8 20 371 https://staging.drfop.org/files/original/feebebaa37399c3b95576ae8e7aa803a.pdf e216245824105b9041905d276496dc47 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_001.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 1 - 12 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Whither Prosthetics and Orthotics?</h2> <h5>George T. Aitken, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The publicity concerning scientific and technical advances keeps us constantly aware of man's increasing competence to master his environment. The technologies available make possible a wide variety of mechanisms that expand man's sphere of activity and make possible comfortable living in environments previously considered undesirable. Some of the modern techniques, when applied in the biological fields, have eliminated some diseases, controlled others, and have made possible medical and surgical procedures that extend the life expectancy of persons of all ages. Continuing research undoubtedly is going to demonstrate eventually the etiological factors in other disease entities and thus permit the development of a nonsymptomatic approach to therapy.</p> <p> Many of the current scientific advances have been the result of interdisciplinary effort, where two or more separate disciplines have worked together, hopefully synergistically. This interdisciplinary effort in prosthetics and orthotics has produced what is often described as a bioengineering effort. In the past twenty years increasing emphasis has been placed on the engineering aspects of this specific problem. These years have witnessed a rapid advance in the development of new industrial materials and hardware that have been readily applicable to artificial limbs and braces. Many improvements in previous fabrication techniques and components were facilitated by using these newly available industrial developments, and thus some advances were made in upgrading the quality of prosthetic and orthotic devices.</p> <p> There have been varying degrees of concurrent fundamental research in the biological aspects of this interdisciplinary approach.</p> <p> It seems at times, though, that the glamour of technology has overshadowed the purely biological problems. Research activities involving these glamour areas have been more attractive to many, and funds for such research have been more available in these sometimes esoteric areas.</p> <p> At times it would seem that many involved in prosthetics and orthotics research and development have failed to see the entire problem. Basically, it is the problem of achieving the optimum man-machine interface. The ultimate resolution of the problem is the production of designs that result in comfort, maximum function, and reasonable cosmetic restoration.</p> <p>There is little question that much has been accomplished. Certainly we have available currently biological and engineering techniques that are capable, in a high percentage of cases, of producing improved function and cosmesis. Continuing intelligent modification of techniques and components produces more and more improvement in all of these areas. It is fair to assume that amputees and others with orthopaedic impairments are now better served than ever before.</p> <p>Unfortunately, many in the field of prosthetics and orthotics research and development seem to have a tendency to relegate the patient to a secondary position. They appear to be bent on the perfection of the machine without due consideration to the education or alteration, or both, of the man to perfect the interface.</p> <p>It seems timely to give consideration to some of the areas in which continuing, accelerated investigation is desirable.</p> <p>Research in amputation surgery to provide more functional stumps and consequently more comfort to the patient has been significantly lacking. There is a multiplicity of amputation techniques. Myoplastic and osteoplastic techniques either alone or in combination have been recommended to promote comfort and improved function. In this country there has been no well-organized clinical evaluation of these claims made primarily from abroad. It seems logical that such procedures be investigated and evaluated thoroughly. There are good theoretical reasons to justify consideration of these procedures so that they not be simply rejected because of dissimilar training and experience.</p> <p>Cineplastic procedures were critically investigated, and well-established criteria have been developed for their use. A similar review should be made of some of the other surgical problems.</p> <p>The immediate postsurgical fitting of sockets with or without early weightbearing currently is being investigated. Undoubtedly, the results of this wellorganized investigation will develop proper indications and techniques for this procedure. Hopefully, such techniques will be of positive value in influencing the man aspect of the man-machine interface.</p> <p>There are in addition many areas of basic biological research that need further investigation. The problem of biological signal sources for control of external power comes to mind immediately. Other, perhaps less exotic, problems, such as analysis of joint motions to permit more satisfactory alignment and construction of braces, or the metabolic problems incident to amputation and use of prostheses as well as analogous problems in the orthotics field, need further investigation. These are but a few of the many fundamental problems that need clarification.</p> <p>In the truly engineering area, there is a large volume of continuing research and development of systems, components, and techniques to produce better artificial limbs and better braces. Much of this work is in the newer areas of technology and has increasing emphasis on the problems related to the use of external power in prostheses and orthotic devices.</p> <p>There may be a need to review some of our accepted designs in the light of our recent progress and perhaps an effort should be made to determine whether previously acceptable items are really the best that can be developed in relation to some of our improvements in materials and techniques. It may be the time to review terminal-device design. It is possible that we now need (particularly in the light of external power) to redefine the functional requirements of a terminal device and arrive at some design criteria that will permit more efficient utilization of our technical improvements in power sources and transmission.</p> <p>With an increasing emphasis on prosthetic restoration in congenitally limbdeficient children, it may develop that there must be a redefinition of goals, in the case of the upper-extremity patient, as related to age, rather than as related to the needs of an adult. Possibly a careful analysis of the functional needs of pre-school and primary and secondary school children would permit us to develop components for a system that would be more effective than simply using scaled-down adult components and systems.</p> <p>An overall review of research and development in prosthetics and orthotics over the past twenty years cannot help but emphasize that people requiring prostheses and orthotic devices are being increasingly better served. There seems little question but that the efforts of our schools of prosthetics and orthotics education have produced a marked upgrading of the skills in prescribing and fitting these devices as well as greater competency in the training of the patient in the use of such devices.</p> <p>As a clinician, I am very pleased with the improvement of patient care in these areas. As an interested participant in research and development endeavors, I am increasingly aware that there is much more that remains to be done. There exist the technical facilities to do both better research and better development. What is needed is the wisdom to direct our efforts in such a way that we adequately explore all areas of this man-machine problem and so correlate our activities that the result—the functioning man-machine combine— is a continually improving biomechanical unit.</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>George T. Aitken, M.D. </b></td></tr><tr><td class="clsTextSmall">Chairman, Committee on Prosthetics Research and Development, July 1, 1962-June 30, 1965. Upon completion of his term as Chairman of CPRD, Dr. Aitken will continue to serve as a member of CPRD.</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 Whither Prosthetics and Orthotics? Creator An entity primarily responsible for making the resource George T. Aitken, M.D. * https://staging.drfop.org/files/original/7b8252c8f883f24af6692bb69c37688d.pdf 295a867a36ca94a6cf7d56daa6aa3e46 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_022.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 22 - 23 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1967_02_022.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_022.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>Need for Research in Surgical and Medical Considerations Dealing with Prosthetics and Orthotics</h2> <h5>George T. Aitken, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The discussion of the Panel on Surgical and Medical Considerations at a Conference on Prosthetics and Orthotics sponsored by the Committee on Prosthetics Research and Development was divided into two parts-those considerations dealing with prosthetics and those dealing with orthotics.</p> <h3>Prosthetics</h3> <p>Much fundamental work in the area of amputation surgery remains to be done, as briefly outlined in this article.</p> <h4>Indicators For Amputation</h4> <p>It is believed that the modern methods of amputee management may have made amputation a more desirable procedure now than some reconstructive procedures currently in use, and the entire field needs a comprehensive review.</p> <h4>Selection Of Level Of Amputation, Especially In Cases With Vascular Insufficiency</h4> <p>No reliable test for measurement of circulation in the extremities exists. As a result, it is the practice in many centers to amputate above the knee in virtually all cases with peripheral vascular disease. However, it has been shown that many times the knee joint can be saved even when standard tests indicate that the blood supply is apt to be insufficient. Objective tests of circulation coupled with surgical studies should result in more below-knee amputations and fewer above-knee amputations.</p> <h4>Sites Of Election Of Amputation</h4> <p>Although it is generally agreed that all length possible should be saved, a study should be made in which length of stump is correlated with function and comfort when current fitting practices are used.</p> <h4>Surgical Techniques</h4> <p>A comprehensive review of surgical techniques should be made. This should include special attention to the care of transected muscles.</p> <p>The advantages of end-bearing and how much should be carefully reviewed in order to determine whether different techniques, such as myoplasty, osteoplasty and nonviable implants, should be vigorously tested in order to obtain varying degrees of end-bearing. Muscles that must be transected may eventually be control points for externally powered devices and careful attention must be focused on the preservation of their optimal ability to provide control sources such as myoelectric signals or pure biomechanical motion.</p> <h4>Postsurgical Procedures</h4> <p><i>Rigid Postsurgical Dressing</i></p> <p>There was agreement that the application of a rigid dressing postsurgically is desirable. To achieve the best results consistently it is necessary to determine the range and distribution of pressures that bring about the best results. Techniques for achieving and maintaining proper pressure will then need to be developed. Included in this study, of course, will be the problems of suspension of the cast.</p> <p><i>Ambulation</i></p> <p>Studies of the effect of ambulation should be made. Included in such studies would be such factors as time to begin ambulation, the amount of weight-bearing that should be taken, and alignment.</p> <p><i>Effect of Immediate Postsurgical Fitting on Cases with Vascular Problems</i></p> <p>In the opinion of some, immediate postsurgical fitting permits amputation at a lower level than is the case with conventional procedures, but no data have been accumulated to substantiate this opinion. This should be investigated, because the presence of the "normal" knee joint permits meaningful function that cannot be approached with an artificial limb and provides a much better chance for rehabilitation measures to succeed.</p> <p><i>Immobilization of the Next Proximal Joint</i></p> <p>Although it is recognized that a study of the effect of immobilization of the next joint in the early stage of immediate postsurgical fitting is a part of the overall suspension problem, it was recommended that attention be given this matter.</p> <h4>The Phantom Sensation</h4> <p>Although a good deal of work has been carried out in the study of the phantom sensation, especially in reference to phantom pain, very little is understood about these phenomena. It is felt that attention should be continued in this area.</p> <h3>Orthotics</h3> <p>Out of a general discussion of the surgical and medical considerations in orthotics, three broad recommendations developed.</p> <ol> <li>There is an urgent need for the development of criteria for the design of bracing based on the biomechanical needs of patients. Perhaps a system of classification of disability based on biomechanics is not only the proper approach to criteria development but, when brace components are related to it, a sounder basis for prescription can be developed.</li><li>Little is known about the response of human tissues to the application of pressure, yet every function of an orthopaedic brace involves the application of pressure. Studies on the effect of pressure are needed before it is possible to determine the efficacy of certain treatment procedures, especially some of those for children.</li><li>Studies involving buried and partially buried implants for facilitating control of externally powered devices should be continued.</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>George T. Aitken, M.D. </b></td></tr><tr><td class="clsTextSmall">Orthopaedic surgeon, College Avenue Medical Building, 50 College Ave., S.E., Grand Rapids, Mich. 49503; Chairman, Subcommittee on Child Prosthetics Problems, Committee on Prosthetics Research and Development. Dr. Aitken served as Chairman of the Panel on Surgical and Medical Considerations of the Conference on Prosthetics and Orthotics.</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 Need for Research in Surgical and Medical Considerations Dealing with Prosthetics and Orthotics Creator An entity primarily responsible for making the resource George T. Aitken, M.D. * https://staging.drfop.org/files/original/bca9b91aef7e3781b29df6181fc9502d.pdf 5d1adb8f6a4a251bfae87557108dcb7b https://staging.drfop.org/files/original/eba4db041582a948e7b8573f8171e55d.jpg d2d2b8d66e11f8576a2669c92ca431c9 https://staging.drfop.org/files/original/fd1e1b1fed23a83e0b989fbdbee7731c.jpg f2cfcea12c8494514b518ab14dc364a4 https://staging.drfop.org/files/original/02e3a3d141fd7f689df0f060da69142d.jpg 9b11833db8cba18b2e267287fd0b4381 https://staging.drfop.org/files/original/a5f74e0c94bba45447600513cce141f8.jpg 018efbb47c12a9ec5dd55890d76452de https://staging.drfop.org/files/original/cafd284bedbe85e23e4580df59846ea7.jpg 171443759e0f481de14918280826908f https://staging.drfop.org/files/original/98bb321dbfa2d34e578725fb1144ba2f.jpg 1b3540601d776f662c1f47f391614aec https://staging.drfop.org/files/original/eca5fce7b392bd0df7651f5c56ae05c4.jpg 85962872df45d132db9f927a8516721c https://staging.drfop.org/files/original/ab2922020f921ea9dc3260155c6b9855.jpg 4734cb468510d0554f5b80d449a9e507 https://staging.drfop.org/files/original/5efb5f8b47d417ecc3fb56b4e116ff85.jpg 8c2f5c4fa3b6df3b4341c0ec47f5af9b https://staging.drfop.org/files/original/0ff459c59890e9e3a392d35fd4d1a0bb.jpg ec9505e7eff0bdb1e3aad92c00d7e0b4 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1956_01_004.pdf Year 1956 Volume 3 Issue 1 Page Number(s) 4 - 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/1956_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1956_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>Skin Health and Stump Hygiene</h2> <h5>Gilbert H. Barnes, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Literally the word "hygiene" connotes a state or condition of health. But adequate hygiene, or good health, of the human skin presents a complex problem involving much more than a casual acquaintance with soap and water, the concept which usually comes to mind when hygiene is mentioned. The functional state of our human integument is pretty much taken for granted by most of us. We know that this two-square-yard covering will, in most cases, repair itself in event of local injury, provided infection is avoided. Cheerfully we dissolve it in strong chemical solutions. We broil it in the summer sun until it peels off like old birch bark. We allow it to be rubbed and blistered in tight shoes for vanity's sake. As a nation, we spend millions of dollars on elaborate sun-tan lotions guaranteed to produce in it the beautiful brown of the aborigine and at the same time an equal fortune on lotions and creams which promise to bleach it out to the shade of a sheltered lily.</p> <p>Even though the skin has remarkable powers of restoration, the conditions of use are occasionally too damaging, or the opportunities for healing between periods of use are too brief for repair and maintenance. In such instances, there may be an acute breakdown of the skin with a severe inflammatory reaction, or the process may be a gradual one, with a progressive deterioration of the skin and a loss of its protective properties. Among individuals in certain occupations, we frequently see both manifestations of such skin reaction. Housewives, mechanics, laboratory workers, and others whose work exposes certain areas of the body, particularly the hands and arms, to prolonged soaking in solutions and solvents, or even in plain water, are prone to recurrent skin irritation and breakdown. In such cases, the chemical and physiological properties of the skin are altered to such a degree that the skin's built-in protective functions are no longer effective. Even in the absence of prolonged soaking, the skin may be injured locally by contact with an irritant, such as a strong acid, or with a sensitizing agent, such as poison ivy.</p> <p>All of these considerations similarly pertain to amputees who wear some type of prosthesis (<b>Fig. 1</b>), most of which are attached to the stump by means of a snugly fitted socket which excludes circulating air and traps the accumulated sweat against the skin. In the lower-extremity amputee, the effect is aggravated by the added factor of weight-bearing and uneven loading on localized areas of the stump skin, especially in the adductor region of the stump and at other points of contact with the socket rim. Weight-bearing is attended by other mechanical stresses, especially intermittent stretching of the skin and friction from rubbing against the socket edge and interior surface. The latter results in two important and harmful effects on the skin- heat, and abrasion of the skin surface, which in time can, by steady attrition, become highly destructive. Over a long period of time, heat alone may be capable of causing profound changes in the metabolism of living tissues. The stump skin of the amputee is especially vulnerable to the possible irritant or allergic action of various materials that compose the socket of the artificial leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Injury to the stump skin. The gremlins symbolize some of the common types of damage that may be inflicted upon the stump skin inside the socket of a prosthesis. Injury may be incurred mechanically when parts of the socket abrade the skin or burrow into it. The materials of the socket, coming in intimate contact with the skin, sometimes act as irritants or as sensitizing agents to create a local dermatitis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In this situation, then, the state of health of the stump skin is of the utmost importance in determining whether or not the prosthesis can be tolerated. If the skin cannot be maintained in a good functional condition in spite of daily wear and tear, then the weight-bearing prosthesis cannot be worn, no matter how accurate the fit of the socket may be.</p> <p>It is the purpose of this article to review some of the basic principles of skin biochemistry and physiology concerned in the maintenance of good hygiene in the stump area. Included are some remarks relative to the use of certain disinfectant agents in skin cleansing, and to some of the natural skin defenses against bacterial invasion, because these topics also are germane to the principal subject with which this article is concerned.</p> <h3>The Skin as a Vital Organ</h3> <p>Man cannot live without his envelope of skin any more than he can exist without his heart or his liver. It might seem at first thought that the cutaneous covering of the body performs about the same function as the leather cover of a baseball -and very little more. Actually, the biochemical and physiological activities of the skin are every bit as complex as are those of the liver. The respiratory rate of the main cellular portion of the epidermis, based on oxygen-uptake studies and glycolysis measurements, has been computed to be from two to ten times as high as the rates of other body tissues.</p> <p>The skin possesses many properties vital to health and life itself. Of particular interest to us from the standpoint of prosthetic design and use is the part it plays in mechanical support of the soft tissues of the stump. It provides a tough, elastic outer covering with a tensile strength of up to 2 kg. per sq. mm. Furthermore, this covering has a tremendous capacity for repairing itself after injury and for strengthening itself at points of mechanical stress, such as those occurring on the lower-extremity stump in association with the wearing of an artificial limb. A familiar example of this is the "lichenification," or leatherlike thickening of the skin over the ischial tuberosity and in the adductor region of the thigh. We know that "calluses," or localized thickenings of the horny outermost layer of the skin, will form at points of repeated pressure. Sometimes a BB-shotlike condensation of horny material will develop over a pressure point, producing the well-known "corn." All of these thickening processes illustrate the defensive reaction of the skin to abnormal mechanical stress by elaborating a natural cushion from its cellular elements.</p> <p>Mechanical protection, however, is only one of many important services which the skin performs. Its function in the conservation of water and electrolytes, those ionized salts which constitute an essential part of the body fluids, is nearly as indispensable as is the function of the kidneys. The skin is extremely important in the regulation of the body temperature within relatively narrow limits. It possesses certain important electrical and chemical properties. It is also the first barrier, and one of the chief defenses of the body, against infectious diseases.</p> <p>Many other properties of the skin that are of less immediate importance to the problem of stump hygiene nevertheless have a bearing on human health and welfare. For example, we rely on the sensory organs of the skin for a good part of our information about the world around us. Through nerve endings at or near the surface, the body receives the outside environmental stimuli of heat, cold, pain, and touch. Also important to health is the role of the skin in maintaining a highly complex system of pigment metabolism and in providing a source of vitamins important for growth and nutrition.</p> <p>Although there are other vital functions of the skin, those cited serve to illustrate the importance and variety of the services the normal skin performs. Some of these are described at greater length in the following portions of this paper.</p> <h3>The Anatomy of the Skin</h3> <p><b>Plate I</b> shows in semidiagrammatic form the principal structures of the skin concerned in stump hygiene. The skin is seen to consist of two distinct layers-the epidermis and the dermis, or true skin. These two layers are joined by a system of fingerlike projections, the rete pegs, which protrude down from the epidermis and interlock with the papillae, which project up from the dermis. This device furnishes a relatively large surface area at the dermal-epidermal junction, thus providing a strong bond between the two layers.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Plate I. A section of normal human skin. 1, Epidermis; 2, true skin; 3, subcutaneous tissue; 4, horny layer; 5. clear layer; 6, granular layer; 7, germinativc layer; 8, capillary network; 9. artery; 10. vein; 11. lobules of fat; 12. nerve; 13, corpuscle of Vater; 14. sweat gland; 15, duct of sweat gland; 16, pore of sweat gland; 17, hair follicle; 18, hair shaft; 19, bulb of a hair; 20, arrcctor muscle; 21, sebaceous gland; 22, duct of sebaceous gland. Courtesy White Laboratories, Inc., KenilKorth, .V. J. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The most superficial layer of the epidermis is the so-called "horny layer," consisting of a material called "keratin," which is very similar to animal horn. Scattered over the surface of the skin are numerous deep pockets, called "follicles," into which sebaceous, or oil, glands discharge their contents. From the follicles protrude the hairs of the skin.</p> <p>Two other types of glands in the skin have an important bearing on the subject of stump hygiene. They are the eccrine, or small sweat glands, which lie in coils near the base of the dermis, and the apocrine, or large sweat glands (not shown in Plate I), which are similarly situated but are more localized in distribution than are the eccrine glands. The watery sweat secretions pass to the surface of the skin by way of the sweat ducts, discharging on the surface through the sweat-duct opening, or pore.</p> <p>Deep to the dermis lies the subcutaneous zone. Here, cushioned in masses of fat cells, are the large blood vessels which serve the skin. From the arteries, smaller vessels rise, becoming narrower as they branch, until they terminate in fine capillary nets in the papillae of the dermis. Blood from the papillary nets returns again by a venous collecting system to the large veins in the subcutaneous tissue.</p> <h4>Relation of Skin Structures to Disease</h4> <p>All of these structures are vulnerable to damage from prolonged wear of a prosthesis. Injury to each different anatomical site results in a specific disease complex of the skin. For example, excessive heat and moisture may result in a local blocking of the sweat-duct pores. We are familiar with this condition in the form of what is known popularly as "prickly heat," a common malady in warm, humid climates; and the same disorder can occur over stump skin under similar environmental conditions.</p> <p>Prolonged use of negative-pressure sockets, and to a lesser degree of conventional sockets, may lead to engorgement of the small blood vessels of the skin, resulting in local areas of rupture and extravasation of blood into the surrounding tissues. The dark pigmentation often seen on the terminal end of the stump is the result of this bleeding under the skin. It is usually accompanied by some degree of edema, a state in which there is an abnormal collection of watery fluid in the soft tissues. Thus the skin disorder here is essentially focused in the circulatory system, whereas the previously cited condition of sweat-duct blockage affects primarily one of the glandular systems of the skin. It follows, then, that the over-all hygiene or good health of the stump skin reflects, among other things, the functional state of each of the anatomical components of the skin.</p> <h4>Skin Glands and Stump Hygiene</h4> <p>In the skin of the lower extremity, three different types of glands produce secretions that are discharged on the surface of the skin. These are the eccrine glands, the apocrine glands, and the sebaceous glands (Plate I). During daily use of a prosthesis, their secretions accumulate inside the socket, where they may become a serious hazard to local stump hygiene.</p> <p><i>The Eccrine Glands</i></p> <p>The eccrine glands, or small sweat glands, are distributed over the entire surface of the body. They are accessory structures that develop from the epidermis. They are true secretory glands, producing a clear, aqueous fluid, and their functioning is vital to the heat regulation of the body, since these glands are the principal source of sweat. It has been estimated that there are over two million of these glands in the skin of a normal adult and from 500 to 600 per sq. in. over the skin of the thigh and lower leg. It has been reported that the capacity for sweating is considerably less for females than for males. According to Weiner <i>{23), </i>roughly 50 percent of heat sweat comes from the trunk, 25 percent from the head and upper limbs, and 25 percent from the lower limbs.</p> <p><i>Sweat Deposits. </i>Eccrine sweat is a clear, watery solution containing 0.5 to 1.0 percent of solids. These solids play an important role in stump hygiene because, in the absence of adequate daily cleansing, their accumulation on the surface of the stump and in the socket interior may serve as a source of irritation and to some extent as a culture medium for the growth of harmful organisms. The eccrine sweat solids include urea (in at least twice the concentration found in blood plasma); creatine and creatinine in minute quantities; uric acid; a variety of different amino acids; ammonia; free choline; occasional traces of glucose; lactic acid and lactate (to the extent of more than 2 grams in 90 minutes of heavy physical labor); many of the water-soluble B-vitamins; traces of dehydroascorbic acid; and the minerals sodium, potassium, calcium, magnesium, sulfates, phosphates, and iron. In addition to the sweat solids, there are the secretions of local oil or sebaceous glands, plus a quantity of nitrogenous material made up of keratin shreds and other cellular debris which has been desquamated from the surface of the skin.