swing-phase time. A criterion was established that, given the relationship between double-support time and cadence, plotted against a family of curves for varying ratios of swing-phase time to stance-phase time, that amputee-prosthesis combination was best which enabled the amputee group more nearly to approach the normal group.</p> <p><b>Fig. 20</b> shows the average trend line for a group of normals and for a group of above-and below-knee amputees. From the equation indicated, a series of hyperbolas may be plotted for varying values of <i>r. </i>The observed double-support times for normals, for below-knee amputees, and for above-knee amputees at three different speeds were plotted, and straight lines were fitted to these observed points. A line for double-support time crosses each of the hyperbolas at two points. The mean abscissa of these points indicates optimum cadence. Since a deviation from this optimum causes an increase in energy consumption, the increase in the value of <i>r </i>can be used as an indicator of higher energy requirement. The validity of this criterion appears to be borne out, since the below-knee group, having more of their natural limbs, more nearly approach the normals. Again, such data can be obtained only because adequate instrumentation, force plates, tachograph, and camera are available.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Analysis of optimum cadence. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Vertical Stability</i></p> <p>Stability in the erect position is used as another criterion.<a></a> The normal individual keeps himself erect by the interaction of muscle and skeletal groups responding to sensory cues. In the amputee some of the normal cues have been destroyed and new ones, such as pressure on the stump, or pain, have been introduced. Besides this, the amputee has fewer muscle groups available with which to compensate for the effect of external forces tending to throw him off balance. Because the human anatomical structure is not truly rigid, the equilibrium of a normal erect subject will be disturbed by a force of lower magnitude than that which will unbalance a rigid body of the same general mass distribution and with the same general support base (<b>Fig. 21</b>). Since the amputee cannot compensate for the effect of unbalancing forces as readily as can a normal, and since in fact poor alignment or fit of the prosthesis may exaggerate the unbalancing effect, the measure of stability is highly important.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. The base of support. <i>C </i>represents the center of the support base. Shaded areas show the contact zones of feet and ground. The small trapezoid defines the limits of travel of the projection of the center of gravity. <i>P </i>represents the mean of all the readings of center-of-gravity projection. The distances <i>d1, d2, d3, </i>and <i>d4 </i>are the respective distances from the center <i>P.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Three methods are used for obtaining information on stability. In one, the subject is placed in a known position on one force plate and the center of the base of support on the force plate is determined geometrically. The extent and frequency of deviation in the sagittal and transverse planes are recorded simultaneously (<b>Fig. 22</b>). Mean values of recorded oscillations determine the location of the center of pressure, which at the same time is also the projection of the center of gravity on the force plate. Distances measured from the center of pressure of the axis of each foot give an indication as to how the body weight is distributed between the two legs.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Record of stability in standing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since the reduction of force-plate data alone is not sufficient for the purpose of determining stability constants, a simple device, the stability platform shown in <b>Fig. 23</b>, has been fabricated for imposing upon a subject known accelerations and recording that one at which he is unbalanced. The support base is known, the center of mass of the subject vertically above the platform can be established, the acceleration when the platform is suddenly released can be controlled by the known weights in the suspended basket, and thus it can be determined at what acceleration the subject is unbalanced. Stability trapezoids for normals and for above- and below-knee amputees (<b>Fig. 24</b>) have been prepared on the basis of available data. It will be noted that thus far only four positions have been recorded - accelerations tending to unbalance the subject in the forward, rearward, right, and left directions. No positions along intermediate axes have been studied, but it seems likely that, if more positions were measured, the envelope would assume some oval shape. This criterion too seems validated by results, since, although there are differences between individual amputees as well as between normals, as a group the below-knee amputees more nearly approach the normal group.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. The stability platform. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Stability polygon; mean values in percent of <i>g. Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another simple device which has been used to corroborate acceleration data is the inclined platform. A kymograph records the increasing angle of tilt, and the recording is interrupted when the subject topples.</p> <p><i>Standardization of Fit and Alignment</i></p> <p>It is not amiss at this point to mention two devices, developed at the University of California, which are indispensable in the evaluation procedures. The alignment devices for above- and below-knee prostheses and the transfer jig<a></a> are tools useful in assuring that different prostheses on the same amputee are alike in physical dimensions and positioning, and they make it possible to measure the effects of known changes in position or alignment in the same prosthesis. A third device, developed at the Prosthetic Testing and Development Laboratory of the Veterans Administration, makes it possible to duplicate sockets, a matter of importance when shanks requiring different sockets are needed. The internal contours of the socket can be maintained and their effect on changes in performance thus minimized.</p> <p><i>Measurement of Force Distribution</i></p> <p>Engineering knowledge makes it possible also to study special characteristics of a device or of a method of fitting. In evaluating the relative merits of the "soft" and hard sockets for below-knee amputees, three new techniques have been evolved. It is desirable to observe changes which occur in the stump as a result of wearing the socket. Accordingly, there has been devised a jig which will hold the amputee in a given position while an impression or cast is made of his stump. Since a rigid pattern of posture is thus imposed, the impression or cast reflects only physiological changes over a period of time. The contours of the stump are then obtained by using a contour tracer or perigraph, also developed for this special purpose. Small variations in contours at known levels can be recorded and compared.</p> <p>The second technique involves the use of the capacitance gauges previously described. In a study at New York University, in cooperation with the Prosthetic and Sensory Aids Service of the Veterans Administration, they have been applied in an attempt to answer once and for all the question among limb-makers as to the proper distribution of forces within a below-knee socket. Several gauges are attached at points of particular interest on the stump of a below-knee amputee (<b>Fig. 25</b>). The subject then walks at different speeds for a distance of 30 to 40 feet while the unbalance of the gauge bridges is recorded. In this way, simultaneous indications of pressure are obtained at six points on the stump. Although it is still too early to make a general statement, it is evident that great differences exist in the forces exerted by the stump on the socket wall at different points. A composite record of the forces involved during a single stride (<b>Fig. 26</b>) shows the relative magnitudes of forces at a number of points. The maximum observed pressure was 65 lb. per sq. in. at the relatively insensitive patellar tendon. Eventually it is intended to map the total stump contact area for pressure distribution during different phases of the walking cycle.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Experimental arrangement for pressure measurement using capacitors. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Typical oscillograph record of forces in walking. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In addition to the research applications of the pressure gauge, it is likely to find use in the routine fitting of sockets. For this purpose, gauges would be attached to the stump at critical points, such as weight-bearing areas, sore spots, or relieved areas, when a new socket were tried on. A meter reading would give the magnitude of the pressure at the points in question and would tell objectively whether the pressure were excessively concentrated or well distributed when the subject stood or walked.</p> <p>The third technique specially developed makes use of the strain gauge also described previously. By means of this instrument it has been possible to attack the problem of determining the relative distribution of body weight between the sidebars and the socket of the below-knee amputee. In the experimental procedure developed, modified sidebars (<b>Fig. 27</b>) are substituted for the original ones of the test subject. So constructed that the subject's gait is unaffected by the substitution, these modified sidebars permit the mounting of the strain gauges so as to simplify determination of axial and bending strains. In the test procedure, wires are run from the gauges on the bars to a recording oscillograph by means of an eight-conductor cable. Stick diagrams and force-plate records are taken simultaneously with the recording of the dynamic sidebar strains (<b>Fig. 28</b>). Thus, at any particular instant, the position of the leg in space, the forces it exerts on the ground, and the strains in the sidebars all are known. From the knowledge of the axial sidebar loads, plus some logical assumptions and some simple kinematic relationships, the components of socket load along the axis of the shank and normal to the shank axis can be found. At the present time, runs have been made on two test subjects, one unilateral and one bilateral, both wearing conventional wooden sockets.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Conventional sidebar (left) and experimental modification for measurement of bending forces. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Axial load on sidebars. Body weight, 250 lb.; cadence, 120 steps per minute. <i>Courtesy Prosthetic Devices Study, New York University.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Upper Extremity</h4> <p>Engineering techniques have been employed in the evolution of upper-extremity prostheses also, though not to the same extent. The refinements in lower-extremity prostheses are such as to require discrete, fine, and rapid measurements, while those in the upper extremity are comparatively gross and subject, in many cases, to visual observation and judgment. Moreover, the increased performance with the newer arms and terminal devices can be appreciated quite readily by both the amputee and the observer. In the upper extremity, therefore, the employment of measuring devices is required only in those special situations where human observations fail.</p> <p><i>Control Systems</i></p> <p>The efficiency of an upper-extremity control system, from the point of load application at the harness to the point of pressure applied by the terminal device, cannot be obtained other than with measuring instruments. For such measurement, the strain gauge, applied to appropriately designed devices, can be used to measure the pressure at the tips of the fingers or the force applied at any point along the cable of an actuating system. In the course of some of the NYU studies, a channel-shaped structural element was designed in such a way that it could be inserted as a link in the cable system at different points along the cable. Tension in the cable causes deflection in the elements, and the extent of deflection is recorded as a change in voltage through strain gauges cemented to the crossbar of the channel.</p> <p><i>Finger Forces</i></p> <p>A similar principle has been used for measuring hook-finger pressures. Elements resembling tuning forks were designed, the beams being so shaped as to accommodate different grasps. Strain gauges cemented to the crossbar measure the bending stress in the fork, the stress being proportional to the pressure applied by the amputee at the tips of the hook fingers. With knowledge of the linkages involved in the system, it is possible to determine what harness combination is most efficient.</p> <p>At the Army Prosthetics Research Laboratory, a "grip" meter has been developed for the purpose of measuring normal grips and the grips that can be achieved by amputees with artificial hands. The grip is resisted by a spring calibrated to be read directly on a dial gauge.</p> <p><i>Range of Stump Motion</i></p> <p>During the course of development of the electric arm, an unusual instrument was developed by Alderson<a></a> to measure the range of motion of the various muscle groups which later were to actuate the controls of the electric arm. The <i>simul"arm"ator </i>permits the designer and fitter to estimate the range of control available to the amputee in the various muscle groups - biceps, triceps, pectoral, etc., and to allow for this range in designing the control switches of the prostheses.</p> <h4>The Future in Prosthetics Evaluation</h4> <p>As more and more improvements are incorporated into upper- and lower-extremity prostheses, the relative merit of one prosthesis as compared to another will become more and more difficult to evaluate without appropriate instrumentation and recording. The development of recording and measuring devices must therefore keep pace with the combinations to be evaluated. Hence the engineer must continue to function in his role in the evaluation phase of the program.</p> <h3>Conclusion</h3> <p>The contributions of engineers and the role of engineering in all stages of prosthetics design and application now have been well established. But this turn of events could scarcely have materialized without the cooperation of the Government. The program established by the U.S. Congress,<a></a> supervised by the Veterans Administration, and coordinated by the Advisory Committee on Artificial Limbs of the National Research Council assured a continuity of operations - of research, design, and evaluation - in which engineers and engineering groups could become interested.</p> <p>Theretofore engineers had been interested in prosthetics in a desultory fashion only, and engineering principles had been applied only to the extent that that knowledge was available to the individual limbmaker concerned. Engineers have brought to the Artificial Limb Program a curiosity as to the physical principles involved in human performance and an appreciation of the scientific method in approaching the problems. They have contributed their knowledge of measurement and of instrumentation to obtain necessary data, they have translated the results into terms of new needs, and they have applied their knowledge of materials and of mechanisms toward the fulfillment of those needs.</p> <p>It cannot be expected that the present program, born of World War II and under the pressure of veterans' demands, will continue indefinitely. And yet it may be anticipated that more and more amputees will continue to need truly functional artificial limbs. Records indicate that annually there arise from disease and other natural causes - industrial and traffic accidents and accidents in the home - many times more amputees than were produced in all Service-connected activities throughout World War II. And these include the weak and the old and the very young, not alone the average, healthy male represented by the veteran amputee. As in all science, the problems which yet require solution are much more numerous than are those already solved. Programs must therefore be established which will be broad enough in scope and long enough in duration to attract engineers. The limb industry must continue to upgrade itself, to create the positions which require engineering skills, and to offer commensurate rewards. Rehabilitation agencies and all those groups interested in the welfare of the disabled should consider how the role of the engineer and of the physical scientist can be integrated into their work.