8 20 371 https://staging.drfop.org/files/original/c1dcd8002daf073f875a014ab93e6d77.pdf 9f6846fc84195173da86b474bf524650 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_003.pdf Text Any textual data included in the document <h2>Hydraulics and Above-Knee Prosthetics</h2> <h5>A. Bennett Wilson, Jr., B.S.M.E. <a style="text-decoration: none;">*</a></h5> <p>Some of the highlights in the history of the use of hydraulic systems in artificial legs might be useful in understanding the present status and influencing the future application of hydraulic principles in lower-limb prosthetics.</p> <p>One of the prime objectives of the designers of artificial legs for above-knee amputees is control of the knee joint, and, thus, the shank to provide the amputee with the means to stand and walk safely, efficiently, and gracefully. Sporadically since 1918, and possibly before, hydraulic principles were proposed as a means for locking or braking the knee to enhance safety, but none of these ideas seem to have reached a practical stage until after World War II.</p> <p>When the National Academy of Sciences (NAS) initiated a research program in limb prosthetics in 1945 at the request of the Surgeon General of the Army, surveys of amputees indicated that the above-knee amputees felt that their greatest need was a knee lock that would prevent stumbling. This "finding" prompted a number of designs in the United States that used hydraulic systems to provide knee locking or braking on demand. Concurrently, a team in Germany, Ulrich Henschke, a physician, and Hans Mauch, an engineer, developed a leg prototype that used a hydraulic lock activated by motion of the abdominal wall. After Dr. Henschke and Mr. Mauch moved to the United States at the invitation of the United States Air Force, they were encouraged by their host to continue development of their design, and they became active in the NAS Artificial Limb Program.</p> <p>During the 1940's, Mr. Jack Stewart, an AK amputee and inventor, devised, to meet his own needs, an above knee leg which used a hydraulic system to not only provide knee locking, but also to provide shock absorption at the heel, co-ordinated motion between knee and ankle joints, and adjustability of the height of the heel. Swing phase control was provided by hydraulic fluid being forced through a single orifice, a serendipitous sort of circumstance.</p> <p>About 1951, leaders in the research program came to the conclusion, based on data developed at the University of California, that perhaps, more important than control in the stance phase, is control during the swing phase. Mr. Mauch was requested to give high priority to the design of a mechanism that would provide control of the knee during swing phase so that the amputee could vary cadence without changing the friction control setting. At about the same time, it was recognized that the characteristics of a fluid flowing through an orifice had the possibility of providing automatically the change in resistance to knee flexion and extension needed to compensate for changes in the walking cadence.</p> <p>Using many of the same parts designed for the stance-control system as well as data provided by the University of California Biomechanics Laboratory concerning knee movements during swing phase, Mr. Mauch produced a unit with a number of orifices arranged to provide changes in resistance to rotation at the knee corresponding to the "normal." This design, known as the Model "B," after some years of testing and field use, was combined with the stance-control system to produce the Model "A," which when modified was marketed as the Henschke-Mauch S'n'S (Swing and Stance) knee unit. During the development of the Henchke-Mauch units several less complex hydraulic and pneumatic units were also developed by others and marketed commercially with some degree of success.</p> <p>During the early 1950's 18 units of the Stewart design known as the Stewart-Vickers Hydraulic Leg were evaluated by a team at New York University, who found good amputee acceptance, and recommended that the locking feature be eliminated since the cost could be reduced appreciably and the test subjects didn't seem to make use of that feature. This recommendation was followed by Mr. Stewart, who a short while later sold all rights to U.S. Manufacturing Co., who manufactured and marketed it as the Hydra-Cadence Leg. The Hydra-Cadence Leg has been a commercial success, but in spite of a great deal of experience, no one can be sure of the relative importance of its many features.</p> <p>The development of hydraulic mechanisms for artificial legs has been plagued by leakage and breakage, which is only natural in an effort that tries to arrive at the optimum compromise between cost, weight, and function. Whether or not this optimum has been achieved is not yet known. We do know, however, that active above-knee and hip-disarticulation amputees appreciate the swing-phase control function afforded by hydraulic mechanisms and that the present day costs are not prohibitive for a substantial number of amputees. No definitive studies have been made that would delineate the efforts of the various factors and features involved, singly or in combination. With the availability of 4-channel 24-hour physiological surveillance systems and other sophisticated instrumentation, such studies seem to be quite feasible now and certainly should be considered.</p> <p>For at least thirty years the need for voluntary control of the knee joint has been recognized, but until the advent of the microcomputer it was difficult to conceive of a practical method to accomplish this. When microcomputers became available, the first reaction of some designers was simply to add the microcomputer to present hydraulic systems, but these efforts failed most probably because the systems available were not designed for control by computer. At any rate, it would seem that the weight alone of present systems would make voluntary control impractical, and thus any project in this area should begin anew.</p> <p>At present, very little work seems to be going on in the area of voluntary control systems. Some work at the Massachusetts Institute of Technology has been reported for nearly a decade. More recently, the REC at Moss Rehabilitation Hospital started a project where pattern recognition techniques are used to obtain subconscious control of a knee mechanism by EMG signals about the hip joint, which shows a good deal of promise.</p> <p>Perhaps what we need most at this point is more information concerning the contribution of each variable, such as swing-phase control, stance-phase control, ankle action, weight, and weight distribution, singly and in combination, for designers of the next generation of above-knee legs. With the technology now available to us, this appears to be possible as well as practical.</p> <em><b>*A. Bennett Wilson, Jr., B.S.M.E. </b>Assistant Director, Rehabilitation Research and Training Center Dept. of Orthopaedics and Rehabilitation University of Virginia Medical Center Charlottesville, Virginia 22908.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 3 - 4 Year 1983 Volume 7 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 Hydraulics and Above-Knee Prosthetics Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr., B.S.M.E. * https://staging.drfop.org/files/original/acdfaaea21f1bfb4bdf97517f56845da.pdf 8af470c4b6b701d48e3966ab0ccc3937 https://staging.drfop.org/files/original/da4a595957bc641bc12ab26505f5bc08.jpg 23df8755ba0d58ec9874f7994d9987b6 https://staging.drfop.org/files/original/3e1236ea8c0c6360fc9d94a682044776.jpg f6f4a8994e2b10e235ee989b410d0094 https://staging.drfop.org/files/original/f25284165068c830330ede2c991e2476.jpg d4825a44e2c821c04b64c148b394c7e3 https://staging.drfop.org/files/original/5d0bc90db35789e97ef273601770ac77.jpg ccef6e0b55533d001c84558310b107be https://staging.drfop.org/files/original/3ed8dd3d9835175e80b43108f1e0ea71.jpg 0aa14032fb6af7d768b416963fbcd6fb https://staging.drfop.org/files/original/c3873a676dcabeca9b3d3fe41c175283.jpg d8935b1a857dc9988df89329d750a061 https://staging.drfop.org/files/original/2a8d7cea53b9c3f88d25c8d7ad9afca6.jpg 3e5e6cdd2e67572178aba7a53ebb8bf8 https://staging.drfop.org/files/original/c9b975f98002c412af3fafaa613f23c2.jpg 36bcdc363071c806bbb269950ca61d95 https://staging.drfop.org/files/original/c1b80cf0553630bc898178fc4a134a50.jpg 479573d0757401271d9c5e2d2db19e0b Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1988_01_024.pdf Text Any textual data included in the document <h2>Imler Partial Foot Prosthesis I.P.F.P.: "Chicago Boot"</h2> <h5>Clarence D. Imler, CP.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Surgeons are now performing a greater number of distal amputations, including those of the distal forefoot. Among these are the Lis-France, Chopart, Boyd, and other difficult to fit deformities.</p> <p>The Imler Partial Foot Prosthesis fulfills the need for a light weight, structurally strong prosthesis, that provides ankle support, has an anterior lever arm, acts as a shoe filler, and is cosmetically acceptable.</p> <p>The essential element of the prosthesis is the interface, consisting of a vacuum formed copolymer1 U.C.B, type insert with a toe filler of soft foam. This interface is inserted into a laminated, flexible rubber-epoxy-resin (Lyna-dure) cosmetic sleeve that encompasses the foot and interface. This sleeve extends proximally to above the malleolus and has an anterior opening. The interface is removable, and enables the prosthetist to make adjustments (i.e., alignment and/or relief). Closure is obtained by eyelets and lacer for greater suspension, or Velcro® for cosmesis.</p> <h3>Casting Procedure</h3> <p>A negative impression may be obtained using any conventional method. A midfoot amputation should be placed on a casting board or covered with a plastic bag and inserted into a patient's shoe to simulate heel height. Very little weight should be applied to avoid spreading of the foot. With a Chopart amputation, where the calcaneous is plantar flexed or rotated posteriorly, a casting board is not used. The casting in all cases is similar to the procedure used when casting for a U.C.B, shoe insert.</p> <h3>Modification of the Positive Model</h3> <p>Modification includes a standard 3mm anterior relief. A 1mm relief for the malleoli is added, along with relief for any bony prominence or scar tissue as needed. Remove 2mm of plaster both medially and laterally, proximal to the calcaneous to enhance the support effect of the U.C.B, type heel cup. There is no relief needed for the anterior tibia, and in some cases plaster is removed for a tighter fit (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-1.jpg"><b>Fig. 1</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-1.jpg"><strong>Figure 1. A modified positive model.</strong></a><br /> <h3>Interface with Toe Filler</h3> <p>Over the modified positive model, thermo-mold a section of 5mm Pelite™, for an anterior end pad. Trim and bevel the edges to achieve a smooth transition (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-2.jpg"><b>Fig. 2</b></a>). A sheet of 3/16" Colyene is vacuum formed over the cast and end pad, with an anterior seam (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-3.jpg"><b>Fig. 3</b></a>). The interface may also be laminated with either acrylic or polyester resin. The posterior trim line is proximal to the calcaneous. The medial and lateral trimlines are both distal to the malleoli, and the anterior trimline is at mid-height level. Care should be taken not to cut into the Pelite™ pad as it extends above the trimline (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-4.jpg"><b>Fig. 4</b></a>). The anterior toe section can be constructed by various means. Pelite™ of 5mm firm density should be added until a flat surface distally is attained (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-5.jpg"><b>Fig. 5</b></a>). The anterior toe section is constructed of 12mm firm density Pelite™, bonded together lengthwise. This toe section is bonded to the heel cup and shaped to size. Other materials or foams may be used but they must be firm enough to hold their shape during lamination (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-6.jpg"><b>Fig. 6</b></a>). The finished heel cup interface with toe filler is replaced on the cast and inserted into the patient's shoe. At this point, a final determination is made of the alignment, and whether additional material must be added or removed to fit the shoe to leave room for the outer lamination (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-6.jpg"><b>Fig. 6</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-2.jpg"><strong>Figure 2. The positive model with distal cap in place.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-3.jpg"><strong>Figure 3. A vacuum-formed heel cup.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-4.jpg"><strong>Figure 4. A heel cup with distal end cap.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-5.jpg"><strong>Figure 5. A heel cup with distal end built up and flattened.</strong></a><br /><br /><a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-6.jpg"><strong>Figure 6. Toe extension.</strong></a><br /> <p>Adjustments are made at this juncture. The heel cup and toe filler can be divided and the heel cup rotated, relative to the toe filler, to produce eversion, inversion, plantar/dorsi-flexion, toe-in, or toe-out. Due to the flexibility of the outer sleeve, these changes may be accommodated without the need for a new lamination.</p> <p>A 1.5mm thick strip of polyethylene is thermo-formed over the anterior surface. This will act as a separating agent, forming the tongue and overlap. This is cut to a width of approximately 2.6cm The length extends from the proximal edge of the cast, to 5mm past the proximal edge of the Pelite™ toe filler. The edges are beveled for a smooth transition.</p> <p>The layup for the outer sleeve lamination consists of a nylon hose covered by a PVA bag, which is capped off and put under full vacuum. Two layers of Comfort® stretch nylon stockinette and one layer of IPOS stretch nylon are applied. The strip of polyethylene wrapped in two layers of Dynalon3 is sandwiched between this and two additional layers of Comfort® stretch nylon and two layers of IPOS stretch nylon. A second PVA bag is applied with vacuum, and the rubber epoxy resin (Lynadure) is introduced (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-7.jpg"><b>Fig. 7</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-7.jpg"><strong>Figure 7. Lynadure lamination.</strong></a><br /> <p>Before final trimming, determine if closure is to be achieved by eyelets and lace or Velcro®. If eyelets are used, make a center cut through to the polyethylene strip, with inverted "T" slits to the edges of the strip. Remove the polyethylene strip and cut the inner tongue along the medial and distal edges only. To obtain a Velcro® closure, first cut along the medial and distal edge of the polyethylene strip, remove the strip, and cut the inner tongue along the lateral and distal border. Before cutting the laminate, be sure the material has fully cured; if the material has not completely cured, it may pull apart.</p> <p>The I.P.F.P. weighs approximately 250 grams, depending on the shoe size. It is extremely lightweight, but very durable.</p> <p>A leg length discrepancy may be accommodated for in the prosthesis by adding a Pelite™ pad of the proper height, either before or after the interface is vacuum formed.</p> <p>The prosthesis is thinly constructed to be used by the patient with regular shoes. There is no need for split-sized, or extra depth inlay shoes, in most cases. <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-8.jpg"><b>Fig. 8</b></a> shows the finished prosthesis in a patient's shoe.</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-8.jpg"><strong>Figure 8. The prosthesis in the patient's shoe.</strong></a><br /> <p>Fabrication has changed very little since initial development. The Lynadure lamination layup has been strengthened with additional layers of stockinette and Dynalon. A few pros-thetists have requested that the co-polymer heel cup be extended anteriorly to the toes as an A.F.O. for greater push off.</p> <p>Another adaptation is the anterior section of a SACH foot with toes laminated into the Lynadure sleeve with the toes exposed, for cos-mesis when wearing open toe shoes or sandals (<a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-9.jpg"><b>Fig. 9</b></a>).</p> <a href="http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-9.jpg"><strong>Figure 9. The finished prosthesis.</strong></a><br /> <p>This may not be the answer to every partial foot amputation, but is an alternative to be considered when fitting a patient with a particularly difficult situation.</p> <h3>Resources and Materials</h3> <p>Co-Polymer, Colyene: Orthotic Prosthetic Enterprises, 1316 Sherman Avenue, Evanston, Illinois 60202.</p> <p>Lynadure: Medical Center Prosthetics, 6955 Almeda Road, Houston, Texas 77021.</p> <p>Dynalon: Hosmer Dorrance Corporation, 561 Division Street, Campbell, California 95008.</p> <p><em><b>*Clarence D. Imler, CP. </b> Clarence D. Imler, CP., is with Oakbrook Orthopedic Services, Ltd., 1 South 132 Summit Avenue, Suite 102, Oakbrook Terrace, Illinois 60181.<br /><br /><br /></em></p> <div style="width: 400px;"></div> Page Number(s) 24 - 28 Year 1988 Volume 12 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 6 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-7.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-8.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1988_01_024/1988_01_024-9.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Imler Partial Foot Prosthesis I.P.F.P.: "Chicago Boot" Creator An entity primarily responsible for making the resource Clarence D. Imler, CP. * https://staging.drfop.org/files/original/d7b675b0378cee1912a8d5e84687921d.pdf 9d96407f8c68159964c5da7b9a38bd7f https://staging.drfop.org/files/original/3d9d7c0b41f15695d1d34ad758690f2a.png 69bc94cb8f542767a5c7ce6a7afa1b4a https://staging.drfop.org/files/original/d65d1661f0886e3d968a3606ff3a6a5c.jpg 87ff5e2a3fe1a34b03c0c39672002824 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_033.pdf Text Any textual data included in the document <h2>Immediate Post-Operative Orthotic Impression Technique for Thermoplastic Spinal Orthoses Following Spinal Surgery</h2> <h5>James T. Lehner, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Wilbur A. Haines, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Mark E. Horwitz, CO.&nbsp;<a style="text-decoration: none;">*</a><br />Cynthia J. King, CO.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Spinal surgery has been revolutionized in recent years by advances in surgical approaches, surgical techniques, and forms of internal fixation. Post-operative management has progressed from bed rest with log rolling, to mobilization in plaster casts, to modern technology orthoses. Co-polymer plastic composite orthoses have been used by the authors during the last few years. The orthoses have been easy to apply and have been comfortable for our patients. There have been no associated complications which would jeopardize the outcome of the operative procedure.</p> <h3>Patient Selection</h3> <p>The original patient the authors selected for management using a thermo-plastic orthosis was a retarded child with cerebral palsy who had previously been intolerant of casting, developing pressure sores within the cast. Molding for the co-polymer orthosis had to be done while the patient was anesthetized, since this patient was combative and otherwise difficult to work with. While the impression for this patient was being made, it became apparent that this molding technique would be easy to do in the operating room at the conclusion of operative spinal procedures. Initially, this postoperative molding technique was used for "special cases." These included patients with cerebral palsy, myelomeningocele, severe osteoporosis, and patients with severe respiratory problems. Eventually, the older adult idiopathic population which seemed very intolerant of rigid metallic orthoses or casting, was included. Things have gradually evolved to a point where most patients, other than teenage idiopathics, are candidates for this type of orthosis. The authors still prefer using a Kosair metallic axillary crutch style orthosis postoperatively for adolescent idiopathic scoliosis patients, since they seem to tolerate the rigidity of this system well.<a></a></p> <p>The first 80 patients fitted with the co-polymer postoperative spinal orthotic system are reviewed in this study.</p> <p>Diagnoses include all the aforementioned, plus other types of muscular dystrophy, congenital scoliosis, tumors, post-menopausal deformities, and degenerative spinal deformities. All orthoses were applied after long (minimum of six vertebral levels) spinal fusions. All surgical cases, except those of congenital scoliosis, were routinely done with instrumentation.</p> <h3>Orthosis Impression Technique</h3> <p>The orthotic impression is taken immediately after the spinal surgery while the patient is still asleep. The technique is:</p> <ol> <li> <p>After the skin incision is closed, a light layer of Adaptic® and one layer of sterile four-by-fours are placed over the wound.</p> </li> <li> <p>The skin is bilaterally marked longitudinally along the mid-axilla (mid-coronal line) using a wet indelible pencil. Perpendicular hash marks are randomly made across the mid-axillary line to be used as "key" reference marks later.</p> </li> <li> <p>Sterile Vidrape® is placed across the patient's back to establish an impermeable membrane.</p> </li> <li> <p>The Vidrape® is marked by superimposing onto it the marks made previously on the patient's skin.</p> </li> <li> <p>Plaster splints are draped across the required area of the patient's torso, making sure that the plaster crosses the mid-axillary lines on both sides of the patient. The first layer is applied using two or three thicknesses of plaster. Subsequent reinforcing layers are applied, using about six layers of plaster. Finally, a few strips are applied to help prevent distortion of the mold. These are placed across the mold at two or three locations in the shape of an inverted "V."</p> </li> <li> <p>At this point, the posterior section of the impression is removed from the patient when hard (<a href="http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-1.jpg"><b>Fig. 1</b></a>).</p> <span><strong>Figure 1. Orthotist removing posterior mold. Note Vidrape® and markings in mid-axillary line</strong>.</span></li> <li> <p>The Vidrape® is then removed in a manner which keeps plaster or water from touching the wound.</p> </li> <li> <p>Sterile dressings are applied by the scrub nurse, who has remained sterile to this point.</p> </li> <li> <p>The patient is placed on the post-operative bed that has been prepared using one extra sheet.</p> </li> <li> <p>Vidrape® is then applied to the patient anteriorly in preparation for the anterior section molding. (Cover breast and groin areas with four-by-fours or diapers.)</p> </li> <li> <p>The indelible pencil marks are again superimposed onto the Vidrape® along the mid-axillary lines, and appropriate relief markings are made on the rib cage and iliac crests.</p> </li> <li> <p>The anterior mold is made using the technique described in step five. When set, the plaster is removed.</p> </li> <li> <p>Finally, the Vidrape® is carefully removed and the patient is ready to go to the post-operative recovery room.</p> </li> </ol> <p>After the impression has hardened sufficiently, a cast cutter may be used to cut along the mid-axillary indelible lines, visible on the inner surfaces of each half of the impression. Using the "key" hash marks established previously, the two impression halves are joined together with plaster strips. The impression is now ready for orthotic fabrication using the method of choice.</p> <p>Since the impression has been made with the patient in the prone and supine positions, the orthotist must take this into account when fabricating the orthosis. The medial-lateral dimension of the patient is distorted normally about one inch due to the flattening effect created by the patient's weight against the operating and post-operative bed.</p> <p>The time required for the impression procedure adds 15 to 20 minutes of extra anesthesia and operating room time. There have been no infections in any of these cases.</p> <h3>Results</h3> <p>The orthosis described has been applied to 80 post-spinal surgery patients between January 1980 and October 1984. There were no cases of rod dislodgement or pseudoarthrosis. Fifty-eight patients had instrumentation done using segmental spinal wiring with either L-Rod or Harrington Rod fixation. One Mongoloid boy broke a wire in his L-Rod fixation, but over a subsequent 24 month follow-up, has shown no further wire or rod breakage. No other incident of internal fixation failure while wearing the orthosis has been encountered to date. Early in the series, one orthosis had to be remade due to pressure problems. No other orthosis has required anything except routine minimal corrections of trim lines. In the beginning, the average time of orthotic application was the eighth post-operative day. Later in the series, this dropped to the fifth post-operative day. Orthotic application varied from the second to the thirteenth day post-op and was determined by the patient's medical condition in all but one case. The patients were placed upright immediately upon application of the orthosis (<a href="http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-2.jpg"><b>Fig. 2</b></a>). They were dismissed from the hospital an average of four days after the orthosis was applied.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-2.jpg">Figure 2.</a> Post-op Spina Bifida child two days after brace application and four days post-operatively. Note colostomy site on right lower quadrant.</strong><br /> <p>Orthoses were worn about six and one half months post-operatively (the first 25 patients wore theirs for eight months post-op; all subsequent patients have worn theirs for six months post-operatively).</p> <p>Compliance has been monitored by the parents or guardians of the patients. They have reported 100 percent compliance. The parents are instructed that the orthosis may be removed when the patients are supine, for bathing, skin care, and pulmonary toilet as needed. Patients are never allowed up in the sitting position without wearing the orthosis during the six month post-operative period. One-half of the patients were non-ambulatory.</p> <h3>Discussion</h3> <p>This is an easy, quick, and accurate way to measure and apply post-operative thermoplastic orthoses after spinal surgery. It has been possible to eliminate patient discomfort during the molding process and no manipulation of the patient was required during the procedure.</p> <p>While this technique requires a close working relationship between physician, hospital personnel, and orthotist, it has virtually eliminated time delays in orthotic delivery. Historically, orthotic impressions were taken "when the patient was ready post-operative-ly." This left the impression making process in a nebulous time frame. Typically, patients were delayed in the application of their orthosis by a few days. This added additional patient time in the hospital with little benefit. Also, the orthotist had to schedule the impression making process at a time convenient to appropriate hospital personnel.</p> <p>The technique described gives the orthotist and his/her staff adequate time to properly design and fabricate the orthosis. Although none of the patients were felt to be ready to ambulate or sit on the first post-operative day, it would be possible to apply the orthosis, if necessary, within 24 hours. Many of the severe respiratory cases (spinal muscular atrophy) were fitted with their orthoses and sat up while still on a respirator in intensive care. There was only one case where orthotic application delayed patient mobility (orthosis revision was necessary). Usually, comfort was the deciding factor in-getting patients up. Later in this study group, when indications were broadened to include healthier patients, the time frame post-op of ambulation decreased significantly.</p> <p>It is believed that molding for a spinal orthosis while the patient is awake, several days after surgery, is unnecessarily painful. It also places the patient in some jeopardy of dislodging the instrumentation while having the impression made. It is also considered irrational to mold patients for an orthosis at a time when they are actually ready to be up and around. The authors do not trust segmental spinal instrumentation without external bracing, and reports now indicate this conservative approach, including the use of an orthosis, in this group of patients is warranted.<a></a> Retarded children and patients with anesthetic skin easily get into trouble with body casts and non-removable orthoses. The orthotic system described certainly helps to alleviate many of the problems previously encountered with post-operative spinal orthoses. This technique is still not used for the standard adolescent idiopathic patient, who in our judgment currently does well with Harrington Instrumentation fixation and post-operative bracing using a rigid metallic Kosair type orthotic system.</p> <h3>Advantages</h3> <p>The co-polymer post-operative orthotic spinal system has many advantages:</p> <ol> <li> <p>Minimal patient discomfort;</p> </li> <li> <p>Expedient spinal orthosis application;</p> </li> <li> <p>Maximum utility for patient care (skin cleansing, checking anesthetic skin, respiratory therapy, etc.);</p> </li> <li> <p>Taking an accurate impression with minimal post-operative movement of the patient; and</p> </li> <li> <p>Excellent wearing compliance by patients.</p> </li> </ol> <h3>Disadvantages</h3> <p>While there are disadvantages to most anything, the negative points of this technique and system are few. They would include:</p> <ol> <li> <p>Increased anesthesia and operating room time (15-20 min.);</p> </li> <li>Tight post-op scheduling of the orthotist's time (Requires a close working relationship with physician, hospital personnel, and orthotist).</li> </ol> <em><b><br />*James T. Lehner, M.D. </b>James T. Lehner, M.D. is from the Wright State University College of Medicine, Division of Orthopedics.<br /><br /><b>*Wilbur A. Haines, C.P.O. </b>Wilbur A. Haines, CO. is President of LaForsch Orthopedic Laboratories, 536 Valley Street, Dayton, Ohio<b><br /><br />*Mark E. Horwitz, CO. </b>Mark E. Horwitz, CO. is Director of Orthopedic Services for LaForsch Orthopedic Laboratories.<b><br /><br />*Cynthia J. King, CO. </b></em><span><span><em>Cynthia L. King, CO. is with the Clinical Orthotic Services at LaForsch Orthopedic Laboratories</em><br /><br /></span></span> <p><b>References:</b></p> <ol> <li>Benson, S.; McKinley, L.M.; Martin, T., Delto-Pec-toral Axillary Lumbar Thoracic Support. Kosair Orthotic Laboratory, Louisville, Kentucky (Unpublished Data).</li> <li>Broadstone, P.; Johnson, J.R.; Holt, R.T.; Leath-erman, K.D., "Consider Post-operative Immobilization of Double-L Rod S.S.I. Patients," <i>Orthopedic Transactions</i>, 8(1):171-172, 1984.</li> <li>Taddonio, R.F.; Weller, K.; Appel, M., "A Comparison of Patients With Idiopathic Scoliosis Managed With and Without Post-operative Immobilization Following Segmental Spinal Instrumentation With Luque Rods," <i>Orthopedic Transactions</i>, 8(1): 172, 1984.</li> <li>Wallace, S.L.; Fillauer, K., "Thermoplastic Body Jackets for Control of Spine after Fusion in Patients with Scoliosis," <i>Orthotics and Prosthetics</i>, Vol. 33, No. 3, pp. 20-24, September, 1979.</li> </ol> Page Number(s) 33 - 37 Year 1986 Volume 10 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 2 http://www.oandplibrary.org/cpo/images/1986_01_033/1986_01_033-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Immediate Post-Operative Orthotic Impression Technique for Thermoplastic Spinal Orthoses Following Spinal Surgery Creator An entity primarily responsible for making the resource James T. Lehner, M.D. * Wilbur A. Haines, C.P.O. * Mark E. Horwitz, CO. * Cynthia J. King, CO. * https://staging.drfop.org/files/original/bf963a7989acad403aa943778ba020f1.pdf 409d60d0518157719847a792bbaa57d6 https://staging.drfop.org/files/original/0106990b6dd41f117c47cb5fdca17da6.jpg df6ba1aeb28f1c6a9d86a606fe572db8 https://staging.drfop.org/files/original/f2e96714d806c927c09ba51bb59036d1.jpg 40fd5b62c3ecd7ff81b859972eb1341c https://staging.drfop.org/files/original/62eca765fb8a28647e1f1e9858e762b3.jpg d87f8fadb9907c263d1a3fde50944103 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_014.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 14 - 16 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_01_014.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_014.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Immediate Postsurgical Prosthetics Fitting in the Management of Upper-Extremity Amputees</h2> <h5>Augusto Sarmiento, M.D. <a style="text-decoration:none;">*</a><br />Newton C. McCollough, III, M.D. <a style="text-decoration:none;">*</a><br />Edward M. Williams, M.D. <a style="text-decoration:none;">*</a><br />William F. Sinclair, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>In the experience of the authors of this article, immediate postsurgical prosthetics fitting has been the most satisfactory means of managing lower-extremity amputees. <a></a> The procedure has allowed better control of postsurgical edema, reduced postoperative pain, permitted more rapid conditioning of the stump, and shortened the time between amputation surgery and definitive prosthetic fitting. These conclusions are based on the experiences gained with 200 below-knee amputations followed by immediate postsurgical fittings at Jackson Memorial Hospital, the main teaching hospital of the University of Miami School of Medicine. The underlying cause of amputation in 85 per cent of these patients was peripheral vascular disease, usually with diabetes.</p> <h3>Four Upper-Extremity Cases</h3> <p>On four occasions there have been opportunities to apply temporary prostheses to upper-extremity amputees immediately after surgery. The patients in this small series showed a considerable reduction in postoperative pain, rapidly began to use their prosthetic appliances, and were impressive in their psychological adjustment to their disabilities.</p> <p>Brief clinical and prosthetics histories of these four patients follow.</p> <ol> <li>L.M. is a 32-year-old male who was struck in the right hand by a rattlesnake in November 1966. Despite a vigorous therapeutic regimen, extensive damage was sustained. The patient underwent several surgical procedures in attempts to restore function to his hand. One year later, because of a functionless, partially anaesthetic, two-digit hand, a wrist disarticulation was performed, with immediate fitting of prosthesis (<b>Fig. 1</b>). Seventeen hours after surgery, with no instruction other than the preoperative demonstration of the harness and hook control, the patient was capable of operating the terminal device sufficiently well to feed and dress himself (<b>Fig. 2</b>). The patient was fitted with a permanent prosthesis three weeks after amputation. The surgical wound had healed <i>per primam </i>when the stump was first inspected two weeks after the surgical procedure.</li><li>A.S. is a 57-year-old male who severely injured his hand in a meat grinder, requiring a wrist disarticulation. Because of the nature of the injury, it was elected not to close the wound but to perform an open carpal disarticulation. One week later, in the absence of infection or other complications, a wrist disarticulation was performed by conventional means. The patient was fitted immediately postoperative with a below-elbow temporary prosthesis, complete with harness and controls. The patient left the hospital four days after surgery; when seen as an outpatient one week after surgery, he was capable of using the terminal device satisfactorily. He was fitted with the final prosthesis four weeks after surgical procedure.</li><li>L.D. is a 57-year-old male who underwent a right below-elbow amputation in December 1967 because of extensive metastases to the right radius from a hypernephroma (<b>Fig. 3</b>). The operation was performed by conventional methods and a temporary prosthesis, with harness and controls, was applied immediately after surgery. Convalescence was uneventful and the patient was discharged 22 days after surgery, at which time he was capable of controlling the elbow and terminal device in a relatively satisfactory manner. He was fitted with a permanent prosthesis 60 days after the surgical procedure.</li><li>F.M. is a 57-year-old male who sustained a severe sideswipe injury to the left upper extremity, with multiple fractures and extensive arterial and nerve injuries. After approximately nine months and many surgical procedures, the patient was left with a functionless and nearly anaesthetic extremity. An above-elbow amputation was carried out by conventional means, with immediate fitting of the temporary socket. The postoperative course was uneventful. Harness and controls were added one week postoperative. Upon discharge four weeks after surgery, the patient was using the terminal device and elbow lock in a satisfactory manner.</li></ol> <h3>Discussion</h3> <p>The absence of severe peripheral vascular disease in the upper extremities appears to increase the possibility of successful immediate postsurgical prosthetics fitting even above that seen in the lower extremities. Since weight-bearing is not a factor, the possibility of stump damage as a result of excessive pressures is minimized. In all four cases reported in this article, primary healing took place and there were no complications. Phantom pain was not encountered in any instance. The four patients were fitted with plaster temporary prostheses with conventional harness and controls and were instructed to operate the terminal device as early as the first postoperative day. The two wrist-disarticulation patients were allowed to move their elbows freely, and the two above-elbow patients were encouraged to move their shoulders as freely as possible. The psychological advantage of early rehabilitation has been apparent. Immediate postsurgical prosthetics fitting of the upper-extremity amputee appears to have significant advantages.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Preoperative view of a functionless and partially anaesthetic hand resulting from the bite of a rattlesnake. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Photograph taken 24 hours after wrist disarticulation and immediate postsurgical fitting of prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Metastatic lesion of right radius resulting from hypernephroma. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li>Berlemont, M., <i>Notre experience de I'appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck</i>, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec, 1961.</li> <li>Berlemont, M., <i>L'appareillage des ampulis des membres inferieurs sur le table d'operations, paper given at the International Congress of Physical Medicine</i>, Paris, 1964.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr.,<i> Management of lower-extremity amputees using immediate postsurgical Jilting techniques.</i> Prosthetic and Sensory Aids Service, U.S. Veterans Administration. 1967.</li> <li>Weiss, Marian, <i>Neurological implications of fitting artificial limbs immediately after amputation surgery</i>, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</li> <li>Wilson, A. Bennett, Jr., <i>New concepts in the management of lower-extremity amputees</i>, Artif. Limbs, Spring 1967, pp. 47-50.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Berlemont, M., Notre experience de I'appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec, 1961.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Berlemont, M., L'appareillage des ampulis des membres inferieurs sur le table d'operations, paper given at the International Congress of Physical Medicine, Paris, 1964.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Management of lower-extremity amputees using immediate postsurgical Jilting techniques. Prosthetic and Sensory Aids Service, U.S. Veterans Administration. 1967.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Weiss, Marian, Neurological implications of fitting artificial limbs immediately after amputation surgery, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., New concepts in the management of lower-extremity amputees, Artif. Limbs, Spring 1967, pp. 47-50.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>William F. Sinclair, C.P. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward M. Williams, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Newton C. McCollough, III, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Augusto Sarmiento, M.D. </b></td></tr><tr><td class="clsTextSmall">School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, Fla. 33152.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_01_014/spring68b-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_01_014/spring68b-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_01_014/spring68b-03.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 Immediate Postsurgical Prosthetics Fitting in the Management of Upper-Extremity Amputees Creator An entity primarily responsible for making the resource Augusto Sarmiento, M.D. * Newton C. McCollough, III, M.D. * Edward M. Williams, M.D. * William F. Sinclair, C.P. * https://staging.drfop.org/files/original/fc94390daaecbf5fe0e515d25844a562.pdf addcea0ef5d054afe2d97b8b2ed7d402 https://staging.drfop.org/files/original/b63e79eeb63c71071d4e658053cf7453.jpg 7033f3a9ae76997cae29ba015bdf6e1a https://staging.drfop.org/files/original/c916255036e94916ce3f90294984788f.jpg ed7c60521a368679fe0866091d1ba7c5 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_017.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 17 - 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/1968_01_017.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_017.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>Immediate Postsurgical Prosthetics Fitting of a Bilateral, Below-Elbow Amputee, a Report</h2> <h5>Edward Loughlin, M.D. <a style="text-decoration:none;">*</a><br />James W. Stanford, III, C.P. <a style="text-decoration:none;">*</a><br />Marcus Phelps, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The application of immediate postsurgical prosthetics fitting procedures in the management of lower-extremity amputees has been reported as providing a number of advantages, notably control of postsurgical edema, a marked reduction in pain, and a material reduction of the period of hospitalization. <a></a></p> <p>Although somewhat different considerations are involved in upper-extremity cases, immediate postsurgical prosthetics fitting of upper-extremity amputees is a logical progression in the application of these procedures. Upper-extremity amputations are considerably less frequent and are usually in a younger age group. Adequate wound healing is usually not a problem, local factors being the most important determinant. Still the application of a rigid dressing is a sound surgical concept.</p> <p>Unilateral amputees have a high rejection rate for actual use of their prostheses. It is believed that immediate postsurgical fitting of prostheses to upper-extremity amputees permits rehabilitation from the earliest possible moment and, hopefully, a higher acceptance rate. As used in this report, the term "immediate fitting" means the application of a rigid surgical dressing with terminal device at the time of surgery or in the immediate postoperative period. This is in contrast with "early fitting," which is applied at some time after the removal of sutures.</p> <p>During the past two years, the authors have had the opportunity to apply immediate prosthetics fittings to three patients, with four upper-extremity amputations. The case reported here is that of a bilateral, below-elbow amputee.</p> <h3>Case History</h3> <p>LMW, a 26-year-old employee of an electric power company, sustained electrical burns of both upper extremities on March 7, 1967, the result of receiving 19,000 volts of current through both wrists. One month later he was seen in the hospital by a consulting group (general surgeon, plastic surgeon, and orthopaedic surgeon) for consideration of possible reconstructive measures. It was the consensus of the group that no useful hand or part thereof could be salvaged (<b>Fig. 1</b>). As a result, on April 17, 1967, bilateral midforearm amputations were carried out. At the time of surgery extensive muscle necrosis was found-as expected- proximal to the apparent skin defect. This required loose closure of the amputations. Drains were placed in the wounds and compression dressings were applied. On April 20, 1967, the patient was returned to the operating room so that the wounds could be viewed, and they appeared to be clean. At this time rigid surgical dressings with terminal devices and harnessing were applied. From that time on, a marked improvement in the emotional status of the patient was noted (<b>Fig. 2</b>). The patient wore his temporary prostheses until May 26, 1967, when he was fitted with permanent prostheses. The patient made an excellent recovery, returning to full-time work in November 1967.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Neither the left nor the right hand was considered salvageable. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. From the time of the application of the rigid dressings and temporary prostheses, there was an upturn in the patient's emotional status. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Application of Temporary Prostheses</h3> <p>Some details in the application of the rigid dressings and temporary prostheses may be of interest.</p> <p>Autoclaved lamb's wool was applied over the suture lines, and Orion Spandex socks were then rolled into place and held under tension.</p> <p>To satisfy two somewhat conflicting considerations-that is, to ensure that the rigid surgical dressing would not be displaced when the patient flexed and extended his elbows, and to avoid immobilization of the elbow joint with plaster-Ace bandages were applied about 3 in. below the elbow and continued proximally to encase the elbow joint. Elastic plaster bandages were then applied, and the Ace bandages were incorporated into the plaster wrap. The plaster wrap extended to a point just below the condyles of the joint. Thus the rigid dressing was held in contact, and at the same time limited movement was permitted to the joint.</p> <p>Steel straps attached to WE-500 wrist units were then applied to the rigid dressing with regular plaster for reinforcement.</p> <p>A retainer plate riveted to an anchor plate was attached to the socket for cable attachment.</p> <p>A standard bilateral ring harness with plastic triceps pad and flexible leather hinges completed the setup.</p> <p>Two 5XA hooks were applied with one rubber band each.</p> <p>On April 25, 1967, sufficient atrophy had occurred to warrant new rigid dressings. The foregoing procedure was repeated. At this time, extra rubber bands were added to the terminal devices, and the patient demonstrated proficiency at a number of activities.</p> <p>On May 9, 1967, the second cast change was made, and a wrist-flexion unit was applied to the right side. Again, more rubber bands were applied.</p> <h3>Permanent Prostheses</h3> <p>"Definite prostheses" were prescribed for the patient on May 18, 1967. The prostheses were fabricated and subsequently fitted on May 26, 1967. The prescription included:</p> <ul> <li>Bilateral below-elbow plastic prostheses.</li> <li>Double-wall sockets.</li> <li>Flexible joints.</li> <li>5XA hooks.</li> <li>Dorrance No. 4 hands.</li> <li>Two wrist-flexion units.</li> <li>One driving ring.</li> <li>One button hook.