</p> <p>This is the residue which collects on the skin and in the socket under normal conditions. If the skin has been damaged by abrasion against the socket wall, or if an eczematous skin condition is present, there may be "weeping" or oozing of serum over the surface, where it mixes with the sweat, oil, and skin debris. This serous material is deposited on the interior wall of the socket, where it dries and sets almost like glue. Successive laminations are added from each day's accumulation, until a considerable thickness may be attained (<b>Fig. 2</b>). Constant wearing and rubbing against the skin may produce a polished, glassy finish on the surface. In the interests of good hygiene, this deposit should be cleaned out of the socket interior regularly.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Debris in the socket. Accumulation of waste in the socket is not favorable to good stump hygiene. Daily waste, consisting of sweat solids, oily secretions, and cellular debris, often combined with serous ooze, is deposited in successive layers that should be cleaned from the socket regularly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The innervation of eccrine sweat glands, pharmacologically speaking, is parasympathetic or cholinergic. Dale and Feldberg<a></a> demonstrated that the postganglionic nerve fibers liberate acetylcholine at their endings on the receptor cells of the sweat glands. Where excessive perspiration, or hyperidrosis, has been a serious problem, clinical application of this finding has been made by treatment of the patient with an anticholinergic blocking agent to diminish sweating. Drugs like methantheline bromide (Banthine) and diphemanil methyl sulfate (Prantal), which are anticholinergic, have been tried.</p> <p>Such treatment has proved sometimes very helpful, sometimes of slight benefit, and often discouraging. Even though excess perspiration may be reduced, there are not infrequently unpleasant side-effects, such as a sensation oi heat, dryness of the mouth and throat, headache, and urinary retention. In the amputee, who often has an overheating problem in the first place, any further impairment of his cooling mechanism may not be tolerated. In some cases, however, an effort to control excessive sweating may be worth a try; certainly any drying effect that such drug therapy may exercise in the stump area will contribute to the hygienic state of the stump skin.</p> <p><i>Eccrine Sweat Retention.</i> In profuse sweating, the sweat is expelled from the eccrine glands onto the surface of the skin at intraductal pressures ranging as high as 250 mm. of mercury. If the outlet at the surface of the skin becomes blocked by masses of keratin, local inflammation, or other obstruction, this pressure may be sufficient to cause rupture of the duct (<b>Fig. 3</b>). If the rupture takes place near the surface at the level of the horny, or keratin layer, the sweat collects in this layer in a raindroplike configuration of little blisters. If the rupture is deeper in the skin, there may be local inflammation, characteristic of "prickly heat." Where the duct is ruptured still more deeply, symptoms are few or none, and the only surface sign consists of small, noninflammatory elevations, or "papules."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Pressure in eccrine sweat glands. When an eccrine gland is actively secreting sweat onto the surface of the skin, the pressure in the sweat duct may rise to 250 mm. of mercury. If the opening of the gland becomes blocked, as symbolized by the gremlin, this pressure may be sufficient to rupture the gland duct and allow the sweat to escape into the skin. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Sweat retention may involve most of the skin surface of the body and may be accompanied by pronounced generalized symptoms of fever, headache, and exhaustion, a condition usually confined to tropical climates. More commonly it affects only a localized part of the body. It has been reported in many different types of eczema and in a variety of healing inflammatory lesions. Preliminary investigations of eczematous eruptions of the stump suggest that sweat retention occurs in this area also. The heat and humidity which prevail over the stump skin during use of a prosthesis are factors which encourage the development of sweat-duct blockage and localized sweat retention.</p> <p><i>The Apocrine Glands</i></p> <p>The apocrine glands, unlike the eccrine glands, develop from the follicular epithelium of the hair, as do the sebaceous glands. Apocrine glands are much larger than eccrine glands, and they are limited in their distribution to the underarm area, the breasts, the midline of the abdomen, and the anal and genital areas. Modified apocrine glands are also found in the external canal of the ear and in the vestibule of the nose.</p> <p>The apocrine secretion is a turbid, whitish-to-yellowish fluid which dries like glue to form a light-colored plastic. The total number of apocrine glands is greater in women than in men, and axillary sweating starts earlier in adolescent girls than in adolescent boys.</p> <p>The apocrine glands in the groin and axilla are occasionally the site of a chronic, extremely stubborn disease of the skin called "hidraden-itis suppurativa." This disease is characterized by large, burrowing, painful cysts which are filled with a foul discharge. These periodically break down and drain, then heal with scarring, and the process may be repeated indefinitely. Frequently the condition is so severe that surgical extirpation, followed by skin-grafting, affords the only means of controlling it. Rarely, hidradenitis suppurativa is encountered in amputees. In such cases it can cause a really serious handicap, making the use of a prosthesis or crutches impossible.</p> <p>Innervation of the apocrine glands is exclusively adrenergic, as compared with the cholinergic innervation of the eccrine glands. The apocrine system responds sluggishly or not at all to heat. However, it does respond promptly to emotional or painful stimuli. In the management of this aspect of the amputee's hygiene, therefore, it is important to bear in mind that pain or tenderness in the stump, or an emotional disturbance, may aggravate any existing skin disorders in the groin or underarm regions through stimulation of this specialized glandular system.</p> <p>Unfortunately, the apocrine glands occur in the areas upon which the amputee must depend for support in the use of a crutch or an above-knee prosthesis. The apocrine glands can be a source of considerable grief, if, through poor hygiene, infection, or other cause, these areas are allowed to become unserviceable for weight-bearing.</p> <p><i>The Sebaceous Glands</i></p> <p>The sebaceous glands occur wherever there are hair follicles. In addition, there are scattered, free sebaceous glands which are independent of the follicles. Their secretion is an oily liquid composed of fatty acids, alcohols, hydrocarbons, and certain vitamin precursors. This material, called "sebum," becomes solid at about 30 degrees C (86 degrees F), the prevailing skin-surface temperature.</p> <p>A unique feature of sebaceous-gland secretion is the capacity of the glands to secrete very rapidly onto a defatted skin surface, but at a rate which gradually declines until the new fat layer of the surface reaches a certain critical thickness. When this occurs, sebum production stops or falls to a minimum. If, however, the fat layer is removed, rapid secretion starts again. The more viscous the sebum becomes, the earlier the sebum expulsion is stopped. As a result, more oil is secreted per unit time at a high environmental temperature than at a low temperature.</p> <p>Presumably, the counterpressure of the oil film on the surface prevents further production by back-pressure in the gland. There is an interesting fact, however, which is not entirely explained by the back-pressure theory: if the duct of the gland is blocked by sebum only, no pathologic change takes place in the secretory cells of the sebaceous glands, but if the obstruction is caused by masses of keratin or other foreign matter, as in the case of comedones ("blackheads") and various types of follicular keratoses, degenerative changes in the gland set in relatively early.</p> <p>This phenomenon of controlled oil production is one in which a normal physiologic process appears to work with the amputee rather than against him in the wearing of a prosthesis. Here, the accumulating lipid film under the socket will serve as its own shut-off valve for further secretion, without damage to the sebaceous glands in the stump skin.</p> <p>Heat Control and the Healthy Skin Healthy skin exercises a vital role in the thermoregulation of the body, a function in which the skin of the lower extremities normally has an important share. This surface control supplements the central heat-regulatory center in the hypothalamus of the brain. At basal conditions, the heat balance of the normal body is maintained by cutaneous vasomotor adjustment through an environmental temperature range of 25 degrees to 31 degrees C (77 degrees to 88 degrees F), the so-called "zone of vasomotor control." Above this range, at 31 degrees to 32 degrees C (88 degrees to 90 degrees F), when cutaneous blood flow has reached its maximum, sweating sets in-the "zone of evaporative regulation." Between 31 degrees and 36 degrees C (88 degrees and 97 degrees F) and at low humidity, evaporative heat loss easily maintains normal temperature. Below the zone of vasomotor control, the skin temperature falls, and body temperature is maintained chiefly by chills (the "zone of cooling"). If environmental temperature is maintained below a critical level of 31 degrees to 32 degrees C, there is generalized, but grossly invisible, periodic sweating known as "insensible sweating." Consequently, although the principal thermoregulation in this temperature range is vasomotor, there is still an assist from the sweat glands in cooling the skin surface.</p> <p>The values cited are those reported for the normal. In the amputee, significant areas of cooling surface, along with the component sweat glands, have been subtracted from the total reserve of functional skin surface. In addition, the complex and important system of vascular shunts and arterioles in the amputated limb or limbs has also been lost from the total heat-regulatory mechanism. As a result, a number of characteristic and troublesome disturbances of temperature and heat control are associated with amputation.</p> <p>Among these is the phenomenon of the poikilothermic stump, which has been studied by staff members of the University of California Medical School <i>. </i><a></a> In this condition, the surface temperature over the distal part of the stump, and over a considerable portion of the stump proximally as well, tends to become stabilized at the temperature of the surrounding air, more or less independently of any vasomotor control. Thus it is seen that, in a lower-extremity amputation, not only is part of the original heat-control surface permanently lost but the remaining stump surface is no longer normally effective as part of the heat-control mechanism. Nevertheless, it is important to maintain the hygiene, or good health, of this remaining skin area in order to preserve whatever function it may still possess for heat regulating, and particularly for cooling.</p> <h4>Mechanisms of Heat Loss</h4> <p>Heat loss from the normal skin takes place by radiation, convection, conduction, and evaporation. All of these mechanisms are interfered with, if not entirely abolished, over the stump area when a tightly fitted socket is worn, Excessive local heating of the stump can result (<b>Fig. 4</b>), particularly during warm, humid weather, and a major hygienic problem can arise under such conditions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Overheating of the stump. Since air cannot circulate inside a snugly fitted socket, the stump is usually bathed in sweat. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Heat loss from the skin by radiation takes place in the form of infrared rays in the range of 5 to 20 m/u. Under normal conditions, radiation accounts for about 60 percent of total heat lost from the body. In the amputee, it seems probable that loss of heat from the stump area by this mechanism is greatly restricted by the socket of the prosthesis. We do not at present, however, have any data to confirm this supposition.</p> <p>Convection depends upon the transfer of energy by means of moving air and thus is negligible as a means of heat loss from the stump when a prosthesis is worn.</p> <p>Conduction, the transfer of heat between two media in direct contact, is of great importance to the amputee. As the socket becomes warmed to skin temperature, it acts as an insulator against further dissemination of heat from the surface of the stump. It appears probable also that in the vicinity of principal loading, especially along the medial, anterior, and posterior segments of the socket rim, heat is generated by the friction resulting from shearing action between the skin and the socket rim. The insulating effect of the socket would, of course, tend to maintain any such local elevation of temperature. We are initiating a clinical study of this question, employing thermistors for the direct reading of skin temperatures while the prosthesis is being worn under various conditions of normal use.</p> <p>Just how significant increased local heating of the skin may be in adversely affecting skin hygiene and metabolism over a long period of time we cannot say at present. It is known that an increase in environmental temperature elevates the oxygen and nutritional requirements of most tissues. At the same time, the blood supply to the skin of a lower-extremity stump, if changed at all by the active use of a prosthesis, is probably reduced. One might speculate here whether the predilection of these weight-bearing sites for the development of recurrent "pressure sores" may not be related to increased local heat plus diminished nutrition, as well as to mechanical damage and to maceration from sweat. Certainly this area of stump hygiene merits further investigation.</p> <h4>Reflex Sweating</h4> <p>If, in the normal person, the environmental temperature is raised above a critical level between 31 degrees and 32 degrees C (88 degrees and 90 degrees F), there is a sudden, visible outbreak of sweating over the whole body. A similar response, termed "reflex sweating," may be observed when only a portion of the body surface is heated. Whenever there is excessive heating of the stump, the conditions favor reflex sweating, even though the environmental temperature of the rest of the body is below the critical level necessary for visible sweating. Certainly a valuable contribution, both to the comfort of the amputee and to the improvement of his stump hygiene, would be the development of new socket materials and designs which would provide for more rapid heat transfer by conduction and radiation to the outside air.</p> <p>Loss of heat by evaporation from the stump is negligible in the case of the suction socket. Where the conventional socket is worn with a wool stump sock, however, the wicking action of the sock may well provide an avenue for evaporation and consequent cooling. A light stump sock for use with the suction socket may prove feasible. If so, the cooling effect, as well as the added support and protection afforded the stump skin, would be of benefit in maintaining a healthy stump.</p> <p>According to Rothman,<a></a> sweating which is elicited by exercise begins at a lower skin temperature than does sweating produced by external heat. Bazett<a></a> suggested that there may be, deeply situated near vascular plexuses, thermal receptors which are warmed by the working muscles. These receptors may in turn activate the sweat glands of the skin. Whatever the true explanation may be, the combination of excessive sweating (<b>Fig. 5</b>) and increased energy requirements for locomotion is all too familiar to the lower-extremity amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Excessive sweating. An amputee using an artificial leg may complain more of general bodily discomfort from heat and excessive sweating than would a normal individual undergoing similar exertion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Visible sweat secretion and heat loss can also occur independent of thermoregulatory needs. For example, sweating can be elicited with ease at air temperature below 31 degrees C (88 degrees F) by the ingestion of hot drinks, probably through a viscerocutaneous reflex. A variety of other nervous impulses unrelated to heat control may produce sweating. One of the most important of these is "emotional sweating," which may at times affect most of us to some degree. In dermatologic practice, we sometimes see patients in whom this condition has become so severe as to be almost incapacitating. Serious limitations affecting social contacts and employability result. The same disturbance of sweat mechanism may be experienced by amputees. Although the emotional factor may be important in some amputees who have a troublesome hyperidrosis, it is apparent from some of the known physiologic mechanisms for sweating that there may be other reasons for such an increase.</p> <h3>Stump Hygiene and Germs</h3> <p>It has been a matter of frequent observation that the normal skin is not a sterile skin. Such a condition simply does not exist. Normal skin teems with immense numbers of unseen organisms, some harmless and some pathogenic, that is, capable, under the right combination of circumstances, of causing an infection of the skin. Normally, the harmful bacteria and fungi are held in check by a number of different forces. Most of the time we live in some measure of harmony with this enveloping horde. But when resistance to infection is lowered by local skin damage, the presence of some generalized disease, a metabolic disturbance such as diabetes, or any one of numerous other causes, then this harmonious balance is destroyed and the avenue of invasion is opened. Two different classes of bacteria exist on normal skin under average conditions-the resident bacteria, which remain fairly constant, and the transients, which may be almost anything (<b>Fig. 6</b>). In addition, a variety of fungi come and go, chiefly members of the yeasts and molds, although other types, such as those which cause ringworm of the feet and body, may be present.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Flora of the skin. Of the teeming numbers of microorganisms on the normal human skin, some are resident bacteria, which are found on the skin more or less constantly, while others are transient bacteria-only temporary visitors. Common among the residents are Corynebacterium acnes, the so-called "acne bacillus"; Micrococcus epidermidis; and Micrococcus pyogenes, a skin pathogen. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Evans <i>et al. </i><a></a> have studied the resident bacterial flora in 146 sample scrapings from the skin of 17 adults over an eight-month period. They found that the anaerobic bacteria (those which grow in the absence of free oxygen) outnumbered the aerobic bacteria (those which require free oxygen) by a ratio that ranged between 10:1 and 100:1. In most of the cases, one species of anaerobic bacteria predominated, the so-called "acne bacillus," <i>Propionibacterium acnes (Corynebacterium acnes). </i>Of the aerobic bacteria, two species were observed regularly: <i>Micrococcus epidermidis </i>and <i>Staphylococcus albus {Micrococcus pyogenes), </i>the latter a skin pathogen The observation was made that, at least in cultures, some types of bacteria inhibited the growth of others. This finding might constitute one explanation for the overgrowth of certain bacteria, especially the acne bacillus, at the expense of the others. It was also found that the sebaceous glands were the major site of growth of bacteria on the skin and that exercise with sweating caused a transient minor increase in skin flora.</p> <p>What effect might the wearing of an occlusive prosthesis be expected to have on common skin pathogens trapped under the socket? How might the normal defenses of the skin be affected by the conditions attendant upon the use of a prosthesis? To answer these questions, let us consider four common groups of organisms which are likely to cause skin infections in the region of the amputee's stump-the gram-negative organisms like <i>Escherichia coli,</i> the staphylococci, the beta hemolytic streptococci, and <i>Proteus, </i>some strains of which are secondary wound invaders.</p> <p>We know that the normal skin surface has two important natural defenses against bacterial invasion-first, the ordinary drying action on the surface, facilitated, where the skin is uncovered, by the movement of air currents; second, the presence of unsaturated fatty acids (particularly oleic acid), which are components of the sebum, or oily secretion from skin oil glands.</p> <p>Gram-negative organisms, that is, those organisms which do not retain the selective blue dye used in the Gram staining technique, are particularly sensitive to drying. This alone is effective in killing or inhibiting their growth. Unfortunately, the dry state never exists for any length of time over the stump skin during the use of a prosthesis.</p> <p>Both the drying and the action of the fatty acids are slightly to moderately inhibitory against the staphylococcal organisms. In other words, neither factor offers sure protection against invasion by this group of germs, but both have deterrent value in the normal skin. Again, the moist state which usually exists under the socket tends to encourage the growth of staphylococci.</p> <p>Although the beta hemolytic streptococcus is unaffected by drying, it is destroyed by oleic acid. But streptococci will grow in serous exudate, such as may be seen in a weeping eczematoid dermatitis of the stump, because the albumin in the exuded serum neutralizes the oleic acid, the chief natural antagonist of the streptococci. This relation of exudative lesions of the skin to secondary infection underlines the importance of adequate hygienic care in routine management of minor abrasions and irritations of the stump area. Furthermore, it should be apparent that there are times when the continued use of a prosthesis on a stump which is the site of a dermatitis, especially where a serous discharge is present, will prevent healing and is almost certain to invite a secondary infection.</p> <p>The <i>Proteus </i>strains-the fourth group of organisms mentioned-multiply rapidly in a moist environment. Any occlusive dressing or cover, such as the socket, which tends to increase local moisture on the skin will favor a heavy overgrowth of <i>Proteus.</i></p> <p>Thus we see that, in all four of the examples cited, the use of a prosthesis may be expected in some measure to interfere with the defensive mechanisms of normal skin in its resistance to disease. This interference is augmented by prolonged or strenuous use of the prosthesis and by the presence of any pre-existing lesions, however minor they may seem to the amputee.</p> <h3>Electricity and the Skin</h3> <p>The electrical behavior of the skin plays an important part in the preservation of good health. Normally, there is a negative electrical charge in the superficial layers of the skin. When an alkaline condition prevails, this electrical negativity is increased owing to adsorption of negatively charged hydroxyl ions. An acid condition of the skin, however, causes a discharge of this normal negativity, which is complete between pH 3 and pH 4. As the relative acidity of the skin increases, there is eventually a reversal of the charge, the skin surface becoming electrically positive. Furthermore, investigators have reported that scarring of the epidermis<a></a> and prolonged soaking in water or concentrated salt solutions<a></a> tend to cause a discharge of the normally negative charge of the skin. Both of these abnormal conditions may develop over the stump as the result of use of a prosthesis.</p> <p>Just what effect socket wear has on the normal electrical behavior of the stump skin, or how significant this may be in maintaining a healthy condition in the stump area, we do not know at the present time. This is, however, another problem that should receive further investigation. We do know that the negativity of normal skin can be a factor in the defense of the body against pathogenic organisms, which are also negatively charged and which tend to be repelled from, or bound to, the surface of the skin according to variations in the electrical charge on the latter (<b>Fig. 7</b>). It is of interest, incidentally, to note here that in muscle the relationship of negative-positive electrical charges to normal and damaged tissue, as here described for the skin, is just reversed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Electrical charge on the skin as a defense against germ invasion. Germs, which are negatively charged, tend to be repelled from the normally negative surface of the skin but are attracted to the skin when this charge is reversed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Stump Hygiene and Local pH or the Skin</h4> <p>Blank<a></a> has confirmed earlier observations that the pH of healthy skin is always on the acid side, falling usually between 4.2 and 5.6. Furthermore, both eccrine sweat and apocrine sweat are normally acid. These facts have given rise to the concept of the so-called "acid mantle" of the skin, which is cited by some investigators as one of the body's natural defenses against disease. Schmid<a></a> found a significant shift toward the alkaline side in the surface pH of the skin in cases of eczema and in seborrheic dermatitis, an inflammatory disorder involving especially the hairy and more oily regions of the skin. In general, an even greater shift toward the alkaline side takes place in these inflammatory diseases if the intact skin is broken and neutral in charge or if alkaline extracellular fluid diffuses through, as in any acute, weeping dermatitis of the stump. With healing, the original acid pH returns.</p> <h4>Buffering Action of Normal Skin</h4> <p>Another important property of the skin is its buffering action. If the skin surface is exposed to dilute acids or alkalies, there is normally a corresponding shift of the pH locally; but this is temporary, and the former acid pH is rapidly restored. This behavior represents the neutralizing capacity of the skin. Probably the most important agents in this neutralizing property are the sweat constituents, especially the lactic acid-lactate system and the amphoteric amino acids. Any local damage to the sweat mechanism, such as might be caused by socket irritation, could conceivably impair this important function of the skin in the involved areas. Burckhardt <i>{7,8) </i>and others have established that there is a definite correlation between the acid and alkali neutralizing capacity of the skin and its tolerance for acids and alkalies.</p> <p>Pursuing a discussion of acid-base balance brings to mind several unanswered questions with regard to the amputee's problem of stump hygiene. We would like to know, for example, what happens to the normally acid pH of stump skin during the daily wearing of an airtight socket. Does stump skin possess the same pH and buffering properties as the skin of an intact limb? What effect do different socket materials have on the pH of stump skin? Does an interior finish which gives an alkaline reaction necessarily cause more damage to the skin than does one with an acid reaction? These are questions which should receive further investigation in the light of their vital relationship to stump hygiene.</p> <p>It might seem from the foregoing that the cutaneous surface which gives an acid reaction denotes a healthy skin, resistant to invasion and disease, while an alkaline-reacting skin surface denotes the presence of some disease state. Unfortunately it is not quite so simple. Some organisms grow readily on an acid medium. Pathogenic fungi, for example, flourish on certain media at pH 4.9. Nonetheless, in general, it is desirable to maintain the surface of the skin at least slightly on the acid side.</p> <p>Washing, even with plain water, causes moderate hydration of the horny layer, with a drop, according to Szakall ,<a></a> from pH 6.3 to pH 5.3 in 30 minutes. This information may also have some application to lower-extremity prosthetics, since the stump skin becomes soaked with sweat in most cases shortly after the prosthesis is put on. Furthermore, a single washing with soap removes about 50 percent of the surface lipid film, thereby facilitating the outward diffusion of carbon dioxide, the acid reaction of which helps to neutralize an alkaline state on the surface of the skin.</p> <h4>Surface pH and Degerming of the Skin</h4> <p>Control of surface pH is also important in degerming the skin. Blank, Coolidge, and others,<a></a> in an extensive study of the surgical scrub, have investigated many different germicidal agents and techniques of cleansing. Among the agents studied were the quaternary ammonium compounds, like Ceep-ryn and Zephiran, which are widely used in surgical cleansing of the skin. While these compounds do exert a bacteriostatic or bacteriocidal effect, Blank<i>et al.</i><a></a> found that they also have the property of binding the bacteria to the skin. It was demonstrated that, at a pH a little higher than the isoelectric point of keratin, the quaternary ammonium compounds change the normally negative charge on the surface of the skin to positive. Since the bacteria are negatively charged, they are attracted to the skin. If the pH is then increased considerably, for example by rinsing with an alkaline soap, the charge on the skin will revert to negative and the bacteria will be released from the skin, as has been confirmed experimentally by analysis and culture of the rinse water.</p> <p>Another germicidal agent commonly used in disinfecting the skin is G-ll, or hexa-chlorophene. Chemically it is 2,2'-methyl-enebis (3,4,6-trichlorophenol): [pic1]</p> <p>This compound has the double advantage of accumulating on the skin when used daily and of not being inactivated, as most germicides are, when combined with a detergent. If used only at infrequent intervals, G-ll is no more effective as a disinfectant than any nonmedi-cated soap. If used regularly, however, within five to seven days there will develop in the skin a concentration sufficient to cause a definite reduction in the bacterial flora. One contraindication to the use of this agent is the presence of a serous ooze, such as we see not infrequently on the stump in various types of eczematous skin conditions. Seastone<a></a> has reported that as little as 1.0 percent of sterile serum will reduce the bacteriostatic effect of this agent.