</p> <p>As an alternative it has been suggested that a cross-discipline should be evolved, with courses of instruction available to the engineer, the physician, and the rehabilitation specialist to enable each to understand each other's problems. Such a curriculum in biotechnology could offer the engineer instruction in physiology and psychophysiology useful as well in applications other than prosthetics. It could offer the physician and rehabilitation specialist instruction in the physical sciences, instrumentation, and measurement. For such an integrated course of instruction there are already precedents. Physicians have studied engineering for a better understanding of orthopedics. Engineers have studied the physiology of human activity to develop better operational methods in industry. In Europe, particularly in Germany, Russia, and the Scandinavian countries, a whole new science of "work physiology" or "work science" is being developed. In England the Ergonomics Society brings together physiologists, psychologists, and physical scientists interested in the problems of human performance, and their contributions are having effect on the design of equipment and operational processes. A scientist from whatever field, trained in biomechanics, can bring to a prosthetics program a much greater appreciation of the problems to be solved. He will be better equipped to evaluate the solutions that will be offered. But it seems inevitable that the solutions in their final development will be offered only by the engineer.</p> <h4>Acknowledgments</h4> <p>In the preparation of this article a number of people were exceptionally helpful. Special mention needs to be made of Rudolf Drillis, of the Prosthetic Devices Study, New York University, who provided much of the raw data and who was of particular assistance in review and discussion of the technical aspects of the material. Martin Koenig and Seymour Kaplan, both also of the staff of PDS-NYU, supplied the sections on capacitors and on be-low-knee sidebars, respectively. Various other members of the PDS-NYU staff read critically several sections of the manuscript. The Prosthetic Testing and Development Laboratory of the U.S. Veterans Administration supplied a number of the photographs, and George Rybczynski worked up all of the line drawings from rough sketches. To all these, and to others not mentioned specifically, sincere thanks are extended.</p> <p><b>References:</b></p> <ol> <li>Alderson, Samuel W., <i>The electric arm, </i>Chapter 13 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Alderson Research Laboratories, Inc., New YorkCity, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on <i>Research and development of electric arms and electric arm components, </i>1954.</li> <li>Alldredge, Rufus H., Verne T. Inman, HymanJampol, Eugene F. Murphy, and August W. Spittler, <i>The techniques oj cineplasty, </i>Chapter 3 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Amar, Jules, <i>Le moleur humaine et les bases scientifiques du travail professionel, </i>H. Dunod, Paris, 1914.</li> <li>Amar, Jules, <i>Organisation physiologique du travail,</i>H. Dunod et E. Pinot, Paris, 1917.</li> <li>Bechtol, Charles O., <i>The prosthetics clinic team, </i>Artificial Limbs, January 1954. p. 9.</li> <li>Bernshtein, N., <i>Die Kymocyclographische Methode der Bewegungsunlersuchungen, </i>in <i>Hndb. d. biol. Arbeitsmethoden, </i>Lief. 263., Urban und Schwar-zenberg, Wien, 1928.</li> <li>Bernshtein, N., <i>et al., Investigations on biodynamics of locomotion, </i>Vols. 1 and 2, Moscow, 1935 and 1940. In Russian.</li> <li>Borchardt, M., <i>et al., </i>eds., <i>Ersatzglieder und Arbeit-</i><i>shilfen, </i>Springer, Berlin, 1919.</li> <li>Borelli, Giovanni A., <i>De motu animalium, </i>Romae,1679. Two volumes. To be found in <i>Pathologie de chirurgie, </i>Vol. 2 of 3 vols., by Jean Baptiste Ver-duc, Paris, 1727.</li> <li>Carlyle, Lester, <i>Fitting the artificial arm, </i>Chapter 19in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Catranis, Inc., Syracuse, N.Y., Subcontractor'sFinal Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>Improved artificial limbs for lower extremity amputations, </i>June 1954.</li> <li>Committee on Artificial Limbs, National Research Council, Washington, D. C, <i>Terminal research reports on artificial limbs </i>[to the Office of the Surgeon General and the U.S. Veterans Administration] covering the period from 1 April 1945 through 30 June 1947.</li> <li>Contini, R., and R. Drillis, <i>Biomechanics, </i>Appl.Mech. Rev., 7:49 (1954).</li> <li>Drillis, R., <i>Chronocyclographische Arbeitsstudien, </i>in<i>Psychophysiologische Arbeiten, </i>1A, Riga, 1930.</li> <li>Drillis, R., <i>Investigation on axe and woodcutting,</i>Latvijas Lauksaimnieks, Riga, 1935. In Latvian.</li> <li>Drillis, R., <i>Investigations on stability, </i>unpublishedreport, Prosthetic Devices Study, New York University, 1954.</li> <li>Eberhart, H. D., and V. T. Inman, <i>An evaluation of experimental procedures used in a fundamental study of human locomotion, </i>Ann. N. Y. Acad. Sci., 51:1213(1951).</li> <li>Eberhart, Howard D., and Jim C. McKennon,<i>Suction-socket suspension of the above-knee prosthesis, </i>Chapter 20 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Elftman, H, <i>The measurement of the external force in walking, </i>Science, 88:152(1938).</li> <li>Elftman, H., <i>The force exerted by the ground in walking, </i>Arbeitsphysiol., 10:485 (1939).</li> <li>Elftman, H., <i>The basic pattern of human locomotion,</i> Ann. N. Y. Acad. Sci., 51:1207(1951).</li> <li>Faries, John Culbert, <i>Limbs for the limbless, </i>Institute for the Crippled and Disabled, New York, 1934.</li> <li>Fick, R., <i>Handbuch der Anatomic und Mechanik der Gelenke unter Berucksichtigung der bewegenden Muskeln, </i>G. Fischer, Jena, 1904-1911. Three volumes.</li> <li>Fischer, O., <i>Theoretische Grundlagen fur eine Mechanik der lebenden Korper, mit speziellen Andwendungen auf den Menschen, </i>B. G. Teubner, Leipzig and Berlin, 1906.</li> <li>Fletcher, Maurice J., <i>New developments in hands and hooks, </i>Chapter 8 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Fletcher, Maurice J., <i>The upper-extremity prosthetics armamentarium, </i>Artificial Limbs, January 1954.</li> <li>Fletcher, Maurice J., and A. Bennett Wilson, Jr.,<i>New developments in artificial arms, </i>Chapter 10 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Frank, Wallace E., and Robert J. Gibson, <i>New pressure sensing instrument, </i>J. Franklin Inst., in press 1954.</li> <li>Gilbreth, Frank B., and Lillian M. Gilbreth, <i>Motion study for the handicapped, </i>G. Routledge and Sons, Ltd., London, 1920.</li> <li>Haddan, Chester C, and Atha Thomas, <i>Status of the above-knee suction socket in the United States, </i>Artificial Limbs, May 1954. p. 29.</li> <li>Henschke, Ulrich K., and Hans A. Mauch, <i>The improvement of leg prostheses, </i>The Military Surgeon, 103(2) :135 (1948).</li> <li>Hettinger, Th., and E. Muller, <i>Der Einfluss des Schuhgewichtes auf den Energieumsatz beim Gehen und Lastenlragen, </i>Arbeitsphysiol., 15:33 (1953).</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary muscle, </i>Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Kaplan, S., <i>Determination of dynamic loads and strains in below-knee artificial limbs, </i>unpublished report, Prosthetic Devices Study, New York University, 1954.</li> <li>Leonard, Fred, and Clare L. Milton, Jr., <i>Cosmetic gloves, </i>Chapter 9 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Leonardo da Vinci, <i>On the human body, </i>C. D.O'Malley and J. B. DeC. M. Saunders, eds. Schuman, New York, 1952.</li> <li>Marey, E., <i>Mouvement, </i>G. Masson, Paris, 1894.</li> <li>Marey, E.-J., and G. Demeny, <i>Eludes experimentales de la locomotion humaine, </i>Compt. rend. Acad. d. sc, 106:544 (1887).</li> <li>Martin, Florent, <i>Artificial limbs, </i>International Labour Office, Geneva, 1925.</li> <li>Muybridge, Eadweard, <i>The human figure in motion,</i>Chapman &amp; Hall, London, 1901.</li> <li>New York University, College of Engineering,Research Division, [Report to the] Special Devices Center, Office of Naval Research (Contract No. N6onr-279), <i>Investigations with respect to the design, construction, and evaluation of prosthetic devices, </i>June 1, 1949. Two volumes.</li> <li>New York University, Prosthetic Devices Study,(report to the) Advisory Committee on Artificial Limbs, National Research Council, <i>The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, </i>March 1953.</li> <li>Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A report on prosthesis development, </i>1947.</li> <li>Parmelee, Dubois D., U.S. Patent 37,637, February10, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</li> <li>Public Law 729, Eightieth Congress, Second Session,Approved June 19, 1948.</li> <li>Radcliffe, Charles W., <i>Alignment of the above-knee artificial leg, </i>Chapter 21 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Radcliffe, Charles W., <i>Mechanical aids for alignment of lower-extremity prostheses, </i>Artificial Limbs, May 1954. p. 20.</li> <li>Schede, Franz, <i>Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fur den Ober-schenkelamputierten, </i>Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</li> <li>Schlesinger, G., <i>Die Mitarbeit des Ingenieurs bei der</i><i>Durchbildung der Ersatzglieder, </i>Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (1917).</li> <li>Steindler, Arthur, <i>Mechanics of normal and pathological locomotion in man, </i>Charles C Thomas, Springfield, Ill., 1935.</li> <li>Taylor, Craig L., <i>Control design and prosthetic</i><i>adaptations to biceps and pectoral cineplasty, </i>Chapter 12 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity, </i>Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Technical Institute, Charlottenburg, Report of theSpecial Commission for Accident Prevention, <i>Merkblatter der Prufungsstelle fur Ersatzglieder, </i>Berlin, 1916-1917.</li> <li>Thomas, A., and C. C. Haddan, <i>Amputation prosthesis, </i>Lippincott, Philadelphia, 1945.</li> <li>University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</li> <li>Wagner, Edmond M., <i>Contributions of the lower-extremity prosthetics program, </i>Artificial Limbs, May 1954.</li> <li>Wagner, Edmond M., and John G. Catranis, <i>New</i><i>developments in lower-extremity prostheses, </i>Chapter 17 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Wilson, A. Bennett, Jr., <i>The APRL terminal devices,</i>Orthop. &amp; Pros. Appl. J., March 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>46.</b> </td><td class="clsTextSmall">Public Law 729, Eightieth Congress, Second Session,Approved June 19, 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>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New YorkCity, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 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>35.</b> </td><td class="clsTextSmall">Kaplan, S., Determination of dynamic loads and strains in below-knee artificial limbs, unpublished report, Prosthetic Devices Study, New York University, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 20.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Drillis, R., Investigations on stability, unpublishedreport, Prosthetic Devices Study, New York University, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Marey, E., Mouvement, G. Masson, Paris, 1894.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Marey, E.-J., and G. Demeny, Eludes experimentales de la locomotion humaine, Compt. rend. Acad. d. sc, 106:544 (1887).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Hettinger, Th., and E. Muller, Der Einfluss des Schuhgewichtes auf den Energieumsatz beim Gehen und Lastenlragen, Arbeitsphysiol., 15:33 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,(report to the) Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alderson, Samuel W., The electric arm, Chapter 13 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New YorkCity, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alderson, Samuel W., The electric arm, Chapter 13 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alderson Research Laboratories, Inc., New YorkCity, Contractor's Final Report [to the U.S. Veterans Administration (Contract No. V1001M-3123)] on Research and development of electric arms and electric arm components, 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>52.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prostheticadaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, January 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>50.</b> </td><td class="clsTextSmall">Schlesinger, G., Die Mitarbeit des Ingenieurs bei derDurchbildung der Ersatzglieder, Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (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>52.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prostheticadaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, January 1954.</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., The APRL terminal devices,Orthop. &amp;Pros. Appl. J., March 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, January 1954.</td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr.,New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Technical Institute, Charlottenburg, Report of theSpecial Commission for Accident Prevention, Merkblatter der Prufungsstelle fur Ersatzglieder, Berlin, 1916-1917.</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>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Borchardt, M., et al., eds., Ersatzglieder und Arbeit-shilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Schlesinger, G., Die Mitarbeit des Ingenieurs bei derDurchbildung der Ersatzglieder, Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (1917).</td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">Technical Institute, Charlottenburg, Report of theSpecial Commission for Accident Prevention, Merkblatter der Prufungsstelle fur Ersatzglieder, Berlin, 1916-1917.</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>34.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, HymanJampol, Eugene F. Murphy, and August W. Spittler, The techniques oj cineplasty, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Schlesinger, G., Die Mitarbeit des Ingenieurs bei derDurchbildung der Ersatzglieder, Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Borchardt, M., et al., eds., Ersatzglieder und Arbeit-shilfen, Springer, Berlin, 1919.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Schlesinger, G., Die Mitarbeit des Ingenieurs bei derDurchbildung der Ersatzglieder, Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (1917).</td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon,Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United States, Artificial Limbs, May 1954. p. 29.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U.S. Patent 37,637, February10, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Catranis, Inc., Syracuse, N.Y., Subcontractor'sFinal Report to the Advisory Committee on Artificial Limbs, National Research Council, Improved artificial limbs for lower extremity amputations, June 1954.</td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Wagner, Edmond M., Contributions of the lower-extremity prosthetics program, Artificial Limbs, May 1954.</td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Wagner, Edmond M., and John G. Catranis, Newdevelopments in lower-extremity prostheses, Chapter 17 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">In press as of this writing is a large collaboration on the general subject of deterioration prevention. Prepared by the Prevention of Deterioration Center, National Research Council, under the joint editorship of Glenn A. Greathouse and Carl J. Wessel, and titled Deterioration of Materials - Causes and Preventive Techniques, it is to be available this autumn from the publishers, Reinhold Publishing Corporation, New York. Many of the techniques described may find application in the field of prosthetics.