</li> </ul> <p><b>References:</b></p> <ol> <li>Berlemont, M., <i>Notre experience de V appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck</i>, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec. 1961.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., <i>Management of lower-extremity amputees using immediate postsurgical fitting techniques</i>, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, 1967.</li> <li>Weiss, Marian, <i>Neurological implications of fitting artificial limbs immediately after amputation surgery</i>, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</li> <li>Wilson, A. Bennett, Jr., <i>New concepts in the management of lower-extremity amputees</i>, Artif. Limbs, Spring 1967, pp. 47-50.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Berlemont, M., Notre experience de V appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec. 1961.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Management of lower-extremity amputees using immediate postsurgical fitting techniques, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, 1967.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Weiss, Marian, Neurological implications of fitting artificial limbs immediately after amputation surgery, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., New concepts in the management of lower-extremity amputees, Artif. Limbs, Spring 1967, pp. 47-50.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Marcus Phelps, C.P. </b></td></tr><tr><td class="clsTextSmall">J. E. Hanger, Inc., of Georgia, 947 Juniper St., N.E., Atlanta, Ga. 30309.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>James W. Stanford, III, C.P. </b></td></tr><tr><td class="clsTextSmall">J. E. Hanger, Inc., of Georgia, 947 Juniper St., N.E., Atlanta, Ga. 30309.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edward Loughlin, M.D. </b></td></tr><tr><td class="clsTextSmall">Peachtree Orthopaedic Clinic, Atlanta, Ga. 30301</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_01_017/spring68c-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_01_017/spring68c-02.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 Immediate Postsurgical Prosthetics Fitting of a Bilateral, Below-Elbow Amputee, a Report Creator An entity primarily responsible for making the resource Edward Loughlin, M.D. * James W. Stanford, III, C.P. * Marcus Phelps, C.P. * https://staging.drfop.org/files/original/e0d0a9bb3f547362ad9876b219fa7714.pdf 9335229897eae76821807d7a78f7836d 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_02_078.pdf Text Any textual data included in the document <h2>In Support of the Hook</h2> <h5>Eugene F. Murphy, Ph.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>If this were a perfect world, each person would have two perfect, versatile, beautiful hands. Unfortunately, there are individuals who lack one or both of these exquisite devices, whether cogenitally or adventitiously. Thus far, any substitute can only represent a very limited compromise and partial selection of varying fractions among the many desirable functions and cosmetic features needed for a true replacement. There seems no reasonable hope of providing the numerous muscles, nerves, reflexes and voluntary controls needed to position and stabilize mechanical imitations of the multiple joints in the natural hand. Because uncontrolled flexibility, like a loose chain, is merely unstable, the designer is forced to limit the joints severely, providing fixed curves which offer rigidity, yet maximize function.</p> <p>Fortunately, the customary wrist disconnect mechanisms allow reasonable interchanges to suit specific needs. These changes may not be quite as simple for the amputee as for the normal person who dons warm gloves for cold weather, picks up tongs, tweezers, or pliers to "handle" hot, tiny, or rough objects, or scrubs and manicures in preparation for a party. Nevertheless, the possibility of interchange does allow considerable versatility rather than a forced, even heartbreaking, choice of a single limited terminal device. Each amputee may use an artificial hand with substantial but limited function, and lifelike cosmetic glove when appearance is important, but, then change to a considerably more functional terminal device when appropriate, much like changing evening or business clothes to sports clothes or overalls.<a></a> In this context of voluntary choice, then, let us consider the appropriate roles for split mechanical hooks.</p> <p>Note that we can assume that we are far beyond the single hook with sharpened point made notorious by Captain Hook, useful as that was in its time. For the near future, though, we seem limited in practice to a single active control that provides adequate force at any point in a reasonable range of motion and is capable of rapid change, delicate adjustment, and prolonged holding, and preferably offers substantial sensory feedback. The typical Bowden cable (secured to shoulder harness, activated by body motion, and providing some sensory feedback from kinesthetic awareness of human joint position and tactual perception of pressures) provides a substantial degree of function. A source of external power under a single voluntary control, whether valve, switch, or myoelectric signal, may have greater or lesser speed of response, precision of adjustment, and maximum force, but so far it probably supplies less sensory feedback. Occasional adjustments, locking, or presetting of parts can be made by a unilateral amputee with the other hand or by a bilateral amputee through gross motion of the prosthesis to press the terminal device against an object, or squeeze it between the knees, etc.</p> <p>Thus far, both practical clinical experience and research studies have indicated that additional substantial sources of power, control, and feedback are so limited that they are better used for other functions like elbow flexion, elbow locking, or perhaps wrist rotation instead of for additional motions within a hand or hook. If additional practical sources do become available, of course, they can be used to improve both hand and hook by reshaping either for still greater versatility, or to actuate and release a lock, thereby improving both devices. The hook, though, is intrinsically more versatile than a mechanical hand of equivalent control and sophistication.</p> <p>It may be useful to recall that the Klingert artificial arm and hand at the end of the Eighteenth Century attempted to control some, ten independent motions by cords ending in knobs which the unilateral amputee could move with his good hand along a vest-like garment.<a></a> Presumably the user soon decided to use the good hand directly for most tasks!</p> <p>Like many current robots, remotely operated manipulators for nuclear "hot cells" have typically been designed with seven degrees of freedom, including grasp by simultaneous and equal motion of opposing surfaces of the terminal device. Usually a single able-bodied operator has controlled two manual master-slave manipulators, one with each arm, plus assorted leg and body motions to assist in positioning. Even so, we were told some years ago,<a></a> performance of relatively simple tasks typically took eight to ten times the time needed to do them directly with the bare hands, and early unilateral electrical manipulators took over ten times as long as mechanical master-slaves! At a series of conferences called Project ROSE with participants in the prosthetics research program and others,<a></a> experts from the nuclear and space programs seemed awed to learn that no bilateral arm amputee (even though substantially limited in independent body motions) needed anywhere near that additional time to perform complex tasks of industry or of daily living. The current interest in applications of robotics to aid quadriplegics may help to revive these interdisciplinary exchanges.</p> <p>It may be suggested that the performance advantages of the amputee lie not only in motivation, past therapy, and full-time usage, but in basic design philosophy. The classic UCLA studies summarized by Taylor<a></a> and Taylor and Schwarz<a></a> pointed out the great complexity of the human hand and upper extremity, analyzed the motions and forces used for a variety of activities, suggested reasonable priorities and limitations, and preset or limited position selections in contrast to the equal priority and great range assigned to all motions in many manipulators. The designs of prosthetic hooks typically provide a fixed point of reference for arm placement in the fixed finger. This allows relatively easy and accurate positioning against one side of an object, followed by closing of the hook to surround and grip the object as securely as desired. (The slowly moving thumb or "finger" of the Northwestern University<a></a> synergetic hand or hook substantially follows this concept, with the rapidly moving member(s) encircling and the high-force thumb then clamping.) In contrast, if both hook fingers (or the thumb opposing the index and middle fingers of a hand) move simultaneously, the user must initially position the arm in relation to an imaginary centerline while mentally allowing for subsequent (perhaps even unequal) motion of the opposing surfaces. This harder task can be learned by long practice and tolerance of frequent error (as we know from sports involving catching objects), but it seems relatively risky for approaching tall unstable objects like laboratory glassware. It also requires good vision, emphasizing the importance of the large safety window in a hot cell and the limitations of periscopes, mirrors, and television systems.</p> <p>The vast resources of the human hand allow very rapid shaping, grasping, and squeezing to hold objects of assorted sizes, with a reflex adaptation that grips more tightly if slippage starts yet also minimizes the risk of crushing fragile objects. A natural hand spontaneously exerts only modestly more gripping force than needed, whereas the amputee tends to overgrip. With a single control, an artificial terminal device must have a single general shape, though the opposing fingers of the hook may be markedly different. They should encircle and pull in objects within a wide range of sizes rather than extruding them from a V-shaped clamp. At least three contact points are needed for stability; two flat tongs are inadequate or at least require substantial forces to grip rounded objects. The two-position thumb of the APRL hand, preset to normal or wider positions by pressure against some object, is helpful but does not allow the flattening needed to enter pockets.</p> <p>Attempts have been made to provide unusually large thumb motion. This is to allow the choice of palmar prehension of the finger tips against the thumb or more complete flexion of the fingers into the palm, e.g., the Tomovic Beograd (Belgrade) hand.<a></a> That kind of versatility requires at least sensor pads and relatively complex logic such as that used by Tomovic or preferably a second hand control. The addition of independent lateral prehension of the thumb, in which the thumb is rotated to press against the partially flexed fingers, is a commonly used human motion, but is limited to small objects and is not considered useful as the primary grip. It might even require dedication of a third control to the terminal device.</p> <p>In contrast to the severe limitations of an artificial hand with present control sources, a split mechanical hook or other gripping tool may be designed to grasp objects of a wide range of sizes, yet remain sufficiently slim near its closed position to enter pockets to retrieve coins or other objects. Instead of imitating natural form and motion, the hook can be designed solely for function, attaining a sleek though mechanical appearance. In addition, it can be used to push, pull, pry, hammer, touch and hold hot or cold objects, and in general perform many tasks for which even the wonderful human hand requires tools. By ingenious shaping of fingers and choice of axis, the same hook may be used as tweezers for pins, to securely grip many medium-sized objects of daily life, and to surround and lift large objects.</p> <p>Mass-produced hook fingers (in contrast to earlier hand-forged and slightly variable models) may be economically provided with vulcanized rubber lining for higher friction while retaining a slippery metallic outer surface. (In early field tests with this feature, everyone liked the ability to slip easily into pockets or sleeves. However, one subject, who was long accustomed to starting a sewing machine by pushing the flywheel, complained of the absence of the chemical laboratory tubing used over older hooks. Nothing is perfect!) There may well be a major role for softer external surfaces, especially for children's terminal devices so to prevent injuries. Obviously, the materials should be nontoxic, non-allergenic, noncarcinogenic, and durable.</p> <p>The APRL and Northrop-Sierra hooks were designed with symmetrical lyre-shaped aluminum fingers held to the case by jam nuts, allowing replacement. Among the many unfinished items on the old research agendas discussed at the frequent conferences and workshops, was the deployment of stainless steel fingers and alternative shapes, including axes canted in relation to a thin sheet gripped by the hook fingers. Occasionally, there was speculation about color in place of the customary polished metal, or of a cosmetic glove designed to fit over a hook.</p> <p>Greater use of the three-jaw chuck concept, characterized by the index and middle fingers of the APRL hand moving in somewhat inclined planes toward the thumb, is sometimes suggested. However, greater stability must be balanced against greater bulk when closed.</p> <p>The literature, particularly in patents, discloses a great variety of concepts and shapes of terminal devices. Many were invented by amputees to meet their individual needs, especially in farming or industry. Some designers, notably Steeper in England, emphasized development of many special-purpose tools for daily living as well as for agriculture, industry, and avocations, together with disconnect devices for easy interchange. The demonstrator typically had a fitted case carrying a wide assortment. English colleagues have mentioned that a specific amputee typically received a dress hand, a split mechanical hook, perhaps a single tool appropriate to his particular trade, and (particularly in the case of a bilateral) a long straight split device helpful for grasping toilet paper.</p> <p>Since 1945, American research programs have emphasized the development of devices to permit any amputee to independently conduct the activities of daily living. Bimanual activities are so varied, due to the size of objects and the gripping force and dexterity required, that vocational guidance for a motivated amputee should include the selection of appropriate vocations which can be carried out with the same device(s) used in daily living. Indeed, most personal tasks are performed on or close to the body, perhaps suggesting wrist flexion devices, whereas vocational tasks normally are conducted on a table or workbench that do not require wrist flexion.</p> <p>A wide network of clinic teams is available to assist amputees select a prosthesis, return to former occupation, or choose a new vocation. In addition to a reasonably functional hand with cosmetic glove, the unilateral normally receives a versatile hook. The bilateral amputee rarely can function adequately with two artificial hands; sometimes he can use one hand and one hook, if appearance is more crucial than dynamic and independent function. Commonly, the bilateral amputee selects two hooks for routine use.</p> <p>Fortunately the number of bilateral amputees is very small, yet their needs are particularly great. Paradoxically, to meet their special needs, it has been necessary to first develop devices and techniques which are sufficiently versatile and which are accepted by a majority of the much larger unilateral market (and the professionals who serve amputees). Though present terminal devices are useful and cosmetically acceptable, further research on the specific problems of bilateral amputees is needed.<br /><br /><em><b>*Eugene F. Murphy, Ph.D. </b> Dr. Murphy resides in New York City and has long been associated with the American Prosthetic/Orthotic R&amp;D Program. For many years he was in charge of the VA's office of Technology Trades and Editor of the Bulletin of Prosthetic Research.</em></p> <p><b>References:</b></p> <ol> <li><a href="al/1955_02_047.asp">Dembo, Tamara, and Ester Tane-Baskin, "The Noticeability of the Cosmetic Glove," <i>Artificial Limbs</i>, 2(2), pp. 47-56, May, 1955.</a></li> <li>Borchardt, M., et al., <i>Ersatzglieder und Arbeitshilfen</i>, Berlin, Springer, pp. 404-405, 1919.</li> <li>Goertz, Ray, <i>Advancements in Teleoperator Systems, A colloquium held at the University of Denver February 26-27, 1969</i>, Washington, Office of Technology Utilization, National Aeronautics and Space Administration, NASA SP-5081,pp. 176-186, 1970.</li> <li>Murphy, Eugene F., "Manipulators and Upper-Extremity Prosthetics, <i>Bulletin of Prosthetic Research</i>, 10(2), pp. 107-117, 1964.</li> <li>Taylor, Craig, "The Biomechanics of the Normal and of the Amputated Upper Extremity," in Paul E. Klopsteg, Philip D. Wilson, et al., <i>Human Limbs and their Substitutes</i>, pp. 169-221, New York, McGraw-Hill, 1954; reprint edition New York, Hafner, 1968.</li> <li><a href="al/1955_03_004.asp">Taylor, Craig, "The Biomechanics of Control in Upper-Extremity Prostheses," <i>Artificial Limbs</i>, 2(3), pp. 4-25, 1955</a>; reprinted in <i>Selected Articles from Artificial Limbs</i>, Huntington, N. Y., Krieger, pp. 63-84.</li> <li><a href="al/1955_02_022.asp">Taylor, Craig, and Robert J. Schwarz, "The Anatomy and Mechanics of the Human Hand," <i>Artificial Limbs</i>, 2(2), pp. 22-35, 1955</a>; reprinted in <i>Selected Articles from Artificial Limbs</i>, Huntington, N. Y., Krieger, pp. 49-62.</li> <li>Childress, Dudley S., John N. Billock, and Robert G. Thompson, "A Search for Better Limbs: Prosthetics Research at Northwestern University, "<i>Bulletin of Prosthetic Research</i>, 10(22), pp. 200-212, 1974.</li> <li>Veterans Administration Prosthetics Center Research, <i>Bulletin of Prosthetic Research</i>, 10(9), pp. 142-144.</li> </ol> Page Number(s) 78 - 81 Year 1986 Volume 10 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource In Support of the Hook Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/1d1ceef5e0e7ae1a01db4bf1a14f920a.pdf 15dde9b5748aae3e70554e693a2ccc35 https://staging.drfop.org/files/original/7341a1c789bf50c28c6f291e6ce1b8f1.jpg a3415062e2c78119f25ba9e99a91aab7 https://staging.drfop.org/files/original/58d7d562a2d2d25b6b29f764f5d0cfb4.jpg 9323149b8c303a17391f937f755ab79f https://staging.drfop.org/files/original/91b42dd18f1fc3412b1263cdc9856b74.jpg 977982cad4750c82718536539f96a0c1 https://staging.drfop.org/files/original/6a553c553328022c82face981f32bc08.jpg 7be62c5f05196a9b3fcee0f6702c980c https://staging.drfop.org/files/original/be77138d9c5e8b93c403e5150d85485f.jpg b0ac7e722904c5644175eb02eb4e1fda https://staging.drfop.org/files/original/f9cc0bf598af3d0a6e01e53df4364432.jpg 43756341fd355ef896d2d087e0f4aa7d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_011.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 11 - 16 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_011.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_011.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Independent Control Harnessing in Upper Extremity Prosthetics</h2> <h5>Colin A. McLaurin, B.A.Sc. <a style="text-decoration:none;">*</a><br />Fred Sammons, B.A. <a style="text-decoration:none;">*</a><br /></h5> <p>Functionally, the well-designed and well-constructed body harness for an upper-extremity prosthesis serves a twofold purpose: first, it helps to hold the prosthesis in place; second, it transmits body power for operation of the prosthesis. </p> <p> For shoulder-disarticulation amputees and for high above-elbow amputees, the provision of an adequate functional harness presents a challenging problem particularly with respect to power transmission and control. The problem is especially difficult in the case of shoulder-disarticulation amputees because of the lack of a control source from humeral motion, which is the major source of power and control in the case of above-elbow amputees. The typical prosthesis for shoulder-disarticulation amputees utilizes shoulder motions and chest expansion. </p> <p>In the present limited state of the art of prosthetics, there are three minimal operations to be controlled in an upper-extremity prosthesis: lifting of the forearm, operation of the terminal device, and management of the elbow lock. </p> <p> Here in the United States, the usual harnessing method for shoulder-disarticulation and above-elbow amputees utilizes the so-called "dual-control" system.<a></a> Lifting of the forearm of the prosthesis and operation of the terminal device are so linked mechanically that a single control motion (shoulder motion in the case of shoulder-disarticulation amputees arm flexion in the case of above-elbow amputee) produces either operation, dependending on weather the wlbow is locked or unlocked.</p> <p> In shoulder amputees, operation of the elbow lock must be managed by various special arrangements; for example, elevation of the shoulder, expansion of the chest, or use of the chin to nudge the elbow-lock control. In above-elbow amputees, operation of the elbow lock in a dual-control system depends upon extension of the humerus and depression of the shoulder. </p> <p> In a triple-control system, operation of the terminal device is separated from lifting of the forearm of the prosthesis. Triple control has been a recognized method of harnessing upper-extremity amputees for many years, and standard harness patterns providing triple control can be found quite readily in prosthetics literature.<a></a> However, triple-control harnessing in actual application is seldom seen in the United States, although it is used extensively in Germany and elsewhere. A possible reason for lack of use in the States is that in early trials it was difficult for the patients to operate the controls independently. </p> <p>Recent experiments at Xorthwestern University in fitting bilateral shoulder-disarticulation amputees have resulted in a harnessing system that provides acceptable function using standard components. Success with some five or six cases renewed interest in "independent-control" harnessing for above-elbow amputees. </p> <p> In describing this experimental harnessing for bilateral shoulder-disarticulation amputees and above-elbow amputees, the term "independent control," rather than "triple control," is used in order to avoid confusion with the standard harness patterns for triple control. </p> <h4> Bilateral Shoulder-Disarticulation Amputees </h4> <p> The limited availability of control sites constitutes a serious restriction on the effectiveness of a harnessing system for bilateral shoulder-disarticulation cases. Shoulder motions are available on both sides, and chest expansion can be utilized. However, there may be only sufficient control motions to obtain acceptable function from one prosthesis. In this event, activities which require the use of two hands, such as eating with a knife and fork, are necessarily precluded. </p> <p> Major consideration is given to operation of the terminal device and lifting the forearm of the prosthesis. In addition, the elbow lock must be operated and the functions of wrist and shoulder positioning should be supplied. </p> <p> Although there is but one prosthesis, two shoulder sockets are used. On the side of the amputee on which the prosthesis is suspended, the socket must, provide weight-bearing at the top. This socket may be fitted well down toward the lower edge of the rib cage in order to provide good stability. The other socket, or shoulder cap, is designed specifically to provide independent control of the terminal device, and it is made as small and as light as possible. (<b>Fig. 1</b> and <b>Fig. 2</b>) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Shoulder disarticulation on the right and humeral neck amputation on the left. Amputation followed electrical burns. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Bilateral amelia with scoliosis and short left leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> Shoulder Joint </h5> <p> A passively adjustable shoulder joint is essential for ease in putting on a coat, for positioning the prosthesis so that it does not interfere when sitting in an armchair, and for positioning the prosthesis for eating, writing, and similar tasks. Humeral abduction and flexion may be combined in a single axis joint. The friction plate shown in (<b>Fig. 2</b>) includes two wedge-shaped discs ("Wilson-Riblett wedges") which can be rotated during the preliminary fitting to provide the optimum plane of motion for the shoulder joint (<b>Fig. 3</b>). When this is obtained, thev are locked into position. The amount of friction can be regulated by a self-locking nut and washer which hold the assembly together. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Schematic drawing showing principle of "Wilson-Riblett wedges." </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> Forearm Lift </h5> <p> Because the weight-bearing socket has been extended downward over the rib cage, the chest strap may be positioned around the center of the rib cage where maximum excursion can be obtained. The harness pattern shown in <b>Fig. 1</b> uses chest expansion in series with scapular abduction of the prosthesis-litted side to lift the forearm The forearm lift cable terminates in a swivel fitting at the lift tab. Since excursion is usually limited, the lift tab should be positioned close to the elbow joint. II this is not possible, a pulley may be titled to double the effect of the excursion. But. of course, such an arrangement doubles the input toree requirement In <b>Fig. 2</b>. the forearm lift cable is fitted internally in a special groove cut in the locking quadrant ol the elbow unit </p> <h5> Terminal Device </h5> <p> With the chest strap fastened about the middle ot his rib cage, the amputee is free to move the scapula of his nonprosthesis-bcaring shoulder. Thus, a small shoulder cap. carefully lilted to the scapula, can provide independent control of the terminal device. An anterior elastic strap is usually required to hold the shoulder cap in position. In <b>Fig. 2</b>, the available excursion was limited, and therefore a step-up pulley was necessarv in order to achieve full opening of the terminal device, </p> <h5> Elbow Lock </h5> <p> Since operation of the elbow lock requires a relatively small amount of excursion and force, there are several ways in which it can be accomplished. The patient shown in <b>Fig. 1</b> originally was fitted with a cable which ran from the elbow lock, around a pulley high on the shoulder, and thence down to a waist belt, so that shoulder elevation was used, alternately, to lock or to unlock the elbow. Later, this was replaced by the nudge control (<b>Fig. 1</b>), which the amputee preferred. </p> <p> For the patient shown in <b>Fig. 2</b>, the prominent acromioclavicular joint was utilized by cutting a hole in the anterior part of the socket and positioning a lever so that forward motion of the clavicle moved the lever forward and downward to develop tension in the elbow-lock cable. </p> <h5> Wrist Unit </h5> <p> A standard passive wrist-rotation unit, which permits pre-positioning by the amputee, was provided in both cases (<b>Fig. 1</b> and <b>Fig. 2</b>). </p> <p> For many tasks, such as toilet care, wrist flexion is important. Flexion can be provided by building it into the prosthetic forearm (<b>Fig. 2</b>), or by using a nudge control and Bowden cable to operate the lock on a standard wrist-flexion unit (<b>Fig. 1</b>). In the latter case the lock for the wrist-flexion unit is operated by relative motion between cable and housing. In this application the cable is stationary and the housing pushes to open the lock. To achieve this, the cable guides must be drilled out to allow the housing to slide freely. The inner cable passes through a hole drilled in the locking lever on the wrist-flexion unit and is anchored to a post screwed to the cover of the wrist unit (<b>Fig. 4</b>). When the wrist unit is unlocked by pressure on the nudge control, tension in the terminal-device cable will cause the wrist to flex. If the terminal-device cable is relaxed, gravity will cause the wrist to extend. Thus a measure of active wrist flexion is obtained. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Modifications of wrist-flexion unit for use with nudge control. Refer to Figure 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Capabilities and Limitations </h4> <p> The harnessing arrangement just described provides reasonably acceptable prosthetic function without the use of perineal straps. Independent control of the terminal device apart from operation of the elbow allows maximum opening of the terminal device in all positions of elbow flexion and improves the performance rate, since it is not necessary to lock the elbow before using the terminal device. Also, there is no tendency for the terminal device to open when the elbow is being flexed. </p> <p> The amputee who is a skilled foot user may be able to put on or take off the prosthesis without assistance, particularly if Velcro straps are used (<b>Fig. 2</b>). If the amputee is not a skilled foot user, assistance is required in fastening the chest strap snugly. </p> <p> The prime objective in fitting this type of prosthesis to a severely disabled amputee is to provide at least a minimum of self-sufficiency in public. Problems of selfdressing are complex, and their solution can scarcely be achieved without the use of external power and devices which have not yet been developed. </p> <h4> Above-Elbow Amputees </h4> <p> The same three minimal operations (namely, operation of the terminal device, lifting of the forearm, and management of the elbow lock) must be controlled in the prosthesis for a unilateral above-elbow amputee. To avoid restriction of the sound arm, the axilla loop of the harness should provide stabilization only. Hence the shoulder motions available for prosthetic use are those that remain on the amputated side. These are scapular abduction, humeral flexion, and humeral abduction. It is conceivable that humeral extension and humeral abduction could be harnessed, but an entirely different harnessing configuration would be required. As in the case of the shoulder-disarticulation amputee, shoulder elevation can be used only in conjunction with a perineal strap or a firm waistband. Most above-elbow amputees can separate scapular and humeral motion, and the harnessing described here is specifically designed to utilize this independent control. </p> <p> In this harnessing system, lifting of the forearm of the prosthesis is activated by scapular abduction. The anchor point is a ring held in the center of the back by the axilla loop. The reaction point is attached high on the socket, so as to be independent of humeral flexion. If the reaction point is placed centrally near the top edge of the socket, rotation is minimized and humeral abduction can be used to increase the excursion. The cable is passed through the reaction point and terminates in a swivel at the forearm lift tab, the length and position of which should be carefully adjusted to make full use of the available excursion. (The cable housing at the reaction point serves only as a cable guide.) The suspension strap and elbow-lock strap are attached as shown in <b>Fig. 5</b>, the configuration being essentially the same as that used in the Northwestern University dual-control ring-type harness. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Congenital above-elbow amputee fitted with independent control. Scapular abduction is used for forearm lift. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Humeral flexion and abduction are harnessed to provide operation of the terminal device. Experiments indicate that the harness pattern shown in <b>Fig. 5</b> is preferable to that in which the control cable is attached solely to the harness ring. A Bowden cable is used, with the housing anchored on the humeral section and on the forearm in a manner similar to that of a standard below-elbow fitting, so that operation of the terminal device is independent of flexion of the elbow. </p> <p> Optimum results are obtained when the shoulder motions are used in combination. Maximum lift of the forearm is achieved when the humerus is abducted at the same time that the scapula is abducted. This means that the elbow is held close in to the body as the forearm is lifted-a motion that is not ideal for certain tasks, such as switchboard operation. Scapular abduction also tends to affect the terminal-device cable. Thus, when the elbow is held in full flexion, there may be some tension induced in the terminal-device cable, making it difficult to hold the hook closed without locking the elbow. Conversely, the hook is very easy to open fully in this position. </p> <p> Three amputees have been fitted with this type of harness and have been wearing it routinely for several months. In addition, one bilateral amputee has been fitted with dual control on one arm and independent control on the other. All the subjects had been users of prostheses. They learned the basic controls with about an hour's training and became proficient at the end of a week. </p> <p> This harnessing provides excellent terminal-device function throughout the full range of elbow flexion, without locking or even stabilizing the elbow. Since the terminal device is independent of the forearm lift, there is no tendency for the hook to open when the forearm is being raised. However, near the point of full flexion, the interaction of the harness straps does require considerable effort to avoid opening the hook. Moreover, the force available for lifting the forearm is adequate only for the lightest loads. </p> <p> After several months' wear, one of the amputees rejected the harness and was refitted with a different type of independent control (<b>Fig. 6</b>). The operation of the terminal device was left unchanged, but the forearm-lift and elbow-lock straps were interchanged so that shoulder depression was used to raise the forearm, and scapular abduction to operate the lock. This seemed to provide greater force for lifting the forearm, provided the humerus is not flexed more than about 20 deg. Operation of the terminal device appeared to be slightly improved. The amputee is still wearing the prosthesis routinely. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Same amputee as shown in Figure 5 fitted so the shoulder depression is used to lift the forearm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>References:</b></p> <ol> <li><p>Pursley, Robert J., <i>Haness patterns for upper-extremity prostheses</i>, Artificial Limbs, September 1955, p. 26. </p> </li> <li><p>Pursley, Robert J., <i>Harness patterns for upper-extremity prostheses</i>, Chap. 4 in <i>Orthopaedic appliances atlas</i>, Vol. 2, Edwards, Ann Arbor, Mich., 1960. </p> </li> <li><p>Taylor, Craig L., <i>The biomechanics of control in upper-extremity prostheses</i>, Artificial Limbs, September 1955, p. 4. </p> </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Pursley, Robert J., Haness patterns for upper-extremity prostheses, Artificial Limbs, September 1955, p. 26. </td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Chap. 4 in Orthopaedic appliances atlas, Vol. 2, Edwards, Ann Arbor, Mich., 1960. </td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, September 1955, p. 4. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Pursley, Robert J., Haness patterns for upper-extremity prostheses, Artificial Limbs, September 1955, p. 26. </td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Chap. 4 in Orthopaedic appliances atlas, Vol. 2, Edwards, Ann Arbor, Mich., 1960. </td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, September 1955, p. 4. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Fred Sammons, B.A. </b></td></tr><tr><td class="clsTextSmall">Research Therapist, Northwestern University Prosthetics Research Center, Chicago, Ill.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Colin A. McLaurin, B.A.Sc. </b></td></tr><tr><td class="clsTextSmall">Project Director, Northwestern University Prosthetics Research Center; Research Associate, Department of Orthopedic Surgery, Northwestern University, Chicago, Ill</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-15.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-16.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-17.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-18.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-19.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_01_011/1963-Spring_OCRBatch-20.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Independent Control Harnessing in Upper Extremity Prosthetics Creator An entity primarily responsible for making the resource Colin A. McLaurin, B.A.Sc. * Fred Sammons, B.A. * https://staging.drfop.org/files/original/600929dee45085ca12ad1bf2f58a604b.pdf 96ef868f6a75c4473d81d11010115943 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1982_02_001.pdf Text Any textual data included in the document <h2>Influence of Government Funding on Prosthetics Research and Development</h2> <h5>Eugene F. Murphy, Ph.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Historically, tragically, warfare has been the major stimulant for the development of prosthetic devices. Much of the early history is traced in the introductory chapter of the <i>Orthopaedic Appliances Atlas, Volume 2</i>, published by the American Academy of Orthopaedic Surgeons in 1960. A fascinating source is the book <i>Historic Artificial Limbs</i> by the Italian surgeon Putti, published by Hoeber, New York, 1930, based upon the outstanding collection of artificial limbs in the Stibbert Museum at Florence, Italy. With that museum's distinguished collection of armor, it was perhaps natural that the byproduct of artificial hands, arms, and legs made by armorers for knights should also be assembled there. The story of the German knight Goetz von Berlichingen, commemorated in a drama by Goethe, stresses the knight's iron artificial hand.</p> <p>Surgery generally and amputation surgery in particular were developed by the French surgeon Paré in connection with the religious wars in France; a corresponding development of artificial limbs was done by a locksmith known as "le petit Lorrain." Very likely only the relatively well-to-do knights and nobility were able to afford these early prostheses, with common people left to relatively crudely carved prostheses or crutches as illustrated, for example, by Breughel.</p> <p>After the American Civil War, the government provided an allowance for artificial limbs for Union veterans. This financial incentive, plus the rapid increase of amputees from industry and railroads, led to great competition among private developers. In that era artificial limbs were essentially sold as commodities rather than fitted as professional services. Some interesting patents are cited in the <i>Orthopaedic Appliances Atlas, Volume 2</i>.</p> <p>In World War I, countries among both the Central Powers and the Allies carried on simultaneous attempts to treat their patients and to develop better methods of surgery and fitting. Work in the Central Powers, notably in German military hospitals and in the Technical University of Berlin under Schlesinger, an engineering professor, was covered in great detail in the classic book <i>Ersatzglieder und Arbeitshilfen</i> (Substitute Limbs and Work Aids) published in 1919. Florent Martin worked extensively in Belgium, developing relatively early methods of fitting of temporary plaster-of-paris sockets on pylons for amputation of the lower extremity. His work was recorded particularly well in his critical analysis, <i>Artificial Limbs; Appliances for the Disabled</i>, published by the International Labour Office at Geneva in 1924. Efforts in England, including development of the specialty of limb fitting surgeon and the standardization of mechanical construction of a series of light metal limbs for many basic levels of amputation, are described in E. Muirhead Little's book Artificial Limbs and <i>Amputation Stumps</i>, published in England in 1922. During World War I, the Artificial Limb Manufacturers Association (ALMA) in the United States developed rapidly to advance the industry and cooperate with the government. Its descendant, the American Orthotics and Prosthetics Association (AOPA), along with the American Board for Certification (ABC), and the American Academy of Orthotists and Prosthetists (AAOP) continue today to develop the profession.</p> <p>In World War II, the ALMA set up a small laboratory on the premises of the Rowley prosthetics facility in Detroit, under the name of the Research Institute Foundation. Its extremely limited financial and technical resources allowed very meager efforts.</p> <p>Late in the war, partly because of growing demands from servicemen and unfavorable publicity, the Surgeon General of the United States Army asked the National Academy of Sciences (NAS) and its operating arm, the National Research Council (NRC), to select and standardize the best artificial limb designs. At a conference in 1945, the only unanimous agreement seemed to be on the concept that the best was not too good and that further improvements were needed on all aspects.</p> <p>The Surgeon General then asked the NAS-NRC to organize a systematic program "to conduct with utmost dispatch research and development in the field of prosthetic devices." The resulting interdisciplinary Committee on Prosthetic Devices initially was financed by the wartime Office of Scientific Research and Development, then the Army briefly, and later the Army and Veterans Administration (VA) jointly. On July 1, 1947, it was reorganized as the Advisory Committee on Artificial Limbs to provide advice to other agencies which wished to conduct their own programs. The NRC committee structure underwent a variety of changes from 1945 to the mid-1970's but has now disbanded. AOPA-ABC-AAOP members were frequent members of committees, subcommittees, and technical groups in this structure.</p> <p>The Army, Navy, and Veterans Administration each operated a laboratory. The VA, initially alone and later in parallel with other agencies, supported a series of projects with universities, industrial laboratories, and, in recent years, particularly through intramural projects in VA Medical Centers. After a change in its basic laws, the Office of Vocational Rehabilitation or its successors, now the National Institute of Handicapped Research (NIHR), has supported an increasing number of Rehabilitation Engineering Centers and projects.</p> <p>In addition to stimulating a wide variety of basic studies on locomotion and arm and hand motions, phantom limb pain, and psychological aspects, and development of a wide range of devices for all levels of upper-and lower-limb prostheses, the total government-supported program became a major force in educational efforts and dissemination of information. The early suction socket schools brought together distinguished surgeons and prosthetists, teaching the surgeons about mechanisms and the prosthetists about anatomy and physiology, as well as fostering team work between the two professions, promptly involving therapists, and helping to upgrade the entire field. Follow-up of the early suction sockets led to organization of formal clinic teams. The suction socket certification program, operated by Orthopedic Appliance and Limb Manufacturers Association (OALMA) in conjunction with the NRC committee and recorded in the Veterans Administration, led to joint certificates and helped to pave the way for the founding of the American Board for Certification with its remarkable interdisciplinary board of directors. The suction socket schools led, in 1953, to organized university-level post-graduate education in prosthetics and later in orthotics.</p> <p>Frustratingly slow as development often seems, nevertheless in retrospect it would appear that numerous major changes in devices, techniques, materials, and management methods were made in this continuing program. Voluntary cooperation was the key element in holding together this loose confederation. Diverse disciplines, many government agencies, some private foundations, separate organizations, sometimes competitive interests, and strong personalities worked together for the improvement of the lives of the disabled.</p> <p>The fact that substantial government funding was available, though never on the scale needed for the awesome task of truly replacing human parts and functions, tended to minimize the importance of private funding for the research and development and even for the dissemination of results. One chronic problem, though, has always been the transition from a reasonably well-developed laboratory model with a very limited clinical experience on "professional" pilot wearers into a routinely available, commercially manufactured component available in high quality and at low cost to skilled and trained practitioners throughout this country and abroad for fitting to large numbers of individual patients.</p> <p>Some devices were purchased in modest quantities for field tests through the National Academy of Sciences itself in the 1950's or through the Veterans Administration Prosthetics Center after that group was organized in 1956. Typically, AOPA was asked to suggest a group of potential bidders to make proposals for tooling and for construction of some modest number of models needed for a wide scale field trail or evaluation. Because of fiscal restraints and practical problems, numbers of copies were usually smaller, and statistical validity was low. (Early attempts to interest other organizations lacking experience and distribution facilities in the prosthetics field had been frustrating and largely disappointing.) Typically, the manufacturer of the initial test models has evolved into the principal, if not sole, manufacturer of the final device-if indeed it proved to be successful in the field trials. The field has been so small that there frequently has been no room for multiple manufacturers of a single relatively complex device, although other versions with somewhat comparable yet somewhat different functions sometimes evolve in parallel. Field trials should refine not only the hardware but the prescription, fitting, and training techniques, the manuals, and the maintenance procedures. All participants in a clinic team become familiar with the new development.</p> <p>There has long been interest in stimulating private support of research and development, presumably based upon the results of fundamental studies conducted under government auspices. The government-supported program has sometimes received or purchased a few early test models of private inventions and has had its intramural or contract laboratories conduct studies with these test models, thereby providing a useful consulting service to the inventor or manufacturer which he probably could not readily obtain otherwise. This kind of independent evaluation may well become increasingly important under the medical device amendments in order to prove safety and effectiveness of new devices.</p> <p>In any evaluation, there are problems in simultaneously assuring competence without bias and in providing constructive criticism in useful form which can be applied to improving the device for all disabled.