</p> <p>Hexachlorophene is available commercially in combination with various soaps and liquid detergents, in strengths varying from 0.75 to 3.0 percent. These include such brand names as Dial soap, Gammaphen soap, pHisoHex, and Septisol. Another useful preparation of G-ll is an alcoholic solution containing 0.1 percent of G-ll, with 0.5 percent of cetyl alcohol added as an emollient. This solution may be used as a two-minute rinse following soap-and-water cleansing of the stump.</p> <p>A useful cleansing agent for stump skin has been found to be pHisoHex, especially where superficial infection is a problem. It consists of an emulsifying agent known as pHisoderm, to which 3 percent of G-ll has been added. Chemically, pHisoderm is sodium octylphenoxyethoxyethyl ether sulfonate, plus lanolin cholesterols, lactic acid, and petrolatum. Its pH is 5.5, approximately that of normal skin. It lowers the surface tension of water and is an active emulsifier.</p> <p>There are many other agents for degerming the skin, many of which are too irritating for the type of regular use necessary to routine stump care. One of the more readily available of these is alcohol, which remains a useful bacteriocidal preparation. Isopropyl alcohol, for example, is germicidal up to 50-percent dilution. Too-frequent use of such solvents, however, will dry the skin excessively and may do more harm than good. Furthermore, any marked depression of bacterial flora over the stump skin cannot be maintained for long during use of the prosthesis.</p> <h3>Selective Absorption as a Protective Barrier</h3> <p>The healthy cutaneous envelope of the body is constantly active as a physicochemical barrier against the outside world, retaining some substances and passing others through (<b>Fig. 8</b>). As early as 1904, Schwenkenbecher<a></a> showed that the intact skin is permeable to fat-soluble substances and to certain gases but is practically impermeable to water and most electrolytes. Most substances which are soluble in both water and lipids penetrate the skin and pass into the general circulation at rates comparable even to gastrointestinal or subcutaneous absorption. Phenolic compounds, lipid-soluble vitamins, and hormones penetrate rapidly. This property of the skin conceivably could be of serious import in the indiscriminate use of socket materials or finishes capable of liberating absorbable toxic fractions which could be taken up by the stump skin.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. The skin as a protective physicochemical barrier. The skin conserves in the body some substances like water and electrolytes by selectively barring their outward passage. Other substances, for example the gases carbon dioxide and oxygen, are passed freely through the skin. Lipid-soluble vitamins and hormones likewise readily penetrate the skin barrier. Unfortunately, certain materials which are potentially toxic, such as the phenolic compounds, may also be freely absorbed by the skin. Care should therefore be taken to avoid prolonged intimate contact with such materials. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In rare instances, individuals have demonstrated a peculiar sensitivity, known as an "idiosyncrasy," on first exposure to certain drugs and chemicals applied to the skin. Alexander<a></a> described a case of iododerma, a form of iodine reaction, resulting in the death of a 37-year-old woman following routine preoperative cleansing of the surface of the skin over the abdomen with iodine. This is not intended to suggest that any similar hazard exists in the use of present-day, conventional socket materials. It does, however, emphasize the fact that the skin may be, in certain rare cases, an open portal to the systemic circulation.</p> <p>Transfer of gases across the skin barrier may take place with ease in either direction. The biological significance of the movement of oxygen and carbon dioxide through the skin, which was once thought negligible, is given more importance now. Shaw and others<a></a> found that oxygen was given off through the skin when the oxygen content of the ambient air was reduced to about 2 percent and that it was absorbed more rapidly when the skin was surrounded by a gaseous mixture containing about 37 percent of oxygen than when surrounded by air. According to Chambers and Goldschmidt,<a></a> if the total skin surface is surrounded by nitrogen gas instead of air, there may be a compensatory, increased uptake of oxygen by the lungs.</p> <p>Hediger<a></a> reported that, from a water chamber containing the dissolved gas, carbon dioxide passed into the skin as long as the water contained more than 4 percent of carbon dioxide. When the concentration dropped below 4 percent, carbon dioxide diffused outward through the skin, as it does constantly under physiological conditions. Measurements cited by Rothman and Schaaf<a></a> showed that over a 24-hour period 7 to 9 grams of carbon dioxide escaped from the total skin surface, less that of the head, of an adult male. The amount suddenly increased when the temperature was raised to the critical temperature of visible sweat secretion.</p> <p>Cleansing of the skin with organic solvents such as ether, benzene, and, to a lesser degree, alcohol, enhances percutaneous absorption, that is, absorption across the skin barrier. Since such solvents are used frequently in the cleansing of the stump, as well as of the interior of the prosthetic socket, this effect upon the skin's absorption should be borne in mind. Moisture, almost constantly present in the wearing of a prosthesis, also promotes trans-epidermal absorption by an unexplained mechanism.</p> <h3>Summary</h3> <p>Through the use of improved prostheses, many amputees have been able to return to relatively normal physical activity and to take again their rightful place in business and social life. It must be remembered, however, that the use of a prosthesis places upon the leg amputee new and heavy demands, including not only muscular and emotional readjustments but also the infliction of unaccustomed wear and tear upon his stump skin. Daily, for the rest of the amputee's life, his stump will be subjected to an abnormal environment that combines heat, moisture, and darkness with chemical and mechanical irritation. It becomes imperative then, in restoring the amputee to full activity, to make certain that he understands the importance of systematic skin care. An adequate appreciation of the necessary requirements for good stump hygiene must be based on a knowledge of the functions and limitations of normal skin.</p> <p>The skin provides for the other tissues a highly effective, tough and elastic outer covering, which has a great capacity for strengthening itself at points of stress and for repairing itself after injury. But this capacity of the skin for mechanical protection, the limits of which are of special interest in prosthetics design, is only one of its many important functions. The skin possesses, in addition, a variety of anatomical structures, including the eccrine, apocrine, and sebaceous glands, the normal function of which is necessary for the preservation of good skin hygiene. The eccrine glands are indispensable in the heat control of the body. All of the glands produce secretions, some of which are exceptionally copious. This normal function poses an important sanitary problem for the amputee and makes routine cleansing of both the skin and the prosthesis essential.</p> <p>The natural defenses of the skin against germs depend upon good hygiene. Conditions inside the socket tend to impair the resistance of the skin to infection, but through adequate cleansing, frequent airing, and intelligent care of early lesions, serious infection may be avoided.</p> <p>Knowledge is increasing concerning the electrical and chemical buffering properties of the skin and their role in the maintenance of skin health. There is usually a negative charge in the superficial layers of normal skin. It is, however, discharged by injury or by prolonged soaking in water or salt solution. Similarly, normal skin is slightly acid, but in the presence of inflammation of the skin a shift to the alkaline side usually occurs. The sweat constituents contribute largely to the capacity of the skin to neutralize or buffer dilute acids and alkalies to which it is exposed. Whether or not these properties are retained intact by the stump skin of amputees and, if so, how they are affected by the conditions of use of a prosthesis are important areas for further research.</p> <p>Although the skin serves as a protective barrier, it is readily penetrated by certain substances. For this reason the stump should be protected from contact with materials potentially toxic. Similarly, the stump skin may be subject to a variety of local injuries- mechanical, chemical, or allergic in origin. Again the importance of early and close attention to minor lesions and to good preventive hygiene must be emphasized.</p> <p>There have been two chief aims in this discussion of basic principles. The first was to impart an awareness of the complex nature of the problem of stump hygiene and the second to emphasize that good stump hygiene, far from being an academic matter, is one of the utmost importance to the amputee. Like the proverbial dispatch rider whose horse was crippled for want of a horseshoe nail, the amputee may suffer discomfort and serious disability because of neglect of a seemingly insignificant lesion or failure to follow a simple cleansing routine.</p> <h3>Acknowledgments</h3> <p>A special acknowledgment is due Rothman's excellent sourcebook of dermatologic research, <i>Physiology and Biochemistry of the Skin , </i><a></a> which the author found to be a useful guide in the preparation of this article. The cartoons are the work of Tom Raubenheimer, medical illustrator at the University of California Medical Center, San Francisco.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Alexander, R. C, Fatal dermatitis following the use of iodine spirit solution, Brit. Med. J., 2:100 (1930).</li> <li>Bazett, H. C, Theory of reflex controls to explain regulation of body temperature at rest and during exercise, J. Appl. Physiol., 4:245 (1951).</li> <li>Blank, I. H., Measurement of pH of the skin surface. II. pH of the exposed surfaces of adults with no apparent skin lesions, J. Invest. Dermat., 2:75 (1939)</li> <li>Blank, I. H , and M. H. Coolidge, Degerming the cutaneous surface. I. Quaternary ammonium compounds, J. Invest. Dermat., 16:249 (1950).</li> <li>Blank, I. H., and M. H. Coolidge, Degerming the cutaneous surface. II. Hexachlorophene (G-ll), J. Invest. Dermat., 15:257 (1950).</li> <li>Blank, I. H., M. H. Coolidge, L. Soutter, and G. V. Rodkey, A study of the surgical scrub, Surg., Gyn., and Obstet., 91:577 (1950).</li> <li>Burckhardt, W., Beilrage zur Ekzemfrage. II. Die Rolle des Alkali in der Pathogenese des Ekzems speziell des Gewerbeekzems, Arch. f. Dermat. u. Syphilol., 173:155 (1935).</li> <li>Burckhardt, W., and W. Baumle, Die Beziehung der Saureempfindlichkeit zur Alkaliempfindlichkeit der Haul, Dermatologica, 102:294 (1951).</li> <li>Chambers, A. H., and S. Goldschmidt, The influence of cutaneous atmospheric oxygen absorption upon the apparent total oxygen utilization of the body, Am. J. Physiol., 129:P331 (1940).</li> <li>Dale, H. H , and W. Feldberg, The chemical trans- mission of secretory impulses to the sweat glands of the cat, J. Physiol., 82:121 (1934).</li> <li>Evans, C. A., W. M. Smith, E. A. Johnston, and E. R. Giblett, Bacterial flora of the normal human skin, J. Invest. Dermat., 15:305 (1950).</li> <li>Hediger, Stephan, Experimentelle Untersuchungen iiber die Resorption der Kohlensaure durch die Haut, Klin. Wchnschr., 7:1553 (1928).</li> <li>Keller, Phillip, Die biologishen Grundlagen fur die elektrischen Potentiate der Haul, Arch. f. Dermat. u. Syphilol, 160:136 (1930).</li> <li>Rein, Hermann, Die Elektrophysiologie der Haut, in Jadassohn's Handbuch der Haut- und Ge-schlechtskrankheiten, 1:43 (1929).</li> <li>Rothman, Stephen, Physiology and biochemistry of the skin, University of Chicago Press, Chicago, 1954.</li> <li>Rothman, S., and F. Schaaf, Chemie der Haut, in Jadassohn's Handbuch der Haut- und Ge-schlechtskrankheiten, 1:161 (1929).</li> <li>Schmid, Martin, Vergleichende Unlersungen iiber die Sdure-Basen-Verhaltnisse auf der Haul, Dermatologica, 104:367 (1951).'</li> <li>Schwenkenbecher, [A.], Das Absorptionsvermbgen der Haut, Arch. f. Anat. u. Physiol. (Physiol. Abt), p. 121 (1904).</li> <li>Seastone, C. V., Observations on the use of G-ll in the surgical scrub, Surg., Gyn., and Obstet., 84: 355 (1947).</li> <li>Shaw, L. A., A. C. Messer, and S. Weiss, Cutaneous respiration in man. I. Factors affecting the rale of carbon dioxide elimination and oxygen absorption, Am. J. Physiol., 90:107 (1929).</li> <li>Szakall, Alexander, Uber die Physiologie der obersten Hautschichten und ihre Bedeutung fur die Alka-liresislenz, Arbeitsphysiol., 11:436 (1941).</li> <li>University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</li> <li>Weiner, J. S., The regional distribution of sweating, J. Physiol., 104:32 (1945).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Rothman, Stephen, Physiology and biochemistry of the skin, University of Chicago Press, Chicago, 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>16.</b> </td><td class="clsTextSmall">Rothman, S., and F. Schaaf, Chemie der Haut, in Jadassohn's Handbuch der Haut- und Ge-schlechtskrankheiten, 1:161 (1929).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Hediger, Stephan, Experimentelle Untersuchungen iiber die Resorption der Kohlensaure durch die Haut, Klin. Wchnschr., 7:1553 (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>9.</b> </td><td class="clsTextSmall">Chambers, A. H., and S. Goldschmidt, The influence of cutaneous atmospheric oxygen absorption upon the apparent total oxygen utilization of the body, Am. J. Physiol., 129:P331 (1940).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Shaw, L. A., A. C. Messer, and S. Weiss, Cutaneous respiration in man. I. Factors affecting the rale of carbon dioxide elimination and oxygen absorption, Am. J. Physiol., 90:107 (1929).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Alexander, R. C, Fatal dermatitis following the use of iodine spirit solution, Brit. Med. J., 2:100 (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>18.</b> </td><td class="clsTextSmall">Schwenkenbecher, [A.], Das Absorptionsvermbgen der Haut, Arch. f. Anat. u. Physiol. (Physiol. Abt), p. 121 (1904).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Seastone, C. V., Observations on the use of G-ll in the surgical scrub, Surg., Gyn., and Obstet., 84: 355 (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">Blank, I. H., M. H. Coolidge, L. Soutter, and G. V. Rodkey, A study of the surgical scrub, Surg., Gyn., and Obstet., 91:577 (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>4.</b> </td><td class="clsTextSmall">Blank, I. H , and M. H. Coolidge, Degerming the cutaneous surface. I. Quaternary ammonium compounds, J. Invest. Dermat., 16:249 (1950).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blank, I. H., and M. H. Coolidge, Degerming the cutaneous surface. II. Hexachlorophene (G-ll), J. Invest. Dermat., 15:257 (1950).</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Blank, I. H., M. H. Coolidge, L. Soutter, and G. V. Rodkey, A study of the surgical scrub, Surg., Gyn., and Obstet., 91:577 (1950).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Szakall, Alexander, Uber die Physiologie der obersten Hautschichten und ihre Bedeutung fur die Alka-liresislenz, Arbeitsphysiol., 11:436 (1941).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Schmid, Martin, Vergleichende Unlersungen iiber die Sdure-Basen-Verhaltnisse auf der Haul, Dermatologica, 104:367 (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">Blank, I. H., Measurement of pH of the skin surface. II. pH of the exposed surfaces of adults with no apparent skin lesions, J. Invest. Dermat., 2:75 (1939)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Keller, Phillip, Die biologishen Grundlagen fur die elektrischen Potentiate der Haul, Arch. f. Dermat. u. Syphilol, 160:136 (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>14.</b> </td><td class="clsTextSmall">Rein, Hermann, Die Elektrophysiologie der Haut, in Jadassohn's Handbuch der Haut- und Ge-schlechtskrankheiten, 1:43 (1929).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Evans, C. A., W. M. Smith, E. A. Johnston, and E. R. Giblett, Bacterial flora of the normal human skin, J. Invest. Dermat., 15:305 (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>2.</b> </td><td class="clsTextSmall">Bazett, H. C, Theory of reflex controls to explain regulation of body temperature at rest and during exercise, J. Appl. Physiol., 4:245 (1951).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Rothman, Stephen, Physiology and biochemistry of the skin, University of Chicago Press, Chicago, 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>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic Devices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Dale, H. H , and W. Feldberg, The chemical trans- mission of secretory impulses to the sweat glands of the cat, J. Physiol., 82:121 (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>Gilbert H. Barnes, M.D. </b></td></tr><tr><td class="clsTextSmall">Clinical Instructor in Dermatology, School of Medicine, University of California Medical Center, San Francisco, and member of the Study Group on Dermatology, Lower-Extremity Amputee Research Project, University of California, Berkeley and San Francisco. Based on a lecture presented before the University of California Pilot School in Lower-Extremity Prosthetics, August 25, 1955, at the U.S. Naval Hospital, Oakland, California.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1956_01_004/spring56-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1956_01_004/spring56-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1956_01_004/spring56-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1956_01_004/spring56-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1956_01_004/spring56-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1956_01_004/spring56-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1956_01_004/spring56-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1956_01_004/spring56-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1956_01_004/spring56-10.jpg Figure 10 http://www.oandplibrary.org/al/images/1956_01_004/spring56-09.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 Skin Health and Stump Hygiene Creator An entity primarily responsible for making the resource Gilbert H. Barnes, M.D. * https://staging.drfop.org/files/original/35801aa99143213c24197cf394e4d956.pdf 5639c70b68cbd0e4326be89301a23af7 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1961_01_044.pdf Year 1961 Volume 6 Issue 1 Page Number(s) 44 - 51 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1961_01_044.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1961_01_044.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Syme's Amputation for Gangrene from Peripheral Vascular Disease</h2> <h5>Gordon M. Dale, M.B. <a style="text-decoration:none;">*</a><br /></h5> <p>Peripheral vascular disease as a cause of amputation was first forcefully brought out in Canada by the many cases of acute thromboangiitis obliterans occurring in young men after World War I. In the early days of the 20's, amputation for this disorder was carried out at knee level (Gritti-Stokes), an operation itself considered a daring innovation at the time, the site of election in such cases then being viewed as the junction of the upper and middle thirds of the thigh. In the present series, the first Syme amputation for gangrene of the foot was performed in 1925 in a case of thromboangiitis obliterans. Since that time, the Syme amputation has been used in Canada in such cases whenever it seemed warranted.</p> <p>By 1940, Syme's amputation had been used successfully for many and varied conditions, including infected and perforating ulcers in unrecovered sciatic-nerve and cauda-equina lesions, septic and tuberculous arthritis of the ankle joint, frostbite, arterial occlusion, and gangrene owing to peripheral arterial disease. When, after the beginning of World War II, the question of amputations once again became prominent, we were able to refute the views expressed by the British Ministry of Pensions in regard to Syme's and other end-bearing amputations generally.<a style="text-decoration:none;">*</a> We showed, by demonstration of actual cases, the great value and durability of these amputations in active life. We were fortunate in having an excellent prosthetic service started during World War I and concentrated in February 1919 at the Dominion Orthopaedic Hospital (later Christie Street Hospital). It had constantly been improving our prostheses, and to that group we owe much of our success.</p> <p>During the period 1920-1956, many new factors modified our views and methods of treatment. In 1930, lumbar ganglionectomy was adopted in vascular disease, and it is thought that doing so saved or postponed many major amputations. Embolectomy and anticoagulants saved some limbs. Sulfa drugs, penicillin, and later antibiotics bolstered our courage. Although the incidence of infection was no lower after than before the use of such agents, there were operated upon during World War II cases that in World War I would not even have been considered for surgery. Now arterial grafting promises well in selected cases. Advances in anesthesia and in medicine generally have of course helped a great deal. Of the problems facing the Department of Veterans Affairs today, one is senile gangrene owing to the advancing age of veterans.</p> <h3>CASE HISTORIES</h3> <p>The case histories that follow represent most of the Syme amputations performed for gangrene owing to thromboangiitis obliterans, diabetic gangrene where there was also peripheral vascular disease, and senile gangrene from arteriosclerosis <i>per se. </i>Omitted are those cases whose files were destroyed after death, but all failures are recorded. Included are 23 Syme amputations and one mid-tarsal amputation, all for vascular disease and all with gangrene. Six have undergone reamputation.</p> <p>Cases 3, 6, and 7, listed under thromboangiitis obliterans, each underwent reamputation within six months and must therefore be classified as failures. Two cases (17 and 22) listed under arteriosclerotic gangrene are doubtful operative failures. The first underwent reamputation after his stump had healed and he had walked quite well. The reason for reamputation apparently was not breakdown of the stump. The stump of the second healed <i>per primam. </i>Fitted at an early date, the patient bore his weight chiefly on the stump for 18 months. Case 9, discussed under diabetic and arteriosclerotic gangrene, is considered a success. Not only did he wear his limb for nine years but his stump breakdown was occasioned by neglect and later circulatory failure from myocardial infarction. Cases 16 and 19 (arteriosclerotic gangrene) had well-healed stumps and were fitted but never wore their limbs to any useful extent. They are therefore recorded as failures.</p> <p>There are thus seven failures in 23 cases (roughly 30%). So marked is the prevalence of myocardial infarction in thromboangiitis obliterans at all ages that an electrocardiogram and cardiovascular examination are now part of our routine examination.</p> <h4>CASES OF THROMBOANGIITIS OBLITERANS</h4> <p>CASE 1. (W. E.)</p> <blockquote><p>Male, born 1891. Served in the Imperial Army, 1914-19. Wounded and had trench feet in service. On discharge, complained of painful feet and occasional cramp in right calf. Had two attacks of phlebitis. Was doing heavy work.</p> <p>Admitted to Christie Street Hospital 1924 with localized gangrene, dorsum of right foot, arising from infection between second and third toes. Severe pain. No pulse below the femoral on the right side, weak pulsation in dorsalis pedis and posterior tibial arteries on the left.</p> <p>Right Syme amputation 1925, healed <i>per primam. </i>Case followed until 1947, when patient returned to England. No trouble with stump. Increasing disability in left leg had forced change to light work. Arterial pulsation below the femoral had disappeared. Left radial pulse absent. Patient had not smoked since 1924.</p> <p>Patient failed to communicate further as promised.</p> </blockquote> <p>CASE 2. (R. G.)</p> <blockquote><p>Male, born 1900. Served in Army, 1915-19. V.D.S. on service. Subsequently worked as teamster in the bush. Had frequent mild attacks of frostbite. Patient's feet were cold in winter, scalded in summer. Had claudication of left leg 1934. In the winter of 1934-35, left foot was frozen, and gangrene of the left great toe developed. Amputation of toe was performed at local hospital. Wound did not heal for nine months.</p> <p>In February 1936, right foot was frozen, right fifth toe amputated. Wound failed to heal and gangrene extended. Patient was referred to a city hospital, where thromboangiitis obliterans was diagnosed and a right lumbar ganglionectomy was done in March 1937. In May and November, same year, toes were amputated. Gangrene extended slightly.</p> <p>In November 1937, patient was admitted to Christie Street Hospital with gangrene involving the distal third of the right foot. Marked equinus deformity. No palpable pulsation in arteries below the femoral on either side. Vein filling on the right, two minutes. Patient had suffered great pain and was practically a morphine addict.</p> <p>Right Syme amputation in December 1937. Slight necrosis at center of wound, but stump healed well. Patient fitted and walking in March 1938.</p> <p>Patient readmitted in April 1939 for disabling claudication of left leg. Findings as before, except that vein filling was 90 seconds. Left lumbar ganglionectomy done with excellent result. Patient seen February 1940, March 1943, April 1945, December 1946, and January 1947, all for minor infections, left foot, due to lack of cleanliness, a carbolic-acid burn, and an artefact. Left Syme amputation, performed July 1947, healed <i>per primam.</i></p> <p>Review in June 1948 showed excellent stumps. Patient walking well and working at woodcutting. Doing well 1953, when photograph of stumps (<b>Fig. 1.</b>) was taken. Death for coronary thrombosis in 1954.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Case 2 (R. G.). Anterior view of bilateral Syme stumps. Right (viewer's left), 16 years after amputation; left (viewer's right), six years. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>CASE 3. (T. A.)</p> <blockquote><p>Male, born 1886. Served in Army 1914-19. V.D.S. on service. Alcoholic. Onset vague pains in feet 1915. Nothing definite noted on discharge. Subsequent attacks of phlebitis, diagnosed as thromboangiitis obliterans 1928. Patient then had absence of pulsation both arteries right foot and in the left dorsalis pedis. Erythromelia was marked. Vein filling, 30 seconds. Admitted to Christie Street Hospital 1936. Right lumbar ganglionectomy in November 1936. Much improved. Admitted Christie Street in February 1937. Sudden onset gangrene right foot and leg. Right Gritti-Stokes amputation performed in March 1937. Healed well. Fitted with limb and walking, June 1937.</p> <p>Admitted Christie Street Hospital in February 1938. Gangrene of toes, left foot. No pulse below femoral. Left lumbar ganglionectomy, performed in March 1938, produced some improvement, but patient complained greatly of pain. Left Syme amputation, May 1939. Heel flap did not slough, but wound healed slowly. Well healed in November. Patient refused to bear weight on Syme stump and complained so bitterly of pain that a left Gritti-Stokes was carried out.</p> <p>Patient thereafter made no attempt at walking. Remained an invalid until death from coronary thrombosis.</p> </blockquote> <p>CASE 4. (R. E. C.)</p> <blockquote><p>Male, born 1909. In 1947, patient was admitted to a city hospital for a nonhealing infection, right great toe nail. Thromboangiitis obliterans diagnosed and bilateral lumbar ganglionectomy performed. Right great toe was later amputated, and wound healed slowly. In 1949 and 1950, two other toes, right foot, were amputated. Right below-knee amputation, done later in 1950, healed fairly rapidly with some sloughing of the flaps. Four months after amputation, patient was fitted with a prosthesis and walked well. Shortly thereafter stump broke down.</p> <p>Admitted to Sunnybrook Hospital, March 1951, with complete breakdown of end of below-knee stump. No pulsation below the femoral on either side. Left foot blanched sharply on elevation. Vein filling, 25 seconds.</p> <p>Right Gritti-Stokes amputation in May 1951. Healed <i>per primam. </i>Fitted with prosthesis August 1951, and walked well. Readmitted in 1952 with minor infection of left foot requiring only few days to heal.</p> <p>Working steadily as engineer, March 15, 1953. Sudden, severe pain in left foot, which rapidly changed color. Admitted to Sunnybrook Hospital. Purple discoloration, distal half of left foot, which did not change on application of pressure or on elevation. Discolored area insensitive. Vein filling, 25 seconds. Weak femoral pulse. Pain very severe in left leg and foot.</p> <p>Treated by rest, heat, dry dressing, Buerger's exercise, whiskey, and papaverine. Pain not controlled and gangrene extended. Left Syme amputation in April 1953. Healed well with slight necrosis in small area around scar. Patient fitted in June 1953. In September 1953, developed stump abscess, which was opened widely and packed open. Secondary suture, done one month later, healed well.</p> <p>Patient was walking well in June 1954. Returned to full-time work. Died suddenly in October 1954 from acute coronary thrombosis.</p> </blockquote> <p>CASE 5. (W. S.)</p> <blockquote><p>Male, born 1914. While in Army, developed phlebitis in right foot, and claudication ensued. Symptoms increased, and thromboangiitis obliterans was diagnosed. Right lumbar ganglionectomy done and patient discharged.</p> <p>Admitted to Christie Street Hospital in September 1947 with gangrene of left great toe and whole right foot extending to the leg. Condition grave. Had had steadily increasing doses of morphine but obtained little relief. No pulsation below the femoral, either side. Right guillotine amputation at level of tibial tuberosity, October 1947. Patient's condition improved rapidly and pain was largely relieved.