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Committee on Artificial Limbs, National Research Council, Washington, D. C, Terminal research reports on artificial limbs [to the Office of the Surgeon General and the U.S. Veterans Administration] covering the period from 1 April 1945 through 30 June 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Elftman, H, The measurement of the external force in walking, Science, 88:152(1938).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">New York University, College of Engineering,Research Division, [Report to the] Special Devices Center, Office of Naval Research (Contract No. N6onr-279), Investigations with respect to the design, construction, and evaluation of prosthetic devices, June 1, 1949. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Eberhart, H. D., and V. T. Inman, An evaluation of experimental procedures used in a fundamental study of human locomotion, Ann. N. Y. Acad. Sci., 51:1213(1951).</td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Frank, Wallace E., and Robert J. Gibson, New pressure sensing instrument, J. Franklin Inst., in press 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,(report to the) Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Drillis, R., Investigation on axe and woodcutting,Latvijas Lauksaimnieks, Riga, 1935. In Latvian.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Since a constant valueâ€the distance the film is transported in an increment of time must always be subtracted from the measured horizontal displacement of a point.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Drillis, R., Chronocyclographische Arbeitsstudien, inPsychophysiologische Arbeiten, 1A, Riga, 1930.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Bernshtein, N., Die Kymocyclographische Methode der Bewegungsunlersuchungen, in Hndb. d. biol. Arbeitsmethoden, Lief. 263., Urban und Schwar-zenberg, Wien, 1928.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Muybridge, Eadweard, The human figure in motion,Chapman &amp;Hall, London, 1901.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Contini, R., and R. Drillis, Biomechanics, Appl.Mech. Rev., 7:49 (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>42.</b> </td><td class="clsTextSmall">New York University, College of Engineering,Research Division, [Report to the] Special Devices Center, Office of Naval Research (Contract No. N6onr-279), Investigations with respect to the design, construction, and evaluation of prosthetic devices, June 1, 1949. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>56.</b> </td><td class="clsTextSmall">University of California (Berkeley), ProstheticDevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Henschke, Ulrich K., and Hans A. Mauch, The improvement of leg prostheses, The Military Surgeon, 103(2) :135 (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>References</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Elftman, H, The measurement of the external force in walking, Science, 88:152(1938).</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Elftman, H., The force exerted by the ground in walking, Arbeitsphysiol., 10:485 (1939).</td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Elftman, H., The basic pattern of human locomotion, Ann. N. Y. Acad. Sci., 51:1207(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>51.</b> </td><td class="clsTextSmall">Steindler, Arthur, Mechanics of normal and pathological locomotion in man, Charles C Thomas, Springfield, Ill., 1935.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Bernshtein, N., et al., Investigations on biodynamics of locomotion, Vols. 1 and 2, Moscow, 1935 and 1940. In Russian.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">Schede, Franz, Theoretische Grundlagen fur den Bau von Kunstbeinen; Insbesondere fur den Ober-schenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Schlesinger, G., Die Mitarbeit des Ingenieurs bei derDurchbildung der Ersatzglieder, Verein. Deutsch. Ingen., Berlin Ztschr., 61:6 (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>40.</b> </td><td class="clsTextSmall">Martin, Florent, Artificial limbs, International Labour Office, Geneva, 1925.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Amar, Jules, Le moleur humaine et les bases scientifiques du travail professionel, H. Dunod, Paris, 1914.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Amar, Jules, Organisation physiologique du travail,H. Dunod et E. Pinot, Paris, 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>30.</b> </td><td class="clsTextSmall">Gilbreth, Frank B., and Lillian M. Gilbreth, Motion study for the handicapped, G. Routledge and Sons, Ltd., London, 1920.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Fick, R., Handbuch der Anatomic und Mechanik der Gelenke unter Berucksichtigung der bewegenden Muskeln, G. Fischer, Jena, 1904-1911. Three volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Fischer, O., Theoretische Grundlagen fur eine Mechanik der lebenden Korper, mit speziellen Andwendungen auf den Menschen, B. G. Teubner, Leipzig and Berlin, 1906.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Borelli, Giovanni A., De motu animalium, Romae,1679. Two volumes. To be found in Pathologie de chirurgie, Vol. 2 of 3 vols., by Jean Baptiste Ver-duc, Paris, 1727.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>37.</b> </td><td class="clsTextSmall">Leonardo da Vinci, On the human body, C. D.O'Malley and J. B. DeC. M. Saunders, eds. Schuman, New York, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Faries, John Culbert, Limbs for the limbless, Institute for the Crippled and Disabled, New York, 1934.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>55.</b> </td><td class="clsTextSmall">Thomas, A., and C. C. Haddan, Amputation prosthesis, Lippincott, Philadelphia, 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Faries, John Culbert, Limbs for the limbless, Institute for the Crippled and Disabled, New York, 1934.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">A prosthetic device may be defined as one which attempts to restore, in function or appearance or both, any portion of the external human anatomical structure that has been impaired or removed owing to injury or to some degenerative process. In the broadest sense,therefore, artificial eyes and false teeth, as well as braces and artificial limbs, are prostheses. In the more commonly accepted sense, however, prosthetic devices usually refer to artificial arms and legs. The present discussion isconcerned with the role engineering must take in the development, fabrication, and application of artificial limbs.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Renato Contini, B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Research Coordinator, College of Engineering, New York University; member, Upper- and Lower-Extremity Technical Committees, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1954_03_047/tmp3B8-19.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 Prosthetics Research and the Engineering Profession Creator An entity primarily responsible for making the resource Renato Contini, B.S.M.E. * https://staging.drfop.org/files/original/8bb8e9e8755bb707d94843a7f67c3c83.pdf 2d1e1c9eb5739153c629b229aba1573c https://staging.drfop.org/files/original/0aa3c65a77880b3f215c6a379f41ebdf.jpeg 4e53ce2cb0da74c0306d918dbcbf3600 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1979_03_003.pdf Text Any textual data included in the document <h2>Comment</h2> <h5>Lawrence W. Friedman, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><b></b><strong><a href="/files/original/0aa3c65a77880b3f215c6a379f41ebdf.jpeg">Photo</a>: Lawrence W. Friedmann, M.D.</strong></p> <p>Dear Sir:</p> <p>I have just been reading <a href="https://staging.drfop.org/items/show/179433">Volume II, Number 4, 1978</a> of the NEWSLETTER. While I have a lot to say on immediate postsurgical fittings, whose major problem I fear is the inaccurate name since very few people really fit a prosthesis immediately post-surgically, I think that the part of the NEWSLETTER that deserves the most comment is the reprint of the article "<a href="https://staging.drfop.org/items/show/179433">Prostheses, Pain and Sequelae of Amputation as Seen by the Amputee</a>" from Prosthetics and Orthotics International.</p> <p>There appears to me to be little doubt that the complaints of the amputees are accurate. There is not only poor fitting and poor fabrication, but a tremendous absence of knowledge on what is correct on the part of the medical profession, the amputees, and, unfortunately, sometimes even the prosthetists. We must recognize the fact that many doctors "prescribe" an artificial limb with instructions to the prosthetist to "give the patient a prosthesis" or, if they want to be very accurate, "give the patient an above-knee prosthesis". This leaves the entire prescription, fabrication and sometimes training of the amputee on the prosthesis to the prosthetist, who does the best he can, but is not adequately trained to take over the entire responsibility for the care of the patient. It is the exact equivalent of a doctor "prescribing" a medication for a patient and saying "give heart medicine".</p> <p>Most of the doctors doing amputation have little or no interest in the aftercare of the amputee once the wound is healed. For that reason, the amputee is required to be responsible for his own care and must seek out amputee clinics in which adequate prescription, checkout and training can be given to assure that adequate prosthetic fabrication has been achieved. The average general or vascular surgeon cannot be assumed to have been able to keep up with the latest in prosthetic components, fitting and training. While research is important, we are not, at the present, delivering the standard of care which we could have delivered twenty-five years ago had every amputee the access to an amputee clinic team.</p> <p>It is obvious that the amputees questioned are suggesting checkout procedures, such as x-rays, to measure the accuracy of prosthetic fit which have been available to us and have been used for decades. Unfortunately, it is the "consumer" who determines what is produced in the market place. In my view, the amputees must band together and insist on getting adequate service. When they do so, the competitive market place will give them what they need.</p> <p>In some areas, there is a problem because there are very few prosthetists and the amputee is, to some extent, at the mercy at that individual. With modern transportation however, any dissatisfied amputee should be able to get to a knowledgeable amputee team for adequate care. I know that there are many problems. In a neighboring state I know that the orthopedic surgeons have inhibited any competitor from coming into the state to challenge what everyone admits is an inadequate prosthetist-orthotist because they like that individual as a person, even though they know that the devices produced are grossly inadequate. While this is beneficial to the individual prosthetist-orthotist, it is to the detriment of his patients.</p> <p>Part of the problem is that each amputee is concerned with his own welfare, and when his needs are satisfied to a tolerable level, he tends not to band together with his fellows for their common good. This decreases their effectiveness in demanding optimal care. Rehabilitation is a process in which a patient is made responsible for his own well-being. In this regard, we may have made amputees feel so independent that they have lost sight of the power of communal action.</p> <p>Perhaps the NEWSLETTER format should be duplicated for the amputees as well as for those of us serving the amputees, so that the amputee himself could know what is going on and what devices and techniques are available to him should he need them. Certainly a list of the formal clinics and services would be of help.</p> <p>While there is much discussion of the advantages and disadvantages of different socket designs and other prosthetic components, it appears to me that these are, to some extent, academic discussions, since even the plug fit socket can be made comfortable for the majority of above-knee amputees, provided it is properly fabricated for the individual. What is needed is to improve the state of prosthetic delivery, even more than the state of the prosthetic art. The situation in prosthetics is the same as the situaiton in general medicine, in which in many places in this country what has been known in the medical literature is not getting to the individual patient.</p> <p>As far as upper extremity amputees go, the professor is much more satisfied with the appearance of the cosmetic hand cover than are the amputees themselves. I believe that I have the opportunity in this region to see." some of the most cosmetic hand covers available. They are, despite all our efforts, still inadequate and rejected by the great majority of amputees. As far as myo-electric hands are concerned, all of my patients want them. Most of them use them for a period of a few months and then discard them, except for rare use as a cosmetic hand, since they are so poorly functional as well as delicate. I believe it is important to prescribe one, if the patient demands a myo-electric hand, because he will never be satisfied of its mediocre function, until he has the opportunity to try it. I think the professor needs to be aware of many of its limitations. We, perhaps, get carried away too often by our favoritism for our own development.</p> <p>I believe further discussion on this point would be of help to the amputee community and also to the medical community in its broader sense, to give us a proper perspective of where our problems are.</p> <p>Best wishes for a happy and productive year.</p> <p style="margin-left: 50%;"><i>Lawrence W. Friedmann, M.D.</i></p> <br /> <div style="width: 400px;"></div> <em><b>Lawrence W. Friedman, M.D.<br /></b>Chairman of the Department of Rehabilitation Medicine at the Nassau County , Medical Center in East Meadow, New York.<br /></em><b><br /></b> Page Number(s) 3 - 4 Year 1979 Volume 3 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete. Figure 1 http://www.oandplibrary.org/cpo/images/1979_03_003/1979_03_003-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Comment Creator An entity primarily responsible for making the resource Lawrence W. Friedman, M.D. * https://staging.drfop.org/files/original/affc6aca870d2691c532bcb1de52320b.pdf 6da74b52fefbfd84763702e128d153bc https://staging.drfop.org/files/original/4855abea0e973f4417c0b317f993c386.jpg ef252a1fdf4eaa98400bc4eafd5598f5 https://staging.drfop.org/files/original/5f532646ed4a4826e06c36271fd690b0.jpg 86bd762152af57f1311a4b7bda41f25e https://staging.drfop.org/files/original/f10066429e8178e00674e849efd5ad63.jpg 035865f6b9ab5f776a3d2d22e9eaef11 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_009.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 9 - 14 Text Any textual data included in the document The Prosthetics Clinic Team <h5>Charles O. Bechtol, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>With the increasing complexity of medicine and its related sciences, the day is past when a single man can cope successfully with all the specialized problems in the treatment of injury and disease. The "horse-and-buggy" doctor did an excellent job considering the limited number of drugs and facilities avail-able to him. His results, however, can in no way compare with those obtained at a well-conducted, modern clinic, where a team of physicians as well as representatives of all the allied medical specialties are available. A comparable situation now prevails in the field of artificial limbs.</p> <p>The basic Prosthetics Clinic Team is composed of a physician, a therapist, and a prothetist. Workers in other fields, say a psychiatrist or psychologist, a social worker, a vocational counselor, or an engineer, should be available for consultation when the basic team considers that such services are required.</p> <p>Each member of the team has been trained to perform one particular job well, and, despite the considerable education and experience of each of these team members, no one man could be expected to carry out the entire procedure beginning with surgery and ending with the fitting and training of the patient. Although it is not generally stated, the patient himself is also a member of the team, since during the period of fitting and training he must cooperate by carrying out the instructions of the various team members and at the same time make and convey his own observations on the good and bad qualities of the prosthesis.