</p> <p>With the continuing and indeed increasing pressure upon government budgets, it would seem that the developers must increasingly come from private industry. Karl Vesper, the engineer and investment expert who organized the original Hosmer Corporation in the 1940's, was an early participant in the NRC and VA programs. He pointed out that as a private entrepreneur he could effectively estimate the potential strengths of competitors and their ability to develop and market new products within given time periods, so he could make his own choice of development expenditures wisely. Conversely, though, he could not predict what a government agency might do, particularly under political and other pressures. Though the existing government research and development projects are public knowledge, for example through progress reports published in the Bulletin of Prosthetics Research, private developments may well be "proprietary secrets." The net balance between these and other disadvantages and advantages for private development is hard to estimate. From the standpoint of the disabled of the world, one can only hope for a frank, friendly, and cooperative relationship between private entrepreneurs, government sponsors and regulators, government purchasing or using services at all levels, third-party purchasers, and the several professions concerned.</p> <em><b>*Eugene F. Murphy, Ph.D. </b> Director, Office of Technology Transfer Veterans Administration, New York, NY<br /><br /></em> Page Number(s) 1 - 3 Year 1982 Volume 6 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Influence of Government Funding on Prosthetics Research and Development Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/694c8659897265452c14e9ca3192624d.pdf 58cc45863e2c275da7497de4ff593ec2 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_013.pdf Text Any textual data included in the document <h2>Innovation and Improivement of Body-Powered Arm Prostheses: A First Step</h2> <h5>Maurice A. LeBlanc, M.S.M.E., CP.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>Standard body-powered upper-limb prostheses have not changed significantly since developments in the 1950's which were spurred by World War II. They still employ aircraft technology using shoulder harnesses and steel cables for operation. If one looks at the <i>Manual of Upper Extremity Prosthetics</i> first edition (1952)<a></a> and the <i>Orthopaedic Appliance Atlas—Artificial Limbs</i> first edition (1960)<a></a> compared with 1985 state of the art, one will not find a great deal of change.</p> <p>It is the consensus of several leading prosthetists in the U.S. that many arm amputees are being led into purchasing externally powered arm prostheses because they look more modern and "hi-tech." Present body-powered arm prostheses simply do not offer a good alternative. They look more archaic, and the shoulder harnesses are uncomfortable and restrictive.</p> <p>Body-powered systems have more sensory feedback and generally are more functional (for unilaterals) than externally powered systems.<a></a> However, little or no research is being conducted to improve body-powered arms. More and more amputees are opting for externally powered prostheses,<a></a> and the gap is getting larger between the two types.</p> <p>Estimates of population in the U.S. place the number of upper-limb amputees at about 100,000.<a></a> Of the 50,000 arm amputees estimated to be wearing prostheses, surveys of prosthetic facilities suggest the following levels of amputation: 58% below-elbow, 27% above-elbow, and 15% at the hand/wrist and shoulder.<a></a> Of prostheses being worn, educated guesses suggest that the percentage of externally powered prostheses has increased from five to 10% in the past five years.<a></a></p> <p>It is the desire of the author to undertake work to effect innovation in body-powered arm prostheses toward the ultimate goal of increasing the acceptance and use of "conventional" upper-limb prostheses for arm amputees in the U.S. Other people have stated this need.<a></a></p> <p>The author has received support to conduct a one-year study of feasibility for accomplishing the above goal. As a first step, the author has conducted a survey to verify needs and priorities of arm amputees in order to give guidelines for future work.</p> <h3>Conduct Of Survey</h3> <p>Arm amputees and professionals were contacted to assess what wearers like most and like least about their prostheses. Also, ideas for change were solicited.</p> <p>A questionnaire was prepared to provide a standard format, and 30 people were contacted in person or by phone to complete the questionnaire. The people were:</p> <blockquote> <p>17 amputees<br />8 prosthetists<br />3 occupational therapists<br />2 VA prosthetic reps (also arm amputees)</p> 30 total <p></p> </blockquote> <p>Of the 17 arm amputees, there were:</p> <p></p> <blockquote>10 adults and 7 children<br />13 males and 4 females<br />14 unilaterals and 3 bilaterals</blockquote> <p></p> <h3>Results Of Survey</h3> <p>The survey included 11 questions. Results are reported below with the numbers of responses shown. (Some totals exceed 30 because respondents gave two or three answers per question.)</p> <ol> <li> <p><i>What do you like most about your prosthesis?</i><br />Most frequent answers:</p> <ul> <li> <p>Function: 17</p> </li> <li> <p>Reliability: 9</p> </li> <li> <p>Symmetry/body image: 6</p> </li> </ul> </li> <li> <p><i>What do you like least about your prosthesis?</i><br />Most frequent answers:</p> <ul> <li> <p>Axilla/harness uncomfortable: 10</p> </li> <li> <p>Appearance poor: 9</p> </li> <li> <p>Socket hot: 5</p> </li> </ul> </li> <li> <ol> <li> <p><i>Is the harness/cable control system satisfactory?</i> 13—Yes, 16—No</p> </li> <li> <p><i>Does this type of control system need improvement?</i> 25—Yes, 4—No</p> </li> </ol> </li> <li> <ol> <li> <p><i>Are the harness and socket comfortable?</i> 12—Yes, 17—No</p> </li> <li> <p><i>Does the general comfort need improvement?</i> 25—Yes, 4—No</p> </li> </ol> </li> <li> <ol> <li> <p><i>Do the motions and terminal device give you enough function?</i> 11—Yes, 18—No</p> </li> <li> <p><i>Does the function of the prosthesis need improvement?</i> 29—Yes, 0—No</p> </li> </ol> </li> <li> <ol> <li> <p><i>Are you pleased with the appearance?</i> 11—Yes, 19—No</p> </li> <li> <p><i>Does the general appearance need improvement?</i> 25—Yes, 5—No</p> </li> </ol> </li> <li> <p><i>Rate the following four aspects of your prosthesis in importance to you (1 = most important and 4 = least important)</i></p> <blockquote> <p>Average Scores:<br />Function: 1.53<br />Comfort: 1.85<br />Appearance: 2.79<br />Control system: 3.53</p> </blockquote> </li> <li> <p><i>Any other general complaints of this type of prosthesis?</i>—Text answers to these questions were combined with text answers to questions 3-6 and will be discussed later.</p> </li> <li> <p><i>Any other ideas for improvement you would like to see worked on?</i>—Text answers to these questions were combined with text answers to questions 3-6 and will be discussed later.</p> </li> <li> <p><i>If you could dream and create your own perfect prosthesis, what would it look like?</i></p> <p>Most frequent answers:</p> <blockquote> <p>Natural/normal: 12<br />Soft/smooth endoskeletal: 11<br />More function in fingers and wrist: 9</p> </blockquote> </li> <li> <p><i>Do you want your prosthesis to look as normal as possible or would you prefer to have some fun with the appearance in colors and designs?</i></p> <p>Most frequent answers:</p> <blockquote> <p>Want it to look normal: 21<br />Want to have some fun with it: 4</p> </blockquote> </li> </ol> <h3>Miscellaneous Considerations</h3> <p>In talking with each of the 30 people surveyed, a number of interesting comments were made which deserve consideration.</p> <ul> <li> <p>The prosthesis is not a second best arm but something different to itself and should have form and beauty for its own sake.</p> </li> <li> <p>While most people stated the goal of having a prosthesis which looks natural, they asked for one which is smooth, inconspicuous, natural in motion, fast, quiet, and streamline rather than asking for a prosthesis which looks human.</p> </li> <li> <p>Several people visualized having an arm transplant or regeneration.</p> </li> <li> <p>A couple of people talked about "functional appearance" or having a prosthesis which is dynamically alive and not dead looking.</p> </li> <li> <p>Many people expressed a desire for a prosthesis which is soft inside, adjusts to the body, feels like part of the body, and feels flexible.</p> </li> <li> <p>Cleanliness is a big issue with a harness, sockets, and prosthesis exterior. Some expressed the desire for throw-away parts and coverings. Also, it is difficult for bilaterals to clean their prostheses when doffed.</p> </li> <li> <p>Bilateral amputees stressed the importance of using their feet as well as the prostheses. There is more dexterity and sensory feedback for function and a preference for using feet except where social situations dictate using the prostheses.</p> </li> <li> <p>Several amputees stressed the importance of the sensory feedback/proprioception inherent in body-powered arm prosthesis. A few voiced the opinion that increased sensory feedback would provide increased function even with present components.</p> </li> <li> <p>A few parents confirmed the desire for very early fitting of infants for various reasons: body image, balance, symmetry, acceptance and function. One parent felt strongly that an infant should have an arm prosthesis because "the brain is looking for a hand" and it affects the growth/development of the child.</p> </li> <li> <p>While the author was conducting interviews with amputees, many of them asked the author for current information about arm prostheses and components. It was clear that some prosthetists are not fully informing amputees of their options and including them in the decision-making process.</p> </li> <li> <p>A few prominent professionals stated very strongly the importance of the prosthetist conducting a very thorough evaluation with the amputee prior to any prosthetic prescription and fitting. It provides the opportunity for the prosthetist to use his/her ingenuity to truly meet the needs of the amputee.</p> </li> <li> <p>Clinic teams sometimes make decisions on prosthetic fitting in five minutes, which is insufficient time to conduct a thorough evaluation.</p> </li> <li> <p>Central fabrication also can be a detriment to successful prosthetic fitting because standard components are applied by a third party without direct amputee contact, thereby reducing the incentive and likelihood for creative and individual solutions to amputees' needs.</p> </li> <li> <p>Education of prosthetists focuses mainly on the mechanics of fabricating prostheses with available components rather than looking comprehensively at the amputee as an individual with special needs. They "follow the book" too much and are "too rigid in prescribing."</p> </li> <li> <p>The success of upper-limb prostheses depends heavily on the skills of the prosthetist. It is too dependent on individuals. It would be beneficial if systems were more modular whereby they would be easier to fit, and performance could be predicted better.</p> </li> <li> <p>Two trends which seem to be gathering professional concurrence are (1) to fit an arm amputee within the "Golden Period" of 30 days after amputation and (2) to fit all arm amputees with a conventional, body-powered prosthesis first.<a></a></p> </li> </ul> <h3>Conclusions</h3> <p>Function is clearly the most important feature which amputees want and expect from upper-limb prostheses. While the results may be biased because the survey was of body-powered wearers versus myoelectric wearers with hands, the numbers and opinions overwhelmingly emphasize function first.</p> <p>Uncomfortable harness and poor appearance were a close first and second for the most negative feature of arm prostheses. Body-powered arm prostheses need improvement across the board. When making changes, the upper-limb prosthesis should be viewed as a whole system rather than just looking at components. Amputees want a natural moving, pleasant appearing, inconspicuous prosthesis which does not necessarily have to look human.</p> <p>The questionnaire demonstrated a good cross check in validating what amputees and professionals said with how they rated the various aspects of upper-limb prostheses. There has been a great deal of encouragement from amputees and professionals to work on the improvement of body-powered systems. All are anxious to see some innovation and positive change.</p> <h3>Acknowledgment</h3> <p>This work is being supported by Research Fellowship #133FH40021 from the National Institute of Handicapped Research, US Department of Education.</p> <p><b>References:</b></p> <ol> <li><a href="poi/1981_02_092.asp">Agnew, P.J., "Functional Effectiveness of a Myoelectric Prosthesis Compared with a Functional Split-Hook Prosthesis: A Single Subject Experiment," <i>Prosthetics Orthotics International</i>, Vol. 5, No. 2, August 1981.</a></li> <li>Aylesworth, R. Deane, Editor, <i>Manual of Upper Extremity Prosthetics</i>, Artificial Limbs Project, University of California at Los Angeles, 1952.</li> <li>Childress, Dudley S., Ph.D., Director, Rehabilitation Engineering Center, Northwestern University, Chicago, Illinois, personal communication, April 1984.</li> <li>Cottenden, A.M.; B. Stocking; N.B. Jones; S.L. Morrison and R. Rothwell, "Biomedical Engineering-Priorities for Research in External Aids," <i>Journal of Biomedical Engineering</i>, Vol. 3, October 1981.</li> <li>Epps, Charles H., Jr., M.D., "Prosthetic-Orthotic Research-A New Thrust Is Needed: A Clinician's Perspective," <i>Clinical Prosthetics and Orthotics</i>, Vol. 8, No. 1, Winter, 1984.</li> <li>LeBlanc, Maurice A., M.S., CP, Patient Population and Other Estimates of Prosthetics and Orthotics in the USA," <i>Orthotics and Prosthetics</i>, Vol. 27, No. 3, September, 1973.</li> <li>Malone, J.M., M.D.; L.L. Fleming, M.D.; J. Rober-son, M.D.; T.E. Whitesides, Jr., M.D.; J.M. Leal, CP; J.V. Poole, O.T.R. and R. Sternstein Grodin, O.T.R., "Immediate, Early, and Late Postsurgical Management of Upper-Limb Amputation," <i>Journal of Rehabilitation Research and Development</i>, Veterans Administration, May, 1984.</li> <li>National Center for Health Statistics, US Department of Health and Human Services, "Prevalence of Selected Impairments-United States-1977," Series 10, No. 134, February, 1981.</li> <li><i>Orthopaedic Appliance Atlas-Volume 2-Artificial Limbs</i>, American Academy of Orthopaedic Surgeons, J.W. Edwards-Publisher, 1960.</li> <li>Stein, R.B. and M. Walley, "Functional Comparison of Upper Extremity Amputees Using Myoelectric and Conventional Prostheses," <i>Archives of Physical Medicine</i>, Vol. 64, No. 6, June, 1983.</li> <li><a href="http://www.acpoc.org/library/1983_04_009.asp">Trost, Francis J., M.D., "A Comparison of Conventional and Myoelectric Below-Elbow Prosthetic Use," <i>Inter-Clinic Information Bulletin</i>, Vol. 18, No. 4, Fall, 1983.</a></li> <li>Veterans Administration, Rehabilitation Research and Development Service, National Workshop on Prosthetics and Orthotics, Washington, D.C, April 27-28, 1983.</li> </ol> <div style="width: 400px;"><em><b>*Maurice A. LeBlanc, M.S.M.E., CP. </b> Maurice A. LeBlanc, M.S.M.E., CP. is with the Rehabilitation Engineering Center at Children's Hospital at Stanford, Palo Alto, California 94304.</em><br /><br /><br /></div> Page Number(s) 13 - 16 Year 1985 Volume 9 Issue 1 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 Innovation and Improvement of Body-Powered Arm Prostheses: A First Step Creator An entity primarily responsible for making the resource Maurice A. LeBlanc, M.S.M.E., CP. * https://staging.drfop.org/files/original/30b4b4710a8911bc0aea77a638feabd8.pdf d94353f2854ff602c0f9346f778e7e3d https://staging.drfop.org/files/original/ff9bbaad1957b97f9dbdb9a80193dba9.jpeg fafe36c6b4d258417e6f680dddb9b70e https://staging.drfop.org/files/original/571e595fe827f4f47a6bcb256a5c41d3.jpg 293e8f412cb4574591640035f63316e5 https://staging.drfop.org/files/original/6cf829e905f2e447ba594e3384850a62.jpg 4550835e4a6000c414e01462ccfa5217 https://staging.drfop.org/files/original/add90ab6d50a34714b20dca5c661b095.jpg f6b8c5082ce320e83340172ce97d6143 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1979_01_001.pdf Text Any textual data included in the document <h2>Instep Strap</h2> <h5>Richard Rosenberger&nbsp;<a style="text-decoration: none;">*</a><br />Charles H. Pritham <a style="text-decoration: none;">*</a></h5> <p>Ankle-foot orthoses are prescribed for a variety of reasons, but chief among them is the control of undesirable positions of deformities, the most common being equino-varus. Gravity alone will cause the ankle-foot complex to adopt the equino varus position, but spasticity or contracture of the triceps surae can only complicate the situation.</p> <p>A conventional metal ankle-foot orthosis, with either a single or double uprights, can be effective in combating this deforming position, but success depends on proper construction and application of the orthosis. While in most instances the shoe is strong enough, in the presence of severe spasticity it is necessary to reinforce the shank of the shoe lest it break down at the anterior edge of the tongue and thus allow the shoe and foot to adopt a position of equinus. To properly control the foot the shoe should fit snugly when laced up. This latter point can be difficult to achieve and it is not uncommon to find that the heel has ridden up in the shoe. It may be necessary to prescribe a high-top surgical boot with undesirable economic and cosmetic side effects that weigh against use of the orthosis, as does the stipulation, when necessary, that the orthosis be worn at night. It is unconventional, uncomfortable, inconvenient, and unsanitary to wear shoes to bed.</p> <p>The situation with unmodified plastic ankle-foot orthoses is much the same, although it is somewhat easier to apply the orthosis properly than is the case with the shoe. For this reason it has proven popular to modify the basic orthosis by the addition of straps in various configurations. The attraction of this course of action should be obvious. First it makes it possible to don the orthosis and maintain the desired position without a shoe, and thus eliminates the need for expensive high-top surgical boots and it is practical to wear the orthosis in bed. The clear view afforded by these orthoses (as well as the translucency of polypropylene when used) and the strap makes it easy to secure the foot in the proper position before donning the shoe, which obscures the view. Moreover, the use of an instep strap makes the selection of a proper shoe even less critical than it is with the unmodified ankle-foot orthosis. While selection of proper heel height is unaffected, the instep strap allows the use of loose floppy shoes and slippers. This can be important for people who must get up at night or who desire to use the orthosis at poolside.</p> <p>In the hospital the use of an orthosis modified by an instep strap allows ambulation to proceed with an ordinary bedroom slipper while a proper shoe is being obtained. Frequently, delays can be encountered in obtaining shoes, with needless extension of the hospital stay.</p> <p>What is less clearly appreciated is the proper positioning of the strap. For our purposes in this instance the shin-foot complex can be considered as two arms, the tibia and the foot, set at right angles to each other and articulating at the ankle. In combating equinus the orthosis imposes two anteriorly directed forces, one at the top edge of the orthosis, and the other at the metatarsal heads. If unopposed by an anterior third point the leg will ride up in the orthosis, pivoting about these two points with the ankle moving forward. In effect, the leg bowstrings about the two most extreme points. To be maximally effective and comfortable the third force should be as far as possible from the two end points so as to develop the maximum resistance with the minimum force and thus minimum pressure under the strap. In the ordinary course of events this third force is provided by the lace closure of the shoe over the oblique instep of the foot. Since this surface is oblique the force provided normal to this surface can be resolved into two right-angle forces, each of which opposes one of the two anteriorly directed forces of the orthosis. If an accessory strap is added in this bony area it is likely to prove uncomfortable owing to the relatively small area underneath it and the fact that it is positioned too far distally to oppose the anterior motion of the tibia with minimum force. Moreover, if a shoe is worn over it the additional bulk in the shoe is likely to prove undesirable. Conversely, if the strap is added proximal to the malleoli it will be in good position to control the tibia but inadequate to affect the foot.</p> <p>Unless opposed by a second strap or the shoe, equinus is likely to occur and since anterior motion of the tibia is prevented all the motion is likely to occur in a proximal direction with the malleoli riding up and shear taking place under the strap.</p> <p>Following the foregoing analysis then, it seems logical to locate the strap at the deepest point of the radius connecting the oblique dorsal surface of the foot and the vertical tibia, roughly equidistant to the ankle mortice and the subtalar joint. In this position the instep strap is as far as possible from each of the two end points, well positioned to control motion in each segment, and free of the lace area of the standard low-quarter shoe. Instep straps have been used in this configuration a number of years now and, contrary to expectations, irritation under the strap in this relatively unpadded area has not been a problem. This can be attributed, in part, to the fact that the strap is well placed to develop maximum torque with minimum pressure. It is, of course, possible to pad the strap if so desired.</p> <h3>Method</h3> <p>Two methods of adding the strap have proven successful. In one the strap and a narrow loop are riveted to the orthosis on either side along the intended line of force. In the second two slots are cut in the material of the orthosis if the orthosis extends far enough anteriorly to permit it. One end of a Velcro strap is passed through one of the slots and sewn back on to itself. The free end of the strap can then be passed through the other slot and placed back on itself to secure the orthosis. In each case a flexible tape measure can be used to measure the proper length of strap and to plan the proper points of attachment (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>, and <b>Fig. 4</b>). This procedure can be done either over the positive model or the involved extremity itself and a strap can be added at any time.<br /><br /><strong><a href="/files/original/ff9bbaad1957b97f9dbdb9a80193dba9.jpeg">Fig. 1</a>. A tape measure is used to locate the position of the rivet hole for attaching the Velcro strap. This can be done on the patient or around the positive model.</strong></p> <strong><a href="/files/original/571e595fe827f4f47a6bcb256a5c41d3.jpg">Fig. 2</a>. Similarly, a tape measure is used to plan the location of the slots to be cut in the orthosis.</strong><br /><br /><strong><a href="/files/original/6cf829e905f2e447ba594e3384850a62.jpg">Fig. 3</a>. Appearance of the Velcro strap and metal loop once they are riveted to the orthosis. Normally, of course, the patient would be wearing a stocking. The metal loop should be located further posterior so as not to impinge on flesh.<br /><br /><a href="/files/original/add90ab6d50a34714b20dca5c661b095.jpg">Fig. 4</a>. The Velcro strap attached to an orthosis through slots cut in the orthosis. Excess material has been cut away from around the slots to present a neat and finished trimline.<br /></strong><br /> <h3>Summary</h3> <p>A rationale for the use of an accessory strap to control equino-varus in an orthosis without the shoe is given. Some thoughts about its placement and descriptions of two methods of attachment are also given.<br /><em><b><br />Charles H. Pritham&nbsp;<br /></b></em><em>Director, Orthotics and Prosthetics Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadelphia, Pennsylvania<b><br /><br />Richard Rosenberger <br /></b>Director, Prosthetics and Orthotics Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia<b><br /></b><br /></em></p> Page Number(s) 1 - 3 Year 1979 Volume 3 Issue 1 Figure 2 http://www.oandplibrary.org/cpo/images/1979_01_001/1979_01_001-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1979_01_001/1979_01_001-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1979_01_001/1979_01_001-4.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1979_01_001/1979_01_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 Instep Strap Creator An entity primarily responsible for making the resource Richard Rosenberger * Charles H. Pritham * https://staging.drfop.org/files/original/9e60ebed5692df9e5fe07e6d4cd87a96.pdf 77971953d21518efcd4221380ba3b8a3 https://staging.drfop.org/files/original/c2545799ce5601d736f2cd4f1463a521.jpg 16fbd70081beef02a934947a081b6280 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1977_01_001.pdf Text Any textual data included in the document <h2>Introduction</h2> <p>In December of 1969 the Committee on Prosthetic-Orthotic Education of the National Academy of Sciences initiated publication of "NEWSLETTER .... AMPUTEE CLINICS" in an effort to disseminate timely information to amputee clinic teams throughout the country and to provide a vehicle for the interchange of information among clinicians responsible for the care of amputees.</p> <p>The Newsletter met with immediate success and was published every two months until 1975 when policy changes at the National Academy of Sciences precluded publication of the Newsletter .... Amputee Clinics. The final issue, Vol. VIII No. 1 has been published with a date of July 1976 after a hiatus of nearly a year.</p> <p>Because so many members of the American Academy of Orthotists and Prosthetists and their colleagues on the clinic teams that they work with have voiced regret that the forum provided by the Newsletter, no longer exists the Board of AAOP, after a study, determined that the majority of the membership were in favor of assuming responsibility for continuation of this type of publication. Therefore, the board of the AAOP has made the decision to proceed on the basis of four issues per year, initially, and to expand the coverage to include orthotics.</p> <p>It was hoped that an announcement concerning the plans of the AAOP would be made in the final edition published by the NAS, but since such could not be effected this abbreviated edition is being sent to those who in the past have received the "Newsletter-Amputee Clinics" to determine the size of the circulation that can be expected.</p> <p>Our editor for the new publication will be Mr. A. Bennett Wilson, Jr. who helped formulate the original newsletter while in his previous position as Executive Director of CPRD. Mr. Wilson is now acting Director of Training at the Krusen Research Center of the Moss Rehabilitation Hospital in Philadelphia, Pa. The editorial board will be headed by Charles H. Epps, Jr., M.D. of Washington, D.C. Dr. Epps is chief of the Juvenile Amputee Clinic at D.C. General Hospital. Mr. Robert B. Peterson, R.P.T., Supervising Physical Therapist for Hospital Services, Maryland Department of Health and Mental Hygiene and the undersigned will also reside on the board. This group plans to seek technical consultation with representatives of the Veterans Administration Prosthetic Center and the Rehabilitation Services Administration of Health, Education and Welfare on all applicable subject matter.</p> <p>We would also like to thank Mr. Anthony Staros, Director of the Veterans Administration Prosthetic Center for his assistance and guidance in planning this new publication.</p> <p>To begin, four issues per year are contemplated. The initial subscription rate will be $8.00 per year. Each issue will contain short articles on both Prosthetics and Orthotics. AAOP members will receive their copies as a service to members. Prices will be adjusted to reflect costs without profit to the AAOP.</p> <p>A subscription order blank is included in this issue for the use of those who are not members of AAOP. Your participation will help us in assuring the long term success of this publication.</p> <p><a href="/files/original/c2545799ce5601d736f2cd4f1463a521.jpg"><b>Joseph M. Cestaro: AAOP President</b></a></p> Page Number(s) 1 - 1 Year 1977 Volume 1 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1977_01_001/1977_01_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Introduction https://staging.drfop.org/files/original/1bcf24533393a270e599124c79df627d.pdf 60d27e744f0e910fb5a36973e948eeb2 https://staging.drfop.org/files/original/f3330c73f6253b5091be2b01f531b140.jpg dc38c24c7179bb4effb3aae915ea79b5 https://staging.drfop.org/files/original/3bfbe6e6b7b7ca08a21d8a48c3f7aa45.jpg c78a26b9dc50869149e455dbeeb47f7a https://staging.drfop.org/files/original/65d4cca945fc77e2edf91de00c4620ee.jpg 059f9b70cc153445dd52ad38f1197c7a https://staging.drfop.org/files/original/6d57408b37f4a7b475d3206c69df9017.jpg 5054831ea0e4ec721daa3a4edd6360df https://staging.drfop.org/files/original/a0c55a5151b7c247a981368ea9bb74e3.jpg 56e078026c6bd5e04cc4d7a4a7644338 https://staging.drfop.org/files/original/d82cddd653af422dee248f52593085c6.jpg a9098af669adf8d1ac1861e371694404 https://staging.drfop.org/files/original/0d4a99f5d93c2bbb9b5ad821b8208825.jpg 67a7d08af08aa01f3f67a3ba4b200d7b https://staging.drfop.org/files/original/ab25a84fa2da308c0909dc1329c9f9a4.jpg eaf49a7130edc6d667abd9ce0349e04e https://staging.drfop.org/files/original/3ada30036b5b486eab3687d8874e56c2.jpg c89eb22bef8bad2e22f39b8d41c49a39 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_023.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 23 - 26 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1965_01_023.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_023.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>Inverted V-Strap Suspension for PTB Prosthesis</h2> <h5>Jack L Caldwell, C. P. <a style="text-decoration:none;">*</a><br /></h5> <p>The leather cuff-suspension strap described in <i>The Patellar-Tendon-Bearing Below-Knee Prosthesis <a></a> </i> and in the June 1962 issue of <i>Artificial Limbs </i>has been found satisfactory in the majority of cases (<b>Fig. 1</b>). However, in certain cases with short stumps suspension problems have arisen. One particular case (<b>Fig. 2</b>), a patient having a very short stump (2 3/4 in.), presented such a critical suspension problem that other means of achieving suspension were attempted. The first approach was a figure-eight dacron strap with Velcro for adjustment (<b>Fig. 3</b>). A continuous strap encircling the thigh was crossed over the patella. The ends of the strap were attached to the socket. Socket retention was improved, but some disadvantages were noted. When tightened sufficiently to provide good suspension, the strap caused a circumferential constriction above the knee impairing stump circulation (<b>Fig. 4</b>). Furthermore, this type of suspension did not provide an adequate extension stop for the knee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Anterior and posterior views of typical cuff-suspension system for PTB prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Very short below-knee stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Continuous-strap suspension arranged in a figure-eight with Velcro for adjustment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Effect of circumferential constriction above the knee. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Continued experimentation led to the use of the present suspension system using two straps looped through a ring for socket suspension (<b>Fig. 5</b>). The suspension system consists of two straps 1 in. wide and approximately 16 in. in length. When looped through a stainless steel ring, these straps form two inverted V's with the apex of each inverted V passing through the ring. The ends of the V-straps are attached to the socket. Each strap has one end anteriorly and one end posteriorly attached to the proximal socket, thereby providing a four-point suspension. The ring joins both straps and is attached to a flexible waist belt by an elastic thigh strap. No circumferential strap is used about the thigh; a waist belt and a thigh suspension strap, plus the free-sliding characteristics of the two V-straps through the ring, provide firm suspension in all positions of knee extension or flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Anterior view of two inverted V-straps looped through a ring and attached inside a hard socket close to the brim. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The strap attachments to the socket should be placed so as to prevent knee hyperextension. The proper sites for strap attachment to the socket are related to the length of the stump. Usually, the shorter the stump the more anterior and proximal are the sites for attachment of the anterior suspension strap. The average short stump of 3 to 4 in. requires that the anterior attachments be located approximately 1 in. above the patellar-tendon contour of the socket and at each side of the patella, with sufficient space for the patella to pass between the straps as the knee is flexed. The posterior socket attachments may be located in the popliteal section of the posterior socket as shown in Figure 6. If the socket wall is thick, the posterior straps should be permitted to pass between the stump and the inner socket walls as illustrated in <b>Fig. 5</b>, <b>Fig. 6</b>, <b>Fig. 7</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Posterior view showing a common attachment point for the posterior straps. The attachment points may be either together or separate, and the straps may be attached either inside the socket or outside. Care must be taken to prevent the strap from rubbing against the (iliotibial) tendons on the lateral side of the thigh. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Top view of the V-straps with the knee extended. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The V-straps must be sufficiently short to hold the ring down firmly against the superior margin of the patella. The elastic thigh strap may be adjusted for proper tension above the knee to prevent the ring from slipping down upon the patella.</p> <p>The ring must be sufficiently large to permit two 1-in. dacron webbing straps to slide through it without overlapping one another (<b>Fig. 7</b>, <b>Fig. 8</b>, <b>Fig. 9</b>). The ring shown in the illustrations accompanying this article is the Northwestern University upper-extremity harness ring described in the June 1962 issue of <i>Artificial Limbs. </i>It is an O-ring. If a D-ring is used, the flat side should be turned upward. A quick-disconnect snap fastener as illustrated may be used to connect the elastic thigh strap to the ring.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Top view of the V-straps with the knee flexed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Posterior-oblique view showing retention of the prosthesis to the slump while the knee is flexed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As the knee is flexed, the suspension straps remain comfortable, and strap tension does not change regardless of knee position. <b>Fig. 8</b> and <b>Fig. 9</b> show a knee in full flexion. The dark areas on the V-straps demonstrate the amount of their excursion through the ring as the knee is flexed. When the knee is extended, the ring will slip forward over the shadowed areas, returning to the position shown in <b>Fig. 5</b> and <b>Fig. 7</b>.</p> <p><b>References:</b></p> <ol> <li>Artificial Limbs, June 1962.</li> <li>Radcliffe, C. W., and J. Foort, <i>The patellar-tendon-hearing below-knee prosthesis, </i>University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1961.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Radcliffe, C. W., and J. Foort, The patellar-tendon-hearing below-knee prosthesis, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Jack L Caldwell, C. P. </b></td></tr><tr><td class="clsTextSmall">J. E. Hanger, Inc., of Florida, 938 South Orange Ave., Orlando, Fla.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_01_023/spring65-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_01_023/spring65-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_01_023/spring65-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_01_023/spring65-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_01_023/spring65-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1965_01_023/spring65-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1965_01_023/spring65-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1965_01_023/spring65-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1965_01_023/spring65-9.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Inverted V-Strap Suspension for PTB Prosthesis Creator An entity primarily responsible for making the resource Jack L Caldwell, C. P. * https://staging.drfop.org/files/original/c1b212e5569be3980845775e2e5a8a20.pdf b5411e7663896df2ca89672710d0c1cb 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_03_001.pdf Text Any textual data included in the document <h2>Irreversible Contractures: An Impediment to Prosthetic Rehabilitation</h2> <h5>Justin Alexander, Ph.D.&nbsp;</h5> <p>Prosthetic rehabilitation of patients with severe contractures of the remaining joints of the affected lower extremity has been generally viewed as being difficult due to biomechanical problems in fitting, increased energy costs of ambulation and poor cosmesis of the prosthesis. As a result, attempts are often made to "stretch out the contracture" with minimal success, or suggestions are made to the patient to remain in the wheelchair. Our experiences with a number of patients who presented with "irreversible" contractures, indicate that another choice may be available.</p> <p>In 1965(1) we reported our experience in the management of a 59 year old man who had undergone bilateral amputations (BK and AK). Following a herniorrhaphy, he developed occlusions of both iliac arteries and despite attempts to reconstruct the vascular supply, he developed gangrene necessitating the amputations. When he was examined by us, he presented with bilateral hip flexion contractures of about 60° and a knee flexion contracture on the BK side of 90°. In addition, there was limited mobility of the lumbar spine. Primarily because the patient refused our recommendation for wheelchair independence, pylons were constructed. For the left, a bent knee pylon was fabricated and for the right the device was built to hold the stump in about 50° hip flexion with weight bearing on the posterior thigh. Since the patient demonstrated that this solution was a realistic one, prosthetic devices incorporating the features of the pylons were made. When the patient was discharged, he was able to ambulate with the aid of Lofstrand crutches.</p> <p>The patient was re-examined periodically, and <i>after about 2 years</i> it was noted that the contractures had decreased to a point where he was able to wear a PTB prosthesis on the left and a conventionally aligned AK quadrilateral socket prosthesis on the right.</p> <p>Lippman(2) described his observations of a 72 year old man who lost his right leg as a result of trauma, complicated by a long history of arteriosclerosis obliterans. Because of a 40° hip flexion contracture, his prosthetic treatment followed the course outlined above.</p> <p>In our prosthetics clinic (Bronx Municipal Hospital Center), we have seen a number of patients who had undergone below knee amputations and presented with severe knee flexion-hip flexion contractures to a degree which precluded fitting with a standard PTB or condylar bearing prosthesis. We have frequently fitted them with bent knee pylons followed by a similar prosthetic device after they had demonstrated their ability to function with the temporary device. On follow-up we again noted reduction of the "irreversible" contractures to the point where a more conventionally aligned prosthesis could be prescribed.</p> <h3>Discussion</h3> <p>Delagi and co-workers(3) (1955) as well as Blau, <em>et. al</em>(4) (1951) reported their impressions of the benefits of ambulation with a temporary device. Both emphasized the stretching effect of early ambulation. In the devices described in this article, however, stretching has been purposely minimized because the contractures were believed to be "irreversible." Despite the lack of active stretching, the contractures were relieved to a considerable degree.</p> <p>Partridge and Duthie (1963) (5) reviewed the literature describing the effect of immobilization on acutely inflamed rheumatoid joints and cite Hunter (1835) "nothing can promote contraction(s) of a joint so much as motion before the disease is removed." Hunter's observations were confirmed by Thomas (1878), Duthie (1951, 1952) and Partridge and Duthie. Harris and Copp(6) (1962) immobilized acutely inflamed knee joints, keeping one completely immobilized and the other being exercised intermittently. They noted that when the fixed knee lost more than 15° of motion, the mobile knee also lost range, thereby suggesting that some factors other than immobility might be a contributing factor. In their opinion immobilization produced a decrease in muscle spasm, thus permitting restoration of motion.</p> <p>Fried (1969) (7) concurs "complete immobilization is not only <em>not</em> harmful but frequently beneficial, provided that splinting is done judiciously, especially when a joint is inflamed and painful." Under those conditions when patients are likely to dread motion, immobilization leads to decreased pain and inflammation and "it is not unusual for immobilization to result in increase in motion."</p> <p>It seems that those amputees who experience considerable pain pre-operatively or in the immediate post-operative period, might react with a response similar to that described above and when pain is relieved, inhibition, spasm or another mechanism is decreased and motion can be restored.</p> <p>In addition, it appears that the judgment of "irreversible contractures" may be applied too quickly. Patients are treated for a finite period of time and if during that period no appreciable change is observed, a decision must be made based on demonstrable facts.</p> <p>It can, therefore, be concluded that for some patients interim solutions as outlined may be appropriate and that the clinic staff must accept the responsibility for regular, periodic and long term follow-up of patients in order to facilitate accommodation to changes in the patient's condition.</p> <p><b>References:</b></p> <ol> <li>Alexander, Justin and Herbison, Gerald, "Prosthetic Rehabilitation of a Patient With Bilateral Hip-Flexion Contractures: Report of a Case." <i>Archives of Physical Medicine and Rehabilitation</i>, Vol. 46, 708-711, October, 1965.</li> <li>Lippmann, Heinz I., "Rehabilitation of the Lower Extremity Amputee with Marked Flexion Contractures: Report of Two Cases." <i>Archives of Physical Medicine and Rehabilitation</i>, Vol. 48:3, 147-149, March, 1967.</li> <li>Delagi, Edward F., Abramson, Arthur S. and Tauber, Arthur N., "Use of Temporary Plaster Pylon in the Management of the Lower Extremity Amputee." <i>Archives of Physical Medicine and Rehabilitation</i>, Vol. 36: 784-786, December, 1955.</li> <li>Blau, Leslie, Phillips, Joseph J. and Rose, Donald M., "Value of the Pylon in Pre-prosthetic Management of the Lower Extremity Amputee." <i>Archives of Physical Medicine and Rehabilitation</i>, Vol. 32: 585-589, 1951.</li> <li>Partridge, R. E. H. and Duthie, J. J. R., "Controlled Trial of the Effect of Complete Immobilization of the Joints in Rheumatoid Arthritis." <i>Ann. Rheum. Dis.</i>, 22: 91, 1963.</li> <li>Harris, R. and Copp, E. P., "Immobilization of the Knee Joint in Rheumatoid Arthritis." <i>Ann. Rheum. Dis.</i>, 21: 353, 1962.</li> <li>Fried, David M., "Splints for Arthritis." <i>Arthritis and Physical Medicine</i>, S. Licht (edit.), 1969, pp 285-314.</li> </ol> Page Number(s) 1 - 2 Year 1980 Volume 4 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 Irreversible Contractures: An Impediment to Prosthetic Rehabilitation Creator An entity primarily responsible for making the resource Justin Alexander, Ph.D.  https://staging.drfop.org/files/original/e596fe333824d5e3e2ff725137adec85.pdf 22d8a4a169b4a0521aefc4ea4c48e32d https://staging.drfop.org/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg 4cc537e63119f220d2a5d43722b3f2c2 https://staging.drfop.org/files/original/1ada071125459a546f751d970b00a5c8.jpg f8a160cd40afca3e0239b722030d3ecf https://staging.drfop.org/files/original/42144af7cd4c081838ba0ccfce4d5357.jpg 637f5bc31f36cb709581380fd3907536 https://staging.drfop.org/files/original/7abe20d1503c047c2ec9ee334918231e.jpg 6323600ff95773536016f3121ee8684a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_091.pdf Text Any textual data included in the document <h2>Knee Joint Materials and Components</h2> <h5>M.L. Stills, CO.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The primary purpose of any orthotic knee joint, regardless of material or design, is to aid in providing stability to the patient's anatomical knee during loading of the extremity. In the paraplegic patient population, resistance to flexion of the knee is required during the periods of ground contact that occur during reciprocal gait. Orthotic knee joints can be used to provide medial-lateral control while permitting free flexion and extension, provide stance phase stability only during gait, or maintain locked knee extension during all phases of gait.</p> <p>Materials used in the fabrication of knee joints for management for people with paraplegia are generally a hybrid of various metals, or in some cases, high-strength, reinforced composite plastics. Aluminum, and/or stainless steel machined preformed components, are common and can be considered state-of-the-art.</p> <p>Mechanical knee joints are only a single component of a very complex system (<a href="/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg"><b>Fig. 1</b></a> and <a href="/files/original/1ada071125459a546f751d970b00a5c8.jpg"><b>Fig. 2</b></a>). How that component is incorporated into the entire system has an effect on the outcome of successful orthotic management. The success or failure of the entire orthotic system is dependent on many variables, i.e., accuracy of the original prescription, fabrication procedures, placement and alignment of mechanical joints relative to anatomical joints, lever arms, overall fit, training in the use of the orthosis, and the motivation of the patient.</p> <strong><a href="/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg">Figure 1.</a> Conventional metal and leather bilateral knee-ankle-foot orthosis with single axis drop lock knee and double adjustable ankle joint.</strong><br /><br /><strong><a href="/files/original/1ada071125459a546f751d970b00a5c8.jpg">Figure 2.</a> Bilateral polypropylene knee-ankle-foot orthosis with single axis drop lock knee and semi rigid ankle. FES was used with KAFO to facilitate swing through during gait.</strong><br /> <h3>Free Knee Joints</h3> <p>Free knee joints, having only hyperextension stops, are used to provide medial-lateral stability to the knee, or in situations when the patient has adequate extension power, but due to knee ligament laxity or muscle imbalance, is unable to control hyperextension.</p> <p>Care must be taken when using free knee joints to check hyperextension. The orthotist must be assured that the patient has adequate voluntary muscle control to maintain knee extension. The orthosis may be required to permit a limited amount of hyperextension in order to provide stability during stance.</p> <h3>Offset Knee Joint</h3> <p>The purpose of the offset knee joint is to provide stance phase stability of the knee while permitting free knee flexion during swing phase. This should provide a more anatomical reciprocal type of gait and should reduce energy consumption.</p> <p>The patient must have adequate voluntary muscle control to place the mechanical joint in a fully extended position and to move the ground reaction force anterior to the axis of rotation. The combination of ground reaction force, posteriorly offset orthotic knee joint, and a mechanical extension stop can provide stance phase stability for the paraplegic.