</p> <p>Left lumbar ganglionectomy six days later with good result. Disarticulation of the left great toe in November, flaps left open. Right Gritti-Stokes and left Syme December 1. Gritti-Stokes healed <i>per primam, </i>Syme showed slight necrosis at suture line but was well healed in seven weeks.</p> <p>Patient was walking well in August 1948 (<b>Fig. 2.</b>). Has worked as limbfitter ever since. No trouble, either stump.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Case 5 (W. S.). Anterior and lateral views of left Syme stump 11 years after amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>CASE 6. (H. T. O.)</p> <blockquote><p>Male, born 1910. Sprained right ankle while in Army, pain and phlebitis in right leg subsequently. Thromboangiitis obliterans diagnosed and right lumbar ganglionectomy performed in 1943. Twice admitted to Sunnybrook Hospital in 1946, first with gangrene of fourth toe (amputated and healed), second with gangrene of great toe (amputated but did not heal). Right Syme amputation in January 1947. Heel flap did not slough, but wound did not heal. Right Gritti-Stokes, May 1947, healed promptly.</p> <p>In 1951, patient underwent left lumbar ganglionectomy and amputation of a gangrenous great toe, then passed into other hands. Subsequent history includes left mid-tarsal amputation, 1952; left Syme, 1953; left below-knee, 1954; left Gritti-Stokes, 1956.</p> </blockquote> <p>CASE 7. (W. P.)</p> <blockquote><p>Male, born 1899. Discharged from Army in 1919 with history of painful feet. In September 1939, developed phlebitis of right leg with rapidly increasing claudication. Three weeks after onset, patient could walk only a dozen yards.</p> <p>Admitted to Christie Street Hospital in November 1939 with ulceration and gangrene of fourth and fifth toes, right foot. Acute phlebitis at calf and at dorsum of foot. No pulsation in arteries below femoral, either side. On elevation of limb, color faded in two minutes. Vein filling, one minute.</p> <p>Old thrombosed veins on dorsum of left foot and in left calf. On elevation of limb, purplish color remained for three minutes. Vein filling, 30 seconds. Right lumbar ganglionectomy November 17, 1939. Right Gritti-Stokes December 19, 1939. Left lumbar ganglionectomy April 5, 1940.</p> <p>After the last operation, patient returned to work as repair man. No trouble until October 1949, when he had acute onset of pain in left foot and leg. Able to walk only a few steps. Left great toe was gangrenous, left foot livid, cold, and insensitive. Left Syme amputation performed April 1, 1950, at patient's request and against professional advice. Flap remained viable but never regained natural color; wound did not heal completely. Left Gritti-Stokes, performed June 1, 1950, healed <i>per primam.</i></p> <p>Walking on two Gritti-Stokes prostheses, patient was discharged in December 1950. Died August 1957, acute coronary thrombosis.</p> </blockquote> <p>CASE 8. (B. P. H.)</p> <blockquote><p>Male, born 1923. While in Army in 1944, sustained superficial wound of left leg. Healed, but scar frequently broke down. Patient was in Christie Street Hospital on another service in 1948 because of phlebitis and breaking down of wound scar. X-rays showed no retained foreign bodies. Femoral vein was ligated.</p> <p>In a 1949 diagnostic, examination was negative except for erythromelia. Diagnosis of thromboangiitis obliterans was indefinite but patient was advised to stop smoking.</p> <p>Admitted to Sunnybrook Hospital 1952. Two months previously had infection of the left great toe nail. Claudication appeared shortly thereafter. No pulse below femoral on left side. On elevation of limb, color faded slowly. Vein filling, 40 seconds. Marked erythromelia. All pulses palpable on right side. Vein filling, 15 seconds. Left lumbar ganglionectomy done with good result. Three weeks later guillotine amputation of the great toe was effected, and a month after that the stump of the great toe was disarticulated and flaps sutured. Wound healed in three weeks, and patient returned to work.</p> <p>Sudden onset of pain in right leg in December 1953 following infection and gangrene of right great, second, and third toes. Admitted to Medical Service and put on anticoagulants, Priscoline, and heavy doses of morphine. Medication discontinued upon transfer to Orthopaedic Services and papaverine and whiskey substituted. When blood coagulation was again normal, right lumbar ganglionectomy was performed. Eight days later, guillotine amputation of the distal half of foot was done. Right Syme amputation, three weeks after that. Good healing. Patient was walking well on prosthesis in May 1954. Has worked steadily since and has had no trouble.</p> </blockquote> <h4>CASES OF DIABETIC GANGRENE WITH ARTERIOSCLEROSIS</h4> <p>CASE 9. (R. G.)</p> <blockquote><p>Male, born 1901. When patient enlisted in 1940, it was noted that the left third toe had been amputated. Subsequently, it was found that he had had diabetes prior to enlistment. Lues evident. Admitted to Christie Street Hospital in October 1940 with osteomyelitis of the tarsus and gangrene of toes. Many sinuses. Dorsalis pedis pulse absent. Weak posterior tibial. Marked neurotrophic changes. Patient emotionally unstable.</p> <p>Left Syme amputation, 1941, healed well. Patient, fitted with prosthesis and able to walk well, neglected diabetic treatment and was readmitted in 1950 with ulceration in the amputation scar. Ulcer excised, stump healed. While still in hospital, patient had severe myocardial infarct and wound broke down. Gritti-Stokes was carried out.</p> <p>Patient never was active, although he walked fairly well. Died in August 1954 from acute coronary thrombosis. Autopsy showed marked aortic degeneration with mural thrombus. Peripheral vascular endarteritis.</p> </blockquote> <p>CASE 10. (A. E.)</p> <blockquote><p>Male, born 1893. Truck driver. Diabetes discovered in 1948 and patient put on diet. While in local hospital for fractured right tibia, was put on insulin. Admitted to local hospital in 1952 with ulcer on sole of right foot. With incomplete healing, patient returned to Iwork. Perforating ulcer developed, and patient was admitted to Sunnybrook Hospital in January 1955.</p> <p>Examination showed extensive soft-tissue infection about a perforating ulcer. No dorsalis pedis pulse. Weak posterior tibial. X-rays showed extensive osteomyelitis (neurotrophic foot). Marked calcification of vessels. Culture showed organisms resistant to all antibiotics except terramycin.</p> <p>Right Syme amputation January 31, 1955. Healed <i>per primam. </i>Fitted and walked well. Returned to work in November 1955. No trouble since.</p> </blockquote> <p>CASE 11. (W. W.)</p> <blockquote><p>Male, born 1900. Diabetes recognized in 1932. In 1949, following lapse in diet, developed gangrene and osteomyelitis of right foot. Much neurotrophic change. Pulses in feet weak. Right Syme 1949. Wound healed well. Patient worked as caretaker until December 1951, when he developed infection in a callus on the left foot. Ten days later was admitted moribund to Sunnybrook Hospital. Discharging sinuses on sole of left foot, lymphagitis, and femoral adenitis. No sensation in foot. Abscess in sole drained. Patient put on antibiotics, and carbohydrate metabolism improved.</p> <p>Guillotine amputation of left foot January 10, 1952, followed by marked improvement. Left Syme January 22, 1952. Some wound infection, but healed well in six weeks.</p> <p>Patient is still walking on two prostheses. Is not now working, but can walk to bathroom on stumps alone (<b>Fig. 3.</b>). Sectioned arteries in both stumps show marked endarteritis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Case 11 (W. W.). Front and side views of bilateral Syme stumps. Right stump (viewer's left), after nine years; left stump (viewer's right), after six yeais. Corresponding x-rays show bony proliferation from subperiosteal dissection of the flaps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /></blockquote> <p>CASE 12. (W. C.)</p> <blockquote><p>Male, born 1886. Diabetes diagnosed in 1948. Admitted to Sunnybrook Hospital in 1951 on Medical Service. Diagnosis: "Arteriosclerotic heart disease; peripheral vascular disease; diabetes with peripheral neuritis; lues; gangrene of right foot." No arterial pulsations below the femorals. Gangrene in distal half of foot. Right Syme done and well healed. Fitted with artificial limb on which patient walked well.</p> <p>Admitted 1953 with congestive heart failure and ulcer of left foot. Healed with bed rest.</p> <p>In 1954, dyspnoea, swelling of limbs, nephritis, ulceration (hot-water-bottle burn) on dorsum of foot.</p> <p>Admitted February 10, 1956. Died. Autopsy showed marked peripheral vascular disease, arteriosclerotic heart disease, and myocardial infarction.</p> </blockquote> <p>CASE 13. (A. J.)</p> <blockquote><p>Male, born 1886. Admitted to Sunnybrook Hospital in September 1949. One month previously had developed ulcer in bunion on left foot. Two weeks later great toe "became black." Patient was found to have severe diabetes, had recently lost much weight. Femoral pulse present, no pulse below. X-ray showed osteomyelitis of first and second metatarsals.</p> <p>Treated by bed rest, antibiotics, and dry heat. Fever continued, and pain increased. Great toe disarticulated October 5, 1949, and wound left open. Temperature normal 10 days later, patient much better.</p> <p>Left Syme amputation April 18. 1950. Arteries sectioned showed marked endarteritis obliterans. Stump healed well. Patient fitted in June 1950, discharged in September walking well.</p> <p>Patient admitted February 1951 with uncontrolled diabetes and jaundice. Had discontinued his insulin three months previously. Died June 10, 1951</p> </blockquote> <p>CASE 14. (W. R.)</p> <blockquote><p>Male, born 1872. Medical graduate. Diabetes diagnosed 1941, symptoms of polyuria and foot drop. Patient was put on diet and insulin. Did not follow diet strictly and stopped insulin in 1944.</p> <p>In September 1954, patient pared corn on right great toe. Infection spread over foot. Treated self. Healed in nine months.</p> <p>Infection, right great toe, December 1955. Hospitalized. Healed January 1956.</p> <p>Admitted to Sunnybrook Hospital February 26, 1956, with gangrene of great and second toes, right. Systolic blood pressure, 210; diastolic, 90. No pulsations other than femorals in right and left lower extremities. Treated by rest and antibiotics.</p> <p>Right lumbar ganglionectomy April 13, 1956. Right Syme May 3, 1956. Healed <i>per primam. </i>Fitted in August 1956. Patient gets about well on limb and states he is still (December 1958) fairly active.</p> </blockquote> <p>CASE 15. (R. C.)</p> <blockquote><p>Male, born 1896. Discharged from Army 1919. Diabetes diagnosed 1927. Did well on diet alone for three years. Then noticed numbness and coldness of feet. Health was poor. In 1941, patient developed septic arthritis of left knee and, later same year, of right ankle. Drained at local hospital.</p> <p>Admitted to Christie Street Hospital in February 1942, very ill. Sedimentation rate, 147 mm. X-rays showed destruction of outer condyle of left tibia and erosion of lower end of right tibia and upper margin of right astragalus. Ankle joint drained and knee drainage improved. <i>Staph, aureus </i>cultured from both.</p> <p>Condition improved, and carbohydrate metabolism was balanced in July 1942. Right Syme then performed, but destruction of lower end of tibia required section somewhat higher than usual. Stump healed in three weeks.</p> <p>In September 1942, left knee was excised. Patient fitted with prosthesis and walking well by January 1944. Continued to wear leg until sudden death in 1947, cause unknown.</p> </blockquote> <h4>CASES OF ARTERIOSCLEROTIC GANGRENE</h4> <p>CASE 16. (J. E. N.)</p> <blockquote><p>Male, born 1896. Was in good health until 1945, when intermittent claudication in left calf was noted on walking half a block. In June 1950, patient was put on Priscoline. In July, developed gangrene of fourth and fifth toes. Admitted to local hospital in August 1950 for left lumbar ganglionectomy. Fifth toe amputated, but wound failed to heal. In January 1951, patient underwent transmetatarsal amputation.</p> <p>Admitted to Sunnybrook Hospital September 20, 1951, in poor condition and in great pain. Stump foul with protruding bones. No arterial pulsations below femoral. Patient given choice of gamble with a Syme or almost certainty with a Gritti-Stokes. Left Syme performed September 24, 1951. Stump healed slowly but well. Patient discharged November 5, 1951, returned for fitting. Died of coronary thrombosis before limb could be issued.</p> </blockquote> <p>CASE 17. (L. G.)</p> <blockquote><p>Male, born 1880. Admitted to Sunnybrook Hospital in May 1954. Two years earlier had noticed claudication of left leg. Left inguinal herniotomy performed at local hospital in January 1954. Six weeks later, patient developed infection and gangrene of left third toe. Upon amputation of toe, gangrene spread rapidly involving distal third of foot.</p> <p>Weak femoral pulses. No pulsation in arteries, either foot. Left lumbar ganglionectomy May 12, 1954. Left Syme amputation May 26, 1954. Stump healed slowly but with little necrosis. Patient developed moderate flexion deformity at knee despite all efforts but was walking quite well in March 1955. Patient refused Veterans' care but did not wish to be discharged. Finally discharged walking well, September 1955.</p> <p>Patient returned to home town, where for reasons unknown leg was amputated at mid-thigh level. Syme stump had not broken down. Referred back to Sunnybrook in March 1956, patient had a 45-deg. flexion deformity of the hip and could not be fitted.</p> </blockquote> <p>CASE 18. (F. E.)</p> <blockquote><p>Male, born 1885. Worked as stableman. In summer of 1949, patient noticed fissure in skin on medial side of first tarsometatarsal joint, right. Consulted physicians and chiropodists, but an ulcer formed and increased until, when patient was admitted to a city hospital, it measured 1 in. x 1 1/2 in.. Given bed rest and antiluetic treatment, patient did not improve. Right lumbar ganglionectomy was performed with poor result.</p> <p>Admitted to Sunnybrook Hospital February 3, 1950. No pulsation below the femorals. Ulcer was inflamed and had become larger. Very severe pain. After treatment of a flexion deformity of the knee, a right Syme amputation was done in March 1950. Healing was complete by May. Slight marginal skin necrosis along suture line.</p> <p>Discharged September 1950 walking well on a prosthesis, patient has had no further trouble.</p> </blockquote> <p>CASE 19. (R. E.)</p> <blockquote><p>Male, born 1887. In 1939, had claudication in right leg. Right lumbar ganglionectomy done at a city hospital in 1940. Considerable improvement. In 1950, a left lumbar ganglionectomy was done for similar symptoms on the left side. In January 1951, left great toe nail became infected and was removed. Toe became red and swollen. Redness spread over whole foot, and toe became black. Large doses of morphine gave no relief for the severe pain.</p> <p>Admitted to Sunnybrook Hospital in March 1951 with gangrene affecting toes and distal third of foot. No pulsation below femoral, either limb. Left Syme amputation April 3, 1951. Completely healed May 13. Patient returned for fitting November 1951, died 1952 of coronary thrombosis.</p> </blockquote> <p>CASE 20. (G. E. O.)</p> <blockquote><p>Male, born 1881. Admitted to General Surgical Service, Sunnybrook Hospital, November 1950, intoxicated. Shotgun wounds both feet-superficial on left side, marked bony destruction on right. X-ray showed bony defect in right os calcis, numerous lead pellets in region of right heel. Wound debrided and plaster cast applied. Despite antibiotics, wound became infected and foot gangrenous.</p> <p>When, in February 1951, patient came under care of Orthopaedic Services, distal portion of right foot was gangrenous, and marked edema and cellulitis extended to ankle. No pulsation below femoral artery. Patient very ill. Abscess drained February 19, 1951. Eusol dressings. Right Syme February 28, 1951. Standard operation, except that no section was made of lower end of tibia or of malleoli. Wound left open. Pathological report on sectioned vessels: endarteritis obliterans. Patient improved rapidly.</p> <p>Right Syme completed March 14, 1951. Malleoli removed, but tibia not sectioned. Healing good, although a small sinus persisted until May 1951. Fitted in June, patient walked well.</p> <p>Hospitalized June 4, 1953, for infection about residual shot pellet. Discharged. Readmitted November 30, 1955, for bronchopneumonia and empyema. Discharged. No further trouble with stump, though health is poor.</p> </blockquote> <p>CASE 21. (J. A. S. J.)</p> <blockquote><p>Male, born 1876. A blind vagrant who had slept in an open boxcar while intoxicated, patient was admitted to Sunnybrook Hospital December 27, 1951, in moderate state of shock. Toes of right foot mottled but fairly warm. Distal third of left foot purple and showing no color change on application of pressure or on elevation of the limb. Left toes livid. No sensation in distal third of left foot. Edema in left leg up to knee. No arterial pulsation below the femorals.</p> <p>X-ray showed marked arterial calcification. Patient treated expectantly by antibiotics, rest and dry heat. Well-marked line of demarcation, left foot, by February 16, 1952. No loss of tissue of note, right foot. Left mid-tarsal amputation proximal to line of demarcation, March 4, 1952. Wound healed well. Stump was good, but patient walked poorly. Died February 1954.</p> </blockquote> <p>CASE 22. (W. R.)</p> <blockquote><p>Male, born 1890. Complained in 1953 of coldness and pain in feet, left being most affected. Admitted to a city hospital, where left lumbar ganglionectomy was performed. In 1954, following myocardial infarction. developed gangrene in the second and third toes on the left.</p> <p>Patient admitted to Sunnybrook Hospital in April 1955 on the Medical Service. Weak pulsation in arteries, right foot. Posterior tibial absent; weak dorsalis pedis, left foot. Gangrene extended and caused great pain.</p> <p>Left Syme amputation, March 1, 1956, healed <i>per primam. </i>Fitted with a prosthesis, patient had no trouble with stump. Right foot broke down, and weight was borne mainly on the amputation stump. By October 1957, patient walked with crutches and took weight on the stump only.</p> <p>By January 1958, stump showed bluish discoloration and was cold. Deep fluctuation appeared and was aspirated. Two c.c. of serosanguinous fluid were obtained. Skin was intact. Disarticulation at the left knee was carried out January 29, 1958. Wound healed <i>per primam, </i>but patient has not walked since.</p> </blockquote> <h3>SUMMARY</h3> <p>Between October 1920 and May 1956, I personally conducted or else supervised all Syme amputations performed in the DVA Hospitals at Christie Street and Sunnybrook. Uniformly satisfactory, they resulted in durable and stable stumps. In the cases owing to vascular disease with gangrene, the amputations were equally satisfactory. Six cases (2, 6, 7, 9, 17, and 22) required reamputation. Only two were subjected to amputation for failure of healing. One (Case 9) is considered a success. Two cases (16 and 19), while healed and fitted, died before use of their prostheses and are considered failures. Stumps were in active use for periods of 22, 17, 7, 12, 4, 9, 10, 7, 5, and 5 years, others for shorter periods.</p> <p>From my experience, I would venture to suggest:</p> <ol> <li>Lumbar ganglionectomy at an early date in all cases of thromboangiitis obliterans and, should gangrene develop, Syme's amputation.</li><li>In diabetic gangrene where carbohydrate balance can be maintained and where minor amputations have failed, Syme's amputation.</li><li>In selected arteriosclerotic (senile) gangrene where ganglionectomy and arterial resection and graft have failed to arrest gangrene, Syme's amputation. These patients should understand the great risk of failure.</li><li>In all cases of gangrene with infection, and in diabetics with infection where carbohydrate-metabolism disturbance is not yielding to treatment, a preliminary guillotine amputation.</li><li>Success in the Syme, or other type of tarsal amputation, gives a degree of activity otherwise impossible. Such cases may expect trouble in the other limb.</li><li>Amputation between the knee and ankle (below-knee) is not advisable in cases of severe vascular disease.</li><li>Amputations through the knee (Gritti-Stokes) are almost always successful in healing and give good walking comfort where the patient's condition warrants. Such patients frequently have severe cardiac and cardiovascular lesions, and activity may result in sudden death.</li></ol> <p>-G. M. D.</p> <p><b>References:</b></p> <ol> <li><i>Artificial Limbs and Their Relation to Amputations, </i>British Ministry of Pensions, His Majesty's Stationery Office. London. 1939.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Artificial Limbs and Their Relation to Amputations,British Ministry of Pensions, His Majestys Stationery Office. London. 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Gordon M. Dale, M.B. </b></td></tr><tr><td class="clsTextSmall">Present address: 84 Woodlawn Ave., E, Toronto, Ontario, Canada. Until his retirement in May 1956 as Chief of the Orthopaedic Service at Sunnybrook Hospital, Toronto, Dr. Dale had for more than 35 years (since October 1920) been in charge of all amputations for the Canadian Department of Veterans Affairs at Christie Street Hospital and at Sunnybrook. His patients have been drawn not only from World Wars I and II, the Korean War, the Boer War, and the Northwest Rebellion but also from many lesser campaigns in many parts of the world, from the Canadian Mounted Police, from the Canadian Department of Indian Affairs, and, until recently, from Canada's active Army. The cases here reported upon are of interest for at least two reasons-first because a goodly number were followed for periods ranging from five to 22 years (or until death from other causes), second because Dr. Dale either has performed the operation himself or else has served as the supervisor.-Ed.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Syme's Amputation for Gangrene from Peripheral Vascular Disease Creator An entity primarily responsible for making the resource Gordon M. Dale, M.B. * https://staging.drfop.org/files/original/b95e5342fe7eaaa21c950572d787fbda.pdf 22900e4b73ce0e89c1e8e6b35ce978e9 https://staging.drfop.org/files/original/69a206a2aa84ed680056a9fdc2139438.jpg d2cf4a108bb4637b1831508eed43a6bb https://staging.drfop.org/files/original/bbdcebf3e88af2b9c4154c6ab8600941.jpg 1742853ff042c4f63024eb1c3f70a128 https://staging.drfop.org/files/original/f6b252668fde0f741327f4ce578605b4.jpg d7e17f3201c463458fb90ab1fc6ed3c9 https://staging.drfop.org/files/original/072c8063021ab7603ec812365ca28462.jpg 844e15bf47ec63eb59e4d48548c2ffda https://staging.drfop.org/files/original/3f19c0d013a453a5a3aac4a18fd62be7.jpg 059db7ef417cd22394cde20c77c23ff8 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_03_115.pdf Text Any textual data included in the document <h2>An Alternative Technique for Fabricating Flexor Hinge Hand Orthoses Using Total Contact Molded Plastic Finger Pieces</h2> <h5>Greg Moore, R.T.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The flexor hinge hand orthosis is one of the most demanding orthoses for the orthotist to fit properly. The slightest error can result in failure of the orthosis and loss of patient confidence in the orthotist. Presented here is a technique for fabricating the orthosis with increased fitting accuracy and reduction of patient-practitioner contact time. The procedures presented here have been accumulated from the measurement and fabrication techniques of various practitioners (see acknowledgments) and assimilated into this single technique.</p> <h3>History</h3> <p>The flexor hinge hand splint was originally based on the principle of the flexor hinge hand as described by Nickel, Perry, and Garrett in 1955.<a></a> In the years that followed, it was developed by them and their co-workers, using the principle of the modified three-jaw chuck, in which the index and middle fingers move together towards the thumb. This is accomplished by immobilizing the thumb in a position of opposition and placing the index and middle fingers in a position of semiflexion at the inter-phalangeal joints. To prevent slippage of the object grasped, the thumb pad must oppose the pads of the two fingers.</p> <p>The flexor hinge is that part of the orthosis which hinges at the MP joint and holds the index and middle fingers in a functional position. The range of motion is from a position of full extension of the MP joints to a point where the finger pads contact the thumb. The orthosis is operated in one direction by internal or external power under voluntary control, and returned to the starting position passively, usually by a spring or gravity.</p> <p>The orthosis was originally developed to restore upper extremity function of patients with poliomyelitis. As the incidence of poliomyelitis decreased, the orthosis was used with other patients with severe upper-extremity paralysis such as cervical spine injury, hemiplegia, and brachial plexus injury. The results of treatment in these patients indicated that it is the degree of functional loss rather than the diagnosis that is significant. To a large degree, management of upper-extremity paralysis is the same regardless of the cause.<a></a></p> <h3>Fabrication Technique</h3> <p>After the patient has been assessed by the rehabilitation team and the orthotic design has been determined, the patient is seen by the orthotist.</p> <p>Appropriate measurements are taken and recorded for fabrication of the forearm and/or palmar pieces. Following this initial visit, the orthotist shapes and assembles the pieces according to the measurements, with special attention to accurate placement of the MP mounting plate for the flexor hinge finger piece. Temporary straps are also attached to the orthosis to eliminate migration of the orthosis during trial fitting. Other fabrication steps that can be completed at this time are the placement of temporary padding (if used) and the attachment of the adjustable actuating lever kit (Rancho style wrist-driven). The thumb post can be shaped, but should not be attached to the palmar piece until it has been properly fitted to the patient on the second visit.</p> <p>With the patient's second visit, the forearm and/or the palmar pieces should be fit to the patient and necessary adjustments made to provide for optimal fit and function. The thumb post is fit and attached to the palmar piece in the normal manner at this time. With this accomplished, the orthosis is placed on the patient's hand and secured with the temporary straps.</p> <p>The index and middle fingers are taped together at the distal phalanges using 1/4" masking tape, so as to keep the middle finger slightly longer than the index finger. A position of 35-40° of flexion at the MP joint, 30° of flexion at the proximal interphalangeal joint, and 5-10° of flexion of the distal interphalangeal joint is needed to position the fingers in opposition with the thumb.<a></a> When the positioning of the fingers has been accomplished to the satisfaction of the orthotist, the fingers and thumb are coated with a thin layer of petroleum jelly in preparation for casting.</p> <p>Four layers of 4" plaster bandage material are measured and cut so that the ends of the bandage extend over the ends of the fingers by 3/4" and at the other end over the proximal edge of the MP mounting plate by 3/4" (<a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-1.jpg"><b>Fig. 1</b></a>). The plaster bandage is then dipped in water and with the fingers held in a position of opposition to the thumb, the plaster bandage is placed over the dorsal aspect of the fingers. The edge of the bandage extends distally so that the tip of the thumb is included in the impression. Proxi-mally, the bandage extends over the MP mounting plate so that an impression of this is included. The bandage should not cover the volar (palmar) side of the fingers. The bandage is rubbed into the fingers, tip of the thumb, and the MP mounting plate to obtain a clear impression, and the edges of the bandage should be folded back approximately 1/4" to reinforce the borders (<a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-2.jpg"><b>Fig. 2</b></a>). After the bandage has hardened, it can be removed without the use of a cast saw by gently disengaging it from the MP mounting plate area and tilting it up over the fingers.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-1.jpg">Figure 1.</a> Preparation for casting fingers.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-2.jpg">Figure 2</a>. Cast impression incorporating MP joint plate and fingers.</strong><br /> <p>The proper length of the temporary straps should be marked and the fitted forearm and palmar pieces removed. The patient's hand can now be cleaned, and he/she can be scheduled for a final return visit.</p> <p>The impression is prepared for filling by enclosing it in plaster bandage and coating the inside with a thin layer of liquid soap. A small mandrel should be contoured to fit the inside of the impression, extending as far distally as the tips of the fingers to prevent fracturing of the positive model (a length of 1/2" O.D. aluminum tubing works well for this). The impression is filled with plaster of Paris and stripped, using great care not to fracture the positive model. The model will have good detail, showing the contours of the finger nails, skin lines, and MP mounting plate.</p> <p>The positive model is prepared for vacuum forming, using a length of nylon stocking as the interface for the 1/8" polyethylene. If Surlyn® is used, the Surlyn® is vacuum formed directly over the lightly smoothed impression without an interface. The clarity of Surlyn® facilitates visual assessment of pressure distribution when used with a sensation impaired hand. The plastic should be vacuum formed and not drape formed to insure an exact fit. Once the vacuum forming has been completed, the plastic piece can be removed by using a cast saw and carefully avoiding excessive damage to the impression. The finger piece is now ready to be trimmed using the following general guidelines.