<br /><br /></p> <h3>Function of Each Team Member</h3> <h4>The Physician</h4> <p>The physician acts as the chief of the clinic team. His particular training has prepared him to coordinate various ancillary services in the solution of all types of medical and surgical problems and to follow the progress of the patient until the difficulty for which medical care was sought has been corrected. In the past, this has been known as the "end result idea," more recently as <i>Rehabilitation</i>. The physician, in addition to his specific duties, is able to act in this same supervisory capacity in the prosthetics clinic team.</p> <p>First, the physician can evaluate the general medical status of the patient and either carry out any necessary surgery or, if he is not a surgeon, refer the patient to a properly qualified one. Immediate postoperative care in the hospital is under his direction. Then the prescription for physical therapy, whether preoperative or postoperative, is in his hands, and he is also the person who assumes ultimate responsibility for prescribing the prosthesis.<a style="text-decoration: none;">*</a> Moreover, the physician supervises evaluation of the prosthesis and renders final approval. And lastly, it is his responsibility to ensure that adequate training in use of the prosthesis is provided, to the end that the amputee may be able to gain the full functional advantages offered by a properly constructed, modern prosthesis.</p> <h4>The Therapist</h4> <p>The particular field of the physical and occupational therapists lies in preoperative and postoperative training and physical conditioning. The therapist is almost solely responsible for training in use of the prosthesis and usually for details of the checkout and evaluation procedures. These functions, however, are no more important than are those of physical conditioning and training in use of the prosthesis. And hence the therapist is a most necessary consultant in decisions relating to time of fitting, type of prosthesis, and type of post prosthetic training.</p> <h4>The Prosthetist</h4> <p>The special problem of the prosthetist, of course, is the actual fabrication and fitting of the artificial limb. Thus he is an indispensable member of the team. His consultation is particularly valuable at the time of prescription of the prosthesis. Using the medical data supplied him by the physician and the therapist, he can give excellent advice as to the relative degree of function that can be offered by different artificial-limb components. With cooperation in this respect, later changes in the prosthesis can be held to a minimum and possibly avoided entirely.</p> <h4>Other Consultants</h4> <p>In complex cases, the team will often feel a need for the services of others. It may be necessary to call upon a psychiatrist or psychologist to determine whether the mental attitude of the patient is such that a prosthesis can be used. Or a design engineer may be able to devise a mechanism or component that will be useful in special cases. Finally, the services of a vocational counselor or social worker may be needed in determining some of the future requirements of the amputee.</p> <h4>Administrative Personnel</h4> <p>In addition to the professional services involved, it is mandatory that someone assume the usual administrative responsibilities. An orderly clinic cannot be conducted without someone to schedule the patients' visits, to maintain individual records, and to carry out other administrative functions. This is of course true of any type of clinic operation, but it is perhaps even more important here because of the many factors involved and the numerous disciplines required.</p> <h4>Procedures in the Clinic</h4> <p>An amputee appears before the team a minimum of three times, as shown graphically in <b>Fig. 1</b>. The first visit is for the purpose of preparing the prosthetics prescription, the second to evaluate the amputee and his prosthesis before training, the third to evaluate the amputee and his prosthesis after training.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 1. Steps in the clinic--Team procedure.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h4>Visit No. 1</h4> <p>If, in the opinion of the team, the amputee is ready for fitting, a prescription is prepared. If for some reason—medical or otherwise—he is not ready, appropriate therapeutic measures are recommended.</p> <p>On hand is a preprescription form (<b>Fig. 2</b>) on which have been recorded such data as the cause of amputation, the patient's background, his physical limitations, and his desires for the future. Before attempting to prepare a prescription, each team member should be thoroughly familiar with the information given in the preprescription form. Unless the therapist is familiar with the case, it is desirable to check any existing physical limitations.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Fig. 2. Typical preprescription information form for upper-extremity amputation.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <p>The prescription is prepared through the cooperative effort of the team and is signed by the physician. Fitting is then carried out by the prosthetist in accordance with the prescription. A prescription form for upper-extremity amputees is shown in <b>Fig. 3</b>.</p> <table> <tbody> <tr> <td> <table> <tbody> <tr> <td> <p class="clsTextCaption"><br />Typical prescription form for upper-extremity prostheses.</p> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> <br /> <h4>Visit No. 2</h4> <p>Upon completion of the prosthesis, but before training, the amputee is brought before the clinic team a second time. Here emphasis is placed on "before training." Taken literally, this may mean that the amputee will have no conception of even the simpler control movements. In the final stages of fitting the upper-extremity amputee, however, it is necessary that the prosthetist instruct the amputee in basic control motions in order to ensure that the prosthesis is capable of function as fitted. Accordingly, the prosthetist must be thoroughly familiar with initial training procedures lest unnatural motions have to be unlearned.</p> <p>The primary purpose of the second clinic visit is to ensure that the amputee is ready for training. Included is an evaluation of his physical and mental condition as well as of the degree of comfort and function provided by the prosthesis. A simple but comprehensive series of tests has been developed to aid in evaluating functional aspects in upper-extremity cases, and a description of these appears elsewhere in this issue.</p> <p>When the team is satisfied that training is in order, the patient is referred to the therapist for this phase of the rehabilitation procedure. Although a patient and his prosthesis may meet all the criteria of the checkout procedures during the clinic session, quite often use of the prosthesis or changes of the stump during training make modifications necessary. Hence, the more familiar the therapist is with the functional aspects of the various components of the prosthesis the more quickly can he call such deficiencies to the attention of the team. Not only is time saved, but factors which tend to discourage many amputees are eliminated. The over-all result is added confidence in the prosthetics team.</p> <h4>Visit No. 3</h4> <p>Upon completion of training, the amputee is once more brought before the clinic team for a final evaluation of his ability to resume an active role in society. The patient should be encouraged to request the services of the team whenever required and also to report for follow-up examinations at regular intervals. The length of time between visits depends, of course, upon the peculiarities of each case, but as a rule it is best that the patient be examined at least once a year.</p> <h4>Conclusion</h4> <p>The concept of the Prosthetics Clinic Team is not a mere theory. Under the direction of Dr. Augustus Thorndike, the Prosthetic and Sensory Aids Service of the Veterans Administration has established 30 such teams since 1949. Others are in operation in private clinics and within the Armed Services. The initial success of these teams, often under very difficult operating conditions, has led the Advisory Committee on Artificial Limbs to stimulate development of evaluation techniques that can be used under clinical conditions and to encourage the use of the clinic-team approach for amputee rehabilitation generally.</p> <br /> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Footnote</b></td> </tr> <tr> <td class="clsTextSmall">It must be emphasized that these prescriptions, even though they be signed by the physician, should correctly be the product of consultation by the entire team. It is perhaps in the preparation of these prescriptions that the knowledge of each team member is utilized to the fullest.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> <div style="width: 400px;"> <table style="background: #003399;"> <tbody> <tr> <td> <table> <tbody> <tr> <td style="text-align: left; padding: 3px;"> <table> <tbody> <tr> <td class="clsTextSmall" style="border-bottom: 1px #666666 solid;"><b>Charles O. Bechtol, M.D. </b></td> </tr> <tr> <td class="clsTextSmall">Assistant Clinical Professor of Orthopedic Surgery, University of California; Western Area Consultant for Prosthetic and Orthopedic Clinics, Veterans Administration; member of the Upper- and Lower-Extremity Technical Committees of ACAL.</td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_009/January-1954-2.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_01_009/ReplacewithFig2.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_01_009/ReplacewithFig3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Prosthetics Clinic Team Creator An entity primarily responsible for making the resource Charles O. Bechtol, M.D. * https://staging.drfop.org/files/original/54dae95f148a182054379dab02968d3b.pdf 8910c8603388bad0090b5916a7fc8ef7 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1979_03_002.pdf Text Any textual data included in the document <h2>Guest Editorial: Thoughts On The Amputee Clinic Team</h2> <h5>Newton C. McCollough, III, M.D.&nbsp;</h5> <p>The Amputee Clinic team as we know it today, evolved during World War II when the Surgeon General of the Army established a number of Amputee Centers within Army Hospitals to upgrade the management of these patients. Impetus to this multidisciplinary approach was given by the Veterans Administration in 1948 when suction suspension was introduced for the above knee amputee and a protocol was developed establishing the Amputee Clinic Team which initially comprised the physician, the prosthetist and the therapist.</p> <p>Since that time as a more holistic approach to disability developed the team has been enlarged in most clinics to include the occupational therapist, social worker and vocational specialists among other disciplines.</p> <p>The clinic team approach is comprehensive and unquestionably has resulted in superior management of patients with limb loss over the past thirty years. However, recently questions have been raised regarding the efficiency of such a clinic and whether or not a more streamlined approach is desirable from the standpoint of the logistical management of relatively large numbers of patients. The impersonal nature of such a clinic has also been impugned in recent years, and some have felt that the patient may actually be intimidated by such a host of professional personnel.</p> <p>Several years ago, at the University of Miami, a compromise approach to amputee management was undertaken. All new patients and patients with identifiable medical problems (including skin breakdown) were seen in the traditional setting with the physician as the amputee team leader in clinic. Routine follow-up visits and problems which were purely prosthetic in nature were seen in "prosthetic clinic" by the prosthetist and therapist with a prosthetist as the team leader or clinic chief. Other clinic personnel including physicians were available for these clinics but were not necessarily in attendance. This approach was far more efficient in terms of man hours and in many ways more practical than imposing the traditional approach upon all patients at every clinic visit.</p> <p>Two major drawbacks to this system of care slowly became apparent and currently we have resumed the traditional approach to all patients. The first difficulty encountered was that many routine prosthetic visits were also accompanied by concurrent medical problems which could not be identified before the patient was actually seen. Of course, the patient could be referred to the next "full team clinic" but this resulted in undue delay of treatment. Psychological or vocational problems though less frequent were also concurrent in some patients. Secondly, in a major teaching hospital, the education of residents, interns and students suffered from this approach. The critical analysis of prosthetic problems in relation to alignment, gait, suspension, etc. was lost upon students in the absence of interchange between prosthetist, physician and therapist. Additionally, innovative techniques in prosthetic management not infrequently result from discussions involving the prosthetist and physician and the presence of all team members in clinic greatly enhances this aspect of the amputee program.</p> <p>In conclusion, I now feel that the multidisciplinary clinic team approach is sound and has no equal in the educational sphere. Spinoffs from the dialogue created may enhance prosthetic research and thus ultimately patient care. Efficiency in this sytem is less than ideal, but the benefits are greater in the long run. Suitable precautions must be taken to avoid "depersonalization" of the amputee in the multi-disciplinary environment and it is encumbent upon each team member to insure that the clinic experience is a rewarding one for the patient.</p> Page Number(s) 2 - 3 Year 1979 Volume 3 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 Guest Editorial: Thoughts On The Amputee Clinic Team Creator An entity primarily responsible for making the resource Newton C. McCollough, III, M.D.  https://staging.drfop.org/files/original/bfcefefb32a201912fdc868f0f0cc04e.pdf 0148ecdd9b99d82897c6b1c95fb4d6cd Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1979_03_001.pdf Text Any textual data included in the document <h2>To Check Out Or Not To? That Is The Question</h2> <h5>Kurt Marschall, CP&nbsp;</h5> <p>It is now over twenty-five years since the introduction of intensive short-term courses in prosthetics and orthotics at New York University, Northwestern, and the University of California at Los Angeles. These condensed courses have benefitted every practitioner, not only in his practical approach to patient management, but also in his inter-relationship with his peers through a unified and common language that we call "nomenclature." In countless cases, these formal educational courses have served as a springboard to successful completion of the certification examination.</p> <p>It was the Veterans Administration which at that time took the primary responsibility of disseminating and funding prosthetic research programs. Their Clinic Team approach became very popular, leading to the simultaneous education of physicians, therapists and prosthetists/orthotists. Undoubtedly, this close relationship of the three disciplines, working together for one common goal, namely, the rehabilitation of the disabled, has narrowed a gap that formerly was all too visible. I feel it has also helped to lift the field of prosthetics and orthotics out of the dark age, out of its sole "craftsmanship concept" into the more comprehensive classification of "professionalism"—all in all, an appropriate tribute that was long overdue.</p> <p>Every prosthetist/orthotist, having successfully completed these short-term courses, came out a better person, a better clinician. The physician and therapist, by the same token, gained insight into our field as never before. Now all three disciplines in their deliberations at clinic meetings spoke at the same level through a unified language, and intelligent solutions were arrived at by understanding the underlying problems.