</p> <p>Many of the same factors that influence stability of the bilateral above-knee amputee also can be applied to the paraplegic patient using bilateral offset knee joints. Voluntary hip extension power is required. The use of crutches or assistive devices are almost always mandatory. Consideration must be given to the problems of uneven walking surfaces, changes in heel heights, and patient endurance. Dynamic extension assists are often added to this type joint, or an extension lock may be added and dropped into place when additional security is required.</p> <h3>Locked Knee Joints</h3> <p>A locked knee joint (<a href="/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg"><b>Fig. 1</b></a> and <a href="/files/original/1ada071125459a546f751d970b00a5c8.jpg"><b>Fig. 2</b></a>) provides stability during the stance phase of gait and remains locked even during phases of non-ground contact. A mechanism is generally provided to unlock the knee for cosmesis and comfort during sitting. Mechanisms for locking the knee joint in extension vary from simple gravity ring (drop) locks, spring-assisted drop locks, cams, pawls, and Swiss locks. Difficulty in unlocking the knee to permit sitting has led to the development of a variety of designs, again beginning with the simple ring lock, extensions added to drop locks, and bails (mechanical links between medial and lateral locks on a single extremity). To avoid accidentally unlocking a joint, designers have added ball retainers, springs, and elastic straps, all in an attempt to prevent accidental, unintentional flexion of the knee joint and subsequent falls and possible injury to the patient. There does not exist, however, a failsafe system that will completely eliminate the possibility of inadvertent knee flexion.</p> <p>Solid knee orthoses have been used with limited success because of functional difficulties. Granted, the knee is stable during gait, but the inability to flex the knee during sitting makes the use of public and private transportation difficult and many times impossible. Social and public functions are difficult to manage when the user of a solid knee type device tries to sit and avoid blocking aisles or passageways. Difficulties related to a stiff knee have greatly reduced the use of surgical knee arthrodesis.</p> <p>The use of medial and lateral components when fabricating knee-ankle-foot orthoses (KAFO) is commonplace. The use of such bilateral double upright construction certainly increases the weight of an orthosis and requires that the fabricator use techniques that ensure both medial and lateral joint surfaces are absolutely parallel and in alignment with each other.</p> <p>Nitschke in 1971 reported the results of using a single lateral upright in the fabrication of KAFOs. This technique reduced the weight of the KAFO and the problem of joint alignment.</p> <p>Incorporation of knee joints into a conventional metal and leather type KAFO provides the orthotist with the option of adjustability and limited skin contact (<a href="/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg"><b>Fig. 1</b></a>). Incorporation of knee joints into laminated and thermo-formed KAFOs (<a href="/files/original/1ada071125459a546f751d970b00a5c8.jpg"><b>Fig. 2</b></a>) provides a means for more intimate fit, better control of the extremity, improved cosmesis, and lighter weight, but limited adjustability in alignment and fit of the orthosis.</p> <p>The Lower Extremity Telescoping Orthosis (LETOR) (<a href="/files/original/42144af7cd4c081838ba0ccfce4d5357.jpg"><b>Fig. 3</b></a>) incorporates a new concept in knee joints. It really does not have a knee joint, but a telescoping posterior rod that, when in its extended position, bridges the anatomical knee joint and does not permit knee flexion. By lowering the telescoping rod, knee flexion is permitted during sitting. This simple telescoping bar attachment and a solid ankle system provides knee stability in ambulation and becomes a valuable training system and may be used as a definitive orthosis for the limited household ambulator.</p> <strong><a href="/files/original/42144af7cd4c081838ba0ccfce4d5357.jpg">Figure 3</a>. LETOR-Posterior telescoping rod bridges the knee and prevents knee flexion.</strong><br /> <p>Other methods of controlling the knee joint externally must include the use of Functional Electrical Stimulation. These externally applied electrodes provide a means of electrically stimulating the muscles controlling the knee. Work has been done using electrical stimulation with and without forms of external knee support with mixed results. This work is still considered experimental, but there is every indication that it may become a means of providing control of the knee in the paraplegic population.</p> <h3>Conclusion</h3> <p>A number of knee joint designs exist. Those developed from metal, i.e., stainless steel and/ or aluminum, are best used when orthotically managing the paraplegic patient. Thermoplastic knee joint designs can be used in the unilaterally involved patient or when the problem is related to structural instability and not voluntary muscle control.</p> <p>Knee joints are made stable by including mechanical locks or stops, by alignment techniques to ensure that the ground reaction force is anterior to the axis of rotation, or by the addition of springs, elastic straps, or cords that dynamically extend the knee.</p> <p>Ground reaction forces can be combined with the paraplegic's own intact anatomical knee joint to provide knee extension without orthotic extension above the knee joint (<a href="/files/original/7abe20d1503c047c2ec9ee334918231e.jpg"><b>Fig. 4</b></a>). This has been used with limited success in selected pediatric paraplegic patients.</p> <strong><a href="/files/original/7abe20d1503c047c2ec9ee334918231e.jpg">Figure 4.</a> Floor reaction orthosis—posterior directed force on knee producing knee extension. Note hyperlordosis due to hip flexion contracture.</strong><br /> <p>Present and future research may drastically alter components and materials used in the future. At present, however, the combination of appropriate prescription, components, fabrication and fitting skills, along with skilled training in the use of an orthosis, will result in the potential for successful orthotic management of the paraplegic patient.</p> <p><b>References:</b></p> <ol> <li>Anderson, E.G., and J.T. Henshaw, "The Design and Prescription of Above Knee Orthosis." <i>Orthotics and Prosthetics</i>, Vol. 31, No. 3. September, 1977, pp. 31-40.</li> <li><a href="cpo/1986_03_111.asp">Bajd, T., B.J. Andrews, A. Krulj, and J. Katakis, "Restoration of Walking in Patients with Incomplete Spinal Cord Injuries by Use of Surface Electrical Stimulation-Primary Results." <i>Clinical Prosthetics and Orthotics</i>, Vol. 10, No. 3, Summer, 1986, pp. 111-114.</a></li> <li>Clark, D.R., J. Perry, and T.R. Lunsford, "Case Studies-Orthotic Management of Adult Post Polio Patients." <i>Orthotics and Prosthetics</i>, Vol. 40, No. 1, Spring, 1986, pp. 43-50.</li> <li>Condie, D., C. Pritham, A.B. Wilson, III, and M. Stills, <i>Lower-Limb Orthotics, A Manual</i>, First Edition, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadelphia, PA.</li> <li>Foster, R., and J. Milani, "The Genucentric Knee Orthosis-A New Concept." <i>Orthotics and Prosthetics</i>, Vol. 33, No. 2, June, 1979, pp. 31-44.</li> <li>Glancy, J., and R.E. Lindseth, "The Polypropylene Solid Ankle Orthosis." <i>Orthotics and Prosthetics</i>, Vol. 26, No. 1, March, 1972, pp. 14-26.</li> <li>Pokora, M.B., J. Ober, and P.T. Milewski, "Lower Extremity Telescoping Orthosis LETOR." <i>Prosthetics and Orthotics International</i>, Vol. 8, No. 2, August, 1984, pp. 114-116.</li> <li>Pritham, C, and M. Stills, "Knee Cylinder," <i>Orthotics and Prosthetics</i>, Vol. 33, No. 4, December, 1979, pp. 11-18.</li> <li>Rubin, G., M. Dixon, and M. Danisi, "VAPC Prescription Procedures for Knee Orthosis and Knee Ankle Foot Orthoses," <i>Orthotics and Prosthetics</i>, Vol. 31, No. 3, September, 1977, pp. 9-25.</li> <li>Stills, M., "Lower Limb Orthotics." Report: <i>The Current Status of Prosthetics and Orthotics and Trends for Future Research and Development</i>, University of Miami, April 1-3, 1977.</li> </ol> <em><b>*M.L. Stills, CO. </b> M.L. Stills is an Instructor of Orthopedic Surgery in the Division of Orthopedics at the University of Texas Health Science Center in Dallas, Texas and Assistant Professor at the University of Texas School of Allied Health Sciences.<br /><br /><br /></em> Page Number(s) 91 - 94 Year 1987 Volume 11 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_091/1987_02_091-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_091/1987_02_091-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_091/1987_02_091-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_091/1987_02_091-4.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 Knee Joint Materials and Components Creator An entity primarily responsible for making the resource M.L. Stills, CO. * https://staging.drfop.org/files/original/ae05e878bd64c3dbd3b2584c3a8af1c3.pdf 908af03ad8cb34c07750c64b92d97c44 https://staging.drfop.org/files/original/eff05f3ff73679cc3aa9f244a0b01ee1.jpeg edfa643666b367de3ccf1505947074ee https://staging.drfop.org/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg 673473bd1e41e590c4e9c60e9599e2fc https://staging.drfop.org/files/original/6e9b5d4a5957258a4958635acfc8fbda.jpg 682e526dd8cd44af055581f51d3543b0 https://staging.drfop.org/files/original/29254ec4552c6b302e11d7249167147b.jpg 5872069631752d0d3d9eb1f39bd37b76 https://staging.drfop.org/files/original/be009fdace4d2d0fce8a7757ab25edf7.jpg fc1c45950fcf019e826c6035112ac38e https://staging.drfop.org/files/original/a8017df2f33ae779bbc361ad9d87e7ee.jpg f72d46285c6e66bf702f8dc9c651e66b https://staging.drfop.org/files/original/51d4491374c4e678089f6cdf6c27afae.jpg f51626e0ef82b0a4dfb1ee8ab4693ced https://staging.drfop.org/files/original/822789265194f5be4e60727bb55d3108.jpg 4499acf3c75535c673217cfa36745c01 https://staging.drfop.org/files/original/20bbec62ad79b83acbdb384867dd8dfe.jpeg e67daa763e1a8051b264102cc6bd4c8b https://staging.drfop.org/files/original/df0e494105bf2580379ea0532148fd6e.jpeg 821ac6be13efc72dd02bf99301f354ec https://staging.drfop.org/files/original/56713088198c8c2e3e4a0e824e14d79b.jpeg efa1d6a37f55c3e4ec5ba5c6f99c1555 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_04_005.pdf Text Any textual data included in the document <h2>Knee Orthoses: Biomechanics</h2> <h5>Charles H. Pritham, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>Derived from a lecture given at the ISPO Lower Limb Orthotics Course, Dallas, Texas, March 9-13, 1981.</i></p> <p>Irrespective of etiology, deformities of the knee can be divided into three broad categories: angular (genu valgum, genu varum, genu recurvatum), rotary (internal, external rotation of the tibia relative to the femur), translatory (anterior/posterior subluxation of the tibia relative to the femur). They can be further categorized as either flexible (secondary to flaccid musculature and/or ligamentous and capsular laxity) or fixed (secondary to spastic musculature and/or ligamentous and capsular tightness). For a variety of reasons orthotics has traditionally devoted the majority of its attention to cases of angular deformity and coped with instances of rotary or translatory deformity only secondarily as they arise as complications of angular deformity. For that reason, then, the majority of discussion will focus on this aspect of the situation.</p> <p>Viewed in the frontal plane (the case is the same in the sagittal plane) with the body aligned so that the weightbearing line coincides exactly with the mechanical axis of the leg (<a href="/files/original/eff05f3ff73679cc3aa9f244a0b01ee1.jpeg"><b>Fig. 1</b></a>), there is no tendency for the knee to bend into either genu valgum or genu varum. If the weightbearing line deviates to one side, a bending moment or torque is created (<a href="/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg"><b>Fig. 2</b></a>) that causes a change in angle (angle of deformity, 0) of the femur relative to the tibia. The bending moment can be quantified by multiplying the deforming force (body weight, W) times the perpendicular distance (x) from the line of action to the center of rotation. As body weight is essentially constant, any increase in angle of deformity will lead to an increase in distance x and an increase in the deforming moment. In real life this tends to create a vicious circle since the deformity is resisted by the capsular and ligamentous elements on the opposite side of the knee. The stress is greatest on those elements farthest away from the center of rotation, as they are best positioned by virtue of their longer lever arm to oppose the deforming force. When the stress becomes intolerable, they yield, and the load falls on elements less strategically placed. As the angle of deformity increases, distance x increases, the deforming moment increases, and a compromised knee is jeopardized further. To correct this situation and prevent further damage, it is necessary to introduce a corrective moment and reduce the angle of deformity.</p> <strong><a href="/files/original/eff05f3ff73679cc3aa9f244a0b01ee1.jpeg">Fig. 1</a>. Lower limb positioned so that weightbearing axis falls through the mechanical axis of the limb.</strong><br /><br /><strong><a href="/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg">Fig. 2</a>. As the weightbearing axis deviates to one side a bending moment or torque is created</strong><br /> <p>This corrective moment is created by a three-point pressure system (<a href="/files/original/6e9b5d4a5957258a4958635acfc8fbda.jpg"><b>Fig. 3</b></a>). For the laws of equilibrium to be satisfied, the forces acting on each side of the structure must be equal, and the clockwise moments acting about the center of rotation must be equal to the counterclockwise moments. The farther forces H and A are from the center of rotation, the smaller they can be, due to increased lengths of their lever arms a and b. Force K can seldom be applied directly at the center of rotation (<a href="/files/original/29254ec4552c6b302e11d7249167147b.jpg"><b>Fig. 4</b></a>), as the anatomical structures vary in their ability to tolerate the pressure. It may very well prove necessary to locate force K some distance from the knee and apply it as two sub-elements, S and I. K would be equal to the sum of the two and vary in point of application according to their relative strength. As K moves away from the center of rotation (<a href="/files/original/be009fdace4d2d0fce8a7757ab25edf7.jpg"><b>Fig. 5</b></a>), it increases the bending moment acting in one direction or another, and if the laws of equilibrium are to be satisfied, the opposing moment will have to increase in magnitude, leading to an increase in total force on the limb. <a href="/files/original/a8017df2f33ae779bbc361ad9d87e7ee.jpg"><b>Fig. 6</b></a> summarizes the discussion thus far. It should be noted that any orthosis fabricated to satisfy these conditions must be strong enough to do so without yielding or bending as the old pattern of the vicious circle (<a href="/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg"><b>Fig. 2</b></a>) will assert itself. Yet another factor to be taken into account is the familiar relationship of pressure, force, and area (<a href="/files/original/51d4491374c4e678089f6cdf6c27afae.jpg"><b>Fig. 7</b>)</a>. The need to satisfy these conditions and thus reduce the total force exerted must be, of course, balanced with the desire not to encumber adjacent joints, and to keep the orthosis as cool and light as possible.</p> <strong><a href="/files/original/6e9b5d4a5957258a4958635acfc8fbda.jpg">Fig. 3.</a> Three-point pressure system acting about the knee.</strong><br /><br /><strong><a href="/files/original/29254ec4552c6b302e11d7249167147b.jpg">Fig. 4</a>. Force K acting as two sub-forces, S and I.</strong><br /><br /><strong><a href="/files/original/be009fdace4d2d0fce8a7757ab25edf7.jpg">Fig. 5.</a> As force K moves away from the knee the total force on the limb increases.</strong><br /><br /><strong><a href="/files/original/a8017df2f33ae779bbc361ad9d87e7ee.jpg">Fig. 6.</a> A summarization of criteria necessary to minimize the force on the limb.</strong><br /><br /><strong><a href="/files/original/51d4491374c4e678089f6cdf6c27afae.jpg">Fig. 7.</a> The relationship of pressure to force and area.</strong><br /> <p>Another way to tackle the problem is to use a weightbearing brim (<a href="/files/original/822789265194f5be4e60727bb55d3108.jpg"><b>Fig. 8</b></a>). This, of course, reduces the deforming force and thus the deforming moment. What is not so apparent is that it might very well change the length of the lever arm x and reduce the bending moment. If some of the body weight is borne medially on an ischial seat, it would tend to shift the line of action of the body weight medial to its usual course through the head of the femur. This phenomenon is at work when a KAFO with a quadrilateral brim is used in cases of gluteus medium lurch. It might very well have implications in cases of genu varum and genu valgum. In the sagittal plane (<a href="/files/original/20bbec62ad79b83acbdb384867dd8dfe.jpeg"><b>Fig. 9</b></a>), a similar situation is identified in the UCLA Functional Long Leg Brace<a></a>. Moving the line of action of the weight line anterior by virtue of the load on the Scarpa's Triangle, a knee extension moment is generated. Knee extension is further aided by the intimate fit of the quadrilaterial brim and a firm fit of the foot in the shoe which produces a distractive effect on the leg, straightening it, as would pulling on opposite ends of a rope.</p> <strong><a href="/files/original/822789265194f5be4e60727bb55d3108.jpg">Fig. 8.</a> Use of a weightbearing brim creates a proximally acting force, R, that counteracts weight, W.</strong><br /><br /><strong><a href="/files/original/20bbec62ad79b83acbdb384867dd8dfe.jpeg">Fig. 9.</a> Forces applied to the higher anterior wall of a quadrilateral brim tend to move the weightbearing axis anterior to the head of the femur, and the knee center.</strong><br /> <p>Subluxation of the tibia (such as might occur due to the pull of the quadriceps secondarily to ligamentous laxity in cases of genu valgum in arthritis, a situation described by Smith, et al.<a></a>), can be corn-batted by separate force couples acting on the femur and the tibia (<a href="/files/original/df0e494105bf2580379ea0532148fd6e.jpeg"><b>Fig. 10</b></a>). This is a feature of the University of Michigan Arthritic Knee Brace.</p> <strong><a href="/files/original/df0e494105bf2580379ea0532148fd6e.jpeg">Fig. 10.</a> Use of force couples acting on the femur and tibia to prevent anterior subluxation of the tibia relative to the femur. The force system would be reversed in an instance of posterior subluxation. A system of force couples is subject to the same sort of analysis and criteria as a three-point pressure system.</strong><br /> <p>In the absence of direct action on the skeleton, control of rotation is more problematical. As the proximal portion of the shin is triangular, considerable rotational control can be achieved as in the PTB prosthesis, the spiral ankle-foot orthosis (AFO), and the hemi-spiral AFO. Purchase about the condyles of the femur and the patella can be achieved, but is compromised by the necessity for unencumbered knee flexion. It is, of course, possible to use a quadrilateral brim to gain a purchase on the proximal structures, but any prosthetist will be glad to regale his orthotist companion with tales or rotary instability in above-knee prostheses. The last alternative is a frictional coupling between the soft tissue and broad elastic straps as in the Lenox Hill Derotation Orthosis (<a href="/files/original/56713088198c8c2e3e4a0e824e14d79b.jpeg"><b>Fig. 11</b></a>). As considerable slack must be taken up in the soft tissues, 20 degrees of motion at the surface may result in only 10 degrees of motion of the femur about its axis. Moreover, the efficacy of even the best such measures is called into question considering the magnitude of the bending moment generated by the action of the center of gravity about the long axis of the leg and comparing it with the moments that can be induced about the same axis by the maximum tolerable force acting at the surface of the leg.</p> <strong><a href="/files/original/56713088198c8c2e3e4a0e824e14d79b.jpeg">Fig. 11.</a> Schematic cross-section of a limb, on the left, with the skin (outer circle) connected to the bone (middle circle) by soft tissue (radiating rippling lines) and acting about the center of rotation (innermost circle). The broad vertical line is for reference. As rotary forces (arrows) are applied, on the right, the force is transmitted from the skin to the bone by the soft tissue. As slack in the soft tissue must be taken up it becomes apparent that the bone moves less than the skin.</strong><br /> <p>In conclusion, some of the biomechanical factors involved in the function of knee orthoses are reviewed. Due consideration of these factors, the anatomical structures involved, and the intended purpose of the orthosis at the time of prescription should inevitably lead to a more functional orthosis.</p> <p><b>References:</b></p> <ol> <li><em>Final Report, Functional Long Leg Brace Research</em>. University of California, Los Angeles. Prosthetics/Orthotics Education Program, March 30, 1971.</li> <li>Edwin M. Smith, M.D., Robert C. Juvinall, M.S.M.E., Edward B. Correll, M.S.M.E., and Victor J. Nyboer, M.D., "Bracing the Unstable Arthritic Knee," <em>Archives of Physical Medicine and Rehabilitation</em>, Vol. 51, No. 1, Jan. 1970, pp. 22-28, and 36.</li> </ol> <div style="width: 400px;"><em><br />*<b>Charles H. Pritham, C.P.O. </b> Formerly Director, Prosthetics and Orthotics Laboratory, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadelphia. Presently Branch Manager, Snell's of Louisville.</em></div> <div style="width: 400px;"><br /><br /></div> Page Number(s) 5 - 7 Year 1981 Volume 5 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-11.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 Knee Orthoses: Biomechanics Creator An entity primarily responsible for making the resource Charles H. Pritham, C.P.O. * https://staging.drfop.org/files/original/09ae6273b7efa1eca6cc0322ff308dd3.pdf c37e010a6efb7da15ebc3041aebdd09c https://staging.drfop.org/files/original/0e3e1220253af6aa4b191462f1226ca4.jpg b0082ad957d997d1c0132891b476d3b6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_044.pdf Year 1965 Volume 9 Issue 2 Page Number(s) 44 - 45 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_02_044.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_02_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>L'Attelle Monotubulaire, a Review</h2> <h5>Ralph Lusskin, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>L'Attelle Monotubulaire is the second fascicle, or increment, of the Atlas d'Appareillage Prothetique et Orthopedique (Atlas of Prosthetic and Orthopaedic Appliances) being published under the direction of Professor Louis Pierquin of the Faculty of Medicine of Nancy {Artificial Limbs, Spring 1964). L'Attelle Monotubulaire describes a lower-extremity brace of novel design and function-the monotubular brace. This interesting departure in French orthotics utilizes a single straight tubular upright to provide lightness and strength. The conventional medial upright is eliminated.</p> <p>Additional departures include a round caliper shoe attachment placed anterior to the ankle joint as well as below it. Geometry is accommodated during ankle movement and spring action is added to the joint by the use of a telescoping lower leg piece which inserts into an upper tube below the calf band. Stops and additional springs can be attached to the stirrup piece.</p> <p>Thus there has been developed a brace that uses a straight upright anterior to the axis of the leg, which has a moderate posterior offset of the knee joint, which varies in length with ankle motion and is easily adjusted to the torsional alignment of the leg. Patellar-tendonbearing-type leg bands and quadrilateral sockets can be utilized in place of narrow leg and thigh bands. Wide, contoured plastic bands are attached by metal bands soldered to the brace.</p> <p>To evaluate such a novel device, one must determine whether construction would present significant problems, whether fitting and alignment procedures can be standardized, and whether utilization corroborates the claimed attributes. Unfortunately, the publication does not provide sufficiently detailed information to answer these questions. This work is presented in broad terms for the general information of the physician-therapist-orthotist team. It does introduce the device but does not describe the metals used or the fabrication methods. Alignment procedures are not discussed, although two errors-improper depth of the thigh and leg bands and improper rotational alignment due to faulty positioning of the shoe piece-are demonstrated. No analysis of failure rates or comparison of the effectiveness of this brace versus that of standard braces is given. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. "When viewed laterally, the monotubular brace is traight; it does not show even the slightest curve at the level of the knee. It rests on a forward pin; that is, on a pin located in front of the axis of the limb." From L'Attelle Monotubulaire </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Considerable thought and work have obviously been expended to bring this device to its present state. Thus it is unfortunate that one can only speculate concerning possible limitations or advantages that might be inherent in its design.</p> <h4>Possible Limitations</h4> <p>Difficulties in using this brace might be encountered if deformities of the knee in the frontal plane, for example, genu valgum or genu varum, are present. In addition, the management of any flexion contracture of the knee would apparently be most difficult.</p> <p>Ankle instability would not be controlled by this device. While drop foot could be managed, varus and valgus deformities, both fixed and functional, might exceed the capacities of the brace. It is not apparent whether or not a calcaneal deformity could be adequately stabilized.</p> <p>The report notes the critical nature of the depth of the leg band, indicating that proper alignment and fit are vital factors in the application of this orthosis and that careful supervision by the physician would be required.</p> <h4>Possible Advantages</h4> <p>Certain advantages of the monotubular brace are apparent. The simplicity of the single-bar fabrication, the lightness of the device, and its potential for control of bilateral disorder without clearance problems are all positive values.</p> <h4>Conclusions</h4> <p>Since the monotubular brace appears to have potential value and its limitations can be only assumed, the device should be the subject of a controlled evaluation to identify problem areas and to demonstrate the usefulness of the device. This evaluation should include the training of others in fabrication, alignment, and fitting of the brace, and its utilization by a representative group of patients under controlled conditions.</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>Ralph Lusskin, M.D. </b></td></tr><tr><td class="clsTextSmall">Associate Clinical Professor of Orthopaedic Surgery, School of Medicine and Post-Graduate Medical School, New York University, 550 First Ave., New York, N. Y. 10016.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_02_044/1965_02_044.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 L'Attelle Monotubulaire, a Review Creator An entity primarily responsible for making the resource Ralph Lusskin, M.D. * https://staging.drfop.org/files/original/e678471a88e3fafdcc78502486bb9378.pdf 0c896873793ae2afd1dd418dddff6f7d DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1956_01_001.pdf Year 1956 Volume 3 Issue 1 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1956_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1956_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>Lesson In Lesions</h2> <h5>C. Leslie Mitchell, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The human integument, with its complex structural and functional organization, is one of the most remarkable packaging materials in the world. Unlike inanimate wrappers however elaborate, it has under ordinary circumstances the extraordinary facility of regenerating itself, of adapting to the local environment, and of resisting attack by all kinds of agents-chemical, physical, and biological. The reason for this situation lies in the fact that living skin, as is the case with other living tissues, undergoes continuous metabolism, with consequent growth and decay.</p> <p>But in addition to its mechanical function-that of providing a tough, protective outer covering for the body-the skin has many important but little-recognized physiological properties, among these being its ability to function as a respirator in the exchange of oxygen and carbon dioxide; as a regulator of body temperature by means of sweat glands under control of the sympathetic nervous system; as an agent in the conservation of water and electrolytes; as a sensory organ to record heat, cold, pain, and touch; as a corridor for the reception of vitamins and hormones; and as a barrier against infection. Despite all these indispensable services, the integrity of the skin is so much taken for granted by almost everybody that usually no attention is directed to it until some deviation from the normal develops. Its numerous functions are poorly understood by most laymen, if not indeed by many physicians. Yet neglect of its proper care can result in serious consequences.</p> <p>Proper functioning of the skin is dependent on many factors, such for example as freedom from constriction and irritation, adequate exposure to air, prompt removal of waste products from its surface, and avoidance of extremes of heat and cold. Whenever the skin is subjected to abnormal insults, the problem of skin care is multiplied many times. Since the wearing of a prosthesis, particularly on the weight-bearing lower extremity, unavoidably creates most of the conditions-constriction, excessive moisture, increased heat, mechanical irritation, and undue pressure-conducive to poor skin health, it quite naturally places upon the skin of the stump a set of demands far in excess of the normal. And not only that. Having lost one of his principal heat-radiating "fins," and being at the same time required to exert in locomotion more energy than does the normal person, the leg amputee commonly perspires more freely than normal, and hence his needs for skin hygiene are more acute than are those for one who walks on two natural legs.</p> <p>The basic requirements of a lower-extremity prosthesis are to provide comfort, function, and appearance. Of these, comfort is unquestionably of chief importance, for without comfort the amputee will fail to obtain satisfactory function, or appearance, or both, and will ultimately either limit use of the prosthesis or else find it impossible to wear it at all. In a large percentage of cases of difficulty or failure, skin lesions of one type or another involving the stump are found to be the cause of discomfort, thus preventing the amputee from wearing the limb. Prophylaxis is, therefore, a <i>sine qua non </i>in this regard, and only through adequate knowledge of skin physiology can these disorders be anticipated and thus prevented.</p> <p>Although disabling skin lesions on the stump of the leg amputee have constituted a serious complication ever since prostheses were first used for the lower extremity, full appreciation of the problem and suggestions for solution have not been forthcoming until recently. As has been typical with most problems in medicine, little was accomplished until a concerted effort was made to understand normal function and to investigate reaction to the abnormal. It is encouraging to note that there is now well under way, with the sponsorship of the Prosthetics Research Board of the National Academy of Sciences-National Research Council, a systematic attack aimed at solution of the cutaneous problems of the leg amputee.</p> <p>Because even the most satisfactory lower-extremity prosthesis is of no avail if the amputee is deprived of wearing it, and because painful skin lesions in a leg stump have so frequently been the cause of inability to use an artificial leg properly, the then Prosthetic Devices Research Project at the University of California, Berkeley (now the Lower-Extremity Amputee Research Project), in conjunction with the Department of Dermatology at the University of California Medical School in San Francisco, organized in the autumn of 1954 a skin-study group to investigate the cutaneous difficulties of the lower-extremity amputee. In the course of the succeeding two years there has been accumulated a considerable body of new knowledge, not only on the nature and physiology of healthy skin but also on some of the specific clinical manifestations of skin disorders in amputees. Since the proper management of cutaneous disturbances is so essential to lower-extremity function, this issue of Artificial Limbs is devoted to a presentation of some of the information gathered thus far. In the first of two articles, a dermatologist discusses the anatomy and physiology of normal skin and what is to be expected when healthy skin is subjected to unfavorable conditions. In the second, another dermatologist characterizes the common skin maladies of leg amputees and offers suggestions for prevention and treatment.</p> <p>An interesting observation is that proper care of the stump skin is found to be the responsibility not only of the attending physician and the prosthetist but, and even more important, of the amputee himself. Nevertheless, simple attention to good practices of daily hygiene is not enough. A considerable number of skin disorders peculiar to the lower-extremity stump present themselves despite all precautions. Some are common to all leg amputees. Many are the result of individual skin idiosyncrasies or of climatic conditions. Some are so intractable as to be amenable to cure only by total excision.</p> <p>While the newer understanding has in recent years appreciably decreased the incidence of serious skin lesions in leg amputees and has made it more readily possible to deal successfully with some of those that do occur, it is obvious that much work remains to be done. For the complete etiology of many of the characteristic disease states yet remains to be elucidated. It is to be hoped that the initiative taken by the pilot study group at the University of California may prove to be a stimulus for similar investigative work at other centers of medical research throughout the world. The lesson is here for us to learn. Unless skin problems can be eliminated once and for all, there can be no true rehabilitation of the lower-extremity amputee.</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>C. Leslie Mitchell, M.D. </b></td></tr><tr><td class="clsTextSmall">Surgeon-in-Charge, Division of Orthopaedic Surgery, Henry Ford Hospital, Detroit; member, Prosthetics Research Board, NAS-NRC.</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 Lesson In Lesions Creator An entity primarily responsible for making the resource C. Leslie Mitchell, M.D. * https://staging.drfop.org/files/original/c3460a2dab08b833441c25bf7385221d.pdf 07ff006625669bcbaab152e35ddbab6e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1982_02_007.pdf Text Any textual data included in the document <h2>Letter To The Editor: A Return To Research?</h2> <h5>A. Bennett Wilson, Jr.&nbsp;</h5> <p>Thirty-seven years ago, with funds from the United States Government, the National Academy of Sciences initiated a research and development program in artificial limbs because amputees in Army and Navy hospitals expressed quite vociferously their dissatisfaction with the artificial limbs provided at that time, and because there had never been, in this country, any concerted scientific effort to solve the problems of amputees. Although the research program, funded until the late 1950's largely by the Veterans Administration, was not looked upon with favor by many prosthetists during its early stages, with the help of a few of the more progressive prosthetists and orthopaedic surgeons sufficient progress was made by 1952 to warrant the initiation of a formal education project at the University of California at Los Angeles, which set the pattern for the present education program in prosthetics and orthotics.</p> <p>The Department of Health, Education, and Welfare, about 1955, joined the VA in supporting research, development, evaluation, and education; orthotics was added to the mission in the late 50's; and progress continued to the point that by the early 70's nearly every aspect of prosthetics had been replaced by newer techniques and devices, and work in orthotics was progressing rapidly. Although it was, and is, recognized by many that further, continuing research was needed, the government agencies have all but abandoned research and development in prosthetics and orthotics, and as a result very few improvements have been introduced to the practice of prosthetics and orthotics during the last few years.</p> <p>This unfortunate situation has been brought about because of a number of factors: the decision by the National Academy of Sciences to withdraw from the program; reorganization by the VA in 1973 that resulted in transferring research and development responsibility from the Prosthetic and Sensory Aids Service to general medical research, and to conduct most of the research and development in VA hospitals; and an unbelievable proliferation in all government agencies of "red tape" required in awarding contracts and grants.</p> <p>During these 37 years, the prosthetics and orthotics profession has become healthy and strong, in part because the research and development program has provided a teachable body of knowledge and an education program that has produced a group of practitioners who are capable of communicating effectively among themselves and with other groups.</p> <p>Given this set of circumstances, it seems reasonable that the prosthetists and orthotists in this country should consider taking responsibility for research, development, and evaluation, and relieve the government of most of the responsibility it has assumed in this area for the last 37 years. Certainly a program administered by AAOP-AOPA could be more efficient and more effective than one administered by the government. One way to finance this undertaking is to include in the price of each new prosthesis and orthosis an appropriate percentage of the price to be set aside for the research program. This sum would, of course, be a legitimate business expense.</p> <p>The coordination and "clearing-house" functions would reside in the National Office, and R&amp;D would be carried out in appropriate facilities and institutions. If properly managed such a program would have many obvious advantages, not the least of which would be improved patient care.</p> Page Number(s) 7 - 7 Year 1982 Volume 6 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Letter To The Editor: A Return To Research? Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr.  https://staging.drfop.org/files/original/2454e632e42420f5fbd9bce3b94c5d26.pdf 3fb2fc0e82bf0e81ff3b766417726825 https://staging.drfop.org/files/original/0fbb48cc7f8be2062a6ef1860380b1db.jpg 10f58f606d2826e85a8834bcf4ce1618 https://staging.drfop.org/files/original/390aa04ec4ca8747dd76e9b7bd7ee923.jpg a420b9510857f5050d953cc7c1dee1ba https://staging.drfop.org/files/original/d6c388c96a97ee0286d3f33bcc663dd9.jpg a71b2664ba6bc532c8b584aafd92456d https://staging.drfop.org/files/original/2cc3677702fc63277a84b78b31553d0f.jpg 6bf6d709cea5e41e4181f8eb491dc322 https://staging.drfop.org/files/original/05e2635a31f6705d8964743ef1ab1c97.jpg cc7ec1ecaa1920e120445f96e23716d0 https://staging.drfop.org/files/original/67b2a42098ed37709567c9cd073a9523.jpg bc01ac1ea334653d58fecdd6f5232991 https://staging.drfop.org/files/original/4c7372b87bbc2e39ea813a2106c92c3f.jpg e272ccb3f9305d4b903f02dcd80224a3 https://staging.drfop.org/files/original/8ff31674a51e9a5d98c2f2188c482daa.jpg 396fb37a1bb92c6bcb2510bb162e656d https://staging.drfop.org/files/original/5abdff87ef605569db6e6ab85ad9b943.jpg c0a32d7611423c170a7177848c2b005b https://staging.drfop.org/files/original/3ec5b5db0ac4ca86109c5997049d32cb.jpg 522c4216b81d5039e308af4c1224f86b https://staging.drfop.org/files/original/b1431bea1bd1d049787c1fa4eb76a711.jpg 0fb3c0624d8f212d8e80f17509fc503a https://staging.drfop.org/files/original/bfbeba79a2bad347ee410568ae691658.jpg 19e99f2f82038d2f139eb8f7e65cbab7 https://staging.drfop.org/files/original/31ae0055d196b577a378c7c29d9c0ca6.jpg f164e0fce76adab851b700520eec3f55 https://staging.drfop.org/files/original/ecf043f5da4a407762cbc21b2649ac2a.jpg db341d796ac5ee6990d6d22dd0553957 https://staging.drfop.org/files/original/157812260024af546d8310f288656a54.jpg 2305349ac4bfcc69d72d871d8b8ba666 https://staging.drfop.org/files/original/ba2062e98c97e0ad3402067cb4590bed.jpg b8fb3650cf8864acf85624db8ba24d54 https://staging.drfop.org/files/original/f85cd06ba61564a5b292b694411a6b82.jpg f9189a9e041000dbde0205ca6ef3c979 https://staging.drfop.org/files/original/300196424114c54c85384a83479a82f4.jpg 8964e11122634a6bea8dc3b70d105b17 https://staging.drfop.org/files/original/c00ea5fedee712bef421e1419159012f.jpg ad2e82f7a0a3b3ed35a29be5c8b4bee0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_02_001.pdf Year 1963 Volume 7 Issue 2 Page Number(s) 1 - 42 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Limb Prosthetics Today</h2> <h5>A. Bennett Wilson, Jr., B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>Loss of limb has been a problem as long as man has been in existence. Even some prehistoric men must have survived crushing injuries resulting in amputation, and certainly some children were born with congenitally deformed limbs with effects equivalent to those of amputation. In 1958 the Smithsonian Institution reported the discovery of a skull dating back about 45,000 years of a person who, it was deduced, must have been an arm amputee, because of the way his teeth had been used to compensate for lack of limb. Leg amputees must have compensated partly for their loss by the use of crude crutches and, in some instances, by the use of peg legs fashioned from forked sticks or tree branches (<b>Fig. 1</b> and <b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Mosaic from the Cathedral of Lescar, France, depicts an amputee supported at the knee by a wooden pylon. Some authorities place this in the Gallo-Roman era. From Putti, V., Historic Artificial Limbs, 1930. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Pen drawing of a fragment of antique vase unearthed near Paris in 1862 which shows a figure whose missing limb is replaced by a pylon with a forked end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The earliest known record of a prosthesis being used by man was made by the famous Greek historian, Herodotus. His classic "History," written about 484 B.C., contains the story of the Persian soldier, Hegistratus, who, when imprisoned in stocks by the enemy, escaped by cutting off part of his foot, and replaced it later with a wooden version.</p> <p>A number of ancient prostheses have been displayed in museums in various parts of the world. The oldest known is an artificial leg unearthed from a tomb in Capua in 1858, thought to have been made about 300 B.C., the period of the Samnite Wars. Constructed of copper and wood, the Capua leg was destroyed when the Museum of the Royal College of Surgeons was bombed during World War II. The Alt-Ruppin hand (<b>Fig. 3</b>), recovered along the Rhine River in 1863, and other artificial limbs of the 15th century are on display at the Stibbert Museum in Florence. Most of these ancient devices were the work of armorers. Made of iron, these early prostheses were used by knights to conceal loss of limbs as a result of battle, and a number of the warriors are reported to have returned successfully to their former occupation. Effective as they were for their intended use, these specialized devices could not have been of much use to any group other than the knights, and the civilian amputees for the most part must have had to rely upon the pylon and other makeshift prostheses.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Alt-Ruppin Hand (Circa 1400). The thumb is rigid; the fingers move in pairs and are sprung by the buttons at the base of the palm; the wrist is hinged. Putti, V., Chir. d. org. di movimento, 1924-25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the use of ligatures was set forth by Hippocrates, the practice was lost during the Dark Ages, and surgeons during that period and for centuries after stopped bleeding by either crushing the stump or dipping it in boiling oil. When Ambroise Pare, a surgeon in the French Army, reintroduced the use of ligatures in 1529, a new era for amputation surgery and prostheses began. Armed with a more successful technique, surgeons were more willing to employ amputation as a lifesaving measure and, indeed, the rate of survival must have been much higher. The practice of amputation received another impetus with the introduction of the tourniquet by Morel in 1674, and removal of limbs is said to have become the most common surgical procedure in Europe. This in turn led to an increase in interest in artificial limbs. Pare, as well as contributing much in the way of surgical procedures, devised a number of limb designs for his patients. His leg (<b>Fig. 4</b>) for amputation through the thigh is the first known to employ articulated joints. Another surgeon, Verduin, introduced in 1696 the first known limb for below-knee amputees that permitted freedom of the knee joint (<b>Fig. 5</b>), in concept much like the thigh-corset type of below-knee limb still used by many today. Yet, for reasons unknown, the Verduin prosthesis dropped from sight until it was reintroduced by Serre in 1826 and. until recently, was the most popular type of below-knee prosthesis used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Artificial leg invented by Ambroise Pare (middle sixteenth century). From Pare, A, Oeuvres Completes, Paris, 1840. From the copy in the National Library of Medicine. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Verduin Leg (1696). From MacDonald, J., Am. J. Surg., 1905. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After Pare's above-knee prosthesis, which was constructed of heavy metals, the next real advance seems to be the use of wood, introduced in 1800 by James Potts of London. Consisting of a wooden shank and socket, a steel knee joint, and an articulated foot, the Potts invention (<b>Fig. 6</b>) was equipped with artificial tendons connecting the knee and the ankle, thereby coordinating toe lift with knee flexion. It was made famous partly because it was used by the Marquis of Anglesea after he lost a leg at the Battle of Waterloo. Thus it came to be known as the Anglesea leg. With some modifications the Anglesea leg was introduced into the United States in 1839. Many refinements to the original design were incorporated by American limb fitters and in time the wooden above-knee leg became known as the "American leg."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anglesea Leg (1800). Below knee at left above knee at right. Knee, ankle, and foot are articulated. From Bigg, H. H.. Orthopraxy, 1877. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Civil War produced large numbers of amputees and consequently created a great interest in artificial limbs, no doubt inspired partly by the fact that the federal and state governments paid for limbs for amputees who had seen war service.