</p> <p>The distal border should be 1/8" distal to the proximal edge of the fingernails of the index and middle fingers. The proximal border should be trimmed to the proximal aspect of the proximal phalanges. In the coronal plane, the plastic piece is trimmed along the midline of the fingers. The plastic finger piece is then placed back on the positive impression and a stainless steel superstructure is fabricated using the MP mounting plate impression as the reference for the MP operating lever (<a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-3.jpg"><b>Fig. 3</b></a>). This saves an enormous amount of time since the reference between the palmar piece and finger piece is part of the positive impression. A regular Jaeco style proximal finger piece is used for the proximal bar of the superstructure, and a 3/32" rod connects it to a distal stainless bar located at the middle of the middle phalange. Both of the bars are silver soldered to the 3/32" rod and simply bent to the contours of the plastic finger piece.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-3.jpg">Figure 3</a>. Shows ease of aligning MP joint and finger pieces with MP joint included in the cast.</strong><br /> <p>The proximal finger piece is connected to the MP operating lever in the usual manner. A Velcro® closure can be attached to the distal superstructure bar on a stainless steel closure and can be fabricated using the bar as the dorsal half of the closure. With the finger piece completed and the remainder of the orthosis finished, the patient can be fitted and the orthosis delivered (<a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-4.jpg"><b>Fig. 4</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-5.jpg"><b>Fig. 5</b></a>). Patient training and minor adjustments are done following regular rehabilitation procedures.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-4.jpg">Figure 4.</a> Complete orthosis wih polyethylene finger piece.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-5.jpg">Figure 5.</a> Orthosis showing use of Surlyn® finger-piece for observation of the skin.<br /></strong><br /> <h3>Summary</h3> <p>Fabrication of the intimate fitting flexor hinge component of the flexor hinge wrist hand orthosis can be tedious. The procedure detailed here can facilitate fabrication of a more accurately fitting flexor hinge. The use of a vacuum formed finger section assures a total contact fit resulting in fewer pressure problems on the fingers. The optional use of Surlyn® for fabrication of the plastic finger piece permits direct skin observation when deemed beneficial.</p> <h3>Acknowledgments</h3> <p>I would like to express my special thanks and admiration to Jack E. Greenfield, CO. at Rancho Los Amigos Hospital and David Bird, CO. at University of Michigan Hospitals for their willingness to share their experience and knowledge.</p> <p><b>References:</b></p> <ol> <li>Nickel, V.L., Perry, J., and Garrett, A.L., "Development of Useful Function in the Severely Paralyzed Hand," <i>Journal of Bone and Joint Surgery</i>, 45:933, 1963.</li> <li>Rae, J.W., Jr.: Personal communication. Conference on Upper Extremity Devices, Rancho Los Amigos Hospital, Downey, California, May 15-16, 1957.</li> <li>Malick, M.H., and Meyer, C.M.H., "Manual on Management of the Quadriplegic Upper Extremity," Har-marville Rehabilitation Center, 1978, p. 39.</li> <li>Engel, W.H., Kmiotek, M.A., Hohf, J.P., French, J., Barnerias, M.J., and Sievens, A.A., "A Functional Splint for Grasp Driven by Wrist Extension." <i>Archives of Physical Medicine &amp; Rehabilitation</i>, January, 1967, pp. 43-52.</li> <li>Bisgrove, J.G., "A New Functional Dynamic Wrist Extension-Finger Flexion Hand Splint-A preliminary report, <i>Journal of Ass. Phys. Ment. Rehab.</i>, 8, September-October 1954, pp. 162-163.</li> <li>Redford, J.B., ed. <i>Orthotics Etcetera</i>. Baltimore, Md. Williams and Wilkins, 1980, pp. 238-248.</li> </ol> <em><b>Greg Moore, R.T.O. </b> At the time of writing, Greg Moore, R.T.O., was a student in the Long Term Orthotic Practitioner Program at 916 Vo-Tech. He may be reached at: c/o Bill Moore, 7366 S. Bannock Drive, Littleton, CO 80110.</em> <div style="width: 400px;"><br /><br /></div> Page Number(s) 115 - 118 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_03_115/1986_03_115-5.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 An Alternative Technique for Fabricating Flexor Hinge Hand Orthoses Using Total Contact Molded Plastic Finger Pieces Creator An entity primarily responsible for making the resource Greg Moore, R.T.O. * https://staging.drfop.org/files/original/d387177f1743b2d3eb2e5fd8a7efd4c6.pdf 5152d646cade58bf58af3b450a7b5ac2 https://staging.drfop.org/files/original/cf533beb527fcd368a66e40b0251877b.jpeg 746bfce96a05847c161f7f8919e43c51 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_04_001.pdf Text Any textual data included in the document <h2>S-N-S Knees and the Bilateral A/K Amputee</h2> <h5>Gustav Rubin, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>We have under our care at VAREC eleven adult male bilateral A/K <i>ambulators</i>. Ten of these use Swing and Stance (S-N-S) knees and one, a missionary to a remote area in Africa, was fitted with single axis knees because of the obvious need for simplicity in his special circumstances. Eight of our S-N-S users are active individuals, but two are household and limited community ambulators. As would be anticipated, all of our above-knee amputee ambulators are in good physical condition and strongly motivated. These were important aspects in prescribing prostheses. The S-N-S knees provided the amputees with the smooth gait characteristic of hydraulics, greater security, improved ease in reaching the sitting position, improved opportunity to recover from sudden stops or potential stumbles, better control when descending stairs, and the ability to lock one or both knees for negotiation of stairs. We have also found the S-N-S to be the sturdiest of the hydraulic units.</p> <p><b><a href="/files/original/cf533beb527fcd368a66e40b0251877b.jpeg">Image</a>: </b>A.H., an active bilateral A/K ambulator.<br /><br />No one of our amputee veterans demonstrates the potential of S-N-S knees better than A.H., injured in Vietnam at 21 years of age. A. H. was initially evaluated by the VAREC Clinic Team over one year later on Sept. 24,1970.</p> <p>A.H. sustained bilateral A/K amputations. The right A/K stump was eight inches in length and multiply scarred. The left A/K stump, partially covered by healed split thickness skin grafts, was seven and one-half inches in length. A.H. also sustained partial amputations of the fingers of both hands. The index and middle fingers of the left hand were amputated; on the right hand, the proximal phalanges of the fourth and fifth fingers and the first metacarpal of the thumb were retained. A.H. demonstrated that he was capable of grasping crutches with both residual hands. On the right he could come within an inch of opposing the first metacarpal to the fourth and fifth proximal phalangeal stumps. Opposition could be achieved on the left.</p> <p>A.H. was in excellent physical condition, very well motivated, without hip contractures, and with good muscle power of the trunk and residual extremities. He had been working out in his garage, which he had converted to a gym. When seen, he weighed 160 lbs. and indicated that his pre-amputation height was 6 feet, 1-1/2 inches (a height that was subsequently successfully reachieved at his request).</p> <p>The VAREC Clinic Team decided to prescribe bilateral A/K partial suction quad sockets with waist belt, rigid uprights and band, multiplex knees (to allow trial of several knee units "in the rough"), and, finally, a trial with first SACH feet, and then single axis feet. The S-N-S knee units and single axis feet were selected on the basis of A.H.'s performance with them.</p> <p>On May 13, 1971 A.H. walked to VAREC without a cane or crutches. After a subsequent trial with total suction and silesian belts he had to be returned to his original prescription, due to stump scarring.</p> <p>A.H. had been an accomplished skier prior to amputation and, on January 25, 1974, requested prostheses with which he could ski again. The clinic team notes of that date follows.</p> <p>"He has been informed that skiing will be dangerous. Nevertheless, he is anxious to try it, and, because of the morale factor and the intensity with which this patient wishes to ski, plus the fact that he was a skier prior to his leg amputations, the prostheses have been ordered." Outrigger ski poles with special adjustments for the hand grips were also prescribed.</p> <p>The first prescription was determined after another bilateral A/K skier was invited to visit the clinic team with his prostheses. That concept was copied and prostheses were supplied to A.H. with solid knees fixed at 45 degrees and correspondingly dorsiflexed feet. They were rejected shortly thereafter by A.H. since they allowed him to slide down only low slopes.</p> <p>The prostheses with S-N-S knees and single axis feet however, did allow him to actively ski. It is noteworthy that the most efficient position of his stumps, since he required strong abductor power for skiing, was found to be in sockets set up in almost twenty degees of abduction. Since the neutral position of the feet was more efficient for skiing the feet were not out-toed.</p> <p>A.H. proved his proficiency on skis (<a href="/files/original/cf533beb527fcd368a66e40b0251877b.jpeg">see photo</a>) by winning the handicapped Olympics in Norway in 1982. He has competed in numerous events in the U.S. and overseas and he reports that he can negotiate 40 slalom gates in 60 seconds.</p> <p>He has not been trouble free, however. The most serious of his problems occurred when a spur was removed from his left stump and overlying soft tissue breakdown occurred. Although this healed secondarily, the clinic team advised that the area be covered by adequate soft tissue. This was done and the amputee had no further difficulty. A.H. continues to be active and, in addition to skiing, sails his own boat.</p> <p>Not all amputees, however, follow the same road to successful ambulation. At one time, the clinic team believed they had two patients who had the potential and motivation to ambulate. The team provided prostheses but the patients became obese and gave up the effort. The rehabilitation of one, a triple amputee (BE on one side) was, unfortuntately, a notable failure.</p> <p><em><b><b>*Gustav Rubin, M.D. </b></b>FACS Chief, VAREC Special Clinic Team</em></p> <p><em>&nbsp;</em></p> Page Number(s) 1 - 2 Year 1983 Volume 7 Issue 4 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/1983_04_001/1983_04_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 S-N-S Knees and the Bilateral A/K Amputee Creator An entity primarily responsible for making the resource Gustav Rubin, M.D. * https://staging.drfop.org/files/original/5fbec4052a52f2f96c332992054740bd.pdf 20e1c68a1e68c26c17ebe0dcbed427db https://staging.drfop.org/files/original/1aa501ac55eba1dc5a0b97d8b3391563.jpg 1c3a60d6625ab486da03f8e2fc2f4e77 https://staging.drfop.org/files/original/16e17501c3eb200567a45563f807c9bd.jpg a2e25a04633c58de9d3fe329ed8a47d6 https://staging.drfop.org/files/original/6dc1d516628f4acd9f6a74eea19e37e0.jpg d80207c27684f55a49e165cd49c6f76a https://staging.drfop.org/files/original/f8ee04e92547ecb0cde7b37fab8d661f.jpg ecad7b10960f167cd183869d747a981e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_01_024.pdf Text Any textual data included in the document <h2>The Use of the AFO and PTB Orthoses for Severe Pes Planus</h2> <h5>Gustav Rubin, M.D., F.A.C.S.&nbsp;<a style="text-decoration: none;">*</a><br />Malcolm Dixon, M.A., R.P.T.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>When the severely deformed pes planus foot is rigid, the deformity fixed, and the arch totally dropped, to provide the patient with a conventional molded arch "support" is an exercise in futility. Placement of a shoe insert under the non-existent long arch cannot prevent further dropping on weight-bearing if the talar head is already in contact with the floor and the intertarsal joints are immobile.</p> <p>It is the purpose of this paper to report the use of the Ankle Foot Orthosis and Patellar Tendon Bearing Orthosis for such a situation.</p> <p>Because it would not be feasible to attempt to raise the arch of a rigid foot with an orthosis, the authors decided to employ an orthosis to decrease stresses on the foot and ankle by transferring push-off forces to an AFO.<a></a> This was to be accomplished by fabricating the orthosis with a solid ankle and modifying the shoe to incorporate a long steel spring and a rocker bar. Since it was anticipated that this approach might not provide adequate relief, it was considered that the next procedure would be to introduce partial unweighting with a Patellar Tendon Bearing Orthosis.<a></a> This would also be fabricated with a solid ankle and include a shoe with a long steel spring and a rocker bar.</p> <h3>Case Report</h3> <p>B.L., age 62, was initially referred to the VA Prosthetic Center on June 14, 1982, with a history of painful feet since World War II, which had become worse in recent years. The patient stated that "my feet are going to collapse and I can hardly walk and barely make it when I stand and walk." He had a cerebral vascular accident on January 18, 1982, but had made an almost complete recovery. There was also a history of aortic valve insufficiency and gout. The patient was receiving Coumadin, in-deral, digoxin, and allopurinal for his medical problems. He had not had relief of his foot pain from arch supports in the past.</p> <p>On examination there was noted medial downward dislocation of the talar heads, abduction of the forefeet, absence of the long arches, marked restriction of joint motion, marked splaying of the forefeet and severe hallux valgus, bilaterally (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-1.jpg"><b>Fig. 1</b></a>). The dorsalis pedis and posterior tibial arteries were palpable.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-1.jpg">Figure 1.</a> The severe bilateral pes planus noted when patient was first seen at VAPC.</strong><br /> <p>X-Rays confirmed the clinical findings of severe pes planus and hallux valgus bilaterally. The patient's private orthopedic surgeon had fit him with short AFOs (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-2.jpg"><b>Fig. 2</b></a>). These were a significant improvement over previous arch supports, but were bio-mechanically inefficient. Bilateral solid ankle AFOs and shoes with long steel springs and rocker bars were prescribed (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-3.jpg"><b>Fig. 3</b>)</a>.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-2.jpg">Figure 2.</a> Orthosis prescribed by patient's private orthopedic surgeon.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-3.jpg">Figure 3.</a> Bilateral AFOs and shoe corrections prescribed at the VAPC.</strong><br /> <p>On July 16, 1982 the patient reported that he was much more comfortable.</p> <p>When re-evaluated on October 21, 1982 it was indicated that the left side was subjectively worse than the right. He was experiencing very painful weight-bearing directly on the talar head. The "comfort" that he had reported in the previous note was relative. A PTB orthosis was prescribed for the left side (<a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-4.jpg"><b>Fig. 4</b></a>), in accordance with the originally outlined plan of procedure.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-4.jpg">Figure 4.</a> The final prescription included an AFO on the less symptomatic right side and a PTB orthosis for the left side.</strong><br /> <p>On April 19, 1983 the patient stated that the PTB was an improvement over the AFO.</p> <p>On August 7, 1984 he returned for a new orthosis because of loss of fit. The patient had lost weight following cardiac surgery for aortic valve replacement and triple bypass in March, 1984.</p> <p>On October 4, 1984 he reported that the new orthoses were "comfortable, that he feels much better with them, and is able to ambulate." He and his wife both stated that he "would not be able to walk" without these orthoses.</p> <h3>Discussion</h3> <p>Severe pes planus of the type described in this report can only be helped to a limited degree by orthoses. However, if a maximally efficient approach is employed, the limited degree of relief can be significant and allow an almost non-ambulatory patient to achieve a useful degree of ambulation.</p> <p>A solid ankle AFO not only functions to stabilize the ankle and foot, but when combined with shoe corrections (rocker bar and long steel spring), it acts to diminish the stresses on the foot and ankle. The PTB provides, in addition, partial unweighting while retaining the features that permit transfer of forces to the orthosis.</p> <p>We have employed the AFO in other similar instances, but this was the first occasion in which we employed the PTB for severe pes planus.<br /><br /><em><b>*Malcolm Dixon, M.A., R.P.T. </b>Malcolm Dixon, M.A., R.P.T., is Chief of Clinical Services at the Veterans Administration Prosthetics Center.<br /><br /><b>*Gustav Rubin, M.D., F.A.C.S. </b>Gustav Rubin, M.D. F.A.C.S., is Chief of Special Clinics at the Veterans Administration Prosthetics Center, 252 7th Avenue, New York City, New York 10001.</em></p> <p><b>References:</b></p> <ol> <li>Rubin, Gustav; Dixon, Malcolm; and Danisi, Michael, "VAPC Prescription Procedures for Knee Orthoses," <i>Orthotics and Prosthetics</i>, 31:3: pp. 9-25, September, 1977.</li> <li>Rubin, Gustav, "Patellar-Tendon-Bearing (PTB) Orthosis," <i>The Bulletin of the Hospital for Joint Diseases</i>, XXXIII:2: pp. 155-172, October, 1972.</li> </ol> Page Number(s) 24 - 26 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_01_024/1986_01_024-4.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 The Use of the AFO and PTB Orthoses for Severe Pes Planus Creator An entity primarily responsible for making the resource Gustav Rubin, M.D., F.A.C.S. * Malcolm Dixon, M.A., R.P.T. * 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/8c11b3cbe55906e1a1186e314abc12de.pdf 89e25364859efdc360a9591d8eafde92 https://staging.drfop.org/files/original/6cd45f3b1fecdd1934f70f5984f7f04e.jpg 17a303332067cd2cc381bb5fef3e72a9 https://staging.drfop.org/files/original/280c3bdf5f55120e4c0ff0ca8df2cef8.jpg 9a6fcac68852c85bdace0fecdbd25448 https://staging.drfop.org/files/original/e27129c49cee597181f097ae05458f31.jpg 70e3eb3d448acc0502e384554fc7add8 https://staging.drfop.org/files/original/09cab4907fea00930e6fcb6e8e4313e4.jpg 47629a5785f7d3b3038584a0bf02b2e2 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_04_171.pdf Text Any textual data included in the document <h2>Prostheses to Achieve Independent Ambulation for a Geriatric Quadruple Amputee</h2> <h5>Gustav Rubin, M.D., FACS&nbsp;<a style="text-decoration: none;">*</a><br />Fred Harris, B.S., CO.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The elderly quadruple amputee presents a challenge to a prosthetic clinic team. Although this problem is occasionally noted in children with congenital amputations,<a></a> it is much less commonly encountered in adults. During the past fifteen years there has been only one other total quadruple amputee-a young adult who was treated at our center and did not wish to have his case published.</p> <p>Here we have the opportunity to present a report on the prosthetic fitting of a 64 year old veteran who was referred to our Special Clinic Team in 1981, from the VA Medical Center in Cleveland, Ohio, with a history of quadruple amputations secondary to frost bite.</p> <p>H.F. was found on January 8, 1981, on a cold winter day, lying outside his home. He was unresponsive and had a rectal temperature of 77°. After a period of conservative care, amputations on all four limbs were done on February 4, 1981, at the private hospital in Canton, Ohio, to which he had been initially taken. The surgery resulted in a right wrist disarticulation, a left distal forearm amputation just proximal to the carpus, and bilateral below-knee amputations. The residual limbs healed without complications and the patient was transferred, on March 11, 1981, to the V.A. Medical Center in Cleveland, Ohio, where he was started on a course of physical and corrective therapy, including daily strengthening exercises to all four extremities.</p> <p>He was considered highly motivated and an "excellent candidate" for prostheses. He was referred to our center, which was then the V.A. Prosthetics Center, and was examined by the Special Prosthetic Clinic Team on May 21, 1981.</p> <p>H.F. also had a background history of gastrointestinal surgery ten years earlier for a perforated peptic ulcer. The report of the physical examination at the hospital prior to referral for prosthetic prescription revealed a normal cardiovascular examination, a blood pressure of 110/70, but a liver enlarged three cm. below the costal margin. The popliteal pulses were good.</p> <p>The evaluation by the clinic team confirmed that H.F. was well-motivated. He was an intelligent, cooperative, slender individual, whose amputations were all well-healed. The right below-knee residual limb measured 4 inches to the bone end and the left below-knee limb measured 4 1/2 inches to the bone end. There were mild knee flexion contractures which were not considered fitting problems. On the right below-knee limb there was a palpable, slight, irregular, distal anterior tibial bone prominence, unattached to the overlying tissues. On the left side the below-knee limb was poorly padded by soft tissue. As the examiner attempted to mimic piston motion of the soft tissue sleeve by drawing the soft tissue proxi-mally, the distal skin, overlying a slight bone irregularity, blanched. X-rays of the left below-knee residual limb confirmed the clinical impression of bone irregularity and x-rays of the upper extremities confirmed the right true wrist disarticulation and the left amputation just proximal to the carpus at the level of the distal radius and ulna.</p> <p>The amputee had been through a great deal (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-1.jpg"><b>Fig. 1</b></a>) prior to referral to the Clinic Team and it was the consensus, at this time, that referral for a lower extremity revision would have adverse impact on his motivation. It was the aim of the staff to make the patient as independent as possible by adapting the prostheses to his donning and doffing capabilities. PTS prostheses were prescribed to be fabricated with loops on the soft socket inserts (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-2.jpg"><b>Fig. 2</b></a>) to aid donning. The prostheses for the upper extremities employed a Northwestern ring for the figure of eight harness, double wall sockets, friction wrists, and Dorrance Lyre hooks.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-1.jpg"><strong>Figure 1. H.F., a 64 year old veteran and quadruple amputee.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-2.jpg"><strong>Figure 2. Below-knee prostheses were adapted with loops on the soft socket inserts to aid in donning.</strong></a><br /> <p>In addition, he was prescribed for platform crutches, which were modified with distal rings for the hooks and forearm loops (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-3.jpg"><b>Fig. 3</b></a>). The forearm loops had to be pre-adjusted into a fixed position so that H.F. could slip the prostheses through the loops and avoid the need for repeatedly adjusting the Velcro® straps.</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-3.jpg"><strong>Figure 3. Platform crutches were also modified with distal rings for the hooks and forearm loops.</strong></a><br /> <p>On June 11, 1981, fabrication of the below-knee prostheses was completed and the amputee demonstrated that he could stand and take several steps in parallel bars with assistance on each side. An exercise and training program with the prostheses was outlined at the hospital. The instructions included careful monitoring of the stumps during this time.</p> <p>On June 18, 1981, the amputee was observed to be doing "extremely well," as indicated by the clinic team's notes. By this time he had also been fitted with his upper extremity prostheses and forearm crutches. He rapidly progressed to unassisted ambulation with crutches (<a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-4.jpg"><b>Fig. 4</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-4.jpg"><strong>Figure 4. H.F. progressed to unassisted ambulation with crutches.</strong></a><br /> <p>When seen by the clinic team on August 10, 1981, H.F. walked with the aid of a platform crutch. Because of irritation over the right ulnar styloid process, which was unresponsive to modification of the socket, a new socket was prescribed incorporating a soft liner and he had no further problems with this.</p> <p>On September 16, 1981, four months after his initial presentation to the team, H.F., who had been under continuous training by the Rehabilitation Service at the VAMC, NY, demonstrated that he was able to don and doff his own prostheses and even walk without crutches. He did, however, have more confidence when using one crutch. He was advised to continue using at least one crutch at all times. He reported the prostheses to be comfortable. Objectively, they appeared to fit satisfactorily and they were accepted. The amputee was returned to the VA Medical Center in Ohio. Subsequent attempted follow-up has been unsuccessful.</p> <p><b>References:</b></p> <ol> <li><a href="http://www.acpoc.org/library/1977_11_001.asp">Sullivan, Richard A., and Celikyol, Felice, "Prosthetic Fitting of the Congenital Quadrilateral Amputee: A Rehabilitation-Team Approach to Care," <i>Inter Clinic Information Bulletin</i>, XVI:11-12, November-December, 1977, pp. 1-6.</a></li> <li><a href="http://www.acpoc.org/library/1972_11_013.asp">D'onofrio, F. and Cope, P.C., "Crutches for the Quadrimembral Amputee," <i>Inter Clinic Information Bulletin</i>, XI:11, August, 1972, pp. 13-15.</a></li> </ol> <em><strong><b>*</b>Fred Harris, B.S., CO</strong>. Fred Harris, B.S., CO., is also with STAMP, NY.</em><br /> <p><em><b>*Gustav Rubin, M.D., FACS </b> Gustav Rubin, M.D., FACS, is Director of the Special Team for Amputations, Mobility, Prosthetics/Orthotics, New York (STAMP, NY), 252 Seventh Avenue, New York City, NY 10001.</em></p> <br /><br /><strong></strong> Page Number(s) 171 - 173 Year 1986 Volume 10 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_04_171/1986_04_171-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prostheses to Achieve Independent Ambulation for a Geriatric Quadruple Amputee Creator An entity primarily responsible for making the resource Gustav Rubin, M.D., FACS * Fred Harris, B.S., CO. * https://staging.drfop.org/files/original/b6eb0984e5194084f16aa1bb9f96f8cf.pdf 9ceae6af2557c11b5e7c66bcaacd9215 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1978_04_003.pdf Text Any textual data included in the document <h2>Prostheses, Pain and Sequelae of Amputation, As Seen By the Amputee</h2> <h5>H. C. Chadderton&nbsp;</h5> <blockquote> <p>Reprinted from Prosthetics and Orthotics International, Vol. 2, No. 1, 1978, by permission</p> </blockquote> <p><i>The War Amputations of Canada, Ottowa, Ontario</i></p> <h3>Abstract</h3> <p>Results of a survey of 19 organizations belonging to World Veterans Federation indicate that major complaints of amputees include; poor fitting, poor dissemination of knowledge to doctors and amputees regarding new prostheses, lack of opportunity for "input" from amputees at research level and inadequate measures to deal with phantom and stump pain. Suggested improvements by amputees; decrease in weight of prostheses, reduction in maintenance for swing and stance-phase control units, development of recreational prostheses, more frequent checks through use of X-ray and film techniques, particularly during the "break-in" of a new appliance. Older veterans showed increasing concern in regard to development of consequential disabilities arising from amputation; premature arthritic changes in spine and remaining limb, circulatory problems and gastro-intestinal problems due to ingestion of drugs to control pain.</p> <h3>Introduction</h3> <p>With the co-operation of the World Veterans Federation, information was requested from 19 veteran organizations in 14 countries. Replies were received of varying significance from all. The enquiries were based on a questionnaire, the basic elements of which were:</p> <p><i>Legs</i></p> <p>Weight of the prosthesis.<br />SACH feet versus articulated feet.<br />Wearing of rubber-soled shoes.<br />Cosmetic appearance.<br />Soft socket versus hard socket, below-knee.<br />Plug socket versus quadrilateral socket, above-knee.<br />Swing phase control units, above-knee.<br />Modular versus standard limb.</p> <p><i>Arms</i></p> <p>Munster fitting versus harness.<br />Myo-electric hands.<br />Cosmesis—hands.<br />Wearing of prosthesis, above-elbow.</p> <p><i>Adjustment</i></p> <p>Do you see yourself in your dreams as an amputee?<br />Psychological effect of dismemberment.<br />Sequelae (medical) of amputations.<br />Recreational limbs.</p> <p>The replies to the questionnaire were, in the initial stages of review, sent to a computer firm for analysis. It was evident, however, that the response could not be measured in terms of "yes" or "no" and it was recommended that an attempt be made to obtain a "feeling" from the replies which might be useful. Therefore, this survey should not be considered as a fully accurate statement of response and the views herein must be seen in this light.</p> <p><i>Fitting</i></p> <p>It seems possible to draw a startling conclusion from the replies concerning comfort. It appears that many amputees were prepared to accept an uncomfortable fit as "part of the game".</p> <p>A significant number of amputees suggested that use should be made of X-ray and film techniques and of bio-mechanical devices in measuring the accuracy of a prosthetic fit.</p> <p><i>Information on new prostheses</i></p> <p>The amputees seemed to be overwhelmingly of the opinion that there was a lack of information on the part of medical doctors in this area.</p> <p>It was evident also that, with certain exceptions the amputees themselves were poorly informed on new prostheses. Understandably, a number of amputees commented that they knew far more about the new models of automobiles than about the new models of limbs.</p> <p><i>Input at the research level</i></p> <p>The respondees stated they were unaware of any concerted effort to obtain opinions from amputees concerning the types of research which should be done to improve prostheses. To be fair, some replies indicated that "amputee input" may be going on but they did not know about it. Significantly, however, they felt that there should be more liaison at the "user" level with the researchers.