</p> <p>A by-product of this progressive and noteworthy approach was the respect the prosthetic/orthotic practitioner gained from the medical and paramedical professions, once his continued striving for excellence in performance and elevation of standards was realized by them. This respect, however, was not attained very easily. In our quest for sharing the knowledge and insight into our field with the physician and therapist, we also committed a monumental mistake—making them experts in the fitting, alignment and fabrication of every prosthetic/orthotic device there is. Without realizing it at the time, we gave into their hands a powerful tool, even further, a most powerful weapon —<em>the check-out sheet!!!</em></p> <p>There, in black and white, we developed a questionnaire telling them exactly how to pick a device apart, piece by piece, making them the sole, omnipotent judge of whether to pass or fail it. By setting up this systematic method of examining our devices we have admitted that one cannot trust our professional judgment or technical expertise. I know of no other group in the health care profession that has so mindlessly relinquished its professional prerogatives and intricate understanding of a subject to another discipline, with certainly less knowledge of the particular subject, for its scrutiny. Even today, after 25 years of continuous upgrading, we sheepishly subject ourselves to this procedure. This permits even a therapist fresh out of school, but equipped with a check-out sheet, to suddenly become powerful and to be feared for his or her "judgment" when check-out day rolls around. Countless man-hours and precious components and materials have been wasted when physician and therapist could not see eye-to-eye with the prosthetist/orthotist on alignment, fitting and finishing procedures. A device often had to be altered, sometimes even done over entirely, for rather trivial reasons, not to mention the immense damage inflicted on the patient-prosthetist/orthotist relationship when these so-called "problems" were hashed out in the open, for everyone to hear, rather than in a more private setting.</p> <p>There is no doubt in my mind that the level of education and the competence of every prosthetist/orthotist has risen tremendously in the last two and one-half decades, especially for one who takes advantage of the continued education process. He is a better person than he was 25 years ago, and his knowledge of the subject, "Prosthetics and Orthotics," is vastly greater than that of a physician or therapist. He is a professional who will, without complaint, work his way around a poorly-amputated limb that may not be to his liking for fitting purposes and come up with a functional prosthetic device without asking the surgeon for a revision. He will produce an adequate prosthetic device despite flexion contractures and edema, due to insufficient exercise and lack of proper stump-wrapping.</p> <p>Nobody denies the need for a check-out after a prosthetic/orthotic device has been completed. But yesterday's check-out sheet should be scrapped in its entirety —the sooner the better—and replaced with one consisting of only three questions:</p> <ol> <li>Is the prosthesis/orthosis as prescribed?</li> <li>Is the patient comfortable?</li> <li>Is the prosthesis/orthosis functional?</li> </ol> <p>The above criteria should more than satisfy any physician or therapist.</p> <p>The decision as to pleasing cosmetic appearance, insofar as possible, should be left to the patient.</p> <p>The decision on whether or not accepted standards and principles have been met in the fitting, alignment and fabrication of the device, should be entirely that of the prosthetist/orthotist.</p> <p>The field of prosthetics and orthotics has come of age; so have its practitioners. The check-out sheet has not kept pace with changing times and should be abolished in its present form.</p> Page Number(s) 1 - 2 Year 1979 Volume 3 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 To Check Out Or Not To? That Is The Question Creator An entity primarily responsible for making the resource Kurt Marschall, CP  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 Review Status Status of review after import from old O&P Library into Omeka platform. Not Performed https://staging.drfop.org/files/original/5a4fc207f88a465ad37dcf6b41150096.pdf 479c711e6dc5b0867b71528e3903ffe9 https://staging.drfop.org/files/original/d9ff1b62874d00a6e00a0d672fb43173.jpg 0e51c21a9139763ce305a13968b0cec8 https://staging.drfop.org/files/original/470d0172053dbf6511badf4a238ae5be.jpg 15352b6afae30f74a1a8e9f9ad3f67b6 https://staging.drfop.org/files/original/407855162477bbeecc14efd62661a52c.jpg 724072469eb262d7f443f6bfd29433f7 https://staging.drfop.org/files/original/ea665054cf74df0afd40296eaa419d88.jpg 18d5adb11fc47556e504851627efe5d5 https://staging.drfop.org/files/original/115a307852ee295ff5a6479530d3b830.jpg 57a34343d50ccf4fd7303046f6a9bdcc https://staging.drfop.org/files/original/e9eb5b5f48d616e1dd25a731a081527f.jpg f8fd1d577ec78d9e1f12a765caf2a199 https://staging.drfop.org/files/original/f751c384bf9fac833690768a5251a514.jpg 0f1756a2ea50caf1741b0411c7bdf878 https://staging.drfop.org/files/original/00a80e563c204095cf4122ec59ed733c.jpg 129961f2dc91933885eded5d7c503983 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_008.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 8 - 19 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_008.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_008.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Contributions of the Lower-Extremity Prosthetics Program</h2> <h5>Edmond M. Wagner, M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>When, in 1945, the National Research Council launched its program for improvement of artificial legs, the original concept was that the major portion of the work would in all probability consist simply of devising mechanically improved artificial knees, ankles, and feet and of applying new materials to existing designs. But it soon became apparent that, if any appreciable success were to be had, the scope of the work would have to be broadened considerably. For new items that were designed failed Lo satisfy the amputee, and there were insufficient fundamental data on which to base improvements. Such information as was available on the mechanics of the lower extremity was either incomplete or else not presented in such form as to be useful to designers.</p> <p>The character of the fit was shortly found to be a matter of paramount importance in determining the success or failure of a given device. But fitting itself was based largely on the personal experience of individual fitters, and there were in existence no formalized standards or rules for guidance in obtaining proper fit. Moreover, the results of testing of devices were too often based on the impressions of only a few amputees and casual observers, either or both generally not qualified to express a competent opinion. There was not even general agreement on some of the principles involved in the surgery of amputations. Before any real progress could be made, information had to be secured in all these fields and coordinated with data from others.</p> <p>The task of obtaining the required information was assigned by the National Academy of Sciences to a number of subcontractors. At the outset, basic research on problems concerned in lower extremities, including studies on surgery, pain,<a></a> and fitting,<a></a> was placed with the University of California at Berkeley.<a></a> To assist designers and fitters, and to provide a record of the devices and techniques being used in the limb industry, a review of prior art was carried out at Northwestern University,<a></a> and the Surgeon General of the Army sent to Europe a commission<a></a> to study and report on the prosthetics art as practiced in various other countries. Solutions attempted in the past for many problems in leg design are cataloged and described in the Northwestern report<a></a> and in the report of the European commission .<a></a> Development of devices was undertaken by Goodyear Tire and Rubber Company;<a></a> Vickers, Inc.,<a></a> Detroit; C. C. Bradley and Son;<a></a> Catranis, Inc.;<a></a> Adel Precision Products;<a></a> A. J. Hosmer Corporation;<a></a> Northrop Aircraft;<a></a> the U.S. Naval Hospital at Oakland, California;<a></a> National Research and Manufacturing Company;<a></a> the Aero-Medical Laboratory of the U.S. Air Force, Wright-Patterson Air Force Base; the Army Prosthetics Research Laboratory, Walter Reed Army Medical Center; and the University of California at Berkeley . <a></a> Later in the program, the Denver Research Institute<a></a> of the University of Denver carried out an investigation of below-knee prostheses, some additional basic data have been supplied by New York University<a></a> and by the Prosthetic Testing and Development Laboratory of the Veterans Administration in New York City, and another commission<a></a> was sent to Europe to observe progress abroad after 1945. Testing and evaluation of devices has been developed and carried out at New York University,<a></a> and the Orthopedic Appliance and Limb Manufacturers Association has cooperated in general program guidance.</p> <h3>Development of Basic Data</h3> <p>Because prior to 1945 little study had been conducted on the characterislics of human locomotion, because of the complexity of the problem, and because of its highly specialized nature, it was necessary first to devise special equipment for collecting information which, ultimately, would lead to determination of the mechanical and physiological changes occurring during various activities of the lower extremity. A number of pieces of unusual apparatus, such as force plates, a glass walkway (<b>Fig. 1</b> and <b>Fig. 2</b>), and special photographic equipment were designed,<a></a> and from the data collected using this equipment it was possible to determine such factors as the forces and moments in human and artificial legs and the roles played by major muscle groups under a series of conditions. From such findings it has been possible to describe fully the phenomenon of human locomotion and thus to establish a set of realistic criteria for the design and evaluation of artificial-leg components. Aside from applicability to the field of prosthetics, the data collected are useful also to designers of leg braces and to the medical profession in the treatment of pathological gait.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The University of California glass walkway. With this device, motion pictures taken from a single camera yield sufficient information to determine relative motions of various segments of the body during level walking. Subject shown here is wearing an above-knee experimental leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Normal subject prepared for participation in studies using the University of California glass walkway. Some targets are mounted on levers to amplify motions otherwise of small magnitude. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The major portion of this work was performed at the University of California, Berkeley, and many of the results have been documented in reports and in the journal literature. Of the many reports issued, most, such as those of Cunningham<a></a>, of Bresler and Berry<a></a> and of Radcliffe,<a></a> generally cover a single phase of the subject.</p> <h3>Creation of Design Objectives</h3> <p>From study of the basic data, and from careful review of current practices, it has been possible to set up a listing of design objectives for leg prostheses, it being understood that above all the prosthesis must satisfy the amputee. Arranged in generally decreasing order of importance, these requirements are as follows:</p> <ol> <li>Security from fall.</li><li>Minimum consumption of energy in normal walking</li><li>Appearance of the walking pattern to compare favorably with that of a normal person.<br /> a. Smooth swing phase, including deceleration of the prosthesis at the end of extension, control of heel rise at the end of flexion, and deceleration of the prosthesis just prior to heel contact.<br /> b. Smooth stancephase, includingattainmentof full extension without final snapping action.<br /> c. Ability to change gait to maintain smooth, normal-appearing gait.</li><li>Ability to extend the leg under load at any time.</li><li>Proper phasing of the locking action, if used, with all portions of the stance and swing phases.</li><li>Performance of incidental operations—such as going up and down stairs and ramps, turning, and sitting down—with reasonable ease and smoothness.</li></ol> <p>A listing of the features desired of leg prostheses at three functional levels (<b>Table 1</b>) has finally evolved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Improvement of Fitting and Alignment</h3> <p>As a result of the early attempts to improve existing knee-brake devices, it was found that fitting and alignment were together often more of a determining factor in amputee acceptance than was the performance of the device itself. In the two trips to Europe,<a></a> various techniques and several mechanical aids for obtaining greater uniformity in fitting were observed. These techniques and devices have been analyzed, and from the resulting knowledge, together with information from the basic studies, improved methods of fitting and aligning above- and below-knee legs have been formulated. All of these observations have been published in a report of the University of California at Berkeley .<a></a></p> <p>In order to make these principles of fitting and alignment easier to apply, an adjustable leg (page 23) for above- and below-knee prostheses, with provisions for individual adjustment of major elements, was designed by the project at Berkeley and turned over to the limb industry. This leg, once adjusted, can be worn by an amputee for periods of a few days to determine if the fitting is satisfactory. To transfer to the permanent prosthesis the measurements thus determined by the adjustable leg, there has been designed a fixture which holds the elements of the prosthesis in position while they are being assembled with the predetermined alignment. With these two devices, which are now available commercially, fittings become quite exact. The ease with which minor adjustments can be made in the adjustable leg makes it possible to try variations in fitting which, previously, were avoided because of the time and expense involved. Moreover, the adjust- able leg has the psychological advantage of demonstrating to the amputee that the fit of the device he is obtaining is the optimum for him.</p> <h3>Methods Of Suspension</h3> <p>A major factor involved in fitting of both above- and below-knee legs is the socket. On the first trip to Europe,<a></a> a number of exceptionally well-fitted suction sockets (page 29) were observed in Germany. This type of suspension had been tried previously in the United States<a></a> and in England with poor results. The successful cases seen in Germany in 1946, however, prompted another trial of the technique in the United States. A thorough study of the shape of the socket and other features involved in fitting of suction sockets was undertaken at the University of California at Berkeley.<a></a> As a result of the successful conclusion of this work, the suction socket has since been widely applied by the United States limb industry and has been accepted by the Veterans Administration as an improved method of fitting prostheses for above-knee amputees where there are no contraindications. The knowledge gained in perfecting the technique of suction-socket fitting and in determining the optimum shape of the suction socket has contributed to improvement in the fitting of other sockets. Development work is now proceeding on suction sockets for below-knee amputees.</p> <p>In addition to the work on suction sockets, a "soft" socket for below-knee amputees, consisting of a thin, resilient pad under a conventional leather or plastic socket lining in a plastic or wooden socket, has reached the testing stage at New York University.