</p> <p>J. E. Hanger, one of the first Southerners to lose a leg in the Civil War, replaced the cords in the so-called American leg with rubber bumpers about the ankle joint, a design used almost universally until rather recently. Many patents on artificial limbs were issued between the time of the Civil War and the turn of the century, but few of the designs seem to have had much lasting impact.</p> <p>During this period, with the availability of chloroform and ether as anesthetics, surgical procedures were greatly improved and more functional amputation stumps were produced by design rather than by fortuity.</p> <p>World War I stirred some interest in artificial limbs and amputation surgery but, because the American casualty list was relatively small, this interest soon waned and, because of the economic depression of the Thirties, some observers think, very little progress was made in the field of limb prosthetics between the two World Wars. Perhaps the most significant contributions were the doctrines set forth and emphasized by Haddan and Thomas, a prosthetist-surgeon team from Denver, that fit and alignment of the prosthesis were the most critical factors in the success of any limb and that much better end-results could be expected if prosthetists and physicians worked together.</p> <p>Early in 1945, the National Academy of Sciences, at the request of the Surgeon General of the Army, initiated a research program in prosthetics. The initial reaction of the research personnel was that the development of a few mechanical contrivances would solve the problem. However, it soon became evident that much more must be known about biomechanics and other matters before real progress could be made. Devices and techniques based on fundamental data have materially changed the practice of prosthetics during the past dozen years. However, the best conceivable prosthesis is but a poor substitute for a live limb of flesh and blood, and so the research program is still continuing. Fiscal support for research and development by some 20 laboratories is provided by the Veterans Administration, the Vocational Rehabilitation Administration, the National Institutes of Health, the Children's Bureau, the Army, and the Navy. The over-all program is coordinated by the Committee on Prosthetics Research and Development of the National Academy of Sciences-National Research Council.</p> <p>Soon after the close of World War II, the Artificial Limb Manufacturers Association, which had been formed during World War I, engaged the services of a professional staff to coordinate more effectively the efforts of individual prosthetists. Known today as the American Orthotics and Prosthetics Association, this organization consists of some 415 limb and brace shops, and plays a large part in keeping individual prosthetists and orthotists advised of the latest trends and developments in prosthetics and orthotics.</p> <p>In 1949, upon the recommendation of the Association, the American Board for Certification of Prosthetists and Orthotists was established to ensure that prosthetists and orthotists met certain standards of excellence, much in the manner that certain physicians' specialty associations are conducted. Examinations are held annually for those desiring to be certified. In addition to certifying individuals as being qualified to practice, the American Board for Certification approves individual shops, or facilities, as being satisfactory to serve the needs of amputees and other categories of the disabled requiring mechanical aids. Certified prosthetists wear badges and shops display the symbol of certification (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Symbol of certification by the American Board for Certification in Orthotics and Prosthetics. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The research program, with the cooperation of the prosthetists, has introduced a sufficient number of new devices and techniques to modify virtually every aspect of the practice of prosthetics. To reduce the time lag between research and widespread application, facilities have been established within the medical schools of three universities for short-term courses in special aspects of prosthetics. Courses are offered to each member of the prosthetics-clinic team-the physician, the therapist, and the prosthetist. Also, special courses are offered to vocational rehabilitation counselors and administrative personnel concerned with the welfare of amputees. Approximately 2,100 physicians, 1,900 therapists, and 1,400 prosthetists have been enrolled in these courses during the period 1953 through 1962.</p> <p>Prior to 1957 medical schools offered little in the way of training in prosthetics to doctors and therapists. To encourage the inclusion of prosthetics into medical and paramedical curricula, the National Academy of Sciences organized the Committee on Prosthetics Education and Information, and as a result of the efforts of this group many schools have adopted courses in prosthetics at both undergraduate and graduate levels.</p> <p>Today there are approximately 200 amputee-clinic teams in operation throughout the United States. Each state, with assistance from the Vocational Rehabilitation Administration, carries out programs that provide the devices and training required to return the amputee to gainful employment. The Children's Bureau, working through a number of states, has made it possible for child amputees to receive the benefit of the latest advances in prosthetics. The Veterans Administration provides all eligible veterans with artificial limbs. If the amputation is related to his military service, the beneficiary receives medical care and prostheses for the remainder of his life. The Public Health Service, through its hospitals, provides limbs and care to members of the Coast Guard and to qualified persons who have been engaged in the Maritime Service.</p> <p>In addition to these Government agencies that are concerned with the amputee, there are several hundred rehabilitation centers throughout the United States that assist amputees, especially those advanced in age, in obtaining the services needed for them to return to a more normal life.</p> <p>Thus, through the cooperative efforts of Government and private groups, considerable progress has been made in the practice of prosthetics and there is little need for an amputee to go without a prosthesis.</p> <h3>Reasons For Amputation</h3> <p>Amputation may be the result of an accident, or may be necessary as a lifesaving measure to arrest a disease. A small but significant percentage of individuals are born without a limb or limbs, or with defective limbs that require amputation or fitting (like that of an amputee).</p> <p>In some accidents a part or all of the limb may be completely removed; in other cases, the limb may be crushed to such an extent that it is impossible to restore sufficient blood supply necessary for healing. Sometimes broken bones cannot be made to heal, and amputation is necessary. Accidents that cause a disruption in the nervous system and paralysis in a limb may also be cause for amputation even though the limb itself is not injured. The object of amputation in such a case is to improve function by substituting an artificial limb for a completely useless though otherwise healthy member. Amputation of paralyzed limbs is not performed very often but has in some cases proven to be very beneficial. Accidents involving automobiles, farm machinery, and firearms seem to account for most traumatic amputations. Freezing, electrical burns, and power tools also account for many amputations.</p> <p>Diseases that may make amputation necessary fall into one of three main categories-vascular, or circulatory, disorders; cancer; and infection. The diseases that cause circulatory problems most often are arteriosclerosis, or hardening of the arteries, diabetes, and Buerger's disease. In these cases not enough blood circulates through the limb to permit body cells to replace themselves, and unless the limb, or part of it, is removed the patient cannot be expected to live very long. In nearly all these cases the leg is affected because it is the member of the body farthest from the heart and, in accordance with the principles of hydraulics, blood pressure in the leg is lower than in any other part of the bod}'. Vascular disorders are, of course, much more prevalent among older persons. Considerable research is being undertaken to determine the cause of vascular disorders so that amputation for these reasons may at least be reduced if not eliminated, but at the present time vascular disorders are the cause of a large number of lower-extremity amputations.</p> <p>In many cases amputation of part or all of a limb has arrested a malignant or cancerous condition. In view of present knowledge, the entire limb is usually removed. Malignancy may affect either the arms or legs. Much time and effort are being spent to develop cures for the various types of cancer.</p> <p>Since the introduction of antibiotic drugs, infection has been less and less the cause for amputation. Moreover, even though amputation may be necessary, control of the infection may allow the amputation to be performed at a lower level than would be the case otherwise.</p> <p>Recently, "thalidomide babies" have been given extensive press coverage; however, thalidomide is by no means the sole cause of congenital malformations. Absence of all or part of a limb at birth is not an uncommon occurrence. Many factors seem to be involved in such occurrences, but what these factors are is not clear. The most frequent case is absence of most of the left forearm, which occurs slightly more often in girls than in boys. However, all sorts of combinations occur, including complete absence of all four extremities. Sometimes intermediate parts such as the thigh or upper arm are missing but the other parts of the extremity are present, usually somewhat malformed. In such cases amputation may be indicated; however, even a weak, malformed part is sometimes worth preserving if sensation is present and the partial member is capable of controlling some part of the prosthesis. Extensive studies are being carried out to determine the reasons for congenital malformations.</p> <h3>Losses Incurred</h3> <p>Many of the limitations resulting from amputation are obvious; others less so. An amputation through the lower extremity makes standing and locomotion without the use of an artificial leg or crutches difficult and impracticable except for very short periods. Even when an artificial leg is used, the loss of joints and the surrounding tissues, and consequently loss of the ability to sense position, is felt keenly. The sense of touch of the absent portion is also lost, but in the case of the lower-extremity amputee this is not quite as important as it might seem because the varying pressure occurring between the stump and the socket indicates external loading. In the upper-extremity amputee, sense of touch is more important.</p> <p>Most lower-extremity amputees cannot bear the total weight of the body on the end of the stump, and other parts of the anatomy must be found for support.</p> <p>Muscles attached at each end to bones are responsible for movement of the arms and legs. Upon a signal from the nervous system muscle tissue will contract, thus producing a force which can move a bone about its joint (<b>Fig. 8</b>). Because muscle force can be produced only by contraction, each muscle group has an opposing muscle group so that movement in two directions can take place. This arrangement also permits a joint to be held stable in any one of a vast number of positions for relatively long periods of time. How much a muscle can contract is dependent upon its length, and the amount of force that can be generated is dependent upon its circumference.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Schematic drawing of muscular action on skeletal system. The motion shown here is flexion, or bending, of the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Muscles that activate the limbs must of course pass over at least one joint to provide a sort of pulley action; some pass over two. Thus, some muscles are known as one-joint muscles, others as twro-joint muscles. When muscles are severed completely, they can no longer transmit force to the bone and, when not used, wither away or atrophy. It will be seen later that these facts are very important in the rehabilitation of amputees.</p> <h3>Types of Amputation</h3> <p>Amputations are generally classified according to the level at which they are performed (<b>Fig. 9</b>). Some amputation levels are referred to by the name of the surgeon credited with developing the amputation technique used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Classification of amputation by level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Lower-Extremity Amputations</h4> <p><i>Syme's Amputation</i></p> <p>Developed about 1842 by James Syme, a leading Scottish surgeon, the Syme amputation leaves the long bones of the shank (the tibia and fibula) virtually intact, only a small portion at the very end being removed (<b>Fig. 10</b>). The tissues of the heel, which are ideally suited to withstand high pressures, are preserved, and this, in combination with the long bones, usually permits the patient to bear the full weight of his body on the end of the stump. Because the amputation stump is nearly as long as the unaffected limb, a person with Syme's amputation can usually get about the house without a prosthesis even though normal foot and ankle action has been lost. Atrophy of the severed muscles that were formerly attached to bones in the foot to provide ankle action results in a stump with a bulbous end which, though not of the most pleasing appearance, is quite an advantage in holding the prosthesis in place. Since its introduction, Syme's operation has been looked upon with both favor and disfavor among surgeons. It seems to be the consensus now that "the Syme" should be performed in preference to amputation at a higher level if possible. In the case of most women, though, "the Syme" is undesirable because of the difficulty of providing a prosthesis that matches the shape of the other leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Excellent Syme stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Below-Knee Amputations</i></p> <p>Any amputation above the Syme level and below the knee joint is known as a below-knee amputation. Because circulatory troubles have often developed in long below-knee stumps, and because the muscles that activate the shank are attached at a level close to the knee joint, the below-knee amputation is usually performed at the junction of the upper and middle third sections (<b>Fig. 11</b>). Thus nearly full use of the knee is retained- an important factor in obtaining a gait of nearly normal appearance. However, it is rare for a below-knee amputee to bear a significant amount of weight on the end of the stump; thus the design of prostheses must provide for weight-bearing through other areas. Several types of surgical procedures have been employed to obtain weight-bearing through the end of the below-knee stump, but none has found widespread use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical, well-formed, right below-knee stump. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Knee-Bearing Amputations</i></p> <p>Complete removal of the lower leg, or shank, is known as a knee disarticulation. When the operation is performed properly, the result is an efficient, though bulbous, stump (<b>Fig. 12</b>) capable of carrying the weight-bearing forces through the end. Unfortunately, the length causes some problems in providing an efficient prosthesis because the space used normally to house the mechanism needed to control the artificial shank properly is occupied by the end of the stump. Nevertheless, prostheses have been highly beneficial in knee-disarticulation cases. Development of adequate devices for obtaining control of the shank is currently under way, and such devices should be generally available in the near future.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Typical knee-disarticulation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Several amputation techniques have been devised in an attempt to overcome the problems posed by the length and shape of the true knee-disarticulation stump. The Gritti-Stokes procedure entails placing the kneecap, or patella, directly over the end of the femur after it has been cut off about two inches above the end. When the operation is performed properly, excellent results are obtained, but extreme skill and expert postsurgical care are required. Variations of the Gritti-Stokes amputation have been introduced from time to time but have never been used widely.</p> <p><i>Above-Knee Amputations</i></p> <p>Amputations through the thigh are among the most common (<b>Fig. 13</b>). Total body weight cannot be taken through the end of the stump but can be accommodated through the ischium, that part of the pelvis upon which a person normally sits.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical, well-formed above-knee stump. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Hip Disarticulation and Hemipelvectomy</i></p> <p>A true hip disarticulation (<b>Fig. 14</b>) involves removal of the entire femur, but whenever feasible the surgeon leaves as much of the upper portion of the femur as possible in order to provide additional stabilization between the prosthesis and the wearer, even though no additional function can be expected over the true hip disarticulation. Both types of stump are provided with the same type of prosthesis. With slight modification the same type of prosthesis can be used by the hemipelvectomy patient, that is, when half of the pelvis has been removed. It is surprising how well hip-disarticulation and hemipelvectomy patients have been able to function when fitted with the newer type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Patient with true hip-disarticulation amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Upper-Extremity Amputations</h4> <p><i>Partial-Hand Amputations</i></p> <p>If sensation is present the surgeon will save any functional part of the hand in lieu of disarticulation at the wrist. Any method of obtaining some form of grasp, or prehension, is preferable to the best prosthesis. If the result is unsightly, the stump can be covered with a plastic glove, lifelike in appearance, for those occasions when the wearer is willing to sacrifice function for appearance. Many prosthetists have developed special appliances for partial-hand amputations that permit more function than any of the artificial hands and hooks yet devised and, at the same time, permit the patient to make full use of the sensation remaining in the stump. Such devices are usually individually designed and fitted.</p> <p><i>Wrist Disarticulation</i></p> <p>Removal of the hand at the wrist joint was once condemned because it was thought to be too difficult to fit so as to yield more function than a shorter forearm stump. However, with plastic sockets based on anatomical and physiological principles, the wrist-disarticulation case can now be fitted so that most of the pronation-supination of the forearm-an important function of the upper extremity-can be used. In the case of the wrist disarticulation (<b>Fig. 15</b>), nearly all the normal forearm pronation-supination is present. Range of pronation-supination decreases rapidly as length of stump decreases; when 60 per cent of the forearm is lost, no pronation-supination is possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. A good wrist-disarticulation stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Amputations Through the Forearm</i></p> <p>Amputations through the forearm are commonly referred to as below-elbow amputations and are classified as long, short, and very short, depending upon the length of stump (<b>Fig. 9</b>). Stumps longer than 55 per cent of total forearm length are considered long, between 35 and 55 per cent as short, and less than 35 per cent as very short.</p> <p>Long stumps retain the rotation function in proportion to length; long and short stumps without complications possess full range of elbow motion and full power about the elbow, but often very short stumps are limited in both power and motion about the elbow. Devices and techniques have been developed to make full use of all functions remaining in the stump.</p> <p><i>Disarticulation at the Elbow</i></p> <p>Disarticulation at the elbow consists of removal of the forearm, resulting in a slightly bulbous stump (<b>Fig. 16</b>) but usually one with good end-weight-bearing characteristics. The long bulbous end, while presenting some fitting problems, permits good stability between socket and stump, and thus allows use of nearly all the rotation normally present in the upper arm-a function much appreciated by the amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Amputation through the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Above-Elbow Amputation</i></p> <p>Any amputation through the upper arm is generally referred to as an above-elbow amputation (<b>Fig. 9</b>). In practice, stumps in which less than 30 per cent of the humerus remains are treated as shoulder-disarticulation cases; those with more than 90 per cent of the humerus remaining are fitted as elbow-disarticu-lation cases.</p> <p><i>Shoulder Disarticulation and Forequarter Amputation</i></p> <p>Removal of the entire arm is known as shoulder disarticulation but, whenever feasible, the surgeon will leave intact as much of the humerus as possible to provide stability between the stump and the socket (<b>Fig. 17</b>). When it becomes necessary to remove the clavicle and scapula, the operation is known as a forequarter, or interscapulothoracic, amputation. The very short above-elbow, the shoulder-disarticulation, and the forequarter cases are all provided with essentially the same type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. A true shoulder disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Postsurgical Period</h3> <p>The period between the time of surgery and time of fitting the prosthesis is an important one if a good functional stump, and thus the most efficient use of a prosthesis, is to be obtained. The surgeon and others on his hospital staff will do everything possible to ensure the best results, but ideal results require the wholehearted cooperation of the patient.</p> <p>It is not unnatural for the patient to feel extremely depressed during the first few days after surgery, but after he becomes aware of the possibilities of recovery, the outlook becomes brighter, and he generally enters cooperatively into the rehabilitation phase.</p> <p>As soon as the stump has healed sufficiently, exercise of the stump is started in order to keep the muscles healthy and reduce the possibility of muscle contractures. Contractures can be prevented easily, but it is most difficult and sometimes impossible to correct them. At first exercises are administered by a therapist or nurse; later the patient is instructed concerning the type and amount of exercise that should be undertaken. The patient is also instructed in methods and amount of massage that should be given the stump to aid in the reduction of the stump size. Further, to aid shrinkage, cotton-elastic bandages are wrapped around the stump (<b>Fig. 18</b>) and worn continu- ously until a prosthesis is fitted. The bandage is removed and reapplied at regular intervals- four times during the day, and at bedtime. It is most important that a clean bandage is available for use each day.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Compression wrap for above-knee amputation. The wrap of elastic bandage aids in shrinking the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee is taught to apply the bandage unless it is physically impossible for him to do so, in which case some member of his family must be taught the proper method for use at home.</p> <p>To reduce the possibility of contractures, the lower-extremity stump must not be propped upon pillows. Wheel chairs should be used as little as possible; crutch walking is preferred, but the above-knee stump must not be allowed to rest on the crutch handle (<b>Fig. 19</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Actions to be avoided by lower-extremity amputees during the immediate postoperative period. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Phantom Sensation</h4> <p>After amputation the patient almost always has the sensation that the missing part is still present (<b>Fig. 20</b>). The exact cause of this is as yet unknown. The phantom sensation usually recedes to the point where it occurs only infrequently or disappears entirely, especially if a prosthesis is used. In a large percentage of cases, moderate pain may accompany the phantom sensation but, in general, this too eventually disappears entirely or occurs only infrequently. In a small percentage of cases severe phantom pain persists to the point where medical treatment is necessary.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. One form of the "phantom" sensation. Here the two toes seem to reside in the stump itself. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Time of Fitting</h4> <p>Surgeons increasingly have become aware that best results are obtained with artificial limbs when they are fitted as early as possible after surgery, that is, when pain and soreness have disappeared. This time will vary, depending upon type of amputation and condition of the patient. The earliest time is about six weeks after the operation. Below-knee stumps as a rule require a longer healing period than above-knee and upper-extremity stumps. An elderly patient whose legs have been amputated by reason of vascular insufficiency usually requires a longer healing period than an otherwise-healthy young person whose legs have been amputated as the result of an accident.</p> <h3>Prostheses for Various Types of Amputation</h3> <p>Much time and attention have been devoted to the development of mechanical components, such as knee and ankle units, for artificial limbs, yet by far the most important factors affecting the successful use of a prosthesis are the fit of the socket to the stump and the alignment of the various parts of the limb in relation to the stump and other parts of the body.</p> <p>Thus, though many parts of a prosthesis may be mass-produced, it is necessary for each limb to be assembled in correct alignment and fitted to the stump to meet the individual requirements of the intended user. To make and fit artificial limbs properly requires a complete understanding of anatomical and physiological principles and of mechanics; craftsmanship and artistic ability are also required.</p> <p>In general, an artificial limb should be as light as possible and still withstand the loads imposed upon it. In the United States willow and woods of similar characteristics have formed the basis of construction for more limbs than any other material, though aluminum, leather-and-steel combinations, and fibre have been used widely. Wood construction is still the type most used in the United States for above-knee prostheses, but plastic laminates similar to those so popular in small-boat construction are the materials of choice for virtually all other types of prostheses. Plastic laminates are light in weight, easy to keep clean, and do not absorb perspiration. They may be molded easily and rapidly over contours such as those found on a plaster model of a stump. Plastic laminates can be made extremely rigid or with any degree of flexibility required in artificial-limb construction. In some instances, especially in upper-extremity sockets, the fact that most plastic laminates do not permit water vapor to pass to the atmosphere has caused discomfort, but recently a porous type has been developed by the Army Medical Biomechanical Research Laboratory (formerly the Army Prosthetics Research Laboratory). Except experimentally, its use thus far has been restricted to artificial arms. Of course, most of the mechanical parts are made of steel or aluminum, depending upon their function.</p> <p>As in the case of the tailor making a suit, the first step in fabrication of a prosthesis is to take the necessary measurements for a good fit. If the socket is to be fabricated of a plastic laminate, an impression of the stump is made. Most often this is accomplished by wrapping the stump with a wet plaster-of-Paris bandage and allowing it to dry, as a physician does in applying a cast when a bone is broken (<b>Fig. 21</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Steps in the fabrication of a plastic prosthesis for a below-knee amputation. A, Taking the plaster cast of the stump; B, pouring plaster in the cast to obtain model of the stump; C, introducing plastic resin into fabric pulled over the model to form the plastic-laminate socket; D, the plastic-laminate socket mounted on an adjustable shank for walking trials; E, a wooden shank block inserted in place of the adjustable shank after proper alignment has been obtained; F, the prosthesis after the shank has been shaped. To reduce weight to a minimum the shank is hollowed out and the exterior covered with a plastic laminate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast, or wrap, is removed from the stump and filled with a plaster-of-Paris solution to form an exact model of the stump which-after being modified to provide relief for any tender spots, to ensure that weight will be taken in the proper places, and to take full advantage of the remaining musculature- can be used for molding a plastic-laminate socket. Often a "check" socket of cloth impregnated with beeswax is made over the model and tried on the stump to determine the correctness of the modifications.</p> <p>For upper-extremity cases the socket is attached to the rest of the prosthesis and a harness is fabricated and installed for operation of the various parts of the artificial arm. For the lower-extremity case the socket is fastened temporarily to an adjustable, or temporary, leg for walking trials (<b>Fig. 22</b>). With this device, the prosthetist can easily adjust the alignment until both he and the amputee are satisfied that the optimum arrangement has been reached. A prosthesis can now be made incorporating the same alignment achieved with the adjustable leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Using the above-knee adjustable leg and alignment duplication jig. Top, Adjusting the adjustable leg during walking trials; Center, the socket and adjustable leg in the alignment duplication jig; Bottom, replacement of the adjustable leg with a permanent knee and shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>There are many kinds of artificial limbs available for each type of amputation, and much has been written concerning the necessity for prescribing limbs to meet the needs of each individual. This of course is true particularly in the case of persons in special or arduous occupations, or with certain medical problems, but actually limbs for a given type of amputation vary to only a small degree. Following are descriptions of the artificial limbs most commonly used in the United States today.</p> <h4>Lower-Extremity Prostheses</h4> <p><i>Prostheses for Syme's Amputation</i></p> <p>Perhaps the major reason Syme's amputation was held in such disfavor in some quarters was the difficulty in providing a comfortable, sufficiently strong prosthesis with a neat appearance. The short distance between the end of the stump and the floor made it extremely difficult to provide for ankle motion needed. Most Syrae prostheses were of leather reinforced with steel side bars resulting in an ungainly appearance (<b>Fig. 23</b>). Research workers at the Prosthetic Services Centre at the Department of Veterans Affairs of Canada were quick to realize that the use of the proper plastic laminate might solve many of the problems long associated with the Syme prosthesis. After a good deal of experimentation, the Canadians developed a model in 1955 which, with a few variations, is used almost universally in both Canada and the United States today (<b>Fig. 24</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Syme prosthesis with side bars mounted on medial and lateral aspects of the shank. This type of construction has been virtually replaced by plastic laminates. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. The Syme prosthesis adopted by the Canadian Department of Veterans Affairs. The posterior opening extends the length of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Necessary ankle action is provided by making the heel of the foot of sponge rubber. The socket is made entirely of a plastic laminate. A full-length cutout in the rear permits entry of the bulbous stump. When the cutout is replaced and held in place by straps, the bulbous stump holds the prosthesis in place. In the American version (<b>Fig. 25</b>), a window-type cutout is used on the side because calculations show that smaller stress concentrations are present with such an arrangement.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Two views of the Canadian-type Syme prosthesis as modified bj the Veterans Administration Prosthetics Center, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In those cases where, for poor surgery or other reasons, full body weight cannot be tolerated on the end of the stump, provisions can be made to transfer all or part of the load to the area just below the kneecap. When this procedure is necessary, it can be accomplished more easily by use of the window-type cutout.</p> <p><i>Prostheses for Below-Knee Amputations</i></p> <p>Until recently most below-knee amputees were fitted with wooden prostheses carved out by hand (<b>Fig. 26</b>). A good portion of the body weight was carried on a leather thigh corset, or lacer, attached to the shank and socket by means of steel hinges. The shape of corset and upper hinges also held the prosthesis to the stump. The distal, or lower, end of the socket was invariably left open. Other versions of this prosthesis used aluminum, fibre or molded leather, as the materials for construction of the shank and socket, but the basic principle was the same. Many thousands of below-knee amputees have gotten along well with this type of prosthesis, but there are many disadvantages. Because the human knee joint is not a simple, single-axis hinge joint, relative motion is bound to occur between the prosthesis and the stump and thigh during knee motion when single-jointed side hinges are used, resulting in some chafing and irritation. To date it has not been possible to devise a hinge to overcome this difficulty. Edema, or accumulation of body fluids, was often present at the lower end of the stump. Most of these prostheses were exceedingly heavy, especially those made of wood.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Below-knee prosthesis with wood socket-shank, thigh corset, and steel side bars. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In an attempt to overcome these difficulties, the Biomechanics Laboratory of the University of California, in 1958, designed what is known as the patellar-tendon-bearing (PTB) below-knee prosthesis (<b>Fig. 27</b>). In the PTB prosthesis no lacer and side hinges are used, all of the weight being taken through the stump by making the socket high enough to cover all the tendon below the patella, or kneecap. The patellar tendon is an unusually inelastic tissue which is not unduly affected by pressure. The sides of the socket are also made much higher than has usually been the practice in the past in order to give stability against side loads. The socket is made of molded plastic laminate that provides an intimate fit over the entire area of the socket, and is lined with a thin layer of sponge rubber and leather. Because it is rare for a below-knee stump to bear much pressure on its lower end, care is taken to see that only a very slight amount is present in that area. This feature has been a big factor in eliminating the edema problem in many instances. The PTB prosthesis is generally suspended by means of a simple cuff, or strap, around the thigh just above the kneecap, but sometimes a strap from the prosthesis to a belt around the waist is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Cutaway view of the patellar-tendon-bearing leg for below-knee amputees. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the socket has been made, it is installed on a special adjustable leg (<b>Fig. 28</b>) so that the prosthetist can try various alignment combinations with ease. When both prosthetist and patient are satisfied, the leg is completed uti- lizing the alignment determined with the adjustable unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Trial below-knee adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The shank recommended is of plastic laminate and the foot prescribed is usually the SACH (solid-ankle, cushion-heel) design but other types can be used.</p> <p>It is now general practice in many areas to prescribe the PTB prosthesis in most new cases and in many old ones, and if side hinges and a corset are indicated later, these can be added.</p> <p>Stumps as short as 2-1/2 in. have been fitted successfully with the PTB prosthesis.</p> <p>In special cases, such as extreme flexion contracture, the so-called kneeling-knee, or bent-knee, prosthesis may be indicated. The prosthesis used is similar to that used for the knee-disarticulation case.</p> <p><i>Prostheses for the Knee-Disarticulation and Other Knee-Bearing Cases</i></p> <p>Because of the bulbous shape of the true knee-disarticulation stump, it is not possible to use a wooden socket of the type used on the tapered above-knee stump. To allow entry of the bulbous end, a socket is molded of leather to conform to the stump and is provided with a lengthwise anterior cutout that can be laced to hold the socket in position (<b>Fig. 29</b>). Because of the length of the knee-disarticulation and supracondylar stump, it is not possible to install any of the present knee units designed for above-knee prostheses and, therefore, heavy-duty below-knee joints are generally used. Most prosthetists try to provide some control of the shank during the swing phase of walking by inserting nylon washers between the mating surfaces of the joint to provide friction and by using checkstraps. Better devices for control of the knee joint are being developed and should be available in the near future.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Typical knee-disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Above-Knee Cases</i></p> <p>The articulated above-knee leg is in effect a compound pendulum actuated by the thigh stump. If the knee joint is perfectly free to rotate when force is applied, the effects of inertia and gravity tend to make the shank rotate too far backward and slam into extension as it rotates forward, except at a very slow rate of walking. The method most used today to permit an increase in walking speed is the introduction of some restraint in the form of mechanical friction about the knee joint. The limitation imposed by constant mechanical friction is that for each setting there is only one speed that produces a natural-appearing gait. When restraint is provided in the form of hydraulic resistance, a much wider range of cadence can be obtained without introducing into the gait pattern awkward and unnatural motions.</p> <p>Throughout the past century much time and effort have been spent in providing an automatic brake or lock at the knee in order to provide stability during the stance phase and to reduce the possibility of stumbling. Stability during the stance phase can be obtained by aligning the leg so that the axis of the knee is behind the hip and ankle axes. For most above-knee amputees in good health, such an arrangement has been quite satisfactory, but an automatic knee brake is indicated for the weaker or infirm patients.</p> <p>The prosthesis prescribed most commonly today for the above-knee amputee consists of a carved wooden socket, a single-axis knee unit with constant but adjustable friction, a wooden shank, and a SACH foot. The shank and socket are reinforced with an outer layer of plastic laminate to reduce the amount of wood required and thus keep weight to an optimum.</p> <p>When an automatic brake is indicated, the Bock, the "Vari-Gait" 100, and the Mortensen knee units (<b>Fig. 30</b>) are the ones most generally used. All are actuated upon contact of the heel with the ground. The Bock and "Vari-Gait" units can be used with almost any type of foot, while a foot of special design is necessary when the Mortensen mechanism is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Some examples of weight-actuated knee units. A, Bock "Safety-knee"; B, Vari-Gait knee; C, Morten-sen leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The "Hydra-Cadence" above-knee leg (<b>Fig. 31</b>) was until recently the only unit available that provided hydraulic friction to control the shank during the swing phase of walking. In addition to this feature, incorporated in the Hydra-Cadence design is provision for coordinated motion between the ankle action and the knee action. After the knee has flexed 20 deg., the toe of the foot is lifted as the knee is flexed further, thus giving more clearance between the foot and the ground as the leg swings through. Other hydraulic units recently made available are the Regnell (a Swedish design) and the DuPaCo. Still others are in advanced stages of development.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. The Hydra-Cadence Leg without cosmetic cover. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of methods for suspending the above-knee leg are available. For younger, healthy patients, the suction socket (<b>Fig. 32</b>A) is generally the method of choice. In this design the socket is simply fitted tightly enough to retain sufficient negative pressure, or suction, between the stump and the bottom of the socket when the leg is off the ground. Special valves are used to control the amount of negative pressure created so as not to cause discomfort. No stump sock is worn with the suction socket. A major advantage of this type of suspension is the freedom of motion permitted the wearer, thus allowing the use of all the remaining musculature of the stump. Another important advantage is the decreased amount of piston action between stump and socket. Additional comfort is also obtained by elimination of all straps and belts.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Above-knee sockets and methods of suspension. A, Total-contact suction socket; B, above-knee leg with Silesian bandage for suspension; C, above-knee leg with pelvic belt for suspension. Most above-knee sockets have a quadrilateral-shaped upper portion as shown. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In some cases additional suspension is provided by adding a "Silesian Bandage," (<b>Fig. 32</b>B), a light belt attached to the socket in such a way that there is very little restriction to motion of the various parts of the body.</p> <p>Patients with weak stumps and most of those with very short stumps will require a pelvic belt connected to the socket by means of a "hip" joint (<b>Fig. 32</b>C). Because the connecting joint cannot be placed to coincide with the normal joint, certain motions are restricted. Pelvic-belt suspension is generally indicated for the older patient because of the problems encountered in donning the suction socket, especially that of bending over to remove the donning sock.</p> <p>Shoulder straps, at one time the standard method of suspending above-knee prostheses, are still sometimes indicated for the elderly patient.</p> <p>Prior to the introduction of the suction socket into the United States soon after the close of World War II, virtually all above-knee sockets had a conical-shaped interior and were known as plug fits, most of the weight being borne along the sides of the stump. Such a design does not permit the remaining musculature to perform to its full capabilities. In the development of the suction socket, a design known as the quadrilateral socket (<b>Fig. 32</b>) evolved, and now is virtually the standard for above-knee sockets regardless of the type of suspension used. When the pelvic belt or suspender straps are used, the socket is fitted somewhat looser than in the case of the suction socket, and the stump sock is generally worn to reduce skin irritation from the pumping action of the loose socket. Most of the body weight is taken on the ischium of the pelvis, that part which assumes the load when an individual is sitting.</p> <p>The quadrilateral socket, because of the method employed to permit full use of the remaining muscles, does not resemble the shape of the stump but, as the name implies, is more rectangular in shape. Until recently the standard method of fitting a quadrilateral socket called for no contact over the lower end of the stump, a hollow space being left in this area. Although this method was quite successful there remained a sufficient number of cases that persistently developed ulcers or edema over the end of the stump. Experiments involving the use of slight pressure over the stump-end led to the development of what is known as the plastic total-contact socket (<b>Fig. 32</b>A). As the name implies, the socket is in contact with the entire surface of the stump. The total-contact socket has helped to cure most of the problem cases and is now being used routinely in many areas.</p> <p>In fitting the above-knee prosthesis, the prosthetist carves the interior of the socket using measurements of the stump as a guide. When a satisfactory fit has been achieved the socket is usually mounted on an adjustable leg for alignment trial, after which the wooden shank and the knee are substituted for the adjustable unit and the leg is finished by applying a thin layer of plastic laminate over the shank and the thigh piece.</p> <p>In the case of the total-contact socket, the prosthetist obtains a plaster cast of the stump, usually with the aid of a special casting jig (<b>Fig. 33</b>), and thus obtains a model of the stump over which the plastic socket can be formed.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. Special jig developed by the Veterans Administration Prosthetics Center to facilitate casting above-knee stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Hip-Disarticulation and Hemi-pelveclomy Cases</i></p> <p>A prosthesis (<b>Fig. 34</b>) developed by the Canadian Department of Veterans Affairs in 1954 and modified slightly through the years has become accepted as standard practice. In the Canadian design a plastic-laminate socket is used, and the "hip" joint is placed on the front surface in such a position that, when used with an elastic strap connecting the rear end of the socket to a point on the shank ahead of the femur, stability during standing and walking can be achieved without the use of a lock at the hip joint. The location of the hip joint in the Canadian design also facilitates sitting, a real problem in earlier designs.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. Hip-disarticulation prosthesis, known as the Canadian-type because its principle was originally conceived by workers at the Department of Veterans Affairs of Canada. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A constant-friction knee unit is most often used with the hip-disarticulation prosthesis, but some prosthetists have reported successful use of hydraulic knee units.</p> <p>The hemipelvectomy patient is provided with the same type of prosthesis but the socket design is altered to allow for the loss of part of the pelvis.