</p> <p><i>Pain</i></p> <p>Universally, phantom limb pain appeared to be a significant problem and the amputees felt that very little was being done to develop remedial measures. A review of the replies indicated that the usual advice was to take aspirin and a hot drink. Obviously this has not been effective and the amputee is looking for something more concrete.</p> <p>Many amputees complained also of stump pain, as separate from phantom limb pain, stating that massage, heat treatments and sometimes surgery had been successful in its elimination.</p> <p><i>Weight of prostheses</i></p> <p>There were two distinct "camps" in the replies, some 62 per cent wanted lighter prostheses but 12 percent stated some weight was essential and felt that good hardware should be used, despite additional weight.</p> <p><i>Feet</i></p> <p>No trend was evident on the question concerning SACH versus articulated feet. There was, however, a small but dedicated group of amputees who sincerely believed that an articulated foot was much superior. This group described the SACH foot as "too springy" or "unstable".</p> <p><i>Rubber-soled shoes</i></p> <p>By far the majority of leg amputees preferred rubber-soled shoes for stability and heel strike.</p> <p><i>Cosmetic appearance</i></p> <p>This did not appear to be a factor. However, the respondees were all war amputees whose average age would be 60 which is perhaps significant.</p> <p><i>Sockets</i></p> <p>By far the majority of below-knee amputees preferred a soft socket for reasons of comfort.</p> <p>The question on the plug versus quadrilateral socket for the above-knee amputee elicited the information that, for the most part, the quadrilateral socket users were well aware of the advantages, stating them as being "better circulation ", " more comfort", "easier standing", "taking the weight on the ischium", etc. Tragically, perhaps, many plug socket users were unaware of the difference between the two types.</p> <p><i>Controls</i></p> <p>The question concerning swing phase controls elicited a very high response, indicating that a large proportion of the amputees were not familiar with these devices. (We had not dared ask for information on stance phase controls as we were reasonably certain that the concept is not known to the majority of amputees.) It would seem, from the replies, that many more amputees would be prepared to try these devices if they knew of their existence!</p> <p><i>Modular versus exo-skeletal</i></p> <p>Here again the majority of the amputees replying (approximately 60 per cent) did not know the difference. There were, however, a dedicated group of modular users who recognized the advantages of alignment, light weight and cosmesis who were "sold" on modulars. Here again, a conclusion can perhaps be drawn regarding the necessity for the dissemination of more information.</p> <p><i>Munster versus harness fitting</i></p> <p>The answer was predictable. The below-elbow amputee is very partial to a light fitting for a passive hand. Alternatively, he seems to have a passionate love affair with his hooks and harness when he wants to do heavy work or engage in recreation. This was an area in which the amputee seemed to be fairly well satisfied, except as brought out below.</p> <p><i>Myo-electric hands</i></p> <p>There was a distinct feeling among World War II veterans that they had been passed over by the myo-electric stage. Many had apparently been told that they were too old to adjust to myo-electric fittings. The majority of the replies stated "yes" to the question of whether they would like an opportunity to be fitted with a myoelectric hand.</p> <p><i>Cosmesis</i></p> <p>The replies on cosmesis (or lack of it) for hands contained comments such as "disgusting" and "lack of sensitivity". Surprisingly, many hand amputees appeared to have no knowledge of the cosmetic skins and stated they were wearing either brown or black leather gloves over their passive hands.</p> <p><i>Wearing of prosthesis, above-elbow amputees</i></p> <p>The rejection rate was predictably high. Some farsighted individuals (amputated one side only) suggested that they should get used to wearing a prosthesis in the event that they developed medical difficulties in their other arm, arising from strokes, arthritis, etc. The second part of this question indicated there was little knowledge of lighter prostheses now available through the use of modular designs.</p> <p><i>Dreams</i></p> <p>The question on dreams was thrown in only for general interest. The respondees seem to divide 50-50 as to whether they visualize themselves as amputees in their dreams or not.</p> <p><i>Psychological effect</i></p> <p>Perhaps surprisingly, a large number of war amputees describe their feelings about the loss of their limb in terms of being "grief stricken", "lost my best friend", "embarrassed", etc. It should be remembered that this survey asked for truthful answers. Psychological effect is perhaps an area which we tend to ignore as it could be interpreted as indicating a lack of machismo, etc. The Adolph Meyer school of psychiatric thought may be of interest on this subject should any one wish to develop it further, that is, depression can follow from a physical disorder such as amputation.</p> <p><i>Sequelae</i></p> <p>Most of the replies indicated consequential disabilities. Leg amputees; bad backs, arthritis in the remaining leg and foot. Arm amputees; cervical pain, headaches. Both; gastro-intestinal problems which were believed due to ingestion of drugs as well as "inner tension" associated with the continuing discomfort of amputation. The respondees were careful to suggest they were not trying to prove their case, but felt that more study should be done upon the medical after effects and side effects of amputation.</p> <p><i>Recreational limbs</i></p> <p>This question resulted in possibly the most significant response. There were requests for special legs for swimming, golfing, skiing, tennis, rowing and motor sports. The arm amputees were almost frightening in their requests for the development of special prostheses for fishing, playing baseball, cricket (for holding bats), golf, tennis and rowing.</p> <h3>Conclusion</h3> <p>It must be said that the information presented in this paper was not the subject of any strict statistical treatment. In this sense this is not a "scientific paper". This highlights the problem of communication in this field between the consumer on the one hand and the professionals involved on the other. However, it is essential that such communication be fostered if energies and resources are to be channelled in the most fruitful direction. It is hoped that against this background the views contained herein will prove useful, highlighting as they do the opinions of a substantial number of patients.</p> Page Number(s) 3 - 5 Year 1978 Volume 2 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 Prostheses, Pain and Sequelae of Amputation, As Seen By the Amputee Creator An entity primarily responsible for making the resource H. C. Chadderton  https://staging.drfop.org/files/original/9719948f0ff1fbce02da39e6232a4372.pdf 5e4f12bcbae522e74f4012c60724a3a5 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_03_011.pdf Text Any textual data included in the document <h2>Evolution of the AK Socket</h2> <h5>H. R. Lehneis, Ph.D., CPO&nbsp;</h5> <p>The lead article for this issue of <i>C.P.O</i>., "Sockets, Linings, and Interfaces," by Dr. Eugene Murphy represents the culmination of many years of research, writing, and studying the principles of socket design and interfaces.</p> <p>Admittedly, very little advance has been made in AK socket design since the development of the total contact socket. Today, the principles espoused by Dr. Murphy of selective flexibility/rigidity of socket interfaces can be realized in clinical practice.</p> <p>There is a pressing need to re-evaluate the traditional quadrilateral AK socket design in light of the drastic changes over the years in the amputee patient population. Today, the vast majority of AK amputees are geriatrics—a complete reversal from the time of development of the quadrilaterally-shaped socket. Most practitioners would agree that the most prevalent complaint of geriatric amputees is discomfort. This is not surprising, considering that most geriatric amputees suffer from reduced muscle tone, sensation, and vascularity.</p> <p>Thus, it has been proposed by this author to re-examine the cross-sectional configuration of AK sockets to specifically address the physiological alterations in stump shape and consistency of geriatric amputees, to evolve a socket design specific for this patient population. Such new configuration, combined with contemporary interface materials, e.g., silicone, copolymer inserts, and selective flexibility/rigidity, should lead to much improved physiological and biomechanical function and comfort (see <a href="cpo/1984_01.asp">Winter issue <i>C.P.O.</i>—Vol. 8, No. 1</a>).</p> <p>Other attempts to improve comfort are seen in Scandinavian socket designs in which the entire socket is semi-flexible except for the medial wall and a portion of the proximal brim area. In the Ockenfels design, the socket contains selective fenestrations and an inner elastic cloth liner or sock to prevent window edema. The so-called Contoured Adducted Trochanteric Controlled Alignment Method (CAT-CAM), developed by Sabolich, is to not only improve comfort but supposedly the patient's gait pattern.</p> <p>Now that these new developments are emerging, it seems rather puzzling, in retrospect, that there was such a long hiatus in the application of soft or flexible interface materials in AK sockets. And so it appears that we are on the verge of a major breakthrough, particularly in AK socket design and interface materials. Though not universally practiced, these noteworthy developments will change the practice of prosthetics in dramatic ways to improve comfort and function our patients so much deserve.</p> Page Number(s) 11 - 11 Year 1984 Volume 8 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evolution of the AK Socket Creator An entity primarily responsible for making the resource H. R. Lehneis, Ph.D., CPO  https://staging.drfop.org/files/original/eaf0a7b425c90dc8b9205c09b4cfeddd.pdf 15e97b748c74abe2a1ca3e141ad14231 https://staging.drfop.org/files/original/b4340fe7dc6294b06bd93a46a9eefcfb.jpg 106945255e1ae54dde98455ab0a3f13e https://staging.drfop.org/files/original/eb21a4e75152f4ff61417686c70f9188.jpg 2bfb40cb9fe53bb031b025e027a5cc4b 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/1980_01_001.pdf Text Any textual data included in the document <h2>Prosthetics Up-Date 1980: Foot and Knee Components</h2> <h5>H. Richard Lehneis, Ph.D., C.P.O.&nbsp;</h5> <p>This paper is, in part, based on a lecture given by the author at the International Congress on Technical Orthopedics, 1979, in Nurenburg, Germany.</p> <p>The data relating to prosthetic foot and knee components was obtained from a survey of the relative sales volume of the various components by three of the largest U.S. distributors of prosthetics components from practically all manufacturers. The distributors cooperating in this were Knit Rite, Inc., Kansas City, Missouri; Northeast Paramedical Industries, New York, New York; and PEL Supply Company, Cleveland, Ohio.</p> <p>These firms were requested to provide the relative percentage of sales of the various foot (<b>Table 1</b>) and knee components (<b>Table II</b>), rather than the absolute volume of sales. The table on knee components includes conventional versus modular constructions. The average (mean) percentages &nbsp;of the various prosthetic feet and knee components sold by the three firms are listed in the last columns of Tables I and II respectively. On the basis of these data, one may infer current prescription and fitting practices in the United States.</p> <p>An attempt to get similar data on below-knee and above-knee suspension systems, based on the percentage of sales of supracondylar cuff, BK side joints, hip joints, suction socket valves, and Silesian belts, appeared not valid after analysing the data collected because of the possibility of various combinations of suspension systems that may be prescribed and used. It is, therefore, hoped that readers of the Newsletter will return the questionnaire on Page 10 which addresses the subject of BK and AK sockets and suspension systems with due consideration of the various possibilities of combination of suspension systems.</p> <h3>Discussion</h3> <p>Referring to <b>Table 1</b>, there appears to be a vastly increased use of SACH feet versus other types of prosthetic feet. This may be interpreted in terms of the far greater frequency in recent years of BK versus AK amputations due to improved surgical techniques. Although, from the author's experience, it appears that SACH feet are used to an increasing extent and with great frequency in AK prostheses. <img src="/files/original/b4340fe7dc6294b06bd93a46a9eefcfb.jpg" br="" /><br /><br />In <b>Table II</b>, one notes a surprisingly low use of hydraulic mechanisms. This may be interpreted in terms of the increase in the geriatric population who, in general, do not benefit as much as younger amputees from the hydraulic systems. Support for this interpretation may be viewed in the larger percentage of safety knees, and single-axis knees with manual knee locks used which total 66 % of all knee units sold.<img src="/files/original/eb21a4e75152f4ff61417686c70f9188.jpg" br="" width="440" height="525" /></p> Page Number(s) 1 - 2 Year 1980 Volume 4 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1980_01_001/1980_01_001-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1980_01_001/1980_01_001-2.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 Prosthetics Up-Date 1980: Foot and Knee Components Creator An entity primarily responsible for making the resource H. Richard Lehneis, Ph.D., C.P.O.  https://staging.drfop.org/files/original/f84bb0c475ca9d030e23df9e4e80658d.pdf 94375248bcccdaeab873ef4e4c97c777 https://staging.drfop.org/files/original/6ec0d5b59e7d232d595707c15372a97c.jpg de00e861806273a4296343544b6bf106 https://staging.drfop.org/files/original/15c0eaaa0b4778e274016ee3e4f0eaef.jpg 2a616dc0bb2ebcf0e39110254f7214fe https://staging.drfop.org/files/original/5349fa590d8d8b526c3f243a7bd1bdd1.jpg f22b164a89f5fea857cfaad0f802eacc https://staging.drfop.org/files/original/cab9f2ad9f641a085d9079b6e82bbc7e.jpg 98f7040eb022de51e27dbc7ee91ab790 https://staging.drfop.org/files/original/544d0554c74d2d5950384e2e1dfd6aff.jpg 559149ef240dff1d7a44a72d9e261ebf https://staging.drfop.org/files/original/cbd70b676214f45b70d3cf9ff79514fd.jpeg 355eedf11c055b25646f742ec329eb73 https://staging.drfop.org/files/original/9872c7817353817cc6a62cc57c60d007.jpeg f54103ca4b7342b6319599df2a9f0aeb 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/1980_02_003.pdf Text Any textual data included in the document <h2>Plastic Ankle-Foot Orthoses: Indications and Functions</h2> <h5>H. Richard Lehneis, Ph.D., C.P.O.&nbsp;</h5> <p>Prescription of plastic ankle-foot orthoses at the Institute of Rehabilitation Medicine, New York University Medical Center (IRM-NYUMC) has, over approximately the past 12 years, been based on the identification of a pathomechanical condition affecting the ankle-foot complex for the purpose of matching that condition with a bio-mechanical device (plastic ankle-foot orthosis). Over the years, this basic system has been improved to include modifying factors such as spasticity and sensory status.&nbsp;<br /><br /><b>Table I</b>.<br /><img src="/files/original/6ec0d5b59e7d232d595707c15372a97c.jpg" p="" /></p> <p><b>Table II.</b><img src="/files/original/15c0eaaa0b4778e274016ee3e4f0eaef.jpg" nbsp="" represents="" an="" elaboration="" of="" the="" system="" in="" describing="" addition="" to="" indications="" bio-mechanical="" actions="" each="" ankle-foot="" orthosis="" as="" well="" contraindications="" afo="" s="" described="" is="" shown="" b="" /><br /><br /><strong>Fig. 1</strong>, <b>Fig. 2</b>, <b>Fig. 3</b>, <b>Fig. 4</b>, and <b>Fig. 5</b>.<br /><strong><br /><a href="/files/original/5349fa590d8d8b526c3f243a7bd1bdd1.jpg">Figure 1.</a> Posterior Leaf Spring Ankle Foot Orthosis.</strong><br /><br /><strong><a href="/files/original/cab9f2ad9f641a085d9079b6e82bbc7e.jpg">Figure 2</a>. Hemi Posterior Leaf Spring Ankle Foot Orthosis.</strong><br /><br /><strong><a href="/files/original/544d0554c74d2d5950384e2e1dfd6aff.jpg">Figure 3</a>. Spinal Ankle Foot Orthosis.</strong><br /><br /><strong><a href="/files/original/cbd70b676214f45b70d3cf9ff79514fd.jpeg">Figure 4</a>. Hemi Spiral Ankle Foot Orthosis.</strong><br /><br /><strong><a href="/files/original/9872c7817353817cc6a62cc57c60d007.jpeg">Figure 5</a>. Posterior Solid Ankle Foot Orthosis.<br /></strong></p> <p><b>Table I</b> and <b>Table II</b>&nbsp;have been used successfully in the training of physicians, orthotists, therapists, and other health-related personnel. We hope that the readers of the Newsletter find these tables useful in their respective clinics to clarify indications and contraindications for the various AFO's.</p> Page Number(s) 3 - 6 Year 1980 Volume 4 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1980_02_003/1980_02_003-3.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1980_02_003/1980_02_003-4.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1980_02_003/1980_02_003-5.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1980_02_003/1980_02_003-6.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1980_02_003/1980_02_003-7.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 Plastic Ankle-Foot Orthoses: Indications and Functions Creator An entity primarily responsible for making the resource H. Richard Lehneis, Ph.D., C.P.O.  https://staging.drfop.org/files/original/b3bb30209b6e347e141d9887fbe0dd84.pdf 8fe2d7fe613164fa18efa52b86f36da9 https://staging.drfop.org/files/original/5bc93a35ec2adce600c9b2fec1513009.jpg 0fe31995eb047f4d749816ffeec36e4c https://staging.drfop.org/files/original/570eebfc4bc5a5450dc2cee53a1356dd.jpg a27208224d59514e3a6eaab581dc3c90 https://staging.drfop.org/files/original/4af954f59f49c76eabdab685dc5eab40.jpg 319799db788cc6ab393c7443e79399a0 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 http://www.oandplibrary.org/cpo/pdf/1984_04_026.pdf Text Any textual data included in the document <h2>Orthotic Pelvis Control in Spina Bifida</h2> <h5>H.R. Lehneis, Ph.D., C.P.O.&nbsp;</h5> <p>Control of the pelvis has been typically problematic in high level spina bifida patients due to the imbalance of motor power around the hip joint. This can be readily appreciated when one considers the differential innervation particularly of the hip flexors versus the hip extensors (<b>Table 1</b>). Note that the hip flexors are at least partially innervated at the L2 and L3 level, whereas the hip extensors are innervated below the L3 level. Such imbalance at the L2 and L3 level of involvement is the cause of lordosis so often seen in these patients, which is often aggravated by hip flexion contractures. Control of the pelvis and thus lordosis has been difficult with conventional designs.</p> <strong>Table 1. Innervation of the Lower Limb</strong><br /><img src="/files/original/5bc93a35ec2adce600c9b2fec1513009.jpg" p="" width="469" height="684" /><br />In analyzing the force system required to prevent hip flexion and thus lordosis, it becomes clear that the rigid portion of the pelvic band needs to be reversed from the conventional location (<a href="/files/original/570eebfc4bc5a5450dc2cee53a1356dd.jpg"><b>Fig. 1</b></a>). It should be noted that this consists of a plastic molded Subortholen panel which extends superiorly to the level of the xyphoid process. The uprights of the hip joints are attached to this panel. An anteriorly directed force is provided by a leather hammock covering the buttocks (<a href="/files/original/4af954f59f49c76eabdab685dc5eab40.jpg"><b>Fig. 2</b></a>). Straps attached on each of the four corners of the hammock run through D rings, attached equi-distant above and below the orthotic hip joint center. This system has worked quite effectively in controlling lordosis since first initiated approximately five years ago. <p>In cases where the patient presents a relatively severe hip flexion contracture, the hip joint uprights are attached to the panel by means of a single pivot placed approximately 5 cm. below the lateral trim line of the panel. By gradually tightening the straps of the buttock pad, some correction can often be achieved. The pivot allows the anterior panel to adapt to the changing angulation as correction is attempted.</p> <p>It should also be noted that in our practice, patients up to the age of approximately six years old are provided with solid ankles and knees since their legs are still short enough to sit through hip flexion without obstructing much of the space in front of the chair. The purpose of this is to provide the patient with maximum stability and lightweight orthoses. As the patient gains upper limb strength and mobility, knee joints with drop locks are added, usually of the lateral single bar type. Double bars are only used when the patient is relatively heavy and when there is a torsional problem in the orthosis. The ankle-foot portion of the orthosis remains of the solid ankle type to provide the largest possible base of support over which the patient's center of gravity can be maintained with a greater degree of latitude than is possible if orthotic ankle joints were to be used.</p> <h3>Acknowledgment</h3> <p>The assistance of Barry Gosthnian, CPO in developing the system described is gratefully acknowledged.</p> Page Number(s) 26 - 28 Year 1984 Volume 8 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1984_04_026/1984_04_026-3.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_04_026/1984_04_026-1.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_04_026/1984_04_026-2.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 Orthotic Pelvis Control in Spina Bifida Creator An entity primarily responsible for making the resource H.R. Lehneis, Ph.D., C.P.O.  https://staging.drfop.org/files/original/6f9164852f923d934924fa8fcf1f17fc.pdf 1b58d80ae3b0054e7a4e88d749254638 https://staging.drfop.org/files/original/e16607ccd46c9c7e42dd07751d977682.jpg 8eaff6854b224c7b799187bdded6988d https://staging.drfop.org/files/original/2166b64e7aaf0c784c32236c01c93747.jpg 410b2c45e6cf4b741c28fe03999558fd https://staging.drfop.org/files/original/331bf1cb4de93a9584b33553af58c3f7.jpg f1b22d42a14fec42d03dc4b116e3a685 https://staging.drfop.org/files/original/df476f11eb4ab1fd182da42ae9133165.jpg 18ded7ff78503d7a542bdbb93f7fa5fa https://staging.drfop.org/files/original/18d2e38e612b0c2cbc33f88021561703.jpg 3c1da62f89d9fe83a64335c1b8383f6a https://staging.drfop.org/files/original/c9afab133e1b7a0100fb05064a779272.png 2ba2e902e2ced64b216af2c281388060 https://staging.drfop.org/files/original/55b9142f83521a8a0e523c679963214e.png 6960cb5288eaf7123f81be484479e8d3 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_01_006.pdf Text Any textual data included in the document <h2>Flexible Prosthetic Socket Techniques</h2> <h5>H.R. Lehneis, Ph.D., CPO&nbsp;<a style="text-decoration: none;">*</a><br />Don Sung Chu, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Howard Adelglass, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The continuous development and availability of new materials of various kinds, e.g., elastomers, copolymer thermoplastics, and composite materials have brought a potentially revolutionary development in the design, configuration, and fitting principles of prosthetic sockets, especially for above-knee prostheses. All of this may result in greater patient comfort, physiological, and psychological advantages.</p> <p>Improvements in socket comfort with concomitant physiological and psychological benefits are not only due to the materials themselves, but rather, the inherent characteristics of the various materials used permit socket configurations heretofore not possible. For example, socket fenestrations over selected or entire stump surface areas are now possible. The desirability and principle of permitting greater flexibility over muscular areas than is possible in a rigid, laminated socket were appreciated more than 25 years<a></a> ago in the fitting and design of the "Flexi-cage" socket<a></a> which consisted of nylon cords strung between the proximal brim and the distal end of the socket. McCollough, et al.,<a></a> as early as 1968, attempted fenestrations over selected socket areas. These attempts, however, were not generally successful because of the potential and real problems with window edema and the properties of the material used. These problems now have been overcome through the availability of materials which can be used as elastic or semi-elastic inserts, preventing window edema, yet permitting removal of the outer rigid socket shell in selected areas.<a></a></p> <p>Below are described several approaches allowing flexible or semi-flexible stump containment, while maintaining the essential biomechanical characteristics required for interface stability to transfer body weight through the prosthesis to the ground, and for dynamic and safe control of the prosthesis.</p> <p>Two systems are curently used at the Institute of Rehabilitation Medicine at NYU Medical Center (IRM-NYU) to provide the characteristics described above. The first system consists of an inner socket laminated of Perlon fiber and silicone elastomer contained in a rigid plastic laminated socket (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-1.jpg"><b>Fig. 1</b></a>). The laminated silicone elastomer has nearly perfect memory and permits fenestrations of the rigid outer socket over the posterior area (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-2.jpg"><b>Fig. 2</b></a>), rectus femoris (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-3.jpg"><b>Fig. 3</b></a>) and the adductor group, without causing window edema. This design permits greater muscle expansion than the designs described below because of the elasticity of the silicone material. It also provides enhanced sensory feedback, particularly when sitting, i.e., the patient is able to feel the surface of the chair or seat. The soft liner is also a boon to improved comfort, particularly in geriatric amputees and those with a history of general socket discomfort.</p> <p>The second design utilized at IRM-NYU is a Surlyn® inner socket (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-4.jpg"><b>Fig. 4</b></a>) which permits removal of even more of the hard outer laminated socket (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-5.jpg"><b>Fig. 5</b></a>). The reason larger areas of the hard socket can be removed is the lesser flexibility of Surlyn®. Thus, more rigid material can be eliminated without compromising the integrity of known biomechanical principles (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-6.jpg"><b>Fig. 6</b></a>).</p> <p>A more recent design developed in Iceland and further refined in Sweden and at New York University, known as the ISNY socket, consists of a medical rigid frame only, leaving the rest of the polyethylene socket semi-flexible.</p> <p>For below knee amputations, similar systems have been developed at IRM-NYU and in Belgium by Van Rolleghm of CEBELOR.<a></a> In the IRM-NYU system, a Surlyn® inner socket permits removal of material in the outer laminated socket over bony or pressure sensitive areas (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-7.jpg"><b>Fig. 7</b></a>). This permits easy inspection of these areas and ease of adjustment by heating the inner socket to further relieve painful areas.</p> <p>The CEBELOR consists of a silicone laminated soft socket insert for the SP-SC below-knee prosthesis. Thus, it is self-suspending, provides improved comfort, and permits selected fenestration over pressure sensitive areas, e.g., head of the fibula, distal end of the tibia. To prevent slippage and rotation of the inner silicone socket, distal and posterior plugs are laminated as an integral part of the soft socket to fit into female counterparts in the plastic laminated socket.</p> <h3>Summary</h3> <p>While the various systems described above employ different materials and socket configurations, certain characteristics are common to all systems. These are: improved muscle physiology due to greater socket flexibility; enhanced sensory feedback; quicker heat dissipation due to thinness of the flexible stump containment material; and improved comfort, especially in the IRM-NYU and CEBELOR systems with the soft silicone liner.</p> <p>All these are important improvements which were made possible through the use of flexible or semi-flexible materials. Yet, the biomechanical principles of providing stump containment, weight transfer, and control of the prosthetic limb are not compromised. In the ISNY System, however, it is not clear how lateral and anterior/posterior stability of the femur is achieved, since there are no structural components in areas conventionally considered to provide such stability. This question, however, will be addressed in studies to be conducted in the near future.</p> <h3>Acknowledgments</h3> <p>The participation of Donald Fornuff, CP, and Roger Chin, CPO, in the development of the IRM-NYU systems is gratefully acknowledged.</p> <p><b>References:</b></p> <ol> <li>Bach, Johann; Essen, Germany, personal communication, 1958.</li> <li>Fillauer, Carlton; Chattanooga, Tennessee, personal communication, 1983.</li> <li>McCollough, Newton, and Sinclair, William, "Some Considerations in Management of the Above-Knee Geriatric Amputee," Artificial Limbs, 12:2, 28-35, Autumn, 1968.</li> <li>Ockenfels, Peter; Columbus, Ohio, personal communication, 1983.</li> <li>Sabolich, John; Oklahoma City, Oklahoma, personal communication, 1983.</li> <li>Van Rolleghm, Jacques; Brussels, Belgium, personal communication, 1983.</li> </ol> <div style="width: 400px;"><em><b>*Howard Adelglass, M.D. </b> Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU).</em><br /><br /><em><b>*Don Sung Chu, M.D. </b>Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU). </em><br /><br /></div> <div style="width: 400px;"><em><b>*H.R. Lehneis, Ph.D., CPO </b> Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU).</em><br /><br /><br /></div> Page Number(s) 6 - 8 Year 1984 Volume 8 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-5.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/1984_01_006/1984_01_006-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-7.