</p> <h3>Schools for Prosthetists and Surgeons</h3> <p>Since the suction socket was as much a technique as a device, it was determined that, if the suction socket was to be as successful in general practice as it had been in the development period under the supervision of the University of California, the technique had to be taught to limbfitters throughout the United States. Accordingly, plans were laid for a series of schools to be held in various cities in the United States. A course of instruction was laid out, and under the auspices of the Veterans Administration, with the assistance of the Orthopedic Appliance and Limb Manufacturers Association, a series of schools was held throughout the country. The Veterans Administration, by requiring that fitters and surgeons have certificates from one of these schools before suction sockets could be provided beneficiaries, ensured that the best practices were provided. Establishment of these schools was an important advance, for it provided a mechanism for bringing to the commercial limb industry and medical pro- fession the new techniques and ideas developed. Their success has led to expansion of the principles of the clinic-team approach for handling both upper- and lower-extremity cases.</p> <p>In connection with the suction-socket schools, manuals were issued on how to fit suction sockets. They constituted the first attempt to present, in a manner that would be useful to the limbfitter, data developed in the program. Their success has led to the issuance of manuals on other subjects.</p> <h3>Amputation Surgery</h3> <p>In the early investigations, it became apparent that relative difficulty of fitting rather than surgical considerations often dictated the site of amputation. This circumstance led to a study of the sites of election and to a consideration of whether some changes might not be advisable. Studies have since clearly shown that the longer the stump the more function and control can be obtained-a matter that has not always been fully appreciated. In the above-knee amputee, the increased length of stump is particularly important, since it is one of the governing factors in obtaining stability of the prosthesis in abduction. In the above-knee amputation, it has also been found advantageous to tie the muscles together across the bottom of the stump or otherwise to attach muscles to the bone to aid in obtaining stability in abduction. These new concepts are leading to a revision of amputation practices. There will, no doubt, be other such advances in amputation surgery as more is learned about body mechanics.</p> <h3>Pain Studies</h3> <p>Pain, both phantom and real, has always been a troublesome problem in amputee management. In order to obtain a clearer understanding of and possible solutions to the pain syndrome, a project was instituted at the University of California. Although practical applications of methods to alleviate pain and eliminate phantom pain have been meager to date, the mechanism of pain radiation has been elucidated, and the results<a></a> form the basis for future work in this field.</p> <h3>New Devices</h3> <p>One of the most important parts of the lower-extremity program is the development of new devices. Consequently, device development has been one of the major efforts. In the early stages of the program especially, there was an urgent demand from new Service-connected amputees for improved devices. At the time, the data from the basic studies at the University of California were not available. But because of the urgent demand, a program for invention and development of devices was undertaken simultaneously with the program for developing basic data. While most of these devices were unsuccessful, the time, money, and effort expended developing them were not entirely wasted. For in trying these devices, much needed information was developed, and the need for long-range research on several items of a basic nature was pointed out. As the data were collected at the University of California, devices were pro- duced incorporating features which seemed desirable.</p> <p>A great deal of effort was expended in attempting to perfect a knee lock for above-knee amputees. But most of these designs were abandoned for one reason or another after a few models had been made and tried on amputees. The particular difficulty in obtaining smooth and reliable action in a knee lock was found to reside in the method of control. In addition to knee locks, considerable effort has been expended on coordinated motion between the knee and ankle, toe pickup, transverse rotation in the leg, and control of the swing phase. Numerous devices incorporating such features have been made. Both mechanical and hydraulic devices, with varying degrees of complexity, have been tried.</p> <p>Of all the knee locks tried to date, only two, the Stewart-Vickers (<b>Fig. 3</b>) and the Henschke-Mauch (<b>Fig. 4</b>), appear to have reached the point of having commercial possibilities. More recently, however, there have been indications that proper swing-phase control, coupled with alignment stability or limited stability over the first few degrees of flexion, are all that the average above-knee amputee may need. The more or less elaborate knee locks might therefore be indicated for special cases, for older persons, or for those who prefer "the best" and can afford it. Both Stewart and Henschke-Mauch have swing-phase control devices incorporated in their designs, and both have under test legs in which only the swing phase is controlled.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Schematic diagram of the Stewart-Vickers hydraulic leg incorporating knee lock, swing-phase control, and coordinated motion between ankle, shank, and thigh. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Schematic diagram of the Henschke-Mauch hydraulic leg incorporating knee lock and swing-phase control. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another lower-extremity device now under test is the University of California four-bar-linkage or polycentric knee (<b>Fig. 5</b>). The four-bar-linkage knee is not a new idea, but the UC version has been so designed that the toggle action existing in prior designs to provide extreme stability as the knee approaches full extension has been eliminated. Instead, it depends for its stability on alignment in fitting. It has the advantage, like many other four-bar linkages, of providing at the start of flexion a pivot point about 6 in. above the actual knee joint-a feature which provides a very favorable mechanical advantage for the amputee to start the leg to flex.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Schematic diagram of the University of California four-bar-linkage (polycentric) knee showing change in center of rotation of shank as knee is flexed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the UC leg the swing phase is controlled by a radial-vane type of damping device in which hydraulic fluid passes from one side of the vane to the other through suitable needle valves. Hence this device is responsive to gait change and limits excessive heel rise as cadence is increased.</p> <p>The limbshop at the U.S. Naval Hospital, Oakland, California, has developed and had accepted by ACAL a complete above-knee leg featuring a very simple mechanical device for controlling the swing phase in connection with a more or less conventional knee bolt (<b>Fig. 6</b>). This type of swing-phase control is not nearly so responsive to gait change as are the hydraulic units, but it marks a definite advance in the design of artificial knees. Also featured in the Navy leg are a plastic shank and the so-called "Navy functional ankle." The latter (<b>Fig. 7</b>) uses a rubber block with different degrees of hardness at front and rear to provide for plantar flexion and dorsiflexion and at the same time to permit some rotation about the vertical axis of the leg. It is anticipated that the Navy above-knee leg will be available commercially early this summer.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. U.S. Navy variable-friction knee. As flexion takes place, projection <i>A </i>of the knee block rotates until it contacts lever arm C, which induces additional friction about the knee bolt to limit heel rise. As extension occurs, projection <i>B' </i>rotates to contact lever arm <i>D, </i>which induces additional friction to decelerate the shank (terminal deceleration). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. U.S. Navy functional ankle. Single cable extends through rubber block of different degrees of stiffness at front and back. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To summarize the work done on new devices for lower extremities, there is now available a large store of information on devices which have been tried and found lacking in one respect or another. With what is now known about performance desired in above-and below-knee legs, it is possible that a review of past developments, coupled with some changes based on present knowledge, may lead to the development of more acceptable leg prostheses. At this time, however, only the Navy functional ankle and the swing-phase control have been accepted as completed devices. Others appear very close to acceptance.</p> <h3>Testing and Evaluation</h3> <p>Throughout the early stages, the development of new devices in the lower-extremity program was retarded by the lack of techniques and organization for objective testing and evaluation. Until the data on the mechanics of walking had been developed, it was almost impossible to set up means for objective evaluation because no satisfactory standards of comparison were available. In addition to this lack of standards, it became apparent early in the program that some means had to be established for testing, under a controlled set of conditions, the devices which appeared ready for production. A testing laboratory at New York University was therefore set up. With its entry into the program, there was obtained a much better evaluation of the desirability of the devices proposed and a much better idea of their mechanical performance . <a></a> It was soon found that most of the devices submitted had minor mechanical shortcomings, and as a result many devices which two or three years ago appeared almost ready for release are only now approaching that point. The field-testing procedure has avoided premature release of several supposedly completed items and has indicated the need for more information on several basic points. It has thus proven to be a very valuable step in the development program, and the information gained in the field tests has fully justified the time and cost of field-testing.</p> <h3>Clinical Program</h3> <p>When the program for development of new devices had reached a certain stage, it became apparent that, if there could be instituted a clinical program to try devices on various amputees under as nearly identical conditions as possible, progress would be much more rapid. Information was also needed to confirm conclusions about the suitability of certain devices for various sites of amputations and for various physical and mental characteristics of the amputee and to determine new types of devices which might be needed under certain sets of conditions. Among others, such questions as the need for, or suitability of, a knee lock, or whether limited stability coupled with swing-phase control would be better, needed investigation and decision.</p> <p>A clinical study was therefore set up under the direction of the University of California at the U.S. Naval Hospital, Oakland, with certain facilities provided by the Surgeon General of the Navy. It is expected that, by providing a complete staff of surgeons, prosthetists, physiotherapists, engineers, and research workers, with the opportunity for controlled fitting and follow-up of patients, rapid progress will be made in improving fitting and alignment techniques, in surgical procedures, and in the development of improved devices.</p> <h3>Development Program</h3> <p>Since the establishment of the lower-extremity clinic, a development group, staffed with people skilled in lower-extremity prosthetic art, including representatives from the industry, has been established. This group has headquarters at the U.S. Naval Hospital at Oakland, California, in close proximity to the clinic. It is expected that they will complete the development of some of the devices partially completed in the past and develop new devices, possibly combining or utilizing some of the ideas and data resulting from development work on these new devices. It is expected that this group will bring the program for new devices somewhere near its required level within the next two years.</p> <h3>Conclusion</h3> <p>Because the improvement of leg prostheses has required research and investigation in many fields, and because of the broad scope of much of the work, its full usefulness will not be realized until some time in the future. Time and study are required to analyze the data and to apply the results of such analyses. Nevertheless, the basic data developed under the ACAL program have already been useful, not only in the design of above- and below-knee prostheses but also in the design of leg braces, and they have proved extremely helpful in the diagnosis of pathological gait. Among the developments of more or less immediate practical applicability are the new techniques introduced for fitting and aligning above- and below-knee prostheses. Devices to facilitate adjustments in fitting so that optimum results can be attained quickly have been developed and introduced to the industry, as has also the equipment for transferring the dimensions determined for the prosthesis.</p> <p>As a result of efforts of ACAL, the suction socket for the above-knee amputee has come into general use in the United States. In addition, the principles developed in the suction-socket program have helped to improve techniques used with other types of sockets, thus contributing generally to the well-being of the leg amputee. Experience gained in the suction-socket program has led either directly or indirectly to the development of the clinic-team concept which is proving so useful in the management of amputees of all types.</p> <p>Certain changes in the surgical procedures of amputation have been suggested, especially in regard to the so-called "sites of election" and to stabilization of the above-knee stump in adduction. Study of the nature and propagation of pain in stumps has yielded results which should be the basis for future advances in treatment and prevention of pain arising from amputation.</p> <p>Outgrowths of the lower-extremity clinical study may be expected to confirm, apply, and develop further the principles of fitting and alignment, to advance further the use of the suction socket, to improve the fitting of conventional above- and below-knee sockets and the "soft" socket for below-knee amputations, and to develop prostheses for other types of amputations. With the above-knee clinic established, the work in surgery, prescription, fitting, and training of the amputee is likely to advance even more rapidly than has been the case in the past.</p> <p>The development of devices with increased function, reliable enough and with benefit enough to the amputee to justify the increased complexity and cost, has proven difficult.</p> <p>Many devices have been built, tested, and found wanting in one detail or another mechanically or else have proven too costly to be practical at the present time. Although thus far only two devices, the Navy variable-friction knee and the Navy functional ankle, have been accepted by ACAL and made ready for distribution, several experimental ones appear to be almost ready for general use. The groundwork in the field of lower-extremity prosthetics has been laid. By 1956 we should see the appearance of many more, and more practical, accomplishments resulting from the preceding eight years of pioneering work.</p> <p><b>References:</b></p> <ol> <li>Adel Precision Products Corp., Burbank, Calif.,ubcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>The development of a hydraulically operated artificial leg for above knee amputations, </i>1947.</li> <li>Bradley, C. C, and Son, Inc., and Catranis, Inc.,yracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and fool position; toe pick up and foot providing lateral, plantar and dorsal flexion, </i>1947.</li> <li>Bresler, B., and F. R. Berry, <i>Energy characteristicsof normal and prosthetic ankle joints, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</li> <li>Catranis, Inc., Syracuse, N. Y., Subcontractor'sinal Report to the Advisory Committee on Artificial Limbs, National Research Council, in preparation, 1954.</li> <li>Cunningham, D. M., <i>Components of floor reactionsduring walking, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950.