</p> <h4>Upper-Extremity Prostheses</h4> <p>The major role of the human arm is to place the hand where it can function and to transport objects held in the hand. The energy for operation of the hand substitute in upper-extremity prostheses is derived from relative motion between two parts of the body. Energy for operation of the elbow joint, when necessary, can be obtained in the same way. The stump, of course, is also a source of energy for control of the prosthesis in all except the shoulder-disarticulation and fore-quarter cases. Force and motion can be obtained through a cable connected between the device to be operated and a harness across the chest or shoulders.</p> <p><i>Hand Substitutes-Terminal Devices</i></p> <p>All upper-extremity prostheses for amputation at the wrist level and above have, in common, the problem of selection of the terminal device, a term applied to artificial hands and substitute devices such as hooks. In some areas of the world there is a tendency to supply the arm amputee with a number of devices, each designed for a specific task such as eating, shaving, hairgrooming, etc. In the United States such an approach has been considered too clumsy, and opinion has been that the terminal device should be designed so that most upper-extremity amputees can perform the activities of daily living with a single device, or at most with two devices.</p> <p>The so-called split hooks are much more functional than any artificial hand devised to date. The arm amputee must rely heavily upon visual cues in handling objects and the hook offers more visibility. The hook also offers more prehension facility, and can be more easily introduced into and withdrawn from pockets than a device in the form of a hand. Therefore, the hook is used in manual occupations and those avocations requiring manual dexterity. When extensive contact with the public is necessary and for social occasions, the hand is of course generally preferred. Many amputees have both types of devices, using each as the occasion warrants. Two basic types of mechanism have been developed for terminal-device operation- voluntary-opening and voluntary-closing. In the former, tension on the control cable opens the fingers against an elastic force; in the latter, tension in the control cable closes the fingers against an elastic force. Each type of mechanism has its advantages and disadvantages, neither being superior to the other when used in a wide range of activities. Both hands and hooks are available with either type of mechanism.</p> <p>The major types of terminal devices are shown in <b>Fig. 35</b> and <b>Fig. 36</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Voluntary-closing terminal devices. A, APRL-Sierra Hand; left, cutaway view showing mechanism; right, assembled hand without cosmetic glove; B, APRL-Sierra Hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Voluntary-opening terminal devices. The wide range of models offered by the D. W. Dorrance Company includes sizes and designs for all ages. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Wrist-Disarticulation Case</i></p> <p>One of the problems in fitting the wrist disarticulation in the past has been to keep the over-all length of the prosthesis commensurate with the normal arm. The development of very short wrist units, especially for wrist-disarticulation cases, has materially reduced this problem. However, these units are available in only the screw, or thread, type, and cannot be obtained in the bayonet type which lends itself to quick interchange of terminal devices.</p> <p>The socket for the wrist-disarticulation case need not extend the full length of the forearm and is fitted somewhat loosely at the upper, or proximal, end to permit the wrist to rotate. A simple figure-eight harness and Bowden cable are used to operate the terminal device <b>Fig. 37</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Typical methods of fitting below-elbow amputees with medium to long stumps. Above, the figure-eight, ring-type harness is most generally used Where possible flexible leather hinges and open biceps cuff or pad are used. When more stability between socket and stump is required, rigid (metal) hinges and closed cuffs can be used (inserts A and B). In insert C, fabric straps are used for suspension in lieu of a leather billet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Long Below-Elbow Case</i></p> <p>The prosthesis for the long below-elbow case is essentially the same as that for the wrist-disarticulation patient except that the quick-disconnect wrist unit can be used when desired.</p> <p><i>Prostheses for the Short Below-Elbow Case</i></p> <p>The socket for the short below-elbow stump, where there is no residual rotation of the forearm, is usually fitted snugly to the entire slump, and often rigid hinges connecting the socket to a cuff about the upper arm are used to provide additional stability. Either the figure-eight harness or the chest-strap harness may be used, the latter being preferred when heavy-duty work is required since it tends to spread the loads involved in lifting over a broader area than is the case with the figure-eight design.</p> <p>A wrist-flexion unit, which permits the terminal device to be tilted in toward the body for more effective use, can be provided in the short below-elbow prosthesis but is seldom prescribed for unilateral cases.</p> <p><i>Prostheses for the Very Short Below-Elbow Case</i></p> <p>Often the very short below-elbow case cannot control the prosthesis of the short below-elbow type through the full range of motion, either because of a muscle contracture or because the stump is too short to provide the necessary leverage.</p> <p>When a contracture is present that limits the range of motion of the stump, a "split-socket" and "step-up" hinge may be used. With this arrangement of levers and gears, movement of the stump through one degree causes the prosthetic forearm to move through two degrees; thus, a stump that has only about half the normal range of motion can drive the forearm through the desired 135 deg. However, when the step-up hinge is used, twice the normal force is required. When the stump is incapable of supplying the force required, it can be assisted by employing the "dual-control" harness wherein force in the terminal-device control cable is diverted to help lift the forearm. When the elbow stump is very short or has a very limited range of motion, an elbow lock operated by stump motion is employed to obtain elbow function.</p> <p>Recently a number of prosthetists have reported success in fitting very short below-elbow cases with an arm which is bent to give a certain amount of preflexion. This type of fitting, which was developed in Munster, West Germany, eliminates the necessity for using the rather clumsy step-up hinges and split socket, thus providing improved prosthetic control without a disadvantageous force feedback. Furthermore, the harness is not necessary for suspension of the prosthesis. The maximum forearm flexion may be limited to about 100 deg., but this does not appear to be a significant disadvantage to unilateral amputees (<b>Fig. 38</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Comparison of split socket and Munster-type fitting of short below-elbow case. A, Split socket and step-up hinge provides 140 deg. of forearm flexion; B, Munster-type fitting permits less forearm flexion but enables the amputee to carry considerably greater weight with flexed prosthesis unsupported by harness. Courtesy New York University College of Engineering Prosthetic and Orthotic Research. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Elbow-Disarticulation Case</i></p> <p>Because of the length of the elbow-dis-articulation stump, the elbow-locking mechanism is installed on the outside of the socket. Otherwise the prosthesis and harnessing methods (<b>Fig. 39</b>) are identical to those applied to the above-elbow case.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Typical prosthesis for the elbow-disarticulation case. The chest-strap harness with shoulder saddle is shown here, but the above-elbow figure-eight is also used. See Figure 40. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for the Above-Elbow Case</i></p> <p>For the above-elbow prosthesis to operate efficiently, it is necessary that a lock be provided in the elbow joint, and it is, of course, preferable that the lock is engaged and disengaged without resorting to the use of the other hand or pressing the locking actuator against an external object such as a table or chair.</p> <p>Several elbow units that can be locked and unlocked alternately by the same motion are available. This action is usually accomplished by the relative motion between the prosthesis and the body when the shoulder is depressed slightly and the arm is extended somewhat. The motion required is so slight that with practice the amputee can accomplish the action without being noticed. These elbow units contain a turntable above the elbow axis that permits the forearm to be positioned with respect to the humerus, supplementing the normal rotation remaining in the upper arm and thus allowing the prosthesis to be used more easily close to the mid-line of the body.</p> <p>The elbow units described above are available with an adjustable coil spring to assist in flexing the elbow when this is desired. The flexion-assist device may be added or removed without affecting the other operating characteristics.</p> <p>The plastic socket of the above-elbow prosthesis covers the entire surface of the stump. The most popular harness used is the figure-eight dual-control design wherein the terminal-device control cable is also attached to a lever on the forearm so that, when the elbow is unlocked, tension in the control cable produces elbow flexion, and, when the elbow is locked, the control force is diverted to the terminal device (<b>Fig. 40</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Typical prosthesis for the above-elbow case. The figure-eight harness is shown here but the chest-strap harness with shoulder saddle may also be used. See Fig. 39. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The chest-strap harness may also be used in the dual-control configuration.</p> <p><i>Prostheses for the Shoulder-Disarticulation and Forequarter Cases</i></p> <p>Because of the loss of the upper-arm motion as a source of energy for control and operation of the prosthesis, restoration of the most vital functions in the shoulder-disarticulation case presents a formidable problem; for many years a prosthesis was provided for this type of amputation only for the sake of appearance. In recent years, however, it has been possible to make available prostheses which provide a limited amount of function (<b>Fig. 41</b>). To date it has not been possible to devise a shoulder joint that can be activated from a harness, but a number of manually operated joints are available. Various harness designs have been employed but, because of the wide variation in the individual cases and the marginal amount of energy available, no standard pattern has developed, each design being made to take full advantage of the remaining potential of the particular patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Typical prosthesis for the shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses for Bilateral Upper-Extremity Amputees</i></p> <p>Except for the bilateral, shoulder-disarticu-lation case, fitting the bilateral case offers few problems not encountered with the unilateral case. The prostheses provided are generally the same as those prescribed for corresponding levels in unilateral cases. Artificial hands are rarely used by bilateral amputees because hooks afford so much more function. Many bilateral cases find that the wrist-flexion unit, at least on one side, is of value. The harness for each prosthesis may be separated, but it is the general practice to combine the two (<b>Fig. 42</b>). In addition to being neater, this arrangement makes the harness easier for the patient to don unassisted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Harness for the bilateral below-elbow/ above-elbow case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some prosthetists have claimed success in fitting bilateral shoulder-disarticulation cases with two prostheses. Because of the lack of sufficient sources of energy for control, most cases of this type are provided with a single, functional prosthesis and a plastic cap over the opposite shoulder which provides an anchor for the harness and also fills this area to present a better appearance (<b>Fig. 43</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Special harness arrangement for the bilateral shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Learning to Use the Prosthesis</h3> <p>To derive maximum benefit from his prosthesis, the amputee must understand how it functions and learn the best means of controlling it. A patient may be of the opinion that he is getting along very well when, in reality, he could do much better. Use of the prosthesis can best be learned under the supervision of an instructor who has had special training.</p> <p>All amputees using an artificial limb for the first time will need some instruction. In some instances, when a prosthesis is replaced with one of a different design, special instruction will be required. The time required for training depends upon the complexity of the device and the physical condition and degree of coordination of the patient. The time required will vary from a few hours to several weeks. In many instances amputees themselves have become excellent trainers, but more often such training is given by physical or occupational therapists. Usually, physical therapists instruct lower-extremity patients and occupational therapists teach upper-extremity cases.</p> <p>During the period of instruction, the trainer is careful to observe any effects the use of the prosthesis has on the patient, especially at points where the prosthesis is in contact with the body. Any changes are reported immediately to the physician in charge.</p> <h4>Lower-Extremity Cases</h4> <p>One of the major goals in training the leg amputee is to enable him to walk as gracefully as possible. Training of the leg amputee is begun as soon as the clinic team is satisfied with fit and alignment, and preferably while the artificial leg is in an unfinished state, or "in the rough." Thus, should there be need for changes in alignment as training progresses, they can be made readily. Often training can be started on an adjustable leg.</p> <p>A patient with a Syme amputation needs a minimum of training. The average below-knee case will require somewhat more, though usually not extensive, unless other medical problems are present. The training required is usually quite extensive for patients who have lost the knee joint.</p> <p>The ability to balance oneself is the first prerequisite in learning to walk, and so it is balance that is taught first to the above-knee amputee. Two parallel railings are used to give the patient confidence and reduce the possibility of falling (<b>Fig. 44</b>). Balancing on both legs is practiced first, then on each leg. Walking in a straight line between the parallel bars is repeated until the patient no longer requires use of the hands for support. Walking in a straight line is practiced until the gait is even and smooth.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Above-knee patient being trained to walk by a physical therapist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a rhythmic gait has been accomplished, more difficult tasks are learned, such as pivoting, turning, negotiating stairs and ramps, and sitting on and arising from the floor.</p> <p>Most unilateral above-knee patients can use their prostheses quite well without the necessity for a cane. However, in the case of short, weak stumps it may be advisable to employ a cane for additional support and stability. If a cane is necessary, it should be selected to meet the needs of the patient, and it must be used properly if ungainly walking patterns are to be avoided. Canes with curved handles and made from a single piece of wood should be used. The shaft should not show any signs of buckling under the full load of the body weight, and should be just long enough so that the elbow is bent slightly when the bottom of the cane rests near the foot. The cane is used on the side opposite the amputation to help maintain balance but is not used to the extent that body weight is centered between the good leg and the cane (<b>Fig. 45</b>). Continued use of the cane in this manner usually results in a limp that is difficult to overcome. It has been found that, for bio-mechanical reasons, it is helpful for the amputee to carry a briefcase or purse on the side of the amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Above-knee patient being taught correct use of cane. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Training the Hip-Disarticulation Cases</i></p> <p>The training of hip-disarticulation cases follows much the same pattern as that for above-knee cases. With the advent of the Canadian-type prosthesis, the training procedure has been considerably simplified. Some special precautions must be taken to avoid stumbling while ascending stairs.</p> <p><i>Special Considerations for Bilateral Leg Cases</i></p> <p>As would be expected, bilateral-leg cases pose special problems in addition to those of the unilateral cases and, therefore, a good deal of time will usually be required in training. Patients with two good below-knee stumps will seldom require canes. Some bilateral above-knee amputees can get along without canes, but as a general rule at least one cane is required.</p> <h4>Upper-Extremity Cases</h4> <p>The first objective in the training program for upper-extremity amputees is to ensure that the patient can perform the activities encountered in daily living, such as eating, grooming, and toilet care. When this goal has been attained, attention is devoted to any special training that might be required in vocational pursuits (<b>Fig. 46</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Upper-extremity amputees performing vocational tasks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before the prosthesis is put to useful purposes, the patient is shown how the various mechanisms are controlled and is made to practice these motions until they can be performed in a graceful manner and without undue exertion. In general, the arm amputee soon becomes so adept in these procedures that they are carried out without conscious thought. During this period, the functioning of the prosthesis, especially of the harness and control cables, is watched carefully by the instructor and constantly rechecked to ensure maximum performance.</p> <p>Only when the patient has mastered use of the various controls is practice in the handling of objects and the performance of activities of daily living undertaken.</p> <h3>Care of the Stump</h3> <p>Even under the most ideal circumstances the amputation stump, when called upon to operate a prosthesis, is subjected to certain abnormal conditions which, if not compensated for, may lead to physical disorders which make the use of a prosthesis impossible.</p> <p>Lack of ventilation as a result of encasing the stump in a socket with impervious walls causes an accumulation of perspiration and other secretions of glands found in the skin. In addition to the solid matter in the secretions, bacteria will accumulate in the course of a day. Both the solid matter and bacteria can lead to infection, and the solid matter, though it may appear to be insignificant, may result in abrasions and the formation of cysts. For these reasons cleanliness of the stump and anything that comes in contact with it for any length of time is of the utmost importance, even when sockets of the newer porous plastic laminate are used.</p> <p>The stump, therefore, should be washed thoroughly each day, preferably just before retiring. A soap or detergent containing hexa-chlorophene, a bacteriostatic agent, is recommended, but strong disinfectants are to be avoided. To be fully effective, the bacteriostatic agent must be used daily. Some six or seven daily applications are necessary before full effectiveness is obtained, and any cessation of this routine lowers the agent's ability to combat the bacteria. A physician who is himself an amputee has suggested that after an amputee takes a bath, the stump should be dried first in order to minimize the risk of introducing infection to it by the towel.</p> <p>When the prosthesis is used without a stump sock, the stump should be thoroughly dry as moisture may cause swelling that will result in rubbing and irritation. For such cases, it is especially desirable for the stump to be cleansed in the evening.</p> <p>The stump sock should receive the same meticulous care as the stump. The socks should be changed daily and washed as soon as they are taken off. In this way the perspiration salts and other residue are easier to remove. A mild soap and warm water are used to keep shrinkage to a minimum. Woolite (a cold-water soap) and cold water in recent trials have given excellent results. A rubber ball inserted in the "toe" during the drying process ensures retention of shape.</p> <p>Elastic bandages should be washed daily in the same manner as stump socks, but should not be hung up to dry; rather they should be laid out on a flat surface away from excessive heat and out of the direct rays of the sun. Hanging places unnecessary stresses on the elastic threads, and heat and sunlight accelerate deterioration.</p> <p>It is of the utmost importance that any skin disorder of the stump-no matter how slight- receive prompt attention, because such disorders can rapidly worsen and become disabling. The amputee should see a physician for treatment. He should also see his pros-thetist; it may be that adjustment of the prosthesis will eliminate the cause of the disorder. In no case should iodine or any other strong disinfectant be used on the skin of the stump.</p> <p>Sometimes the skin of the stump is rubbed raw by socket friction. When this happens, the skin should be gently washed with a mild toilet soap. After the stump has been rinsed and dried, Bacitracin ointment, or some other mild antiseptic, should be applied, and the area covered with sterile gauze. The prosthesis should be completely dry before it is put on. If such abrasions occur frequently, the pros-thetist should be informed. If there is the slightest sign of infection, the amputee should see a physician.</p> <p>Small painless blisters should not be opened; they should be washed gently with a mild soap and left alone. Large, painful blisters should be treated by a physician.</p> <h4>Bandaging the Stump</h4> <p>The stump is usually kept wrapped in an elastic bandage from the time healing permits until the time the prosthesis is delivered. Also, bandaging is recommended when for some reason it is impracticable or impossible for the patient to wear his limb routinely. It is there- fore highly desirable for the amputee, or at least one member of his family, to be able to apply the bandages. Many amputees can wrap their stumps unaided and, indeed, prefer to do so. Others prefer and, in some instances, require the help of another person.</p> <p>Recommended methods for applying elastic bandages for below-knee, above-knee, below-elbow and above-elbow patients are shown in <b>Fig. 47</b>, <b>Fig. 48</b>, and <b>Fig. 49</b>, respectively. These illustrations first appeared in a booklet entitled "Industrial Amputee Rehabilitation," prepared by Dr. C. O). Bechtol under the sponsorship of Liberty Mutual Insurance Co. of Boston.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Recommended method of applying elastic bandage to the below-knee stump. The bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Recommended method of applying elastic bandage to the above-knee stump. The stump is kept in a relaxed position, and the bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Elastic bandages applied properly to upper-extremity stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Care of the Prosthesis</h3> <p>In addition to the care required in keeping the inside of the socket clean, which has been stressed, best results can be obtained only if the prosthesis is maintained in the best operating condition. Like all mechanical devices, artificial limbs can be expected to receive wear and be discarded for a new device, but the length of useful life can be extended materially if reasonable care is taken in its use. An example often quoted is that of two identical automobiles. The car given the maintenance recommended by the manufacturer and operated with care will outlast many times the vehicle given spotty maintenance and operated with disregard for the heavy stresses imposed. So it is with artificial limbs. Some amputees require a new prosthesis every few years, or even more often, while others who follow the manufacturer's instructions, apply preventive maintenance practices, and have minor problems corrected without delay, have received satisfactory service from their limbs for periods as long as twenty years.</p> <p>Manufacturers' instructions vary with the design of the device. They consist mainly of lubrication practices and should be followed closely. Too much lubricant can sometimes produce conditions as troublesome as excessive wear. Looseness of joints and fastenings should be corrected as soon as it is detected, for the wear rate increases rapidly under such a condition. Any cracks that appear in supporting structures should be reinforced immediately in order to avoid complete failure and the necessity for replacement. The foot should be examined weekly for signs of excessive wear.</p> <p>A point often overlooked by leg amputees, but nevertheless one of the factors affecting optimum use of the artificial limb, is the condition of the shoe. Badly worn or improper shoes can have adverse effects on the stability and gait of the wearer. This is a matter that requires especially close attention in the case of child amputees.</p> <p>Hooks and artificial hands should be treated with the same care that the normal hand is given. Because the sensation of feeling is absent in the terminal device, the upper-extremity amputee is all too prone to use hooks to pry and hammer and to handle hot objects that are deleterious to the hook materials. Hands with cosmetic gloves should be washed daily, and of course hot objects and staining materials should be avoided.</p> <h3>Special Considerations in Treatment of Child Amputees</h3> <p>Only a few years ago it was seldom that a child amputee was fitted with a prosthesis before school age and often not until much later. In recent years experience has shown that fitting at a much earlier age produces more effective results.</p> <p>If there are no complicating factors, children with arm amputations usually should be provided with a passive type of prosthesis soon after they are able to sit alone, which is generally at about six months of age. Certain gross two-handed activities are thus made possible, crawling is facilitated, the child becomes accustomed to using and wearing the prosthesis, and moves easily into using a body-operated prosthesis as his coordination develops soon after his second birthday.</p> <p>Lower-extremity child amputees should be fitted with prostheses as soon as they show signs of wanting to stand. The development of muscular coordination of child amputees is the same as for nonhandicapped children and, therefore, this phase may take place as early as eight months or as late as 20 or more months.</p> <p>Children, especially when fitted at an early age, almost always adapt readily to prostheses. As the child grows, the artificial limb seems to become a part of him in a manner seldom seen in adults (<b>Fig. 50</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Children with upper-extremity amputations performing two-handed activities. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Except for the very young, children's prostheses follow much the same design as those for the adult group. Special devices and techniques have been developed for initial fitting of infants and problem cases.</p> <p>Regardless of where the child amputee resides, or the extent of his parents' financial resources, he need not go without the treatment and prostheses required to make full use of his potentials. To ensure that such services are available, the Children's Bureau of the De-partment of Health, Education, and Welfare has assisted a number of states in establishing well-organized child-amputee clinics, and the facilities of these states are available to residents of states where such specialized services are not to be had. There is an agency in each slate that can advise the parents of the proper course of action.</p> <p>Most children can be treated on an outpatient basis, but for the more severely handicapped many of the clinics have facilities for in-patient treatment. The clinic team for children is often augmented by a pediatrician and a social worker, and sometimes by a psychologist.</p> <p>Training very young children is one of the most difficult problems of the clinic team. Although the learning ability of young children may be rapid, their attention span is of such short duration that extreme patience is required. Regardless of the ability of the therapist, successful results cannot be achieved without complete cooperation of the parents. The mental attitude of the parents is reflected in the child, and all too often children have rejected prostheses because the parents, consciously or subconsciously, could not accept the fact that a prosthesis was needed. Parents of children born with a missing or deformed limb often experience a sense of guilt, a feeling that only adds to an already difficult problem. The guilt feeling is unwarranted, inasmuch as the knowledge of the causes of congenital defects -and appropriate preventive measures- is very limited. The recent discovery of the effects of thalidomide suggests that other causes may be found.</p> <p>As a rule, lower-extremity amputees present fewer problems than the upper-extremity cases. It is natural for the child to walk, and almost invariably the lower-extremity patient adapts rather quickly. Parents, however, should keep close observation of the walking habits of the child, the condition of his stump, and the state of repair of his prosthesis, and above all they should present the child before the clinic at the recommended times. A gradual change in walking habit may indicate that the child has outgrown the prosthesis or that excessive wear of the prosthesis has taken place. Any unusual appearance of the stump should be reported to the physician immediately so that remedial steps may be taken, thereby avoiding more complicated medical problems at a later date. Children give a prosthesis more wear and tear than do adults and it is important that the prosthesis be examined carefully at regular intervals and needed repairs made as soon as possible-not only to ensure the safety of the child but to avoid the necessity for major repairs at a later date.</p> <p>Many upper-extremity child amputees adapt readily to artificial arms-some even want to sleep with the arm in place-but in many cases the child will need a great deal of encouragement before he will accept the device and make use of it. At first the unilateral amputee may feel that the prosthesis is a deterrent rather than an aid, but with the proper encouragement this feeling is reversed.</p> <p>Parents can help by continuing the training given in the clinics. From the beginning the artificial arm should be worn as much as possible. Young children should be given toys that require two hands for use and older children should be given household chores that require two-handed activities. In the latter case not only does the child learn to appreciate the usefulness of the prosthesis, but he also gains a feeling of being a useful member of the family and thus a better mental attitude is created.</p> <p>The child amputee should not be sheltered from the outside world but encouraged to associate with other children and, to the extent that he can, to take part in their activities. Of course there are certain limitations, but the number of activities that can be performed with presently available prostheses is amazing. It goes almost without saying that the child should receive no more special attention than is necessary, and should be made to perform the activities of daily living of which he is capable.</p> <p>It has been shown that it is preferable for the child amputee to attend a regular school rather than one for the handicapped. Most child amputees can and do take their place in society and the transition from school to work is much easier if they are not shown unnecessary special consideration. Nonhandicapped children soon accept the amputee and make little comment after the initial reaction.</p> <p>Here again the arm amputee is apt to be faced with the most problems. Some public school officials have hesitated to admit arm amputees wearing hooks for fear that the child may use them as weapons. This attitude is unrealistic. If such incidents have occurred, they are rare indeed. However, arm prostheses should be removed when the child is engaged in body-contact sports such as football.</p> <p>Cleanliness of the stump, prosthesis, and stump sock is just as important for children as for adults. The same procedures as those outlined on pages 35-36 are recommended.</p> <h3>Special Considerations in the Treatment of Elderly Patients</h3> <p>Persons who have had amputations during youth or middle age seldom encounter additional problems in wearing their prostheses as they become older. However, for those patients who have an amputation in later life many unusual problems are apt to be present. Most amputations in elderly patients are necessary because of circulatory problems, almost always affecting the lower extremity. For many years the wisdom of fitting such patients with prostheses was debatable, the thought being that the remaining leg, which in most cases was subject to the same circulatory problems as the one removed, would be overtaxed and thus the need for its removal would be hastened. Energy studies in recent years have shown that crutch-walking is more taxing than use of an artificial limb. Experience with rather large numbers of elderly leg amputees has shown that failure of the remaining leg has not been accelerated by use of a prosthesis, and stumps that have been fitted properly have not been troublesome. As a result more and more elderly patients are benefiting by the use of artificial limbs. A rule of thumb used in some clinics to decide whether or not to fit the elderly patient is that if he can master crutch-walking he should be fitted. This measure should be used with discretion because in some instances patients who could not meet the crutch-walking requirement have become successful wearers of prostheses.</p> <p>Most clinic teams feel that if the patient can use the prosthesis to make him somewhat independent around the house, the effort is fully warranted.</p> <p>Artificial legs for the older patients, as a rule, should be as light as possible. Except for the most active patients, only a small amount of friction is needed at the knee for control of the shank during the swing phase of walking because the gait is apt to be slow. Suction sockets are rarely indicated because of the effort required in donning them. A quadrilateral-shaped socket is used with one stump sock and a pelvic belt. Silesian bandages have been used successfully, allowing more freedom of motion and increased comfort.</p> <p>For the elderly below-knee cases, the patellar-tendon-bearing prosthesis is being used quite successfully.</p> <h3>Cineplasty</h3> <p>In 1896 the Italian surgeon, Vanghetti, conceived the idea of connecting the control mechanism of a prosthesis directly to a muscle. Several ideas involving the formation of a club-like end or a loop of tendon in the end of a stump muscle were tried out in Italy. Just prior to World War I the German surgeon, Sauerbruch, devised a method of producing a skin-lined tunnel through the belly of the muscle. A pin through the tunnel was attached to a control cable, and thus energy for operation of the prosthesis was transferred directly from a muscle group to the control mechanism. With refinements the Sauerbruch method is available for use today, but it must be used cautiously.</p> <p>Although tunnels have been tried in many muscle groups, the below-elbow amputee is the only type that can be said to benefit truly from the cineplasty procedure. A tunnel properly constructed through the biceps can supply power for operation of a hand or hook, and there need be no harnessing above the level of the tunnel. Thus, the patient is not restricted by a harness and the terminal device can be operated with the stump in any position. Training the tunneled muscle and care of the tunnel require a great deal of work by the patient; thus if the cineplasty procedure is to be successful the patient must be highly motivated.</p> <p>Some female below-elbow amputees have been highly pleased with results from a biceps tunnel, but as a rule cineplasty does not appeal to women.</p> <p>Cineplasty is not indicated for children. Sufficient energy is not available for proper operation of the prosthesis and the effects of growth on the tunnel are not known.</p> <p>Tunnels have been tried in the forearm muscles but the size of these muscles is such that the energy requirements for prosthesis operation are rarely met. While tunnels in the pectoral muscle are capable of developing great power, in the light of present knowledge the disadvantages tend to outweigh the advantages. It is extremely difficult to harness effectively the energy generated, and very little, if any, of the harness can be eliminated. It is true that an additional source of control can be created, but with the devices presently available little use can be made of this feature.</p> <p>No application for cineplasty has been found in lower-extremity amputation cases.</p> <p>Still another type of cineplasty procedure is the Krukenberg operation, whereby the two bones in the forearm stump are separated and lined with skin to produce a lobster-like claw. The result, though rather gruesome in appearance, permits the patient to grasp and handle objects without the necessity of a prosthesis. Because sensation is present, the Krukenberg procedure has been found to be most useful for blind bilateral amputees. Although prostheses can be used with Krukenberg stumps when appearance is a factor, the operation has found little favor in the United States.</p> <h3>Agencies That Assist Amputees</h3> <p>For several centuries at least, governments have traditionally cared for military personnel who received amputations in the course of their duties. But only in recent years, except in isolated cases, has the amputee in civilian life had much assistance in making a comeback. Today there are available services to meet the needs of every category of amputee. Aside from the humanitarian aspects of such programs, it has been found to be good business to return the amputee to productive employment and, in the case of some of the more debilitated, to provide them with devices and training to take care of themselves.</p> <p>The Armed Services provide limbs for mili- tary personnel who receive amputations while on active duty, and many of these cases are returned to active duty. After the patient has been discharged from military service, the Veterans Administration assumes responsibility for his medical care and prosthesis replacement for the remainder of his life. The U. S. Public Health Service, through its Marine Hospitals, cares for the prosthetics needs of members of the U. S. Maritime Service.</p> <p>Each state provides some sort of service for child amputees. If sufficient facilities are not available within a state, provisions can be made for treatment in one of the regional centers set up in a number of states with the help and encouragement of the Children's Bureau of the Department of Health, Education, and Welfare. With assistance from the Vocational Rehabilitation Administration of the Department of Health, Education, and Welfare, every state operates a vocational rehabilitation program designed to help the amputee return to gainful employment. Recently some of these programs have been extended to render assistance to housewives and the elderly as well.</p> <p>Private rehabilitation centers, almost universally nonprofit and sponsored largely by voluntary organizations, greatly augment the state and federal programs.</p> <p>Information concerning rehabilitation centers serving a particular area may be obtained from the Association of Rehabilitation Centers, Inc., 828 Davis Street, Evanston, Ill.</p> <p><b>References:</b></p> <ol> <li>Alldredge, R. H., <i>Amputations and prostheses</i>, Chapter 12 in <i>Christopher's Textbook of surgery</i>, 5th ed., W. B. Saunders Co., Philadelphia, 1949.</li> <li>American Academy of Orthopaedic Surgeons, <i>Orthopaedic appliances atlas</i>, vol. 2, Artificial Limbs, J. W. Edwards, Ann Arbor, Michigan, 1960.</li> <li>Batch, Joseph W., August W. Spittler and James G. McFaddin, <i>Advantages of the knee disarticulation over amputations through the thigh</i>, J. Bone and Joint Surg., Boston, 36A. :921-930, October 1954.</li> <li>Brunnstrom, Signe, <i>The lower extremity amputee</i>, in Bierman and Licht's <i>Physical medicine in general practice</i>, Hoeber-Harper, New York, 1952</li> <li>DeLorme, Thomas, Progressive resistive exercise, Appleton and Co., New York, 1951.</li> <li>Eisert, Otto and O. W. Tester, <i>Dynamic exercises for lower extremity amputees</i>, Arch. Phys. Med. and Rehab., 25:11, November 1954.</li> <li>Gillis, Leon, <i>Artificial limbs</i>, Pitman Medical Publishing Co., Ltd., London, 1957.</li> <li>Hitchcock, William E., <i>Notes on the diagnosis and treatment of above-knee fitting problems</i>, Prosthetics Education, Post-Graduate Medical School, New York University, New York, August 1957.</li> <li>Kerr, Donald and Signe Brunnstrom, <i>Training of the lower-extremity amputee</i>, ed. Charles C Thomas, Springfield, Ill., 1956.</li> <li>Klopsteg, Paul E., Philip D. Wilson, et al, <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>MacDonald, J., Jr., <i>History of artificial limbs</i>, Am. J. Surg., 19:76-80, 1905.</li> <li>Motis, G. M., <i>Final report on artificial arm and leg research and development</i>, Northrop Aircraft, Inc., Hawthorne, Calif., Final report to the Committee on Artificial Limbs, National Research Council, February 1951.</li> <li>Slocum, D. B., <i></i>An atlas of amputations, C. V. Mosby Co., St. Louis, 1949.</li> <li>University of California (Berkeley and San Fran- cisco), Biomechanics Laboratory, <i>Manual of below-knee prosthetics</i>, 1959.</li> <li>University of California (Los Angeles), Depart- ment of Engineering, <i>Manual of upper extremity prosthetics</i>, 2nd ed., W. R. Santschi, ed., 1958.</li> <li>University of California (Los Angeles), School of Medicine, Prosthetics Education Program, <i>Manual of above-knee prosthetics</i>, Miles H. Anderson and Raymond E. Sollars, eds., January 1, 1957.</li> <li>University of California Press (Berkeley and Los Angeles), <i>The limb-deficient child</i>, Berton B lakes-lee, ed., 1963.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr., B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Technical Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Avenue, N.W., Washington, D.C. 20418</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1963_02_001/1963-Autumn-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Limb Prosthetics Today Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr., B.S.M.E. * https://staging.drfop.org/files/original/13483799eeef6de665c9bbb9af7b9faa.pdf c58980d044e592784ff92c261572cb70 https://staging.drfop.org/files/original/88328052220571e0fc20a864a6829964.jpg 66cafb6c0ae410559da88d3c6d548b21 https://staging.drfop.org/files/original/96e82ff7eea90594d484b9bd33e81c7e.jpg 1434282fa08d69ba185572ba4a1fcd1b https://staging.drfop.org/files/original/b6d5144215bb3dbbd723c4b8bb3a62a5.jpg e5382c2d9f7afecf74fe925fff7e28a5 https://staging.drfop.org/files/original/9cb7c3ebdffb95d6682116b73f94baa3.jpg 3208b240ca5b9271e98a68e4b09db6d0 https://staging.drfop.org/files/original/79695db2e584586503cc226686d16e5d.jpg 15434912daba69219d4e20745bd20a2a https://staging.drfop.org/files/original/32ad6c8f31a40cf8768910f1f71a1e86.jpg 9ad57bb3f90aece39e7c67bc4ef9a9e7 https://staging.drfop.org/files/original/2dd6ac18d6245c9d29236c6c620a12ad.jpg 6b452113afc75f8a732e203232711048 https://staging.drfop.org/files/original/5b0cbe7e09c8a178d30df13f69f31b97.jpg a90dab8ec34461f8015b8160e1c757a3 https://staging.drfop.org/files/original/aa411e9c0d94b09ee34d8dfe6cd61643.jpg fc2fc8ec437f8c653cbf5204e56de2b5 https://staging.drfop.org/files/original/edc114da52e28e0c0b6b7232ac00385e.jpg 724e3a1f505bb49024a7dfd947aeb382 https://staging.drfop.org/files/original/0c3ce7981d1ba2ffd57a31f9b99441cb.jpg 394e213d7b1c2193df215ac99c04fe37 https://staging.drfop.org/files/original/ad3b7233a6cabfff6c8399230b2a134d.jpg 4d44106fab8c1b1165d4b3fac0937598 https://staging.drfop.org/files/original/88fa3fd1d2928a71d8d8e0999736376b.jpg c2bea47e140174bc3875689af1a1b991 https://staging.drfop.org/files/original/ee51beb02fd85067cd1d579fac60ba28.jpg af3799f1f630e053b0fd5fe9480fb8bd https://staging.drfop.org/files/original/ac4030ee6c7df699fe7d75382c651bdf.jpg 7116e89a6c7eb72b5f55206c520ef96d https://staging.drfop.org/files/original/945bda9a12449fb3635d9974f819b027.jpg ba18513057ab53a915cf3129a30346a8 https://staging.drfop.org/files/original/739f04652820548143db4fa58b496a59.jpg 5030742e0bfdb6beb718ef64ecac8ea0 https://staging.drfop.org/files/original/1737d62016b57b8b2823cb05b2d0c4a0.jpg fd477e4cae07b389d7b5be19e0705ebc https://staging.drfop.org/files/original/3fd18dbb5eab5745097f327f368b2b8b.jpg 1f4f074ccae5fda0c472b769bf69f07a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_01_001.pdf Year 1967 Volume 11 Issue 1 Page Number(s) 1 - 46 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1967_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_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>Limb Prosthetics-1967</h2> <h5>A. Bennett Wilson, Jr., B.S.M.E. <a style="text-decoration:none;">*</a><br /></h5> <p><i>Because of the large demand for reprints of </i>"Limb Prosthetics Today" <i>which originally appeared in the Autumn 1963 issue of ARTIFICIAL LIMBS, the article has been revised to reflect the numerous advances that have been introduced into limb prosthetics since 1963. To distinguish this revision from the original we have chosen the title </i>"Limb Prosthetics-1967."</p> <p>Loss of limb has been a problem as long as man has been in existence. Even some prehistoric men must have survived crushing injuries resulting in amputation, and certainly some children were born with congenitally deformed limbs with effects equivalent to those of amputation. In 1958 the Smithsonian Institution reported the discovery of a skull dating back about 45,000 years of a person who, it was deduced, must have been an arm amputee, because of the way his teeth had been used to compensate for lack of limb. Leg amputees must have compensated partly for their loss by the use of crude crutches and, in some instances, by the use of peg legs fashioned from forked sticks or tree branches (<b>Fig. 1</b> and <b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Mosaic from the Cathedral of Lescar, France, depicts an amputee supported at the knee by a wooden pylon. Some authorities place this in the Gallo-Roman era. From Putti, V., Historic Artificial Limbs, 1930. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Pen drawing of a fragment of antique vase unearthed near Paris in 1862 which shows a figure whose missing limb is replaced by a pylon with a forked end. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The earliest known record of a prosthesis being used by man was made by the famous Greek historian, Herodotus. His classic <i>"History" </i>written about 484 B.C., contains the story of the Persian soldier, Hegistratus, who, when imprisoned in stocks by the enemy, escaped by cutting off part of his foot, and replaced it later with a wooden version.