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 Flexible Prosthetic Socket Techniques Creator An entity primarily responsible for making the resource H.R. Lehneis, Ph.D., CPO * Don Sung Chu, M.D. * Howard Adelglass, M.D. * https://staging.drfop.org/files/original/28274e1bdc8b1f42b700c9e81f28597f.pdf c98bd0663a677efb5cc36261b7c4cb7f https://staging.drfop.org/files/original/b6970149668330ce776434d9198152e3.jpeg 731206ce838388691e18855abcf7eb68 https://staging.drfop.org/files/original/a0bf70a49a9e3db596969c11b0c2c69c.jpg 23969c8fa88696d9a5addf89f363da7e https://staging.drfop.org/files/original/8a915c80bd9484bb8ab1b9a594fe6c66.jpg 7494d39a35704017937591467700f667 https://staging.drfop.org/files/original/f5da1243900128485bea8bd5f391499b.jpg beeee6ab4ded6b95b152fb192d126b8d https://staging.drfop.org/files/original/9ecbbc7b6c0294a18f4bb82b168db309.jpg a3cccb644afd639c1fbbc7860f03f802 https://staging.drfop.org/files/original/628b6e300a318be54667478bf7d69ef8.jpg 0ed7a62e1104b47e6adf43049a770bb2 https://staging.drfop.org/files/original/324715b55eb49ed8d385db9eef8fde73.jpg ef08536eda1fad5db1231816539fca86 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_02_009.pdf Text Any textual data included in the document <h2>Bivalved Spinal Orthoses for the Structurally Unstable Spine</h2> <h5>H.R. Lehneis, Ph.D., CPO&nbsp;<a style="text-decoration: none;">*</a><br />Roger Chin, CPO&nbsp;<a style="text-decoration: none;">*</a><br />Donald Fornuff, CP&nbsp;<a style="text-decoration: none;">*</a></h5> <p>With the advent of plastics, particularly thermoplastics, and plastics technology, plastic molded spinal orthoses are increasingly used in the orthotics management of the structurally unstable spine for nearly all levels of involvement. Depending on the risk factor involved, they may be used in lieu of surgery, i.e. when the patient is not a candidate to undergo surgery for various physiological reasons, or they may be used in the post-surgical management of the structurally unstable spine. Because of the ability of modern plastics to be intimately contoured to the body, they provide for far safer orthotics management, particulary of the cervical spinal region, than conventional orthoses. Often they are a preferred substitute over casts since these bivalved orthoses can be readily removed, either fully or partially, for hygienic reasons and the orthosis can be kept clean much more easily than a cast.</p> <h3>Orthotics Designs</h3> <p>Two types of bivalved spinal orthoses are described below:</p> <ol> <li> <p>Cervico-thoracic orthosis (CTO) with forehead band.</p> </li> <li> <p>Thoraco-lumbo-sacral orthosis (TLSO).</p> </li> </ol> <p>With slight modifications, various combinations of the above can be designed. The area of injury or surgery usually determines the height and design of the orthosis. The contours of the orthosis aid in maintaining the proper position on the patient. Overlapping edges avoid pinching and allow for some weight gain or loss.</p> <p>The bivalved opening allows for fast removal in case of cardiac or respiratory problems, situations in which access has to be almost immediate. It is also a comfort to the patient, while lying in bed, that either half of the orthosis can easily be removed for short periods of time to give some relief from pressure and for ventilation.</p> <p><i>CTO with forehead band (<a href="/files/original/b6970149668330ce776434d9198152e3.jpeg"><b>Fig. 1</b></a>)</i></p> <p>The cervical region is the most flexible of the spine. Rotation, flexion/extension, and lateral bending are difficult to control using just a cervical orthosis. Stabilization of the thoracic spine is necessary in order to provide the base, or foundation, for control of the cervical spine and head.</p> <p>It is extremely important to appreciate that without proper head control the cervical spine cannot be properly stabilized. Thus, the orthosis must extend posteriorly to cover the occipital area (<a href="/files/original/a0bf70a49a9e3db596969c11b0c2c69c.jpg"><b>Fig. 2</b></a>), and anteriorly around the forehead, as well as the mandibular area (<a href="/files/original/8a915c80bd9484bb8ab1b9a594fe6c66.jpg"><b>Fig. 3</b></a>). Inferiorly, it should be noted that the orthosis covers the entire rib cage, including the floating ribs (<a href="/files/original/f5da1243900128485bea8bd5f391499b.jpg"><b>Fig. 4</b></a>).</p> <p><i>Thoraco-Lumbo-Sacral Orthosis (<a href="/files/original/9ecbbc7b6c0294a18f4bb82b168db309.jpg"><b>Fig. 5</b></a>)</i></p> <p>Orthotics design for structural instability of the thoracic and lumbar spine requires the formation of a sound base inferiorly. In general, this is identical to the trimline used in the Milwaukee brace, or other orthoses for scoliosis. The superior trimlines depend on the level of involvement, but extend from at least the level of the xyphoid process to the inferior border of the clavicle (<a href="/files/original/628b6e300a318be54667478bf7d69ef8.jpg"><b>Fig. 6</b></a>). The lateral Velcro® closures are of the cross-diagonal type described earlier by Ekus<a style="text-decoration: none;">*</a> to minimize relative vertical displacement between the bivalved sections.</p> <h3>Indications</h3> <p>The orthoses described are indicated either in lieu of surgery if the patient is not a surgical candidate for any physiologic reason, or post-surgically to maintain the desired position of the spine, instead of a plaster cast.</p> <p>Medical indications are:</p> <ol> <li> <p>Fracture and fracture-dislocations, including the odontoid process.</p> </li> <li> <p>Ligamentous rupture or laxity with resultant instability of the spine.</p> </li> <li> <p>Neoplastic disorders with concomitant degeneration of the vertebrae.</p> </li> </ol> <p>Physical indications are:</p> <ol> <li> <p>Lightweight.</p> </li> <li> <p>Hygiene, i.e. ability to clean the orthosis.</p> </li> <li> <p>Removability of either portion of the orthosis for patient hygiene and ventilation.</p> </li> </ol> <h3>Casting Technique</h3> <p>The casting method requires a Stryker frame. It is essential for accurate casting, and is the safest method for the patient. Body movement is limited to transfer in the supine position from bed to frame and back to bed, if the patient is not already in a Stryker frame and in skeletal traction. The patient can be turned from a supine to a prone position by turning the frame, which has been locked to prevent body movement. This method has proven to be the fastest, simplest, and cleanest.</p> <p>With the patient on the Stryker frame in the supine position, bony prominences and areas of relief are marked with an indelible pencil. The patient's anterior half is covered with a separative jelly (K-Y®, petrolatum), except the hair, which is covered with stockinette for casting for the CTO. Approximately 8-10 layers of plaster splints are applied in alternating vertical and horizontal layers to give the anterior shell added strength. With the patient in the supine position, abdominal pressure (which supports the spinal column internally) is built in at the time of casting.</p> <p>When the anterior half has hardened sufficiently to support the body without distortion, the patient is turned to the prone position. Again, bony prominences and areas of relief are marked with an indelible pencil on the posterior side which is then covered with a separative jelly. Approximately 4-6 layers of plaster splints are applied in alternating horizontal and vertical layers. The posterior half does not have to be as strong as the anterior half, as the patient will not be lying in it as in the anterior half. All casts are bi-valved with approximately 5 cm. overlap of the posterior half on the anterior half. A separative jelly is spread over the anterior areas to be covered by the posterior overlap. When the posterior half has hardened sufficiently to be removed, the sections will part easily because of the separative jelly under the overlap. They are then put back together with the overlap providing the key for proper position of the anterior and posterior halfs.</p> <p>The cast is then filled and modified. All bony prominences or areas of relief are built up approximately 2 to 3 cm. while in the soft tissue areas, e.g., abdomen, plaster is removed.</p> <h3>Fabrication</h3> <p>While any thermoplastic sheet material may be used for molding the orthosis, at this institution Subortholen® is preferred. It is a high strength polyethylene which is not only thermoplastic, but can be cold-formed as well. When heated, it can be drape-molded quite easily, and in a cold state, can be hammered similar to light alloy sheet material (e.g., hammered thin to form a hinge or channeled for rigidity or relief). Subortholen® is available in thicknesses of 1 to 6 mm.</p> <p>Sheets are cut to the size needed and placed in an oven heated to 150-160 degrees centigrade (350°F). The material is ready for molding when the sheet has lost its pink color and is almost translucent (<a href="/files/original/324715b55eb49ed8d385db9eef8fde73.jpg"><b>Fig. 7</b></a>, right). When molding Subortholen®, a half hour oven dry cast or driest possible cast is recommended. The cast should be covered with stockinette to prevent moisture contact to the Subortholen® which, if not done, may cause rapid cooling, bubbling, and an uneven finish on the surface.</p> <p>The posterior half is molded first to extend approximately 5 cm. beyond the lateral midlines. When cooled, the posterior half is removed and cut to the desired trim lines and placed back on the cast. The anterior half is then molded to overlap the posterior half by approximately 5 cm. After the anterior half is cut to the desired trim lines, the orthosis is ready for fitting.</p> <h3>Special Fitting Considerations</h3> <p>Cervico-Thoracic Orthosis with Forehead Band :</p> <ol> <li> <p>Inferior trim line of forehead band should be approximately 1 cm. above the eyebrows.</p> </li> <li> <p>Circumferential pressure adjustability of head band is accomplished by means of a Velcro® strap.</p> </li> <li> <p>Mandibular pressure can be controlled by tightness of forehead band.</p> </li> <li> <p>Inferior trim lines need not extend below rib cage, as not to restrict lateral and posterior/anterior motion.</p> </li> <li> <p>Posterior/superior trim line should extend 3-4 cm. above the apex of the occiput.</p> </li> </ol> <p>Thoraco-Lumbo-Sacral Orthosis:</p> <ol> <li> <p>The orthosis must be keyed in the soft tissue area between the rib cage and iliac crests to prevent vertical displacement of the orthosis.</p> </li> <li> <p>The anterior inferior aspect must be trimmed to avoid sitting problems and pressure on the pubis. The posterior inferior trimline should allow sitting without the orthosis being pushed up from contact with the chair.</p> </li> <li> <p>Depending on the level of involvement, the anterior superior trimline should extend from a point somewhere between the xyphoid process to a level that follows the course of the inferior border of the clavicles.</p> </li> </ol> <div style="width: 400px;"><strong>Footnote</strong> Ekus L., CO, Cross-Diagonal Closure of Pelvic and Spinal Appliances. Newsletter—Prosthetics and Orthotics Clinic, Vol. 5, No. 1, 2/1981 —Winter/Spring Issue<em><b><br /><br />*Donald Fornuff, CP </b> Institute of Rehabilitation Medicine New York University Medical Center New York, NY</em><br /><em><b><br />*Roger Chin, CPO </b> Institute of Rehabilitation Medicine New York University Medical Center New York, NY</em><br /><em><b><br />*H.R. Lehneis, Ph.D., CPO </b> Institute of Rehabilitation Medicine New York University Medical Center New York, NY<br /><br /></em></div> Page Number(s) 9 - 11 Year 1983 Volume 7 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-6.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 7 http://www.oandplibrary.org/cpo/images/1983_02_009/1983_02_009-7.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 Bivalved Spinal Orthoses for the Structurally Unstable Spine Creator An entity primarily responsible for making the resource H.R. Lehneis, Ph.D., CPO * Roger Chin, CPO * Donald Fornuff, CP * https://staging.drfop.org/files/original/bd46617c235c4772e936e7d1a60ba734.pdf 579389d66872bebcf4e498a65ae678ea https://staging.drfop.org/files/original/455ecf115629123392857fe8469670c3.jpg 83423844a564fec85ce56c817a3f5ec7 https://staging.drfop.org/files/original/741a3625b8142c75ec6b345c5bfffc5d.jpg 03abbdb99e38076f14d95a0e59f913a2 https://staging.drfop.org/files/original/1138499b4a4ed059bcd0c8b24e6f8680.jpg 710defbe06f6ae092234a49207f4415e https://staging.drfop.org/files/original/0c94fac2ea4e7c0aacd0c52cbcb94002.jpg 95ae51859297d017d7d6e2924646f528 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_006.pdf Text Any textual data included in the document <h2>Beyond the Quadrilateral</h2> <h5>Hans Richard Lehneis, Ph.D., C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Earlier this year I had the pleasure to be invited to the Academy Midwest Chapter Symposium entitled, "AK Design Principles: Beyond the Quadrilateral." I found the latter half of the title so intriguing and expressive of contemporary thinking and rethinking in AK socket prosthetics that I chose it as the title of this commentary. I hope that the organizers of the Chicago Symposium do not mind my borrowing this title.</p> <p>One of the earliest and major break throughs in AK socket design in this century was the concept of ischial weight bearing. At first glance this appears to be a sound approach and certainly one that has improved general comfort over other sockets. If, however, one analyzes that concept more closely, i.e., biomechanically, it becomes clear that ischial weight bearing is not a reality through all phases of gait. It must be appreciated that the socket and, thus, the prosthesis as a whole during walking is controlled by movement emanating from the center of rotation of the residual hip joint. At heel strike, when the hip is flexed, the distance from the ischial tuberosity to the ischial seat of the socket increases with the angle of hip flexion (<a href="http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-1.jpg"><b>Fig. 1</b></a>). Obviously, at this point in the gait cycle, there cannot be any ischial weight bearing. Yet, the need to support weight is greater than at any other point during locomotion. Body weight, plus the force of impact must be transmitted. How is this possible without direct skeletal support?</p> <p>I believe that, by what in German is called "verspannung" of the musculature, a stable interface is achieved. This is a phenomenon which every AK amputee must learn to prevent the prosthetic knee from buckling.</p> <p>Unlike normal locomotion in which there is phasic interaction of the musculature to produce controlled hip and knee flexion (eccentric contraction), the AK amputee must learn out-of-phase contraction of the hip musculature, i.e., the hip joint must produce an extension moment prior to heel strike so that the knee joint is in full extension at heel strike. Such muscular activity causes "verspannung," an increase in cross sectional volume, which in turn increases the tangential forces in the socket to equal the vertical forces generated at this point in the gait cycle.</p> <p>While it is clear that reasonably comfortable ischial weight bearing is indeed possible in the midstance phase, ischial weight bearing cannot be comfortably maintained at heel off. When the hip joint is extended, the perpendicular distance between the axis of rotation of the hip and the ischial seat of the socket is less than in the mid-stance phase (<a href="http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-2.jpg"><b>Fig. 2</b></a>), yet the distance from the hip joint to the ischium remains constant throughout all phases. Thus, hip extension causes increasing pressure on the ischial tuberosity, which now becomes the fulcrum about which the prosthesis tends to rotate. This results in the stump being pulled out of the socket, gapping of the anterior brim, elevation of the body on the involved side, and discomfort. Clinically, prosthetists have relieved this problem by increasing the radius of the anterior portion of the ischial seat. This maneuver allows the socket and seat to move posterior to the ischium as the hip is extended.</p> <p>Personally, I have always advocated that the ischial seat is sloped forward and downward such that it is tangent to a radius from the hip joint to the ischium (<a href="http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-3.jpg"><b>Fig. 3</b></a>). This not only increases comfort at heel strike, since it reduces the sharpness of the anterior portion of the ischial seat, but at heel off, it allows the ischial tuberosity to be inside the socket and pressure to be transferred to the much larger part of the ischium and gluteus maximus. Placing the ischial tuberosity on the anterior portion of the ischial seat also results in greater comfort, since it reduces skin tension in that area.</p> <p>While one might argue that placing the ischial tuberosity squarely on the seat was a necessity with open-end sockets; it is amazing that this theory continued to persist past the advent of total contact sockets. Under certain conditions, Pascal's law may be applied to total contact sockets, i.e., a hydrostatic condition exists which would eliminate the need for ischial weight bearing. In other words, the quadrilateral shape of AK sockets has remained unchanged despite the fact that total contact has resulted in a different application of the laws of physics which makes ischial weight bearing less important than originally conceived.</p> <p>Practitioners familiar with the fitting of prostheses to patients with Proximal Femoral Focal Deficiency (PFFD) know that the quadrilateral socket is inappropriate for these patients. A more appropriate socket shape resembles that of a flower pot in which the ischium is contained within the socket. In addition, the largest patient population for which the quadrilateral shape must be revised is the geriatric AK amputee. These patients, as a rule, become amputees due to Peripheral Vascular Disease (PVD), often compounded by diabetes. They usually present diminished sensation, reduced muscle tone, poor skin quality, and sometimes senility. Generally, they suffer from great discomfort when fitted with a prosthesis. Although most of this can be ascribed to the problems presented, it appears that some of this discomfort is due to the quadrilateral socket shape, particularly when the patient is provided with a manual knee lock. Unlike amputees who are fitted with an open knee and who must, and are able to, contract the residual muscles prior to heel strike, the geriatric amputee with a manual knee lock simply steps on the prosthesis. This simulates the effect of stepping on a rake (<a href="http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-4.jpg"><b>Fig. 4</b></a>). As a result, the tissue below the ischium is compressed (poor muscle tone), resulting in excessive skin tension, anterior proximal gapping of the socket, and the ischium to be far posterior to the socket.</p> <p>In summary, it seems to me that in light of the change in patient population (overwhelmingly geriatrics) with all the physical problems they present, one should, indeed, think beyond the quadrilateral. One should also note that with the advent of total contact, the concept of ischial weight bearing needs to be re-visited and re-assessed. Designs such as CAT-CAM and work supported by the Veterans Administration at the Rusk Institute of Rehabilitation Medicine hold promise to go beyond the quadrilateral to improve patient comfort.</p> <h3>Acknowledgments</h3> <p>This is to acknowledge that certain concepts presented in this paper are based on, <i>Schnur</i>, J., DAS KUNSTBEIN- Messen und Bauen. Kothen-Anhalt: Buchdruckekel Hans Greiner.</p> <p>I am also grateful to Robert Wilson, M.S., research scientist, designer and medical illustrator, Orthotics &amp; Prosthetics Research for the illustrations in this text.</p> <em><b>*Hans Richard Lehneis, Ph.D., C.P.O. </b> Hans Richard Lehneis, Ph.D., C.P.O., is with the Rusk Institute of Rehabilitation Medicine, 400 East 34th Street, New York, New York 10016.<br /><br /><br /></em> Page Number(s) 6 - 8 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_006/1985_04_006-4.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Beyond the Quadrilateral Creator An entity primarily responsible for making the resource Hans Richard Lehneis, Ph.D., C.P.O. * https://staging.drfop.org/files/original/ef9c33fd77b148aa90de4a15eba38d63.pdf 6b120f4df1e3a107e3d3c68bef3540f9 https://staging.drfop.org/files/original/aecc71c9f63ca3de9635b49186ef0fe2.jpg ee0dd270acf130106c5b30ef3f556f83 https://staging.drfop.org/files/original/9c3a89cb7f7730cd4c6b56b7590d7391.jpg f4cec16ef9035d5921c41f90ca28bcd6 https://staging.drfop.org/files/original/b5fd66a485fcb7d48eb30a63f5504417.jpg 5b69122a27795a14bcb9a1cb7a594a03 https://staging.drfop.org/files/original/17d159b930dfb31d71d62c5ee691ba0d.jpg 2a72b8f6ae90f2e9e1524ac5f30529c3 https://staging.drfop.org/files/original/eb00ea2eaae4f210b268d565e63c7e0d.jpg 54fc0b54bbd8edad785ea19df297b698 https://staging.drfop.org/files/original/640dd4eb6ba2ed2b6c98f608c29c713b.jpg b9543354d744c53f2572778988313b32 https://staging.drfop.org/files/original/b2d38ec808677879975c23042b055df4.jpg aa1d9e01ee14c6de2fde688835090f3a https://staging.drfop.org/files/original/3bb75593aa89a50b825f8368f7f92b73.jpg 347a553c959fa12bd1f4978f9eecf597 https://staging.drfop.org/files/original/d9d8ecde312bfe6431d3e6d17c56d6cb.jpg aec588355a2ba508857a04c899f7bb26 https://staging.drfop.org/files/original/9464bc47067b808f2c144ad6714d4c83.jpg ba3630b2632efa359fc9d1889de8e90d https://staging.drfop.org/files/original/3fbbfc9c24383b1570eb5768ffc83c89.jpg 1798118642ea00b00689a5bfed53f585 https://staging.drfop.org/files/original/5270bfa0fa18365e770ebb78a42d2436.jpg 91718b4d11f9d8da1db4a041219b78b1 https://staging.drfop.org/files/original/4fe6516dbb0072232e7634731bd5069e.jpg 954bd4f2762fc59a0fd590821ab51073 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_005.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 5 - 10 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_005.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>A Preliminary Report on the Amputee Census</h2> <h5>Harold W. Glattly, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>What is the magnitude of the amputee population of the United States? What is the composition of this group of physically handicapped individuals in terms of their sex, ages, and sites of amputation? What proportion of amputations is caused by disease? By trauma? By tumor? The answers to these questions are today more a matter of opinion than of documented fact since statistics relating to amputees that are based on large numbers of cases collected from all states of the Union have never heretofore been available.</p> <p>In the interest of developing certain basic descriptive data concerning the amputee population of the United States, the Amputee Census was initiated in October 1961 as a joint project of the Committee on Prosthetics Education and Information and the American Orthotics and Prosthetics Association. The rationale of utilizing the limb facilities of this country as the data source for the Census is based upon the assumption that a relatively high percentage of new amputees visit these shops for the purpose of being fitted with a prosthetic device. It is believed that this percentage is materially higher today than it was in 1946, at which time a federally sponsored prosthetics research program was initiated. Since that date there has been a very marked improvement in the function and comfort of prostheses, and amputees who formerly were unable to pay for a replacement device now find that there are several Government agencies to assist them. These include the federally supported State Bureaus of Vocational Rehabilitation, the Children's Bureau, the Veterans Administration, and the Workmen's Compensation programs. It has been variously estimated by both surgeons and prosthetists that between 80 and 90 per cent of all new amputees desire a prosthesis. It is hoped that some spot checks can be made in a few large medical centers to document this estimate.</p> <p>The project title, Amputee Census, is strictly speaking a misnomer (although it is a concise expression of the hoped-for result), since no national or regional head count of amputees is involved. In that only new amputee cases are included in this study, it will be possible to establish annual rates of amputation by age and cause. By applying life-expectancy tables to these rates, it is hoped to develop information that will bear upon the size of our amputee population. For example, it is obvious that there is a very wide disparity in the life expectancy of a 55-year-old man in good health who loses a limb by reason of an accident as compared with a man of the same age who suffers an amputation of his leg as the result of vascular disease. This quantitative study will not be undertaken until the census has been completed in the fall of 1964.</p> <p> Two simple data-collection forms were devised that can be executed in a matter of minutes by limbshop personnel ( <b>Fig. 1</b> and <b>Fig. 2</b> ). The participating limbshops were provided with bound books of these serially numbered forms. The books consist of original data slips that are retained by the facilities and carbon copies in the form of self-addressed and stamped postcards to be mailed to the National Academy of Sciences. It will be noted in <b>Fig. 1</b> and <b>Fig. 2</b> that the upper left-hand corners of the data cards are blocked out. It is in this space that the name of the amputee appears on the original forms retained by the facilities. Since the cards are serially numbered, it will be possible at some future time to identify certain types of amputees for further study. In the upper right-hand corner is a symbol consisting of three capital letters that identify each facility. The code to these symbols is known only to the staff of CPEI, and the limbshops have been assured that no information concerning their volume of cases will be disclosed to anyone. ( <b>Fig. 3</b> , <b>Fig. 4</b> , <b>Fig. 5</b> , <b>Fig. 6</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1. Amputee Census Card No. 1. Data form for single amputations and multiple amputations that result from a single cause at the same time.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2. Amputee Census Card No. 2. Data form for multiple amputations that occur serially at different times from the same or different causes.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig 4</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The participating facilities were instructed to fill out a card on each new amputee case for whom an original prosthetic device of some type was provided. Amputees furnished with a replacement for a worn-out or otherwise unusable limb are not recorded in this study. The card shown in ( <b>Fig. 1</b> ) is used for single amputations and for multiple amputations that occur simultaneously from a single cause. The card shown in ( <b>Fig. 2</b> ) is prepared for those cases that have had more than one amputation at separate times from either the same or different causes. Examples of this type of case include: </p> <ol> <li>An individual who is a left, below-knee amputee due to an injury who, years later, becomes a right. above-knee amputee due to vascular disease.</li><li>An individual who is a left, below-knee amputee due to vascular disease and is converted into an above-knee case a year later.</li></ol> <p> Since this card amounted to only three per cent of the total data forms received, an analysis of these cases will not be accomplished until the end of the project. ( <b>Fig. 7</b> , <b>Fig. 8</b> , <b>Fig. 9</b> , <b>Fig. 10</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 7</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The following data items are entered on the census forms:</p> <ul> <li>State of Residence.</li> <li>Age.</li> <li>Sex.</li> <li>Date of Amputation.</li> <li>Date Prosthesis Furnished.</li> <li>Site of Amputation:</li> <li>Upper Extremity:<ul> <li>(SD) Shoulder disarticulation (includes fore-quarter cases and very short above-elbow stumps that require fitting as an SD).</li> <li>(AE) Above elbow.</li> <li>(E) Elbow disarticulation.</li> <li>(BE) Below elbow.</li> <li>(W) Wrist disarticulation.</li> </ul></li> <li>Lower Extremity:<ul> <li>(HD) Hip disarticulation (includes hemipelvec-tomies and above-knee stumps so short that they must be fitted as an HD).</li> <li>(AK) Above knee.</li> <li>(KB) Knee-bearing (includes knee disarticulations, Gritti-Stokes, etc.).</li> <li>(BK) Below knee.</li> <li>(S) Syme's operation or ankle disarticulation. (Partial-hand and partial-foot amputations are not included in the census.)</li> </ul></li> <li>Cause of Amputation:<ul> <li>Trauma-amputations due to physical and thermal injuries.</li> <li>Disease-amputations due to vascular diseases and infections.</li> <li>Tumor-refers to all types of growths for which an amputation is performed.</li> <li>Congenital-only cases that are fitted with a prosthesis are included. The type of prosthesis is used to determine the level of "amputation." It is recognized that the data card is not appropriate for certain types of congenital amputees.</li> </ul></li> </ul> <p>The statistical material that is presented in this preliminary report on the Amputee Census is based upon the data forms received from the prosthetics facilities during the 16-month period from October 1, 1961, through January 31, 1963. During this time, 8,416 new cases were reported. This sampling of the amputee population of the U. S. is sufficiently large so that the distribution by sex, age, side of amputation, levels of amputation, and causes of these new amputations is already well established. This conclusion is based upon the fact that the percentages presented in this report are almost identical to those that were obtained from an analysis of the first 5,000 cases. It is thus possible in this initial census report to present in graphic and tabular form (Figs. 3-13) a simple description of the group of individuals upon whom amputations are presently being performed. The following comments and observations on this statistical material are noteworthy: ( <b>Fig. 11</b> , <b>Fig. 12</b> , <b>Fig. 13</b> ) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12. Actual case numbers in each decade of life.