</li> <li>Denver Research Institute, University of Denver,enver, Colo., Subcontractor's Final Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>A program for the improvement of the below-knee prosthesis with emphasis on problems of the joint, </i>August 1953.</li> <li>Eberhart, Howard D., Verne T. Inman, and Borisresler, <i>The principal elements in human locomotion, </i>Chapter 15 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Eberhart, Howard D., and Jim C. McKennon, <i>Suc-tion-sockei suspension of the above-knee prosthesis, </i>Chapter 20 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954. 9. Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs, </i>Chapter 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Goodyear Tire and Rubber Company, Akron, Ohio,ubcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], <i>The development of a fool prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, </i>1947.</li> <li>Hosmer Corp., A. J , Santa Monica, Calif., Sub-ontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Hydraulic weight bearing knee lock for knee disarticulation amputations, etc., </i>1947.</li> <li>National Research and Manufacturing Company,an Diego, Calif , Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], <i>An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, </i>1947.</li> <li>New York University, Prosthetic Devices Study, Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, </i>March 1953.</li> <li>Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A report on prosthesis development, </i>1947.</li> <li>Northwestern Technological Institute, Evanston,11., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, </i>1947.</li> <li>Parmelee, Dubois D., U. S. Patent 37,637, February, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</li> <li>Radcliffe, C. W., <i>Information useful in the design ofdamping mechanisms for artificial knee joints, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</li> <li>Radcliffe, C. W., <i>Use of the adjustable knee and align-ment jig for the alignment of above-knee prostheses, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</li> <li>Saunders, J. B., V. T. Inman, and H. D. Eberhart, <i>The major determinants in normal and pathological gait, </i>J. Bone and JointSurg., <b>36A </b>(3):543 (1953).</li> <li>Stewart, John H. F., U. S. Patent 2,478,721, August 9, 1949.</li> <li>United States Naval Hospital (Amputation Cen-er), Oakland, Calif., <i>Construction, filling and alignment manual for the U.S. Navy soft socket below knee prosthesis, </i>printer's date 9-29-53.</li> <li>University of California (Berkeley), Prostheticevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</li> <li>University of California (Berkeley), Prosthetic</li> <li>Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>Summary of European observa-tions, summer, 1949 </i>[by H. D. Eberhart <i>el al.], </i>October 1949.</li> <li>University of California (Berkeley), Prostheticevices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>The suction socket above-knee artificial leg, </i>3rd edition, April 1949.</li> <li>University of California (Berkeley), Prostheticevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Studies relating to pain in the amputee, </i>June 1952.</li> <li>War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, <i>Report on European observations, </i>Washington, 1946.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Goodyear Tire and Rubber Company, Akron, Ohio,ubcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a fool prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon, Suc-tion-sockei suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954. 9. Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Information useful in the design ofdamping mechanisms for artificial knee joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart, The major determinants in normal and pathological gait, J. Bone and JointSurg., 36A (3):543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Summary of European observa-tions, summer, 1949 [by H. D. Eberhart el al.], October 1949.</td></tr><tr><td class="clsTextSmall"><b> 26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Use of the adjustable knee and align-ment jig for the alignment of above-knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Bresler, B., and F. R. Berry, Energy characteristicsof normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Cunningham, D. M., Components of floor reactionsduring walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Stewart, John H. F., U. S. Patent 2,478,721, August 9, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and Borisresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Summary of European observa-tions, summer, 1949 [by H. D. Eberhart el al.], October 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Denver Research Institute, University of Denver,enver, Colo., Subcontractor's Final Report to the Advisory Committee on Artificial Limbs, National Research Council, A program for the improvement of the below-knee prosthesis with emphasis on problems of the joint, August 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, Report to the Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston,11., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">National Research and Manufacturing Company,an Diego, Calif , Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Adel Precision Products Corp., Burbank, Calif.,ubcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, The development of a hydraulically operated artificial leg for above knee amputations, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Catranis, Inc., Syracuse, N. Y., Subcontractor'sinal Report to the Advisory Committee on Artificial Limbs, National Research Council, in preparation, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bradley, C. C, and Son, Inc., and Catranis, Inc.,yracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and fool position; toe pick up and foot providing lateral, plantar and dorsal flexion, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">United States Naval Hospital (Amputation Cen-er), Oakland, Calif., Construction, filling and alignment manual for the U.S. Navy soft socket below knee prosthesis, printer's date 9-29-53.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Hosmer Corp., A. J , Santa Monica, Calif., Sub-ontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Hydraulic weight bearing knee lock for knee disarticulation amputations, etc., 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U. S. Patent 37,637, February, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U. S. Patent 37,637, February, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart, The major determinants in normal and pathological gait, J. Bone and JointSurg., 36A (3):543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Goodyear Tire and Rubber Company, Akron, Ohio,ubcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a fool prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edmond M. Wagner, M.E. </b></td></tr><tr><td class="clsTextSmall">Consulting engineer, 930 Rosalind Road, San Marino, California; member, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-2.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-3.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-4.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-5.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-6.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-7.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-8.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-9.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Contributions of the Lower-Extremity Prosthetics Program Creator An entity primarily responsible for making the resource Edmond M. Wagner, M.E. * https://staging.drfop.org/files/original/892fdbb362b8e10138add9644e5ab5c1.pdf bea506cbf5df4cebb34bc4911c8becb0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_03_001.pdf Year 1954 Volume 1 Issue 3 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_03_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_03_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>Bioengineering- Blueprint for Progress</h2> <h5>Augustus Thorndike M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The limbs of man move in space and time, in response to systems of internal and external forces, and in accordance with the laws of mechanics. To restore to any satisfactory extent the functions lost through amputation of an extremity therefore requires intimate knowledge not only of the structure, form, and behavior of the normal limb but also of the techniques available for producing complex motions in substitute devices activated by residual sources of body power. Since adequate replacement of a natural limb with an artificial one requires successful integration of the human mechanism with a toollike device, the biomechanical features of the stump and the physical characteristics of the prosthesis must be wedded as nearly as possible into a single, functional entity.</p> <p>Two-sided as this problem would now obviously appear, it is only in comparatively recent years that the medical sciences of surgery, anatomy, and physiology and the physical one of engineering have been brought together in a unified attack upon the whole problem of amputee rehabilitation. Until recently, surgeons, with few exceptions, had little or no understanding of engineering problems. And heretofore the design and construction of artificial limbs has been conducted mostly by artisans who, however ingenious they may have proved to be, were mostly without formal education in engineering or anatomy. Besides this, except in isolated instances the two worked separately and alone. All of which no doubt accounts for the fact that, as late as World War II, the available artificial limbs fell far short of the standards of accomplishment attained in other fields of research and invention.</p> <p>In the research program coordinated by the Advisory Committee on Artificial Limbs, National Research Council, there have been brought together in harmonious working relationship the individual skills of surgeon and engineer in a sort of mutual bioengineering to produce truly functional artificial limbs. As a result, there has been in the field of prosthetics perhaps more progress during the past decade than in all the preceding 2000 years of limb-making.</p> <p>Because the lower limb is more essential to human activity than is the arm, and also doubtless because the basic functions of the leg are easier to replace than are those of the arm, progress in artificial arms and hands has from the earliest times always lagged far behind developments in artificial legs. This circumstance was reflected in the fact that, when the Artificial Limb Program was established in 1945, much more had already been accomplished in replacements for the lower extremity than in those for the upper. And consequently developments in the ACAL program to date have been most noticeable in upper-extremity prosthetics, despite extensive engineering studies of normal and amputee locomotion and refinements in the techniques of lower-extremity fit and alignment.</p> <p>In any case, the development of prosthetics had necessarily to follow the pattern of developments in surgery, and conversely the surgeon's philosophy with regard to "sites of election" and other matters was necessarily dictated by the character and availability of such prostheses as there were. Since the science of amputation surgery and the art of limbmaking proceed as one, the standards and practices in one field dictate standards and practices in the other, and vice versa. That each of these has now been brought to understand more fully the problems of the other may be looked upon as a major achievement in the art of prosthetics.</p> <p>In the following pages of this issue of Artificial Limbs is to be found substantial evidence that the engineering profession, working with the amputation surgeon, has provided new thoughts, new ideas, and new approaches to the problem of providing adequate functional replacements for the limbless. In the whole Artificial Limb Program there exists no better example of cooperation toward progress than is demonstrated here. In the first of two articles, a surgeon and an engineer collaborate in describing the latest devices and techniques arising from systematic research and the influence which these developments ought rightly to exert upon the philosophy of modern amputation surgery. In the second, an engineer outlines the methodology required in investigation of the normal limbs and in the design of useful replacements. Only through such teamwork in biomechanics can truly great advances in the field of prosthetics be expected. The development of the thirty Veterans Administration and other civilian orthopedic and prosthetic appliance clinic teams has resulted in the better distribution of new knowledge toward improved fitting and alignment of artificial legs and in the design and construction of improved artificial arms.</p> <p>The program of research coordinated by the Advisory Committee on Artificial Limbs involves the participation of government, university, and industrial laboratories. The Veterans Administration, the Army, and the Navy provide the necessary funds for the operation of their own establishments, while the VA provides the contractual authority with the funds necessary for work in the universities and in industrial laboratories. Out of this cooperative effort there have come within recent years improved functional prostheses for almost every level of amputation, particularly for those special amputee cases heretofore considered unsuited for an artificial limb. With the mutual cooperation of surgeon and engineer, there has resulted a cross-fertilization of ideas and a new set of modalities in the rehabilitation of amputees.</p> <p> Nevertheless, the presently available devices, though anthropomorphoid in form, are far from anthropomorphoid in function. Unfortunately, no artificial limb, however elaborate, can ever serve as an ideal substitute for a natural member unless it incorporates some of the features of sensory and muscular control characteristic of the limb it replaces. Therein lies the challenge of the future- to devise mechanisms which not only simulate the motions and the functions of normal limbs but which also provide appropriate feedback of information such as occurs in natural arms and legs. In our present state of knowledge, the ultimate goal of the limb designer is still a long way off. Further progress depends largely upon the continued cooperation of surgeon and engineer, of prosthetist and therapist, and of the amputee himself.</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>Augustus Thorndike M.D. </b></td></tr><tr><td class="clsTextSmall">Acting Director, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, Washington 25, D.C.</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 Bioengineering- Blueprint for Progress Creator An entity primarily responsible for making the resource Augustus Thorndike M.D. * https://staging.drfop.org/files/original/b76e176eea5ade74fc19b1a4179ee035.pdf 70fa24e8024de93a3dac3ead7a24a4c3 https://staging.drfop.org/files/original/8d4e4395448b88c9f47146d10e2bd761.jpg e7aecd53a8fb74f0db642462ee9eacbc DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_004.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 4 - 8 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_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Objectives of the Upper-Extremity Prosthetics Program</h2> <h5>Craig L. Taylor, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The upper-extremity prosthetics program, under the sponsorship of the Advisory Committee on Artificial Limbs, National Research Council, has been a growing and evolving program from its inception in 1945. Its initial objectives were limited to time and motion study of amputees and to device invention and development. But from the vantage point of 1954 we may list many additional objectives that have been assumed according to the necessities of a national program dedicated to the welfare of the amputee. As new activities have been added, none of the original have been abandoned, although certain of the original ones have been reduced in relative emphasis and expenditure.