</p> <p>A number of ancient prostheses have been displayed in museums in various parts of the world. The oldest known is an artificial leg unearthed from a tomb in Capua in 1858, thought to have been made about 300 B.C., the period of the Samnite Wars. Constructed of copper and wood, the Capua leg was destroyed when the Museum of the Royal College of Surgeons was bombed during World War II. The Alt-Ruppin hand (<b>Fig. 3</b>), recovered along the Rhine River in 1863, and other artificial limbs of the 15th century are on display at the Stib-bert Museum in Florence. Most of these ancient devices were the work of armorers. Made of iron, these early prostheses were used by knights to conceal loss of limbs as a result of battle, and a number of the warriors are reported to have returned successfully to their former occupation. Effective as they were for their intended use, these specialized devices could not have been of much use to any group other than the knights, and the civilian amputees for the most part must have had to rely upon the pylon and other makeshift prostheses. Although the use of ligatures was set forth by Hippocrates, the practice was lost during the Dark Ages, and surgeons during that period and for centuries after stopped bleeding by either crushing the stump or dipping it in boiling oil. When Ambroise Pare, a surgeon in the French Army, reintroduced the use of ligatures in 1529, a new era for amputation surgery and prostheses began. Armed with a more successful technique, surgeons were more willing to employ amputation as a lifesaving measure and, indeed, the rate of survival must have been much higher. The practice of amputation received another impetus with the introduction of the tourniquet by Morel in 1674, and removal of limbs is said to have become the most common surgical procedure in Europe. This in turn led to an increase in interest in artificial limbs. Pare, as well as contributing much in the way of surgical procedures, devised a number of limb designs for his patients. His leg (<b>Fig. 4</b>) for amputation through the thigh is the first known to employ articulated joints. Another surgeon, Verduin, introduced in 1696 the first known limb for below-knee amputees that permitted freedom of the knee joint (<b>Fig. 5</b>), in concept much like the thigh-corset type of below-knee limb still used by many today. Yet, for reasons unknown, the Verduin prosthesis dropped from sight until it was reintroduced by Serre in 1826 and, until recently, was the most popular type of below-knee prosthesis used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Alt-Ruppin Hand (circa 1400). The thumb is rigid; the fingers move in pairs and are sprung by the buttons at the base of the palm; the wrist is hinged. Putti, V., Chir. d. org. di movimento, 1924-25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Artificial leg invented by Ambroise Pare (middle sixteenth century). From Pare, A., Oeuvres Completes, Paris, 1840. From the copy in the National Library of Medicine. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Verduin Leg (1696). From MacDonald, J., Am. J. Surg., 1905. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After Pare's above-knee prosthesis, which was constructed of heavy metals, the next real advance seems to be the use of wood, introduced in 1800 by James Potts of London. Consisting of a wooden shank and socket, a steel knee joint, and an articulated foot, the Potts invention (<b>Fig. 6</b>) was equipped with artificial tendons connecting the knee and the ankle, thereby coordinating toe lift with knee flexion. It was made famous partly because it was used by the Marquis of Anglesea after he lost a leg at the Battle of Waterloo. Thus it came to be known as the Anglesea leg. With some modifications the Anglesea leg was introduced into the United States in 1839. Many refinements to the original design were incorporated by American limb fitters and in time the wooden above-knee leg became known as the "American leg."</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Anglesea Leg (1800). Below knee at left, above knee at right. Knee, ankle, and foot are articulated. From Bigg, H. H., Orthopraxy, 1877. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The Civil War produced large numbers of amputees and consequently created a great interest in artificial limbs, no doubt inspired partly by the fact that the federal and state governments paid for limbs for amputees who had seen war service.</p> <p>J. E. Hanger, one of the first Southerners to lose a leg in the Civil War, replaced the cords in the so-called American leg with rubber bumpers about the ankle joint, a design used almost universally until rather recently. Many patents on artificial limbs were issued between the time of the Civil War and the turn of the century, but few of the designs seem to have had much lasting impact.</p> <p>During this period, with the availability of chloroform and ether as anesthetics, surgical procedures were greatly improved and more functional amputation stumps were produced by design rather than by fortuity.</p> <p>World War I stirred some interest in artificial limbs and amputation surgery but, because the American casualty list was relatively small, this interest soon waned and, because of the economic depression of the Thirties, some observers think, very little progress was made in the field of limb prosthetics between the two World Wars. Perhaps the most significant contributions were the doctrines set forth and emphasized by Thomas and Haddan <i>, </i><a></a> a prosthetist-surgeon team from Denver, that fit and alignment of the prosthesis were the most critical factors in the success of any limb and that much better end results could be expected if prosthetists and physicians worked together.</p> <p>Early in 1945, the National Academy of Sciences, at the request of The Surgeon General of the Army, initiated a research program in prosthetics.<a></a> The initial reaction of the research personnel was that the development of a few mechanical contrivances would solve the problem. However, it soon became evident that much more must be known about biomechanics and other matters before real progress could be made <i><a></a>. </i>Devices and techniques based on fundamental data have materially changed the practice of prosthetics during the past 15 years. However, the best conceivable prosthesis is but a poor substitute for a live limb of flesh and blood, and so the research program is still continuing. Fiscal support for research and development by some 30 laboratories is provided by the Veterans Administration, the Vocational Rehabilitation Administration, the National Institutes of Health, the Children's Bureau, the Army, and the Navy. The overall program is coordinated by the Committee on Prosthetics Research and Development of the National Academy of Sciences-National Academy of Engineering.</p> <p>In England and Europe, research in artificial limbs was resumed after World War II at Queen Mary's Hospital, Roehampton, London, by the Ministry of Health, and a new program was initiated in West Germany by the government. Also, a program was started in Russia. The so-called "Thalidomide Tragedy" of 1959-1960 gave incentive for governments to support research, and now there are effective programs in Canada, Denmark, Holland, Scotland, and Sweden, and the studies in England and Germany have been greatly expanded. Under Public Law 480 the United States supports prosthetics research in India, Israel, Poland, and Yugoslavia.</p> <p>Soon after the close of World War II, the Artificial Limb Manufacturers Association, which had been formed during World War I, engaged the services of a professional staff to coordinate more effectively the efforts of individual prosthetists. Known today as the American Orthotics and Prosthetics Association,<a style="text-decoration:none;">*</a> this organization consists of some 500 limb and brace shops, and plays a large part in keeping individual prosthetists and ortho-tists advised of the latest trends and developments in prosthetics and orthotics.</p> <p>In 1949, upon the recommendation of the Association, the American Board for Certification in Orthotics and Prosthetics, Inc.,<a style="text-decoration:none;">*</a> was established to ensure that prosthetists and orthotists met certain standards of excellence, much in the manner that certain physicians' specialty associations are conducted. Examinations are held annually for those desiring to be certified. In addition to certifying individuals as being qualified to practice, the American Board for Certification approves individual shops, or facilities, as being satisfactory to serve the needs of amputees and other categories of the disabled requiring mechanical aids. Certified prosthetists wear badges and shops display the symbol of certification (<b>Fig. 7</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Symbol of certification by the American Board for Certification in Orthotics and Prosthetics, Inc. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The research program, with the cooperation of the prosthetists, has introduced a sufficient number of new devices and techniques to modify virtually every aspect of the practice of prosthetics. To reduce the time lag between research and widespread application, facilities have been established within the medical schools of three universities for short-term courses in special aspects of prosthetics. Courses are offered to each member of the prosthetics-clinic team-the physician, the therapist, and the prosthetist. Also, special courses are offered to vocational rehabilitation counselors and administrative personnel concerned with the welfare of amputees. Approximately 5,787 physicians, 3,962 therapists, and 2,000 prosthetists have been enrolled in these courses during the period 1953 through 1967.</p> <p>Prior to 1957 medical schools offered little in the way of training in prosthetics to doctors and therapists. To encourage the inclusion of prosthetics into medical and paramedical curricula, the National Academy of Sciences organized the Committee on Prosthetics Education and Information, and as a result of the efforts of this group many schools have adopted courses in prosthetics at both undergraduate and graduate levels.</p> <p>Today there are approximately 200 amputee-clinic teams in operation throughout the United States. Each state, with assistance from the Vocational Rehabilitation Administration, carries out programs that provide the devices and training required to return the amputee to gainful employment. The Children's Bureau, working through a number of states, has made it possible for child amputees to receive the benefit of the latest advances in prosthetics. The Veterans Administration provides all eligible veterans with artificial limbs. If the amputation is related to his military service, the beneficiary receives medical care and prostheses for the remainder of his life. The Public Health Service, through its hospitals, provides limbs and care to members of the Coast Guard and to qualified persons who have been engaged in the Maritime Service.</p> <p>In July 1965 the 89th Congress passed Public Law 89-97, the Medicare bill, which includes provision for artificial limbs at essentially no cost for persons 65 years of age and over. The bill also assists individual states in providing artificial limbs for persons who are medically indigent at any age. A number of states have enacted legislation to take advantage of the offer by the federal government.</p> <p>In addition to the government agencies that are concerned with the amputee, there are several hundred rehabilitation centers throughout the United States that assist amputees, especially those advanced in age, in obtaining the services needed for them to return to a more normal life.</p> <p>Thus, through the cooperative efforts of government and private groups, considerable progress has been made in the practice of prosthetics and there is little need for an amputee to go without a prosthesis.</p> <h3>Reasons For Amputation</h3> <p>Amputation may be the result of an accident, or may be necessary as a lifesaving measure to arrest a disease. A small but significant percentage of individuals are born without a limb or limbs, or with defective limbs that require amputation or fitting (like that of an amputee).</p> <p>In some accidents a part or all of the limb may be completely removed; in other cases, the limb may be crushed to such an extent that it is impossible to restore sufficient blood supply necessary for healing. Sometimes broken bones cannot be made to heal, and amputation is necessary. Accidents that cause a disruption in the nervous system and paralysis in a limb may also be cause for amputation even though the limb itself is not injured. The object of amputation in such a case is to improve function by substituting an artificial limb for a completely useless though otherwise healthy member. Amputation of paralyzed limbs is not performed very often but has in some cases proven to be very beneficial. Accidents involving automobiles, farm machinery, and firearms seem to account for most traumatic amputations. Freezing, electrical burns, and the misuse of power tools also account for many amputations.</p> <p>Improved medical and surgical procedures introduced in recent years have resulted in the preservation of many limbs that would have been amputated. Infection, once a cause of a high fraction of amputations, can usually be controlled by use of antibiotics. Newer methods of vessel and nerve suturing make it possible to save limbs that would have had to be amputated some years ago. Highly qualified surgical teams have demonstrated during the last few years that it is possible to replace a completely severed limb.</p> <p>Diseases that may make amputation necessary fall into one of three main categories: vascular, or circulatory, disorders; cancer; and infection. The diseases that cause circulatory problems most often are arteriosclerosis, or hardening of the arteries, diabetes, and Buerger's disease. In these cases not enough blood circulates through the limb to permit body cells to replace themselves, and unless the limb, or part of it, is removed the patient cannot be expected to live very long. In nearly all these cases the leg is affected because it is the member of the body farthest from the heart and, in accordance with the principles of hydraulics, blood pressure in the leg is lower than in any other part of the body. Vascular disorders are, of course, much more prevalent among older persons. Considerable research is being undertaken to determine the cause of vascular disorders so that amputation for these reasons may at least be reduced if not eliminated, but at the present time vascular disorders are the cause of a large number of lower-extremity amputations.</p> <p>In many cases amputation of part or all of a limb has arrested a malignant or cancerous condition. In view of present knowledge, the entire limb is usually removed. Malignancy may affect either the arms or legs. Much time and effort are being spent to develop cures for the various types of cancer.</p> <p>Since the introduction of antibiotic drugs, infection has been less and less the cause for amputation. Moreover, even though amputation may be necessary, control of the infection may allow the amputation to be performed at a lower level than would be the case otherwise.</p> <p>"Thalidomide babies" born between 1958 and 1961 have been given extensive press coverage; however, thalidomide is by no means the sole cause of congenital malformations. Absence of all or part of a limb at birth is not an uncommon occurrence. Many factors seem to be involved in such occurrences, but what these factors are is not clear. The most frequent case is absence of most of the left forearm, which occurs slightly more often in girls than in boys. However, all sorts of combinations occur, including complete absence of all four extremities. Sometimes intermediate parts such as the thigh or upper arm are missing but the other parts of the extremity are present, usually somewhat malformed. In such cases amputation may be indicated; however, even a weak, malformed part is sometimes worth preserving if sensation is present and the partial member is capable of controlling some part of the prosthesis. Extensive studies are being carried out to determine the reasons for congenital malformations.</p> <h3>Losses Incurred</h3> <p>Many of the limitations resulting from amputation are obvious; others less so. An amputation through the lower extremity makes standing and locomotion without the use of an artificial leg or crutches difficult and impracticable except for very short periods. Even when an artificial leg is used, the loss of joints and the surrounding tissues, and consequently loss of the ability to sense position, is felt keenly. The sense of touch of the absent portion is also lost, but in the case of the lower-extremity amputee this is not quite as important as it might seem because the varying pressure occurring between the stump and the socket indicates external loading. In the upper-extremity amputee, sense of touch is more important.</p> <p>Most lower-extremity amputees cannot bear the total weight of the body on the end of the stump, and other parts of the anatomy must be found for support.</p> <p>Muscles attached at each end to bones are responsible for movement of the arms and legs. Upon a signal from the nervous system muscle tissue will contract, thus producing a force which can move a bone about its joint (<b>Fig. 8</b>). Because muscle force can be produced only by contraction, each muscle group has an opposing muscle group so that movement in two directions can take place. This arrangement also permits a joint to be held stable in any one of a vast number of positions for relatively long periods of time. How much a muscle can contract is dependent upon its length, and the amount of force that can be generated is dependent upon its circumference.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Schematic drawing of muscular action on skeletal system. The motion shown here is flexion, or bending, of the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Muscles that activate the limbs must of course pass over at least one joint to provide a sort of pulley action; some pass over two. Thus, some muscles are known as one-joint muscles, others as two-joint muscles. When muscles are severed completely, they can no longer transmit force to the bone and, when not used, wither away or atrophy. It will be seen later that these facts are very important in the rehabilitation of amputees.</p> <h3>Types of Amputation</h3> <p>Amputations are generally classified according to the level at which they are performed (<b>Fig. 9</b>). Some amputation levels are referred to by the name of the surgeon credited with developing the amputation technique used. The general rule in selecting the site of amputation is to save all length that is medically possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Classification of amputation by level. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Lower-Extremity Amputations</h4> <p><i>Syme's Amputation</i></p> <p>Developed about 1842 by James Syme, a leading Scottish surgeon, the Syme amputation leaves the long bones of the shank (the tibia and fibula) virtually intact, only a small portion at the very end being removed (<b>Fig. 10</b>).<a></a> The tissues of the heel, which are ideally suited to withstand high pressures, are preserved, and this, in combination with the long bones, usually permits the patient to bear the full weight of his body on the end of the stump. Because the amputation stump is nearly as long as the unaffected limb, a person with Syme's amputation can usually get about the house without a prosthesis even though normal foot and ankle action has been lost. Atrophy of the severed muscles that were formerly attached to bones in the foot to provide ankle action results in a stump with a bulbous end which, though not of the most pleasing appearance, is quite an advantage in holding the prosthesis in place.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Excellent Syme stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Since its introduction, Syme's operation has been looked upon with both favor and disfavor among surgeons. It seems to be the consensus now that "the Syme" should be performed in preference to amputation at a higher level if possible. In the case of most women, though, "the Syme" is undesirable because of the difficulty of providing a prosthesis that matches the shape of the other leg.</p> <p><i>Below-Knee Amputations</i></p> <p>Any amputation above the Syme level and below the knee joint is known as a below-knee amputation. Because circulatory troubles have often developed in long below-knee stumps, and because the muscles that activate the shank are attached at a level close to the knee joint, the below-knee amputation is usually performed at the junction of the upper and middle third sections (<b>Fig. 11</b>). Thus nearly full use of the knee is retained-an important factor in obtaining a gait of nearly normal appearance. However, it is rare for a below-knee amputee to bear a significant amount of weight on the end of the stump; thus the design of prostheses must provide for weight-bearing through other areas. Several types of surgical procedures have been employed to obtain weight-bearing through the end of the below-knee stump, but none has found widespread use.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical, well-formed, right below-knee stump. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Knee-Bearing Amputations</i></p> <p>Complete removal of the lower leg, or shank, is known as a knee disarticulation. When the operation is performed properly, the result is an efficient, though bulbous, stump (<b>Fig. 12</b>) capable of carrying the weight-bearing forces through the end. Unfortunately, the length causes some problems in providing an efficient prosthesis because the space used normally to house the mechanism needed to control the artificial shank properly is occupied by the end of the stump. Nevertheless, excellent prostheses can be provided the knee-disar-ticulation case.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Typical knee-disarticulation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Several amputation techniques have been devised in an attempt to overcome the problems posed by the length and shape of the true knee-disarticulation stump. The Gritti-Stokes procedure entails placing the kneecap, or patella, directly over the end of the femur after it has been cut off about two inches above the end. When the operation is performed properly, excellent results are obtained, but extreme skill and expert postsurgical care are required. Variations of the Gritti-Stokes amputation have been introduced from time to time but have never been used widely.</p> <p><i>Above-Knee Amputations</i></p> <p>Amputations through the thigh are among the most common (<b>Fig. 13</b>). Because of the high pressures exerted on the soft tissues by the cut end of the bone, total body weight cannot be taken through the end of the stump but can be accommodated through the ischium, that part of the pelvis upon which a person normally sits.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Typical, well-formed above-knee stump-Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Hip Disarticulation and Hemipelvectomy</i></p> <p><i>A </i>true hip disarticulation (<b>Fig. 14</b>) involves removal of the entire femur, but whenever feasible the surgeon leaves as much of the upper portion of the femur as possible in order to provide additional stabilization between the prosthesis and the wearer, even though no additional function can be expected over the true hip disarticulation.<a></a> Both types of stump are provided with the same type of prosthesis. With slight modification the same type of prosthesis can be used by the hemipelvectomy patient, that is, when half of the pelvis has been removed. It is surprising how well hip-disarticulation and hemipelvectomy patients have been able to function when fitted with the newer type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Patient with true hip-disarticulation amputation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Upper-Extremity Amputations</h4> <p><i>Partial-Hand Amputations</i></p> <p>If sensation is present the surgeon will save any functional part of the hand in lieu of disarticulation at the wrist. Any method of obtaining some form of grasp, or prehension, is preferable to the best prosthesis. If the resuit is unsightly, the stump can be covered with a plastic glove, lifelike in appearance, for those occasions when the wearer is willing to sacrifice function for appearance. Many pros-thetists have developed special appliances for partial-hand amputations that permit more function than any of the artificial hands and hooks yet devised and, at the same time, permit the patient to make full use of the sensation remaining in the stump. Such devices are usually individually designed and fitted.</p> <p><i>Wrist Disarticulation</i></p> <p>Removal of the hand at the wrist joint was once condemned because it was thought to be too difficult to fit so as to yield more function than a shorter forearm stump. However, with plastic sockets based on anatomical and physiological principles, the wrist-disarticulation case can now be fitted so that most of the pronation-supination of the forearm-an important function of the upper extremity-can be used. In the case of the wrist disarticulation (<b>Fig. 15</b>), nearly all the normal forearm pronation-supination is present. Range of pronation-supination decreases rapidly as length of stump decreases; when 60 per cent of the forearm is lost, no pronation-supination is possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. A good wrist-disarticulation stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Amputations Through The Forearm</i></p> <p>Amputations through the forearm are commonly referred to as below-elbow amputations and are classified as long, short, and very short, depending upon the length of stump (<b>Fig. 9</b>). Stumps longer than 55 per cent of total forearm length are considered long, between 35 and 55 per cent as short, and less than 35 per cent as very short.</p> <p>Long stumps retain the rotation function in proportion to length; long and short stumps without complications possess full range of elbow motion and full power about the elbow, but often very short stumps are limited in both power and motion about the elbow. Devices and techniques have been developed to make full use of all functions remaining in the stump.</p> <p><i>Disarticulation At The Elbow</i></p> <p>Disarticulation at the elbow consists of removal of the forearm, resulting in a slightly bulbous stump (<b>Fig. 16</b>) but usually one with good end-weight-bearing characteristics. The long bulbous end, while presenting some fitting problems, permits good stability between socket and stump, and thus allows use of nearly all the rotation normally present in the upper arm-a function much appreciated by the amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Amputation through the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Above-Elbow Amputation</i></p> <p>Any amputation through the upper arm is generally referred to as an above-elbow amputation (<b>Fig. 9</b>). In practice, stumps in which less than 30 per cent of the humerus remains are treated as shoulder-disarticulation cases; those with more than 90 per cent of the humerus remaining are fitted as elbow-disar-ticulation cases.</p> <p><i>Shoulder Disarticulation And Forequarter Amputation</i></p> <p>Removal of the entire arm is known as shoulder disarticulation but, whenever feasible, the surgeon will leave intact as much of the humerus as possible to provide stability between the stump and the socket (<b>Fig. 17</b>). When it becomes necessary to remove the clavicle and scapula, the operation is known as a forequarter, or interscapulothoracic, amputation. The very short above-elbow, the shoulder-disarticulation, and the forequarter cases are all provided with essentially the same type of prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. A true shoulder disarticulation. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Postsurgical Period</h3> <p>The period between the time of surgery and time of fitting the prosthesis is an important one if a good functional stump, and thus the most efficient use of a prosthesis, is to be obtained. The surgeon and others on his hospital staff will do everything possible to ensure the best results, but ideal results require the wholehearted cooperation of the patient.</p> <p>It is not unnatural for the patient to feel extremely depressed during the first few days after surgery, but after he becomes aware of the possibilities of recovery, the outlook becomes brighter, and he generally enters cooperatively into the rehabilitation phase.</p> <p>It has been generally agreed through the years that the earlier a patient could be fitted the easier would be the rehabilitation process. However, until a few years ago, virtually no patients were provided with a prosthesis before six weeks after amputation, and such cases were rare, the average time probably being closer to four months.</p> <p>With the advent of improved cast-taking methods, and temporary legs in which alignment can be easily adjusted, Duke University, about 1960, began an experiment to determine the earliest practical time after surgery for providing amputees with limbs. By 1963 it had been shown clearly that it was not only practical but desirable to fit a temporary, but well-fitted, limb as soon as the sutures were removed some two to three weeks after surgery. In 1963 Dr. Marian Weiss of Poland, in an address in Copenhagen, reported success with fitting amputees immediately after surgery while the patient was still anesthetized, and beginning ambulation training the day after.<a></a>Dr. Weiss's work stimulated similar work in this country, notably at the University of California, San Francisco; the Oakland Naval Hospital; Prosthetics Research Study, Seattle, Washington; Duke University; the University of Miami; Marquette University; and New York University. Results with over 400 patients of all types have shown immediate postsurgical fitting of prostheses to be the method of choice when possible. Healing seems to be accelerated, postsurgical pain is greatly alleviated, contractures are prevented from developing, phantom pain seems to be virtually nonexistent, less psychological problems seem to ensue, and patients are returned to work or home at a much earlier date than seemed possible only a few years ago.</p> <p>The procedure consists essentially of providing a rigid plaster dressing over the stump which serves as a socket, and the use of an adjustable leg which can be removed and reinstalled easily (<b>Fig. 18</b>).<a></a> The cast-socket is left in place for 10 to 12 days during which ambulation is encouraged. At the end of this time the cast-socket is removed, the stitches are usually taken out, and a new cast-socket is provided immediately. The original prosthetic unit is replaced and realigned. The second cast-socket is left in place for eight to ten days at which time a new cast can be taken for the permanent, or definitive, prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. Schematic cross section showing most of the elements of the application of a prosthesis to a below-knee amputee immediately after surgery. The suture line, silk dressing, and drain are not shown for the sake of clarity. View "A" is an enlarged schematic section of the cast socket, prosthetic unit attachment straps, stump sock, and fluffed gauze at the distal portion of the stump. The fluffed gauze does not extend beyond the area indicated. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Special courses in immediate postsurgical fitting and early fitting are being offered to qualified prosthetics clinic teams by Northwestern University, the University of California at Los Angeles, and New York University.</p> <h4>Contractures</h4> <p>When immediate postsurgical fitting is employed there is little opportunity for contractures to develop. When these procedures are not used, it is most important to avoid the development of muscle contractures. They can be prevented easily but it is most difficult, and sometimes impossible, to correct them. At first exercises are administered by a therapist or nurse; later the patient is instructed concerning the type and amount of exercise that should be undertaken. The patient is also instructed in methods and amount of massage that should be given the stump to aid in the reduction of the stump size. Further, to aid shrinkage, cotton-elastic bandages are wrapped around the stump (<b>Fig. 19</b>) and worn continuously until a prosthesis is fitted. The bandage is removed and reapplied at regular intervals- four times during the day, and at bedtime. It is most important that a clean bandage is available for use each day.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. Compression wrap for above-knee amputation. The wrap of elastic bandage aids in shrinking the stump. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The amputee is taught to apply the bandage unless it is physically impossible for him to do so, in which case some member of his family must be taught the proper method for use at home.</p> <p>To reduce the possibility of contractures, the lower-extremity stump must not be propped upon pillows. Wheelchairs should be used as little as possible; crutch walking is preferred, but the above-knee stump must not be allowed to rest on the crutch handle (<b>Fig. 20</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. Actions to be avoided by lower-extremity amputees during the immediate postoperative period. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Phantom Sensation</h4> <p>After amputation the patient almost always has the sensation that the missing part is still present. The exact cause of this is as yet unknown. The phantom sensation usually recedes to the point where it occurs only infrequently or disappears entirely, especially if a prosthesis is used. In a large percentage of cases, moderate pain may accompany the phantom sensation but, in general, this too eventually disappears entirely or occurs only infrequently. In a small percentage of cases severe phantom pain persists to the point where medical treatment is necessary.<a></a> </p> <h3>Prostheses for Various Types of Amputation</h3> <p>Much time and attention have been devoted to the development of mechanical components, such as knee and ankle units, for artificial limbs, yet by far the most important factors affecting the successful use of a prosthesis are the fit of the socket to the stump and the alignment of the various parts of the limb in relation to the stump and other parts of the body.</p> <p>Thus, though many parts of a prosthesis may be mass-produced, it is necessary for each limb to be assembled in correct alignment and fitted to the stump to meet the individual requirements of the intended user. To make and fit artificial limbs properly requires a complete understanding of anatomical and physiological principles and of mechanics; craftsmanship and artistic ability are also required.</p> <p>In general, an artificial limb should be as light as possible and still withstand the loads imposed upon it. In the United States willow and woods of similar characteristics have formed the basis of construction for more limbs than any other material, though aluminum, leather-and-steel combinations, and fibre have been used widely. Plastic laminates so popular in small-boat construction form the basis for construction of most artificial limbs. Some artificial legs are made of wood, and occasionally leather is used for sockets, but the trend is toward the plastic laminates. They are light in weight, easy to keep clean, and do not absorb perspiration. They may be molded easily and rapidly over contours such as those found on a plaster model of a stump. Plastic laminates can be made extremely rigid or with any degree of flexibility required in artificial-limb construction. In some instances, especially in upper-extremity sockets, the fact that most plastic laminates do not permit water vapor to pass to the atmosphere has caused discomfort, but recently a porous type has been developed by the Army Medical Biomechanical Research Laboratory (formerly the Army Prosthetics Research Laboratory). Except experimentally, its use thus far has been restricted to artificial arms. Of course, most of the mechanical parts are made of steel or aluminum, depending upon their function.</p> <p>As in the case of the tailor making a suit, the first step in fabrication of a prosthesis is to take the necessary measurements for a good fit. If the socket is to be fabricated of a plastic laminate, an impression of the stump is made. Most often this is accomplished by wrapping the stump with a wet plaster-of-Paris bandage and allowing it to dry, as a physician does in applying a cast when a bone is broken (<b>Fig. 21</b>). A number of devices have been introduced in recent years to aid the prosthetist in obtaining accurate casts rapidly <i><a></a>. </i>Most use an apparatus that permits the patient to absorb some of the weight-bearing load through the affected side while the cast is being formed (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. Steps in the fabrication of a plastic prosthesis for a below-knee amputation. A, Taking the plaster cast of the stump; B, pouring plaster in the cast to obtain model of the stump; C, introducing plastic resin into fabric pulled over the model to form the plastic-laminate socket; D, the plastic-laminate socket mounted on an adjustable shank for walking trials; E, a wooden shank block inserted in place of the adjustable shank after proper alignment has been obtained; F, the prosthesis after the shank has been shaped. To reduce weight to a minimum the shank is hollowed out and the exterior covered with a plastic laminate. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Special jig developed by the Veterans Administraton Prosthetics Center to facilitate casting above-knee stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cast, or wrap, is removed from the stump and filled with a plaster-of-Paris solution to form an exact model of the stump which-after being modified to provide relief for any tender spots, to ensure that weight will be taken in the proper places, and to take full advantage of the remaining musculature can be used for molding a plastic-laminate socket. Often a "check" socket of cloth impregnated with beeswax is made over the model and tried on the stump to determine the correctness of the modifications.</p> <p>For upper-extremity cases the socket is attached to the rest of the prosthesis and a harness is fabricated and installed for operation of the various parts of the artificial arm. For the lower-extremity case the socket is fastened temporarily to an adjustable, or temporary, leg for walking trials (<b>Fig. 23</b>). With this device, the prosthetist can easily adjust the alignment until both he and the amputee are satisfied that the optimum arrangement has been reached. A prosthesis can now be made incorporating the same alignment achieved with the adjustable leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Using the above-knee adjustable leg and alignment duplication jig. Top, Adjusting the adjustable leg during walking trials; Center, the socket and adjustable leg in the alignment duplication jig; Bottom, replacement of the adjustable leg with a permanent knee and shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An even more refined procedure uses the "Staros-Gardner" coupling (<b>Fig. 24</b>).<a></a> Not only is the need for the alignment jig eliminated but in the case of above-knee fittings the alignment adjustments can be made with the knee unit that is to be used permanently, an important factor when sophisticated knee units are used because the present adjustable leg is available with only a single-axis, constant-friction joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Adjustable coupling used for alignment of artificial legs. This unit was designed by the Veterans Administration Prosthetics Center and is suitable for below-knee as well as above-knee legs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>There are many kinds of artificial limbs available for each type of amputation, and much has been written concerning the necessity for prescribing limbs to meet the needs of each individual. This of course is true particularly in the case of persons in special or arduous occupations, or with certain medical problems, but actually limbs for a given type of amputation vary to only a small degree. Following are descriptions of the artificial limbs most commonly used in the United States today.</p> <h4>Lower-Extremity Prostheses</h4> <p><i>Prostheses For Syme's Amputation</i></p> <p>Perhaps the major reason Syme's amputation was held in such disfavor in some quarters was the difficulty in providing a comfortable, sufficiently strong prosthesis with a neat appearance. The short distance between the end of the stump and the floor made it extremely difficult to provide for ankle motion needed.</p> <p>Most Syme prostheses were of leather reinforced with steel side bars resulting in an ungainly appearance (<b>Fig. 25</b>). Research workers at the Prosthetic Services Centre at the Department of Veterans Affairs of Canada were quick to realize that the use of the proper plastic laminate might solve many of the problems long associated with the Syme prosthesis. After a good deal of experimentation, the Canadians developed a model in 1955 which, with a few variations, is used almost universally in both Canada and the United States today (<b>Fig. 26</b>)<a></a>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Syme prosthesis with side bars mounted on medial and lateral aspects of the shank. This type of construction has been virtually replaced by plastic laminates. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. The Syme prosthesis adopted by the Canadian Department of Veterans Affairs. The posterior opening extends the length of the shank. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Necessary ankle action is provided by making the heel of the foot of sponge rubber. The socket is made entirely of a plastic laminate. A full-length cutout in the rear permits entry of the bulbous stump. When the cutout is replaced and held in place by straps, the bulbous stump holds the prosthesis in place. In the American version (<b>Fig. 27</b>), a window-type cutout is used on the side because calculations show that smaller stress concentrations are present with such an arrangement.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Two views of the Canadian-type Syme prosthesis as modified by the Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In those cases where, for poor surgery or other reasons, full body weight cannot be tolerated on the end of the stump, provisions can be made to transfer all or part of the load to the area just below the kneecap. When this procedure is necessary, it can be accomplished more easily by use of the window-type cutout.</p> <p><i>Prostheses For Below-Knee A mputations</i></p> <p>Until recently most below-knee amputees were fitted with wooden prostheses carved out by hand (<b>Fig. 28</b>). A good portion of the body weight was carried on a leather thigh corset, or lacer, attached to the shank and socket by-means of steel hinges. The shape of corset and upper hinges also held the prosthesis to the stump. The distal, or lower, end of the socket was invariably left open. Other versions of this prosthesis used aluminum, fibre or molded leather, as the materials for construction of the shank and socket, but the basic principle was the same. Many thousands of below-knee amputees have gotten along well with this type of prosthesis, but there are many disadvantages. Because the human knee joint is not a simple, single-axis hinge joint, relative motion is bound to occur between the prosthesis and the stump and thigh during knee motion when single-jointed side hinges are used, resulting in some chafing and irritation. To date it has not been possible to devise a hinge to overcome this difficulty. Edema, or accumulation of body fluids, was often present at the lower end of the stump. Most of these prostheses were exceedingly heavy, especially those made of wood.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Below-knee prosthesis with wood socket-shank, thigh corset, and steel side bars. Courtesy Veterans Administration Prosthetics Center. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In an attempt to overcome these difficulties, the Biomechanics Laboratory of the University of California, in 1958, designed what is known as the patellar-tendon-bearing (PTB) below-knee prosthesis (<b>Fig. 29</b>). In the PTB prosthesis no lacer and side hinges are used, all of the weight being taken through the stump by making the socket high enough to cover all the tendon below the patella, or kneecap.<a></a> The patellar tendon is an unusually inelastic tissue which is not unduly affected by pressure. The sides of the socket are also made much higher than has usually been the practice in the past in order to give stability against side loads. The socket is made of molded plastic laminate that provides an intimate fit over the entire area of the socket, and is lined with a thin layer of sponge rubber and leather. Because it is rare for a below-knee stump to bear much pressure on its lower end, care is taken to see that only a very slight amount is present in that area. This feature has been a big factor in eliminating the edema problem in many instances. The PTB prosthesis is generally suspended by means of a simple cuff, or strap, around the thigh just above the kneecap, but sometimes a strap from the prosthesis to a belt around the waist is used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Cutaway view of the patellar-tendon-bear-ing leg for below-knee amputees. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the socket has been made, it is installed on a special adjustable leg (<b>Fig. 30</b>) so that the prosthetist can try various alignment combinations with ease. When both prosthetist and patient are satisfied, the leg is completed utilizing the alignment determined with the adjustable unit.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Trial below -knee adjustable leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The shank recommended is of plastic laminate and the foot prescribed is usually the SACH (solid-ankle, cushion-heel) design but other types can be used.</p> <p>It is now general practice in many areas to prescribe the PTB prosthesis in most new cases and in many old ones, and if side hinges and a corset are indicated later, these can be added.</p> <p>Stumps as short as two and one-half inches have been fitted successfully with the PTB prosthesis.</p> <p>In special cases, such as extreme flexion contracture, the so-called kneeling-knee, or bent-knee, prosthesis may be indicated. The prosthesis used is similar to that used for the knee-disarticulation case.</p> <p>Several simplified adjustable shanks have been made available recently expressly for use in the immediate postsurgical fitting technique (<b>Fig. 31</b>). Straps are provided for lamination into the plaster cast-socket. Provisions are incorporated for adjustability in all planes. The shank and foot can be connected to and disconnected from the socket easily and quickly. Although these units were designed for temporary use, they are sturdy enough for use on a permanent basis. A natural appearance can be obtained by using plastic cosmetic covers.