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <ol> <li>The disparity in the amputation rates for males and females is due primarily to the facts that: <ol> <li> Amputations in males by reason of injury are nine times as frequent as in females. This is due to the vocational and avocational hazards to which males are more liable ( <b>Fig. 8</b> ). </li><li> Amputations in males by reason of disease are 2.6 times as frequent as in females ( <b>Fig. 8</b> ). </li></ol> </li><li> Amputations due to tumor are roughly comparable between the sexes ( <b>Fig. 8</b> ). </li><li> Congenital deformities of the extremities that are fitted with prostheses occur with almost equal frequency in males and females ( <b>Fig. 8</b> ) </li><li> There is no significant difference in the incidence of left- and right-sided amputations in either the upper or lower extremities ( <b>Fig. 7</b> ). </li><li> There is a surprisingly large number of lower-extremity amputees over 70 years of age who are being fitted with prostheses. In this series, they number 1,020, or 13.2 per cent, of the total number of reported cases. It will be noted that there are four who are over 90 years of age ( <b>Fig. 5</b> ). </li><li> The incidence of malignancy resulting in amputation is fairly constant for individuals between 21-60 years of age. The decade 11-20 years has an indicated rate of twice that of any other ten-year period ( <b>Fig. 12</b> , <b>Fig. 13</b> ). </li><li>In this series there were 162 cases of multiple amputations that occurred from the same cause at the same time. Twenty-two were bilateral upper-extremity cases, 132 were bilateral lower-extremity amputations, and eight involved one upper and one lower extremity.</li><li>During the 16-month report period there were 1,798 cases of below-knee amputations for disease. It is believed that the vast majority of this group falls into the vascular insufficiency category. During this same period there were 2,520 cases due to disease in which the initial amputation was above the knee. There is no reason to doubt but that similar numbers of below-knee and above-knee amputations for vascular disease have been performed in years past during comparable periods of time. Although theoretically the site of amputation in vascular disease is based on the level of vascular sufficiency in the extremity, it may be that too many surgeons are overly concerned with the possibility that amputations at the below-knee level will later require re-amputation above the knee. This possibility is suggested by the fact that in this series there were only 12 instances in which below-knee amputations due to disease were re-amputated at a later date. This is an extremely low incidence, considering the number of below-knee amputations that are performed annually for vascular conditions. A clinical study may be needed that is designed to define better the criteria that bear upon the decision as to the level of amputation in cases of lower-extremity vascular disease. The advantages of preserving the knee joint are obvious, especially in the older age group.</li><li>The reader must recognize that the foregoing statistical material relates only to new amputee cases. The statistics are not valid for the amputee population at large due to the wide variation in the life expectancy of various types of amputees.</li></ol> <h4>Acknowledgments</h4> <p>The Committee on Prosthetics Education and Information wish to express their appreciation to the owners and managers of the participating prosthetics facilities who made this study possible and to the officers, directors, and staff of the American Orthotics and Prosthetics Association for their full cooperation in this project.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Harold W. Glattly, M.D. </b></td></tr><tr><td class="clsTextSmall">Executive Secretary, Committee on Prosthetics Education and Information of the Division of Medical Sciences, NAS-NRC. This Committee is jointly supported by the Training Division, Vocational Rehabilitation Administration, Department of Health, Education, and Welfare, and the Prosthetic and Sensory Aids Service, Veterans Administration.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-2.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-3.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-4.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-5.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-6.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-7.jpg Figure 7 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-11.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-10.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-8.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-9.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-12.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-13.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_01_005/1963-Spring_OCRBatch-14.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Preliminary Report on the Amputee Census Creator An entity primarily responsible for making the resource Harold W. Glattly, M.D. * https://staging.drfop.org/files/original/8697a8f963d8891708f7146a8800f1fa.pdf 49a4a04ffbca3021f555d7b987e35685 https://staging.drfop.org/files/original/4caa47c2d021f88d058ca6724b453a4c.jpg 87d9e4145cc6305c442954af03851d1a https://staging.drfop.org/files/original/db019b84f1068a9dd8b7a17c9f3c82f5.jpg 4b54d9acd0a32a50d47ca3a3315312b8 https://staging.drfop.org/files/original/daf8c596c8eb7e9d49656325de183a55.jpg abe05f2d30dae891020dbda823205d85 https://staging.drfop.org/files/original/2cf7234b28f3f375fd1f6ba2eb438cba.jpg 5007228a1cc68268e5171f413d39e00f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_02_001.pdf Year 1966 Volume 10 Issue 2 Page Number(s) 1 - 4 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1966_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Aging and Amputation</h2> <h5>Harold W. Glattly, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The loss of a part of a lower extremity due to peripheral vascular disease (PVD) incident to the effects of arteriosclerosis with or without the presence of diabetes is today the predominant type of amputation that is being performed in peacetime in the Western World; <i>i.e., </i>the United States and Europe. These ischemic amputations begin to make their appearance in the late forties of life and their incidence increases rapidly in succeeding decades. Lower-extremity PVD cases constituted 85 per cent of all amputations performed at the Massachusetts General Hospital during the period 1962-1964 and the average age of these patients was 70 years.</p> <p>This predominance of PVD lower-extremity cases in the field of amputation surgery is a development of quite recent origin. A survey of lower-extremity amputations by Doctor Jan Hansson in Sweden for the period 1947-1962 documents this fact. During this period, the incidence of lower-extremity amputations in individuals under 60 years of age remained constant at an annual rate of 4 to 5 per 100,000 population. In males over 60, the rate rose from 34 per 100,000 in 1947 to 129 in 1962. In females over 60 years of age, the amputation rate increased from 24 to 62 per 100,000 during this period. Doctor Hansson expressed the opinion that these rates would continue to rise over the coming years.</p> <p>One cannot but surmise that these rapidly increasing rates of lower-extremity amputations in individuals over 60 years of age are but a reflection of the change in the character of our older aged population that has occurred over the past four decades as a result of the dramatic advances that have been made in the prevention, care, and management of disease. Before the advent of insulin, it is doubtful that many diabetics lived long enough to develop gangrene of a lower extremity. Countless numbers of people are now reaching the age of 65 or older with medical conditions which, forty years ago, would have been fatal at a much earlier age.</p> <p>Ischemic amputations of the lower extremity formed an insignificant part of the workload of prosthetic facilities forty years ago. This is borne out by Doctor Hansson's Swedish study. In 1926, only 2 per cent of fitted lower-extremity cases were due to PVD amputations, whereas by 1955, they had increased to 57 per cent. Older prosthetists in the United States, whose professional experience dates back to the 1920's, have unanimously stated that this Swedish study accurately reflects their own experience in that forty years ago they rarely fitted a PVD amputee, whereas today these cases form the major part of their workload. The incidence of ischemic amputations was relatively low in 1926 and at that time the mortality rate for these operations was extremely high in view of the fact that no means were available to control infection. Furthermore, it appears that forty years ago very few of these cases were considered as candidates for prosthetic rehabilitation.</p> <p>Potentially, the Medicare Act for the Aged which became effective in July 1966 can relieve a serious national inequity that in the past has involved the older aged amputees in this country. Over the years federal and state programs have been available to provide financial assistance for needy amputees from birth until they reached the 60 to 65 year age period. The Children's Bureau and the Vocational Rehabilitation Administration of the Department of Health, Education, and Welfare have conducted these assistance programs through their support of corresponding state agencies. Until the Medicare Act, amputees and other handicapped individuals over 65 years of age who needed assistance, except for beneficiaries of the Veterans Administration, have been dependent upon local welfare programs that varied widely in their character throughout the country. The 1964 annual VRA report revealed that only 1.7 per cent of their rehabilitated cases for that year were over 65 years of age. Yet this older aged segment of our population is characterized by multiple disabilities and, as a group, does not have the financial resources to take advantage of the rehabilitation opportunities that are available in most sections of this country. A bulletin of the National Health Survey of the Public Health Service, Series 10, Number 32, reports that 50 per cent of citizens 65 years or older have incomes of less than $3,000 per year and that 50 per cent have disabilities that limit materially their daily activities.</p> <p><b>Table 1</b> compares, in terms of their ages, a study of 12,000 new, fitted amputees that were collected during the two-year period 1961-1963 in the United States with all new cases that were furnished prostheses in Great Britain in 1962. No unfitted or old amputee cases provided with a new replacement device are included in these two groups of amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The basis for this wide disparity between Great Britain and the United States with respect to the fitting of older aged amputees is economic. Any amputee in Great Britain, regardless of his age, can receive a prosthesis at government expense if he demonstrates that he has some useful prosthetic rehabilitation potential.</p> <p><b>Table 2</b> presents the sources of payment for prostheses of the 12,000 new, fitted cases cited in <b>Table 1</b> above. Cases assisted by welfare agencies are almost exclusively geriatric since the state programs subsidized by the Children's Bureau and VRA are available to younger amputees.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The data presented in <b>Table 2</b> apply to the United States as a whole and vary widely between individual states. This is illustrated by <b>Table 3</b> that compares the percentage of new, fitted cases over 65 years of age in two states that have, roughly, the same numerical population. The relatively higher economic status of state A and its well-developed welfare programs, as compared with state B, form the basis for the very wide disparity in the fitting of older aged amputees in these two states. The Medicare Act is now available to provide the geriatric amputees in state B with the prosthetic rehabilitation services that have been denied them in the past.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Individuals with peripheral vascular disease of their lower extremities of a severity requiring amputation have, as a group, multiple disabilities that can abridge and even reduce to zero their prosthetic rehabilitation potential. The prosthetic evaluation of these cases, therefore, is critical. They have widely varying rehabilitation goals. Recent studies of these geriatric amputees indicate that, under present management concepts, only about 30 per cent will ever be able to obtain any use of their prostheses. This percentage could be significantly increased if the surgical community would adopt a conservative philosophy in its management of PVD amputations with respect to the original level of amputation and the indications for reamputation in cases of delayed wound healing.</p> <p>The study of PVD amputations at the Massachusetts General Hospital, referred to above, documents the fact that the preservation of the knee joint is all important in determining the rehabilitation potentials of these cases. Percentage-wise, twice as many below-knee cases will be able to use effectively a replacement device as those with above-knee amputations. That there are today widely divergent views concerning the level of amputation in PVD cases is indicated by the fact that, in one large metropolitan area, two-thirds of these cases were amputated above the knee and, in another large city, two-thirds were amputated below the knee. A study of all ischemic amputations performed in 1964 at 14 Veterans Administration hospitals reveals this same disparity in surgical philosophy as regards the level of amputation. The two extremes among these hospitals is shown in <b>Table 4</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The study of 12,000 new, fitted cases cited earlier reveals that the reamputation rate in successfully fitted, below-knee cases is almost zero. The reamputation of a BK is nearly always due to wound complications at the time of amputation. Pedersen and others have shown that a high percentage of these cases of delayed wound healing following amputation below the knee will successfully respond to conservative management and, because of the preservation of the knee joint, will become effective users of prostheses.</p> <p>The percentage of geriatric amputees that can achieve some useful degree of prosthetic rehabilitation would be increased by early fitting and ambulation. There is today an undue time lag between amputation and the fitting of these cases. A recent spot check revealed that this interval averages seven and one-half months. During this period, many of these older amputees will have developed contractures that may preclude prosthetic restoration, or they may become wedded to a wheelchair existence.</p> <p>It is hoped that orthopedic surgeons who are knowledgeable in the field of amputee rehabilitation will endeavor to inform the general surgeons in their respective communities with regard to modern concepts in the care and management of this form of disability.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Harold W. Glattly, M.D. </b></td></tr><tr><td class="clsTextSmall">Executive Secretary, Committee on Prosthetic-Orthotic Education, Division of Medical Sciences, National Academy of Sciences-National Research Council, 2101 Constitution Ave., N.W., Washington, D. C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_02_001/aut66-1-04.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 Aging and Amputation Creator An entity primarily responsible for making the resource Harold W. Glattly, M.D. * https://staging.drfop.org/files/original/4bc63286a052815b611c768021f481ba.pdf f1ec48cc2c9ab7ffffb5c555da764187 https://staging.drfop.org/files/original/f6478fbe791a100f3c1e5cc7f7ab632b.jpg de9916706b45884b00e9ba6dd49f8cac DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1971_02_006.pdf Year 1971 Volume 1 Issue 2 Page Number(s) 6 - 10 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1971_02_006.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1971_02_006.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 Children's Prosthetics and Orthotics Program</h2> <h5>Hector W. Kay <a style="text-decoration:none;">*</a><br /></h5> <p>During the early 1950s, pioneering clinicians in the management of the child amputee repeatedly insisted that children were not miniature adults, to whom modes of fitting developed for adults could be applied indiscriminately. The physicians argued that these children had characteristics and problems that required special study and treatment. Primarily because of the missionary efforts of these men, the Committeee on Prosthetics Research and Development in February 1956 moved from an indirect role in the area of children's prosthetics to an active and dynamic one by the establishment of a standing Subcommittee on Child Prosthetics Problems (SCPP). The first chairman, Charles H. Frantz, M.D., guided the activities of the subcommittee until 1965, when he was succeeded by George T. Aitken, M.D. The current membership of the subcommittee appears at the end of this article.</p> <p>Concurrently with the establishment of the SCPP, the Child Prosthetics Studies program at New York University was created under the direction of Sidney Fish-man, Ph.D. From its inception, the New York University program has been closely related to the activities of the Subcommittee on Child Prosthetics Problems. In essence, New York University has acted as an executive arm of the subcommittee in implementing many of its recommendations. This relationship led to the initiation and completion of numerous significant studies, some of which were: (1) extensive laboratory and field evaluations of various models of the APRL-Sierra no. 1 hand; (2) tests of the Dorrance juvenile hand, size no. 2; (3) studies of the application of the quadrilateral suction socket to the juvenile above-knee amputee, and of the patellar-tendon-bearing prosthesis to the skeletally immature below-knee amputee; (4) a field evaluation, preceded by the development of a fabrication manual and an instructional course, on the Minister-type fitting for the below-elbow amputation stump; and (5) laboratory and field studies of the CAPP electric cart.</p> <p>Significant nonevaluation activities included studies of the prosthetic fitting of children amputated for malignancy, numerous surveys and census-type studies of children under treatment, and follow-up studies related to the early work of Frantz and O'Rahilly in the classification of congenital limb deficiencies, with efforts to achieve an internationally acceptable system.</p> <p>As a result of the activities of the subcommittee and of the studies conducted at its instigation by New York University, a number of important by-products have emerged:</p> <ol> <li>The treatment of the limb-deficient child has become a recognizable subspecialty in medicine that has attracted many competent physicians.</li><li>The principle of fitting the child with congenital limb deficits at a very early age has been well established.</li><li>The early fitting of the juvenile who loses a limb because of malignancy, other diseases, or trauma has also become generally accepted.</li><li>Developers and manufacturers have been encouraged to produce prosthetic components for all age levels of the child-amputee population.</li></ol> <h3>Cooperative Clinic Program</h3> <p>A significant early action of SCPP was to bring together in August 1958 a group of persons with a known interest in the treatment of the child amputee. Included were the chiefs of 11 existing child-amputee clinics who agreed to cooperate in studies seeking improved treatment for the limb-deficient child. The participants in this historic meeting were:</p> <ul> <li>Gen. F. S. Strong, Jr., Washington, D.C.</li> <li>Tonnes Dennison, Beverly Hills, Calif. </li> <li>George T. Aitken, M.D., Grand Rapids, Mich.</li> <li>Carleton Fillauer, Chattanooga, Tenn.</li> <li>Charles H. Frantz, M.D., Grand Rapids, Mich.</li> <li>Colin A. McLaurin, Chicago, HI.</li> <li>Charles Radcliffe, Ph.D., Berkeley, Calif.</li> <li>Harry Campbell, Los Angeles, Calif.</li> <li>Leon DeVel, M.D., Grand Rapids, Mich.</li> <li>Edward Hitchcock, New York, N.Y.</li> <li>Bertram Litt, New York, N.Y.</li> <li>Edward Peizer, Ph.D., New York, N.Y.</li> <li>Anna M. Bahlke, Albany, N.Y.</li> <li>Milo Brooks, M.D., Los Angeles, Calif.</li> <li>Capt. Thomas Canty, Oakland, Calif.</li> <li>Carleton Dean, M.D., Lansing, Mich.</li> <li>George G. Deaver, M.D., New York, N.Y.</li> <li>Sidney Fishman, Ph.D., New York, N.Y.</li> <li>Col. Maurice Fletcher, Washington, D.C.</li> <li>James Glessner, M.D., Newington, Conn.</li> <li>J. Leonard Goldner, M.D., Durham, N.C.</li> <li>Richard E. King, M.D., Atlanta, Ga.</li> <li>Claude N. Lambert, M.D., Chicago, HI.</li> <li>Arthur J. Lesser, M.D., Washington, D.C.</li> <li>Robert Mazet, Jr., M.D., Los Angeles, Calif.</li> <li>John R. Moore, M.D., Philadelphia, Pa.</li> <li>Frank Potts, M.D., Buffalo, N.Y.</li> <li>Frederick Vultee, M.D., Richmond, Va.</li> </ul> <p>Subsequently, other child-amputee clinics sought affiliation with the cooperative program, and, upon meeting the criteria or standards established by the subcommittee, additional clinics have been accepted into the cooperative research endeavor. Thirty clinics, broadly distributed, have now been accepted.</p> <p>A large proportion of the studies authorized by the subcommittee have been carried out by the participating clinics under the guidance of New York University.</p> <p>In addition to the 30 clinics currently enrolled in the cooperative program, contact is being maintained with 36 other child-amputee clinics.</p> <h3>Projects</h3> <p>By the mid-1960s, it had become apparent that significant advances had been made in prosthetics generally. Many of the improved fitting techniques that had been developed were found to be applicable to children, and numerous components of advanced design had been made available for use by the child amputee. As a result, children with less severe or with uncomplicated limb deficits, of either congenital or acquired origins, could be treated, and reasonably satisfactory results could be expected. However, the management of the child with severe losses, particularly those affecting both upper limbs at high levels, left much to be desired. The solutions to these problems were considered to be in the successful application and control of externally powered devices. Although available components and systems of this type were (and are) relatively crude, they are regarded as the hope of the future, and a major evaluation and redevelopment effort is being mounted. Already in progress or about to be initiated as a result of prior action by the Subcommittee on Child Prosthetics Problems are a number of studies of great potential value in the evaluation of improved devices and treatment procedures.</p> <p>Studies will be conducted by New York University, through the participating clinics, on the Ontario Crippled Children's Centre (OCCC) coordinated electric arm, an advanced model of the Michigan Crippled Children Commission feeder arm, the OCCC electric elbow, the Rancho Los Amigos Hospital electric elbows, the Otto Bock myoelectric hand, and the Viennatone myoelectric hand.</p> <p>At the request of SCPP, New York University has conducted an annual census of the child amputees who are being treated at the cooperating clinics. For 1969, the data indicated that the total population under treatment was 4,625-an increase of 236 over the prior year. An expanded census relative to the calendar year 1970 has been completed. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Specialized Fitting Centers</h3> <p>At its meeting on October 21, 1967, the Committee on Prosthetics Research and Development approved a proposal by the Subcommittee on Child Prosthetics Problems that an ad hoc committee be established to develop a detailed plan for the creation of specialized prosthetics fitting centers for severely handicapped children. At its meeting on June 12, 1968, CPRD received the report of the committee, which presented criteria for operation of the centers. This plan, which had been previously approved by the child-amputee clinics, was also approved by CPRD.</p> <h3>Children's Orthotics</h3> <p>At its meeting on November 4-5, 1969, the Committee on Prosthetics Research and Development charged the Subcommittee on Child Prosthetics Problems with the responsibility for enlarging its sphere of activities to include children's orthotics. An ad hoc committee of SCPP was appointed to investigate the implications of this new responsibility and to make recommendations for its implementation. It should be noted that the Subcommittee on Design and Development of CPRD had already conducted a number of meetings and workshops on orthotics topics, particularly in the area of lower-extremity bracing, which was the first segment of the orthotics field to be investigated, and many items with possible applications to orthopedically disabled children were beginning to emerge from this work.</p> <p>Upon the recommendation of the ad hoc committee, a number of selected lower-extremity orthotics items that had emerged from the design and development effort and several bracing and ambulation aids that had been developed at the Ontario Crippled Children's Center were demon- strated at a meeting of amputee-clinic chiefs on June 11, 1970, and the clinic chiefs were polled as to their interest in clinical applications of the items demonstrated. Their responses were tabulated by New York University and revealed considerable interest in virtually all items. The Subcommittee on Child Prosthetics Problems reviewed these findings at its October 16, 1970, meeting and recommended that NYU undertake the recruitment of a nucleus of clinics interested in a cooperative research program on treatment devices for cerebral palsy, Legg-Perthes disease, and myelomeningocele. It was further recommended that orthopedic surgeons currently participating in the program be surveyed to identify clinics they knew to be interested in these problems. Subsequently, NYU reported that three clinics in the New York City area had indicated an interest in participating, and that discussions were being held with these clinics to develop a format for the initiation of a mutually useful program.</p> <h3>Education</h3> <p>A major requirement for participation in the cooperative clinical program has been that clinic personnel attend the appropriate upper- and lower-extremity courses at one of the three universities offering such programs. Moreover, since December 1961 at Northwestern University, and since 1964 at the University of California at Los Angeles, 26 courses in the management of the child amputee have been offered to 864 students, including 450 physicians, 238 therapists, and 146 prosthetists. New York University has offered special lectures in the management of the child amputee in its regular prosthetics courses. In connection with the evaluation of specific items where special application skills are required, courses of instruction have been given to the participants.</p> <p>All these educational activities have tended to provide an increasingly higher level of competence among physicians and others in the management of the child with limb deficiencies. Moreover, the Child Amputee Program has been a direct par- ticipant in, and contributor to, the general transition procedures governing the overall prosthetics research and education program. These procedures have served to bring new research-derived information directly and expeditiously to the consumer through courses of instruction and published materials.</p> <h3>Publications</h3> <p>In May 1961, at a meeting of the 12 clinic chiefs then participating in the cooperative program, the chairman of the Subcommittee on Child Prosthetics Problems proposed the creation of a bulletin or newsletter that would serve as a medium for the exchange of information between the clinics. The idea was received enthusiastically by the clinic chiefs, who undertook to provide articles on a scheduled basis. The first issue of the <i>Inter-Clinic Information Bulletin </i>was published in October 1961. It was six pages long, and 100 copies were distributed. Now, 10 years later, the <i>Bulletin </i>is a 16-page printed booklet with circulation in excess of 2,700 copies per issue.</p> <p>Initially, <i>ICIB </i>dealt solely with amputees and prosthetics management. In the past year, however, in line with the general trend, the scope of the <i>Bulletin </i>has been enlarged to include orthotics topics. Since 1967, <i>ICIB </i>has been catalogued in the Library of Congress (Catalogue Number 67-304).</p> <p>At the last four annual meetings of the chiefs of the cooperating clinics, a feature of the program has been a symposium on a selected area of child-amputee management. The proceedings of the symposia held in 1967 <i>(Normal and Abnormal Em-bryological Development), </i>1968 <i>(Proximal Femoral Focal Deficiency), </i>and 1969 <i>(Surgical and Prosthetic Management of Lower-Extremity Anomalies) </i>have been published and distributed to clinicians, medical schools, and other interested groups. The proceedings of the 1970 meeting <i>(The Child with an Acquired Amputation) </i>are being prepared for printing.</p> <p>Effective communication with and between the clinics has been maintained by means of the <i>Inter-Clinic Information Bulletin, </i>the annual meeting of clinic chiefs, and personal contacts through CPRD and NYU staff. These factors have been critical elements in the extremely successful operation of the cooperative child-amputee research program. As the scope of the endeavor now expands to include conditions requiring orthotic assistance, the same elements may be used to develop an equally successful program for children with orthopedic disabilities other than amputation.</p> <h3>Subcommittee on Child Prosthetics Problems, CPRD</h3> <ul> <li>George T. Aitken, M.D., Chairman, Grand Rapids, Mich.</li> <li>Charles H. Epps, Jr., M.D., Washington, D.C.</li> <li>Sidney Fishman, Ph.D., New York, N.Y.</li> <li>Cameron B. Hall, M.D., Los Angeles, Calif.</li> <li>Douglas A. Hobson, P.Eng., Winnipeg, Canada</li> <li>Leon M. Kruger, M.D., Springfield, Mass.</li> <li>Claude N. Lambert, M.D., Chicago, 111.</li> <li>Robert E. Tooms, M.D., Memphis, Tenn.</li> </ul> <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>Hector W. Kay </b></td></tr><tr><td class="clsTextSmall">Assistant Executive Director, Committee on Prosthetics Research and Development.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1971_02_006/ArtificialLimbs-Autumn1971-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Children's Prosthetics and Orthotics Program Creator An entity primarily responsible for making the resource Hector W. Kay *