</p> <p><b>Fig. 1</b> illustrates in schematic form the major phases of the upper-extremity program as they have waxed and waned over the years from 1946 to 1953. The scope and magnitude of these activities represent a program with few parallels in our peacetime economy. As is evident in <b>Fig. 1</b>, not all the activities were started (or even conceived) at the outset. But, as has been pointed out by Strong,<a style="text-decoration:none;">*</a> no one could predict at the outset the ramifications of a program dedicated to the tangible goal of putting new and improved prostheses on amputees. The appropriateness of this program under the auspices of the National Research Council was underscored by President Bronk, who praised the ACAL program as a fitting example of the service to the public welfare for which NRC was founded.<a style="text-decoration:none;">*</a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Trends in the upper-extremity prosthetics program, 1945-53. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Fundamental Studies</h4> <p>The study of normal and amputee biomechanics underlies all improvement in prosthetic replacement. A continuous program of inquiry in this field is therefore essential. Although much of such research is undertaken without immediate practical goal, free inquiry brings to light ideas which find widespread application, as has already been demonstrated time and again. The continuous observation of arm motions and of prosthetic motions provides a nourishing bed of interest and information from which the application phases draw strength and purpose.</p> <p>The program of fundamental studies has featured research on normal motions, analyzed in terms of physical mechanics and in terms of industrial time and motion concepts. These investigations have built up a body of information on the patterns of motion, speeds, forces, and skills that is invaluable in conceiving, planning, and predicting the results of new developments. A special phase of this program has had to do with cineplasty, where the direct utilization of muscle force has remarkable potentialities for prosthetic replacement but where intimate knowledge of the mechanics of the muscle is required in order to obtain successful operation of the prosthesis. Knowledge of stump shrinkage, of finger forces, of external power controls, of accessory body mechanics, of mechanical stresses in the prosthesis during use—all these are fundamental to the proper assessment of normal and of amputee biomechanics.</p> <p>The objectives of the program of fundamental studies in the upper extremity may be summarized as:</p> <ol> <li>To study the performance of manipulative activities in normal individuals and to analyze the activities in terms of biomechanics and of time and motion criteria.</li><li>To compare the motions of amputees with pros-theses with similar motions of normals in order to define the erns of altered and substitute motions peculiar amputees.</li><li>To measure the forces and displacements of muscles and muscle groups in relation to cineplasty, harness controls, and external power controls.</li><li>To define the alterations in general body mechanics in amputees as a result of the asymmetrical loss body weight.</li></ol> <h4>Development of Prosthetic Devices</h4> <p>The "bread and butter" of the ACAL program is the development of improved prosthetic devices, and a major emphasis has always been placed upon this phase of the program. Development of each device originates in the need shown by fundamental studies or by experience with amputees. design, experimental fabrication, amputee test, and field evaluation are the successive steps through which each device must pass. The past and present development laboratories include Northrop Aircraft, Inc., the Army Prosthetics Research Laboratory, and the University of California at Los Angeles, but other agencies, such as New York University and many cooperating industry limbshops, function in the final evaluation phases.</p> <p>ACAL developments in prosthetic devices include new inventions and many adaptations of mechanisms and materials from other technical fields. Engineers have delved deep into the rich heritage of American technology to find applications of plastics, lightweight metals, and mechanisms that have immensely improved the structural and functional characteristics of upper-extremity prostheses. In short, the development objectives are:</p> <ol> <li>To invent, adapt, and apply new materials and mechanisms so as to add new functions, or to improve old functions of prostheses, seeking in the end to provide an armamentarium of devices to meet the needs of every amputee type.</li><li>To design and redesign prosthetic components for simplicity and ease of manufacture, and for durability, without loss of essential function.</li><li>To create a system of interchangeable components which may be singly prescribed for the individual amputee case, but which can be combined into a functionally integrated and an esthetically compatible prosthesis.</li><li>To incorporate cosmetic and anthropomorphic principles into basic design so that prostheses are not abnormally conspicuous and are pleasing from the standpoint of color, texture, and form.</li></ol> <h4>Industry Advisory Participation</h4> <p>From earliest days, ACAL has recognized the benefit that would accrue to its activities if the experienced "know-how" of the industry could be utilized in an effective way. To attain this goal, it was considered necessary to bring into the planning meetings of the ACAL group the counsel of leading prosthetists and limb manufacturers. Accordingly, three members of the limb industry were made members of the Upper-Extremity Technical Committee to serve at the national level, while in Los Angeles a local Industry Advisory Committee was set up to advise and aid the UCLA project. These cooperative ventures have proved to be of great mutual benefit, the objectives being briefly as follows:</p> <ol> <li>To learn from the industry the needs for device development, for advancement in prosthetics technology, and for improvement of amputee services.</li><li>To utilize the experience and judgment of members of the limb industry in determining policy and in planning cooperative ventures involving field application studies.</li></ol> <h4>Contributions to Prosthetics Technology</h4> <p>With the wealth of World War II technological development to draw upon, the ACAL program rapidly adopted new materials and practices, not only in the design and development of new prostheses but also in shop fitting and fabrication practices. Most outstanding of these innovations is the incorporation of plastics for prosthetic use. The principal laboratories under the program, APRL, Northrop Aircraft, Inc., and UCLA, have exemplified these uses, and their reports have been a source of information to the industry.</p> <p>The objectives are:</p> <ol> <li>To adapt new and different materials for use in fitting and fabrication.</li><li>To introduce into prosthetics practice methods of measurement and fabrication tending to improve quality of service and economic efficiency.</li></ol> <h4>Amputee Case Study</h4> <p>In the early stages, the ACAL program emphasized research and development on devices, and amputees necessarily were fitted with experimental prostheses in order to conduct studies, trials, and tests of the equipment. It soon became apparent, however, that established practices in prescription, fitting, and training of amputees were highly variable and that, to round out consideration of all factors bearing on amputee rehabilitation, these practices themselves should become the subject of investigation. This objective was strengthened by the knowledge that no single design of prosthesis is superior for all amputees but rather that, of many types of equipment, the most suitable selection for a given amputee depends upon his individual personal, social, and occupational needs and desires. Accordingly, the Case Study Program was initiated at UCLA in 1950 and continued until 1952. The large amount of information on the 70 amputees in this study is being reduced for publication; much of it has been directly transferred into the Educational Program (see below).</p> <p>The case study of cineplastic amputees at APRL has followed in its major outline the procedures at UCLA, and much valuable information is being gathered on this important class of amputee.</p> <p>These programs serve an especially important role in bridging the gap between fundamental work in the laboratory and practice in the field. Prosthetics involves, in unique degree, a combination of science and technology with the practical arts. Every amputee is to some extent a special case. It has therefore been . necessary to incorporate the case-study phase in order to ensure the applicability of technical improvements.</p> <p>In concise form, the objectives of the Case Study Program may be stated as follows:</p> <ol> <li>To investigate the application of prostheses to a wide range of amputee types so that a rational procedure for prescription for the needs of the amputee can be formulated.</li><li>To test and develop the elements of physical and occupational therapy that apply to amputee rehabilitation and prosthetic use.</li><li>To discover the effect of occupation, education, recreational interest, and other personal factors of the amputee upon his prescription, fitting, and training.</li><li>To determine effective methods for evaluation of amputee service, not only pertaining to the quality of mechanical equipment but also to the results of training, to the end that the amputee obtains a truly functional prosthesis.</li></ol> <h4>Prosthetics Education</h4> <p>It has been a cardinal principle of the ACAL group that the products of its research, investigation, and development should be speedily disseminated to all technical and professional groups interested in applying such knowledge for the welfare of the amputee. The scope of these activities has steadily in-creased. Early discoveries were conveyed by means of technical reports which were primarily useful to the other member laboratories and to manufacturers within the industry. Later, as case study and other application phases of the program developed, the broader responsibility was assumed of supplying educational materials dealing with many aspects of technical and professional prosthetics service. Two volumes have been prepared. <i>Human Limbs and Their Substitutes</i> (McCraw-Hill, in press) supplies an authoritative reference on prosthetics, while the Manual of Upper-Extremity Prosthetics (University of California at Los Angeles, 1952) has been issued to serve as a shop guide for the practicing prosthetist.</p> <p>Valuable as the printed material has proved to be, it was found that the needs of the prosthetist for advanced training could not be met with sufficient rapidity and thoroughness. These craftsmen, lacking formal institutional training in their specialty, and with the highly variable backgrounds of apprentice training, displayed great need for direct instruction to bring "them up to the standard required by the new technology. Two other professional groups most concerned in amputee service, physical and occupational therapists and physicians and surgeons, were no less in need of learning the newer knowledge of prosthetics. This condition made it imperative to offer an accelerated advanced training in the theory and practical arts concerned in prosthetics.</p> <p>Accordingly, the Prosthetics Training Program was instituted at UCLA with the following objectives:</p> <ol> <li>To give for selected groups of prosthetists advanced training in the skills and knowledge needed to make and fit upper-extremity prostheses using many of the most recent refinements arising from research.</li><li>To give for selected groups of physical therapists and occupational therapists advanced training in the skills and knowledge needed to assist amputees in adjusting themselves physically, mentally, and vocationally to the use of the newer developments in upper-extremity prostheses.</li><li>To enable physicians and surgeons to expand their understanding of the possibilities and limitations of the more recent developments in prostheses and of some effective procedures for taking advantage of these developments.</li><li>To encourage the acceptance and practice of the "team approach" to the problem of prosthetic prescription, in which the physician or surgeon, as captain of the team, is assisted by professionally qualified physical therapists, occupational therapists, and prosthetists.</li></ol> <h4>Field Research Studies</h4> <p>To test the usefulness of the knowledge gathered during the ACAL research program, a field research project was instituted in Chicago during 1952. The intent was to determine whether the local rehabilitation people concerned with the problems of prosthetics-the physician, the therapist, and the prosthetist-would benefit from the new knowledge. Accordingly, a group of Chicago physicians, therapists, and prosthetists were invited to attend a "pilot" course in upper-extremity prosthetics at UCLA, the content of the course being based almost exclusively upon the research performed under the ACAL program.</p> <p>Upon completion of the training, a clinic-was established in Chicago, where a group of 50 amputees was processed in accordance with the information taught at UCLA. The status of each amputee was carefully evaluated both before and after clinic treatment. Results showed a dramatic and clear-cut improvement in the functional and psychological attributes of this group of amputees. Thus, initial field evaluation clearly demonstrated the practical usefulness of the research results when applied to amputees in the local situation.</p> <p>Upon completion of the Chicago study, and in close coordination with the educational program already described, nationwide field studies were instituted under the supervision of the Prosthetic Devices Study, New York University. The purposes of these studies, which are presently going on, are as follows:</p> <ol> <li>To ensure the proper application of the research findings to upper-extremity amputee cases throughout the country.</li><li>To provide the local clinics throughout the country with administrative and technical consultation so that assistance may be provided in the resolution of difficult problems.</li><li>To evaluate the effectiveness of these procedures when applied to amputees, in order to determine where problem areas still exist and thus to direct future research toward the resolution of these difficulties.</li></ol> <p>It is anticipated that, upon conclusion of the present field research program, studies will have been conducted in conjunction with clinics operating in some 40 of our largest communities.</p> <h4>Conclusion</h4> <p>As a result of the upper-extremity prosthetics program, arm amputees can now be provided with reasonably comfortable, functional prostheses. Studies indicate that between 80 and 90 percent of the arm amputees fitted during the UCLA Case Study Program and the Chicago Project continue to wear and use their prostheses. When this is compared with the 10-percent figure estimated for arm amputees throughout the country who wear prostheses, it appears that some measure of success has been achieved. But it is apparent to workers in this field that the progress made to date is merely a step in the proper direction and that we can expect continued improvement in all aspects of upper-extremity rehabilitation.</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">Bronk, D.W., President, National Academy of Sciences. Address to the Advisory Committee on Artificial Limbs, Annual Meeting, Washington, May 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Strong, F. S., Jr., The Artificial Limb Program: Five Years of Progress. Advisory Committee on Artificial Limbs, NRC, Washington, November 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>Craig L. Taylor, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Engineering and Biophysics, University of California, Los Angeles; member, Advisory Committee on Artificial Limbs, National Research Council; chairman, Upper-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_01_004/January-1954-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Objectives of the Upper-Extremity Prosthetics Program Creator An entity primarily responsible for making the resource Craig L. Taylor, Ph.D. * 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 *