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. Prosthetic unit designed especially for fitting below-knee cases immediately after surgery. The stainless steel straps are laminated into the plaster socket. All parts below the top plate are easily removed without affecting alignment. A sach foot is normally used with this device. Although designed for temporary use, this device can form part of a "permanent" prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Knee-Disarticulation And Other Knee-Bearing Cases</i></p> <p>Because of the bulbous shape of the true knee-disarticulation stump, it is not possible to use a wooden socket of the type used on the tapered above-knee stump. To allow entry of the bulbous end, a socket is molded of leather to conform to the stump and is provided with a lengthwise anterior cutout that can be laced to hold the socket in position (<b>Fig. 32</b>). The length of the knee-disarticulation and supracondylar stump makes it difficult to install any of the present knee units designed for above-knee prostheses and, therefore, heavy-duty below-knee joints are generally used. Most prosthetists try to provide some control of the shank during the swing phase of walking by inserting nylon washers between the mating surfaces of the joint to provide friction and by using checkstraps. Some prosthetists have installed commercially available piston-type hydraulic swing-phase control units, but this requires extreme care to achieve the proper result.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. Typical knee-disarticulation prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For Above-Knee Cases</i></p> <p>The articulated above-knee leg is in effect a compound pendulum actuated by the thigh stump. If the knee joint is perfectly free to rotate when force is applied, the effects of inertia and gravity tend to make the shank rotate too far backward and slam into extension as it rotates forward, except at a very slow rate of walking. The method most used today to permit an increase in walking speed is the introduction of some restraint in the form of mechanical friction about the knee joint. The limitation imposed by constant mechanical friction is that for each setting there is only one speed that produces a natural-appearing gait. When restraint is provided in the form of hydraulic resistance, a much wider range of cadence can be obtained without introducing into the gait pattern awkward and unnatural motions.</p> <p>In recent years a number of hydraulic units have been made available for control of the shank during the swing phase. Among them are the DuPaCo, the Henschke-Mauch Model <i>"B" </i>(<b>Fig. 33</b>), and the Hydra-Knee. These units are all of the piston-cylinder-type, provide for swing-phase control only, and are designed so that they can be incorporated into the more conventional leg structures. The Hydra-Cadence leg (<b>Fig. 34</b>), a complete knee-shin-foot unit, in addition to providing swing-phase control hydraulically, uses the hydraulic system to control ankle action in concert with knee motion. After the knee is flexed 20 deg., the toe of the foot is lifted as the knee is flexed further, thereby giving more clearance between the foot and the floor as the leg swings through.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 33. The Henschke-Mauch "HYDRAULIK" set-up. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 34. The Hydra-Cadence Leg without cosmetic cover. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Throughout the past century much time and effort have been spent in providing an automatic brake or lock at the knee in order to provide stability during the stance phase and to reduce the possibility of stumbling. Stability during the stance phase can be obtained by aligning the leg so that the axis of the knee is behind the hip and ankle axes. For most above-knee amputees in good health, such an arrangement has been quite satisfactory, but an automatic knee brake is indicated for the weaker or infirm patients.</p> <p>When an automatic brake is indicated, the Bock, the "Vari-Gait" 100, and the Mortensen knee units (<b>Fig. 35</b>) are the ones most generally used. All are actuated upon contact of the heel with the ground. The Bock and "Vari-Gait" units can be used with almost any type of foot, while a foot of special design is necessary when the Mortensen mechanism is used. A promising stance-phase control unit currently being evaluated is the Henschke-Mauch Model "A" hydraulic unit. The Model "A" unit contains the same swing-phase control device as the Model "B" and provides a braking action about the knee when there is a tendency to buckle. The braking action is brought about by the attitude of a pendulum which in turn is controlled by the inertia forces in the shank. The Model "A" and Model "B" units are interchangeable.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 35. Some examples of weight-actuated knee units. A, Bock "Safety-knee"; B, Vari-Gait knee; C, Mortensen leg. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A number of methods for suspending the above-knee leg are available. For younger, healthy patients, the suction socket (<b>Fig. 36</b>A) has generally been the method of choice. In this design the socket is simply fitted tightly enough to retain sufficient negative pressure, or suction, between the stump and the bottom of the socket when the leg is off the ground. Special air valves are used to control the amount of negative pressure created so as not to cause discomfort. No stump sock is worn with the suction socket. A major advantage of this type of suspension is the freedom of motion permitted the wearer, thus allowing the use of all the remaining musculature of the stump. Another important advantage is the decreased amount of piston action between stump and socket. Additional comfort is also obtained by elimination of all straps and belts.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 36. Above-knee sockets and methods of suspension. A, Total-contact suction socket; B, above-knee leg with Silesian bandage for suspension; C, above-knee leg with pelvic belt for suspension. Most above-knee sockets have a quadrilateral-shaped upper portion as shown. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In some cases additional suspension is provided by adding a "Silesian Bandage," (<b>Fig. 36</b>B),a light belt attached to the socket in such a way that there is very little restriction of motion of the various parts of the body.</p> <p>Patients with weak stumps and most of those with very short stumps will require a pelvic belt connected to the socket by means of a "hip" joint (<b>Fig. 36</b>C). Because the connecting joint cannot be placed to coincide with the normal joint, certain motions are restricted. Pelvic-belt suspension is generally indicated for the older patient because of the problems encountered in donning the suction socket, especially that of bending over to remove the donning sock.</p> <p>Shoulder straps, at one time the standard method of suspending above-knee prostheses, are still sometimes indicated for the elderly patient.</p> <p>Prior to the introduction of the suction socket into the United States soon after the close of World War II, virtually all above-knee sockets had a conical-shaped interior and were known as plug fits, most of the weight being borne along the sides of the stump. Such a design does not permit the remaining musculature to perform to its full capabilities. In the development of the suction socket, a design known as the quadrilateral socket (<b>Fig. 36</b>) evolved, and now is virtually the standard for above-knee sockets regardless of the type of suspension used. When the pelvic belt or suspender straps are used, the socket is fitted somewhat looser than in the case of the suction socket, and the stump sock is generally worn to reduce skin irritation from the pumping action of the loose socket. Most of the body weight is taken on the ischium of the pelvis, that part which assumes the load when an individual is sitting.</p> <p>The quadrilateral socket, because of the method employed to permit full use of the remaining muscles, does not resemble the shape of the stump but, as the name implies, is more rectangular in shape. Until recently the standard method of fitting a quadrilateral socket called for no contact over the lower end of the stump, a hollow space being left in this area. Although this method was quite successful there remained a sufficient number of cases that persistently developed ulcers or edema over the end of the stump. Experiments involving the use of slight pressure over the stump-end led to the development of what is known as the plastic total-contact socket.<a></a></p> <p>(<b>Fig. 36</b>A). As the name implies, the socket is in contact with the entire surface of the stump. In taking some pressure over the end of the stump, the pressure on the ischium area is reduced, thereby providing more comfort to the patient. It also appears that the pressure over the end of the stump helps circulation and improves proprioception. Today the total-contact socket is the method of choice for use by above-knee amputees.</p> <p>In fitting the wooden above-knee prosthesis, the prosthetist carves the interior of the socket using measurements of the stump as a guide. When a satisfactory fit has been achieved the socket is usually mounted on an adjustable leg for alignment trial, after which the wooden shank and the knee are substituted for the adjustable unit and the leg is finished by applying a thin layer of plastic laminate over the shank and the thigh piece.</p> <p>In the case of the total-contact socket, the prosthetist obtains a plaster cast of the stump, usually with the aid of a special casting jig (<b>Fig. 22</b>), and thus obtains a model of the stump over which the plastic socket can be formed.</p> <p>Special adjustable pylon-type legs (<b>Fig. 37</b> and <b>Fig. 38</b>) are available for fitting immediately after surgery, or use as a temporary leg. Provisions are made for all necessary adjustments, and a manually operated knee lock is provided for use by infirm patients.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 37. Prosthetic unit designed especially for fitting above-knee cases immediately after surgery. The same principles used in the below-knee device (Fig. 31.) are incorporated. In addition, mechanical friction about the "knee" axis and a mechanical "knee" lock are provided. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 38. Prosthetic unit designed especially for fitting above-knee cases immediately after surgery. This is essentially the same unit shown in Fig. 37. except that hydraulic resistance instead of mechanical friction is provided about the knee joint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For Hip-Disarticulation And Hemi-pelveclomy Cases</i></p> <p>A prosthesis (<b>Fig. 39</b>) developed by the Canadian Department of Veterans Affairs in 1954 and modified slightly through the years has become accepted as standard practice. In the Canadian design a plastic-laminate socket is used, and the "hip" joint is placed on the front surface in such a position that, when used with an elastic strap connecting the rear end of the socket to a point on the shank ahead of the femur, stability during standing and walking can be achieved without the use of a lock at the hip joint. The location of the hip joint in the Canadian design also facilitates sitting, a real problem in earlier designs.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 39. Hip-disarticulation prosthesis, known as the Canadian-type because its principle was originally conceived by workers at the Department of Veterans Affairs of Canada. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A constant-friction knee unit is most often used with the hip-disarticulation prosthesis, but some prosthetists have reported successful use of hydraulic knee units.</p> <p>The hemipelvectomy patient is provided with the same type of prosthesis but the socket design is altered to allow for the loss of part of the pelvis.</p> <h4>Upper-Extremity Prostheses<a></a></h4> <p>The major role of the human arm is to place the hand where it can function and to transport objects held in the hand. The energy for operation of the hand substitute in upper-extremity prostheses is derived from relative motion between two parts of the body. Energy for operation of the elbow joint, when necessary, can be obtained in the same way. The stump, of course, is also a source of energy for control of the prosthesis in all except the shoulder-disarticulation and forequarter cases. Force and motion can be obtained through a cable connected between the device to be operated and a harness across the chest or shoulders.</p> <p>In recent years artificial arms powered by electricity have received considerable publicity. An artificial hand powered by electricity and controlled by electrical signals from muscles has been developed in Russia for below-elbow amputees. Versions of the Russian design are available in England and Canada. Similar devices have also been developed in Austria and Italy. However, the below-elbow patient, of all the types of upper-extremity amputees, is the least handicapped and therefore less in need of sophisticated devices. The devices are expensive and in their present state of development seem to offer no real advantage over the simpler conventional devices. The real need is for patients with amputations above the elbow and higher. Efforts to develop useful externally powered arms, both electrical and pneumatic, are being made in both the United States and abroad, especially in reference to severely handicapped children <a></a>.</p> <p><i>Hand Substitutes - Terminal Devices</i></p> <p>All upper-extremity prostheses for amputation at the wrist level and above have, in common, the problem of selection of the terminal device, a term applied to artificial hands and substitute devices such as hooks. In some areas of the world there is a tendency to supply the arm amputee with a number of devices, each designed for a specific task such as eating, shaving, hairgrooming, etc. In the United States such an approach has been considered too clumsy, and opinion has been that the terminal device should be designed so that most upper-extremity amputees can perform the activities of daily living with a single device, or at most with two devices.</p> <p>The so-called split hooks are much more functional than any artificial hand devised to date. The arm amputee must rely heavily upon visual cues in handling objects and the hook offers more visibility. The hook also offers more prehension facility, and can be more easily introduced into and withdrawn from pockets than a device in the form of a hand. Therefore, the hook is used in manual occupations and those avocations requiring manual dexterity. When extensive contact with the public is necessary and for social occasions, the hand is of course generally preferred. Many amputees have both types of devices, using each as the occasion warrants.</p> <p>Two basic types of mechanism have been developed for terminal-device operation-voluntary-opening and voluntary-closing. In the former, tension on the control cable opens the fingers against an elastic force; in the latter, tension in the control cable closes the fingers against an elastic force. Each type of mechanism has its advantages and disadvantages, neither being superior to the other when used in a wide range of activities. Both hands and hooks are available with either type of mechanism.</p> <p>The major types of terminal devices are shown in <b>Fig. 40</b> and <b>Fig. 41</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 40. Voluntary-closing terminal devices. A, APRL-Sierra Hand; left, cutaway view showing mechanism; right, assembled hand without cosmetic glove; B, APRL-Sierra Hook. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 41. Voluntary-opening terminal devices. The wide range of models offered by the D. W. Dor-rance Company includes sizes and designs for all ages. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Wrist-Disarticulation Case</i></p> <p>One of the problems in fitting the wrist disarticulation in the past has been to keep the overall length of the prosthesis commensurate with the normal arm. The development of very short wrist units, especially for wrist-disarticulation cases, has materially reduced this problem. However, these units are available in only the screw, or thread, type, and cannot be obtained in the bayonet type which lends itself to quick interchange of terminal devices.</p> <p>The socket for the wrist-disarticulation case need not extend the full length of the forearm and is fitted somewhat loosely at the upper, or proximal, end to permit the wrist to rotate. A simple figure-eight harness and Bowden cable are used to operate the terminal device <b>Fig. 42</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 42. Typical methods of fitting below-elbow amputees with medium to long stumps. Above, the figure-8, ring-type harness is most generally used. Where possible flexible leather hinges and open biceps cuff or pad are used. When more stability between socket and stump is required, rigid (metal) hinges and closed cuffs can be used (inserts A and B). In insert C, fabric straps are used for suspension in lieu of a leather billet. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Long Below-Elbow Case</i></p> <p>The prosthesis for the long below-elbow case is essentially the same as that for the wrist-disarticulation patient except that the quick-disconnect wrist unit can be used when desired.</p> <p><i>Prostheses For The Short Below-Elbow Case</i></p> <p>The socket for the short below-elbow stump, where there is no residual rotation of the forearm, is usually fitted snugly to the entire stump, and often rigid hinges connecting the socket to a cuff about the upper arm are used to provide additional stability. Either the figure-eight harness or the chest-strap harness may be used, the latter being preferred when heavy-duty work is required since it tends to spread the loads involved in lifting over a broader area than is the case with the figure-eight design.</p> <p>A wrist-flexion unit, which permits the terminal device to be tilted in toward the body for more effective use, can be provided in the short below-elbow prosthesis but is seldom prescribed for unilateral cases.</p> <p><i>Prostheses For The Very Short Below-Elbow Case</i></p> <p>Often the very short below-elbow case cannot control the prosthesis of the short below-elbow type through the full range of motion, either because of a muscle contracture or because the stump is too short to provide the necessary leverage.</p> <p>When a contracture is present that limits the range of motion of the stump, a "split-socket" and "step-up" hinge may be used. With this arrangement of levers and gears, movement of the stump through one degree causes the prosthetic forearm to move through two degrees; thus, a stump that has only about half the normal range of motion can drive the forearm through the desired 135 deg. However, when the step-up hinge is used, twice the normal force is required. When the stump is incapable of supplying the force required, it can be assisted by employing the "dual-control" harness wherein force in the terminal-device control cable is diverted to help lift the forearm. When the elbow stump is very short or has a very limited range of motion, an elbow lock operated by stump motion is employed to obtain elbow function.</p> <p>Recently a number of prosthetists have reported success in fitting very short below-elbow cases with an arm which is bent to give a certain amount of prerlexion. This type of fitting, which was developed in Munster, West Germany, eliminates the necessity for using the rather clumsy step-up hinges and split socket, thus providing improved prosthetic control without a disadvantageous force feedback. Furthermore, the harness is not necessary for suspension of the prosthesis. The maximum forearm flexion may be limited to about 100 deg., but this does not appear to be a significant disadvantage to unilateral amputees (<b>Fig. 43</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 43. Comparison of split socket and Munster-type fitting of short below-elbow case. A, Split socket and step-up hinge provides 140 deg. of forearm flexion; B, Munster-type fitting permits less forearm flexion but enables the amputee to carry considerably greater weight with flexed prosthesis unsupported by harness. Courtesy New York University College of Engineering Prosthetic and Orthotic Research. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Elbow-Disarticulation Case</i></p> <p>Because of the length of the elbow-disarticulation stump, the elbow-locking mechanism is installed on the outside of the socket. Otherwise the prosthesis and harnessing methods (<b>Fig. 44</b>) are identical to those applied to the above-elbow case.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 44. Typical prosthesis for the elbow-disarticulation case. The chest-strap harness with shoulder saddle is shown here, but the above-elbow figure-eight is also used. See Figure 45. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For The Above-Elbow Case</i></p> <p>For the above-elbow prosthesis to operate efficiently, it is necessary that a lock be provided in the elbow joint, and it is, of course, preferable that the lock is engaged and disengaged without resorting to the use of the other hand or pressing the locking actuator against an external object such as a table or chair.</p> <p>Several elbow units that can be locked and unlocked alternately by the same motion are available. This action is usually accomplished by the relative motion between the prosthesis and the body when the shoulder is depressed slightly and the arm is extended somewhat. The motion required is so slight that with practice the amputee can accomplish the action without being noticed. These elbow units contain a turntable above the elbow axis that permits the forearm to be positioned with respect to the humerus, supplementing the normal rotation remaining in the upper arm and thus allowing the prosthesis to be used more easily close to the mid-line of the body.</p> <p>The elbow units described above are available with an adjustable coil spring to assist in flexing the elbow when this is desired. The flexion-assist device may be added or removed without affecting the other operating characteristics.</p> <p>The plastic socket of the above-elbow prosthesis covers the entire surface of the stump. The most popular harness used is the figureeight dual-control design wherein the terminal-device control cable is also attached to a lever on the forearm so that, when the elbow is unlocked, tension in the control cable produces elbow flexion, and, when the elbow is locked, the control force is diverted to the terminal device (<b>Fig. 45</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 45. Typical prosthesis for the above-elbow case. The figure-8 harness is shown here but the chest-strap harness with shoulder saddle may also be used. See Fig. 44. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The chest-strap harness may also be used in the dual-control configuration.</p> <p><i>Prostheses for the Shoulder-Disarticulation and Forequarter Cases</i></p> <p>Because of the loss of the upper-arm motion as a source of energy for control and operation of the prosthesis, restoration of the most vital functions in the shoulder-disarticulation case presents a formidable problem; for many years a prosthesis was provided for this type of amputation only for the sake of appearance. In recent years, however, it has been possible to make available prostheses which provide a limited amount of function (<b>Fig. 46</b>). To date it has not been possible to devise a shoulder joint that can be activated from a harness, but a number of manually operated joints are available. Various harness designs have been employed but, because of the wide variation in the individual cases and the marginal amount of energy available, no standard pattern has developed, each design being made to take full advantage of the remaining potential of the particular patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 46. Typical prosthesis for the shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prostheses For Bilateral Upper-Extremity Amputees</i></p> <p>Except for the bilateral, shoulder-disarticulation case, fitting the bilateral case offers few problems not encountered with the unilateral case. The prostheses provided are generally the same as those prescribed for corresponding levels in unilateral cases. Artificial hands are rarely used by bilateral amputees because hooks afford so much more function. Many bilateral cases find that the wrist-flexion unit, at least on one side, is of value. The harness for each prosthesis may be separated, but it is the general practice to combine the two (<b>Fig. 47</b>). In addition to being neater, this arrangement makes the harness easier for the patient to don unassisted.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 47. Harness for the bilateral below-elbow/ above-elbow case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some prosthetists have claimed success in fitting bilateral shoulder-disarticulation cases with two prostheses. Because of the lack of sufficient sources of energy for control, most cases of this type are provided with a single, functional prosthesis and a plastic cap over the opposite shoulder which provides an anchor for the harness and also fills this area to present a better appearance (<b>Fig. 48</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 48. Special harness arrangement for the bilateral shoulder-disarticulation case. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Learning to Use the Prosthesis</h3> <p>To derive maximum benefit from his prosthesis, the amputee must understand how it functions and learn the best means of controlling it. A patient may be of the opinion that he is getting along very well when, in reality, he could do much better. Use of the prosthesis can best be learned under the supervision of an instructor who has had special training.</p> <p>All amputees using an artificial limb for the first time will need some instruction. In some instances, when a prosthesis is replaced with one of a different design, special instruction will be required. The time required for training depends upon the complexity of the device and the physical condition and degree of coordination of the patient. The time required will vary from a few hours to several weeks. In many instances amputees themselves have become excellent trainers, but more often such training is given by physical or occupational therapists. Usually, physical therapists instruct lower-extremity patients and occupational therapists teach upper-extremity cases.</p> <p>During the period of instruction, the trainer is careful to observe any effects the use of the prosthesis has on the patient, especially at points where the prosthesis is in contact with the body. Any changes are reported immediately to the physician in charge.</p> <h4>Lower-Extremity Cases</h4> <p>One of the major goals in training the leg amputee<a></a> is to enable him to walk as gracefully as possible. Training is begun as soon as the amputee is provided with a comfortable prosthesis. In the case of immediate postsurgical fitting,<a></a> training is begun usually on the day following surgery and an adjustable leg is used. There is a growing tendency to train lower-extremity amputees on legs with adjustable features even though they have not been fitted immediately after surgery. Some other goals of training are to teach the patient proper methods of donning the prosthesis, caring for the stump, arising after a fall, and use of canes and crutches when necessary. The type of training will, of course, depend upon the level of amputation.</p> <p>A patient with a Syme amputation needs a minimum of training. The average below-knee case will require somewhat more, though usually not extensive, unless other medical problems are present. The training required is usually quite extensive for patients who have lost the knee joint.</p> <p>The ability to balance oneself is the first prerequisite in learning to walk, and so it is balance that is taught first to the above-knee amputee. Two parallel railings are used to give the patient confidence and reduce the possibility of falling (<b>Fig. 49</b>). Balancing on both legs is practiced first, then on each leg. Walking in a straight line between the parallel bars is repeated until the patient no longer requires use of the hands for support. Walking in a straight line is practiced until the gait is even and smooth.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 49. Above-knee patient being trained to walk by a physical therapist. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When a rhythmic gait has been accomplished, more difficult tasks are learned, such as pivoting, turning, negotiating stairs and ramps, and sitting on and arising from the floor.</p> <p>Most unilateral above-knee patients can use their prostheses quite well without the necessity for a cane. However, in the case of short, weak stumps it may be advisable to employ a cane for additional support and stability. If a cane is necessary, it should be selected to meet the needs of the patient, and it must be used properly if ungainly walking patterns are to be avoided. Canes with curved handles and made from a single piece of wood should be used. The shaft should not show any signs of buckling under the full load of the body weight, and should be just long enough so that the elbow is bent slightly when the bottom of the cane rests near the foot. The cane is used on the side opposite the amputation to help maintain balance but is not used to the extent that body weight is centered between the good leg and the cane (<b>Fig. 50</b>). Continued use of the cane in this manner usually results in a limp that is difficult to overcome. It has been found that, for biomechan-ical reasons, it is helpful for the amputee to carry a briefcase or purse on the side of the amputation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 50. Above-knee patient being taught correct use of cane. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Training The Hip-Disarticulation Cases</i></p> <p>The training of hip-disarticulation cases follows much the same pattern as that for above-knee cases. With the advent of the Canadian-type prosthesis, the training procedure has been considerably simplified. Some special precautions must be taken to avoid stumbling while ascending stairs.</p> <p><i>Special Considerations For Bilateral Leg Cases</i></p> <p>As would be expected, bilateral-leg cases pose special problems in addition to those of the unilateral cases and, therefore, a good deal of time will usually be required in training. Patients with two good below-knee stumps will seldom require canes. Some bilateral above-knee amputees can get along without canes, but as a general rule at least one cane is required.</p> <h4>Upper-Extremity Cases</h4> <p>The first objective in the training program for upper-extremity amputees is to ensure that the patient can perform the activities encountered in daily living, such as eating, grooming, and toilet care. When this goal has been attained, attention is devoted to any special training that might be required in vocational pursuits (<b>Fig. 51</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 51. Upper-extremity amputees performing vocational tasks. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before the prosthesis is put to useful purposes, the patient is shown how the various mechanisms are controlled and is made to practice these motions until they can be performed in a graceful manner and without undue exertion. In general, the arm amputee soon becomes so adept in these, procedures that they are carried out without conscious thought. During this period, the functioning of the prosthesis, especially of the harness and control cables, is watched carefully by the instructor and constantly rechecked to ensure maximum performance.</p> <p>Only when the patient has mastered use of the various controls is practice in the handling of objects and the performance of activities of daily living undertaken.</p> <h3>Care of the Stump</h3> <p>Even under the most ideal circumstances the amputation stump, when called upon to operate a prosthesis, is subjected to certain abnormal conditions which, if not compensated for, may lead to physical disorders which make the use of a prosthesis impossible.</p> <p>Lack of ventilation as a result of encasing the stump in a socket with impervious walls causes an accumulation of perspiration and other secretions of glands found in the skin. In addition to the solid matter in the secretions, bacteria will accumulate in the course of a day. Both the solid matter and bacteria can lead to infection, and the solid matter, though it may appear to be insignificant, may result in abrasions and the formation of cysts. For these reasons cleanliness of the stump and anything that comes in contact with it for any length of time is of the utmost importance, even when sockets of the newer porous plastic laminate are used.</p> <p>The stump, therefore, should be washed thoroughly each day, preferably just before retiring. A soap or detergent containing hexa-chlorophene, a bacteriostatic agent, is recommended, but strong disinfectants are to be avoided. To be fully effective, the bacteriostatic agent must be used daily. Some six or seven daily applications are necessary before full effectiveness is obtained, and any cessation of this routine lowers the agent's ability to combat the bacteria. A physician who is himself an amputee has suggested that after an amputee takes a bath, the stump should be dried first in order to minimize the risk of introducing infection to it by the towel.</p> <p>When the prosthesis is used without a stump sock, the stump should be thoroughly dry as moisture may cause swelling that will result in rubbing and irritation. For such cases, it is especially desirable for the stump to be cleansed in the evening.</p> <p>The stump sock should receive the same meticulous care as the stump. The socks should be changed daily and washed as soon as they are taken off. In this way the perspiration salts and other residue are easier to remove. A mild soap and warm water are used to keep shrinkage to a minimum. Woolite (a cold-water soap) and cold water in recent trials have given excellent results. A rubber ball inserted in the "toe" during the drying process ensures retention of shape.</p> <p>Elastic bandages should be washed daily in the same manner as stump socks, but should not be hung up to dry; rather they should be laid out on a flat surface away from excessive heat and out of the direct rays of the sun. Hanging places unnecessary stresses on the elastic threads, and heat and sunlight accelerate deterioration.</p> <p>It is of the utmost importance that any skin disorder of the stump-no matter how slight- receive prompt attention, because such disorders can rapidly worsen and become disabling. The amputee should see a physician for treatment. He should also see his pros-thetist; it may be that adjustment of the prosthesis will eliminate the cause of the disorder. In no case should iodine or any other strong disinfectant be used on the skin of the stump.</p> <p>Sometimes the skin of the stump is rubbed raw by socket friction. When this happens, the skin should be gently washed with a mild toilet soap. After the stump has been rinsed and dried, Bacitracin ointment, or some other mild antiseptic, should be applied, and the area covered with sterile gauze. The prosthesis should be completely dry before it is put on. If such abrasions occur frequently, the pros-thetist should be informed. If there is the slightest sign of infection, the amputee should see a physician.</p> <p>Small painless blisters should not be opened; they should be washed gently with a mild soap and left alone. Large, painful blisters should be treated by a physician.</p> <h4>Bandaging The Stump</h4> <p>The stump is usually kept wrapped in an elastic bandage from the time healing permits until the time the prosthesis is delivered. Also, bandaging is recommended when for some reason it is impracticable or impossible for the patient to wear his limb routinely. It is therefore highly desirable for the amputee, or at least one member of his family, to be able to apply the bandages. Many amputees can wrap their stumps unaided and, indeed, prefer to do so. Others prefer and, in some instances, require the help of another person.</p> <p>Recommended methods for applying elastic bandages for below-knee, above-knee, below-elbow and above-elbow patients are shown in <b>Fig. 52</b>, <b>Fig. 53</b>, and <b>Fig. 54</b>, respectively. These illustrations first appeared in a booklet entitled "Industrial Amputee Rehabilitation," prepared by Dr. C. O. Bechtol under the sponsorship of Liberty Mutual Insurance Co. of Boston.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 52. Recommended method of applying elastic bandage to the below-knee stump. The bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 53. Recommended method of applying elastic bandage to the above-knee stump. The stump is kept in a relaxed position, and the bandage is wrapped tighter at the end of the stump than it is above. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 54. Elastic bandages applied properly to upper-extremity stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Care of the Prosthesis</h3> <p>In addition to the care required in keeping the inside of the socket clean, which has been stressed, best results can be obtained only if the prosthesis is maintained in the best operating condition. Like all mechanical devices, artificial limbs can be expected to receive wear and be discarded for a new device, but the length of useful life can be extended materially if reasonable care is taken in its use. An example often quoted is that of two identical automobiles. The car given the maintenance recommended by the manufacturer and operated with care will outlast many times the vehicle given spotty maintenance and operated with disregard for the heavy stresses imposed. So it is with artificial limbs. Some amputees require a new prosthesis every few years, or even more often, while others who follow the manufacturer's instructions, apply preventive maintenance practices, and have minor problems corrected without delay, have received satisfactory service from their limbs for periods as long as twenty years.</p> <p>Manufacturers' instructions vary with the design of the device. They consist mainly of lubrication practices and should be followed closely. Too much lubricant can sometimes produce conditions as troublesome as excessive wear. Looseness of joints and fastenings should be corrected as soon as it is detected, for the wear rate increases rapidly under such a condition. Any cracks that appear in supporting structures should be reinforced immediately in order to avoid complete failure and the necessity for replacement. The foot should be examined weekly for signs of excessive wear.</p> <p>A point often overlooked by leg amputees, but nevertheless one of the factors affecting optimum use of the artificial limb, is the condition of the shoe. Badly worn or improper shoes can alter alignment and therefore have adverse effects on the stability and gait of the wearer. This is a matter that requires especially close attention in the case of child amputees.</p> <p>Hooks and artificial hands should be treated with the same care that the normal hand is given. Because the sensation of feeling is absent in the terminal device, the upper-extremity amputee is all too prone to use hooks to pry and hammer and to handle hot objects that are deleterious to the hook materials. Hands with cosmetic gloves should be washed daily, and of course hot objects and staining materials should be avoided.</p> <h3>Special Considerations in Treatment of Child Amputees <a></a></h3> <p>Only a few years ago it was seldom that a child amputee was fitted with a prosthesis before school age and often not until much later. In recent years experience has shown that fitting at a much earlier age produces more effective results.</p> <p>If there are no complicating factors, children with arm amputations usually should be provided with a passive type of prosthesis soon after they are able to sit alone, which is generally at about six months of age. Certain gross two-handed activities are thus made possible, crawling is facilitated, the child becomes accustomed to using and wearing the prosthesis, and moves easily into using a body-operated prosthesis as his coordination develops soon after his second birthday.</p> <p>Lower-extremity child amputees should be fitted with prostheses as soon as they show signs of wanting to stand. The development of muscular coordination of child amputees is the same as for nonhandicapped children and, therefore, this phase may take place as early as eight months or as late as 20 or more months.</p> <p>Children, especially when fitted at an early age, almost always adapt readily to prostheses. As the child grows, the artificial limb seems to become a part of him in a manner seldom seen in adults (<b>Fig. 55</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 55. Children with upper-extremity amputations performing two-handed activities. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Except for the very young, children's prostheses follow much the same design as those for the adult group. Special devices and techniques have been developed for initial fitting of infants and problem cases.</p> <p>Regardless of where the child amputee resides, or the extent of his parents' financial resources, he need not go without the treatment and prostheses required to make full use of his potentials. To ensure that such services are available, the Children's Bureau of the Department of Health, Education, and Welfare has assisted a number of states in establishing well-organized child-amputee clinics, and the facilities of these states are available to residents of states where such specialized services are not to be had. There is an agency in each state that can advise the parents of the proper course of action.</p> <p>Most children can be treated on an outpatient basis, but for the more severely handicapped many of the clinics have facilities for in-patient treatment. The clinic team for children is often augmented by a pediatrician and a social worker, and sometimes by a psychologist.</p> <p>Training very young children is one of the most difficult problems of the clinic team. Although the learning ability of young children may be rapid, their attention span is of such short duration that extreme patience is required. Regardless of the ability of the therapist, successful results cannot be achieved without complete cooperation of the parents. The mental attitude of the parents is reflected in the child, and all too often children have rejected prostheses because the parents, consciously or subconsciously, could not accept the fact that a prosthesis was needed. Parents of children born with a missing or deformed limb often experience a sense of guilt, a feeling that only adds to an already difficult problem. The guilt feeling is unwarranted, inasmuch as the knowledge of the causes of congenital defects-and appropriate preventive measures- is very limited. The recent discovery of the effects of thalidomide suggests that other causes may be found.</p> <p>As a rule, lower-extremity amputees present fewer problems than the upper-extremity cases.</p> <p>It is natural for the child to walk, and almost invariably the lower-extremity patient adapts rather quickly. Parents, however, should keep close observation of the walking habits of the child, the condition of his stump, and the state of repair of his prosthesis, and above all they should present the child before the clinic at the recommended times. A gradual change in walking habit may indicate that the child has outgrown the prosthesis or that excessive wear of the prosthesis has taken place. Any unusual appearance of the stump should be reported to the physician immediately so that remedial steps may be taken, thereby avoiding more complicated medical problems at a later date. Children give a prosthesis more wear and tear than do adults and it is important that the prosthesis be examined carefully at regular intervals and needed repairs made as soon as possible-not only to ensure the safety of the child but to avoid the necessity for major repairs at a later date.</p> <p>Many upper-extremity child amputees adapt readily to artificial arms-some even want to sleep with the arm in place-but in many cases the child will need a great deal of encouragement before he will accept the device and make use of it. At first the unilateral amputee may feel that the prosthesis is a deterrent rather than an aid, but with the proper encouragement this feeling is reversed.</p> <p>Parents can help by continuing the training given in the clinics. From the beginning the artificial arm should be worn as much as possible. Young children should be given toys that require two hands for use and older children should be given household chores that require two-handed activities. In the latter case not only does the child learn to appreciate the usefulness of the prosthesis, but he also gains a feeling of being a useful member of the family and thus a better mental attitude is created.</p> <p>The child amputee should not be sheltered from the outside world but encouraged to associate with other children and, to the extent that he can, to take part in their activities. Of course there are certain limitations, but the number of activities that can be performed with presently available prostheses is amazing. It goes almost without saying that the child should receive no more special attention than is necessary, and should be made to perform the activities of daily living of which he is capable.</p> <p>It has been shown that it is preferable for the child amputee to attend a regular school rather than one for the handicapped. Most child amputees can and do take their place in society and the transition from school to work is much easier if they are not shown unnecessary special consideration. Nonhandicapped children soon accept the amputee and make little comment after the initial reaction.</p> <p>Here again the arm amputee is apt to be faced with the most problems. Some public school officials have hesitated to admit arm amputees wearing hooks for fear that the child may use them as weapons. This attitude is unrealistic. If such incidents have occurred, they are rare indeed. However, arm prostheses should be removed when the child is engaged in body-contact sports such as football.</p> <p>Cleanliness of the stump, prosthesis, and stump sock is just as important for children as for adults. The same procedures as those outlined on pages 37-39 are recommended.</p> <h3>Special Considerations in the Treatment of Elderly Patients</h3> <p>Persons who have had amputations during youth or middle age seldom encounter additional problems in wearing their prostheses as they become older. However, for those patients who have an amputation in later life many unusual problems are apt to be present. Most amputations in elderly patients are necessary because of circulatory problems, almost always affecting the lower extremity. For many years the wisdom of fitting such patients with prostheses was debatable, the thought being that the remaining leg, which in most cases was subject to the same circulatory problems as the one removed, would be overtaxed and thus the need for its removal would be hastened. Energy studies in recent years have shown that crutch-walking is more taxing than use of an artificial limb. Experience with rather large numbers of elderly leg amputees has shown that failure of the remaining leg has not been accelerated by use of a prosthesis, and stumps that have been fitted properly have not been troublesome. As a result more and more elderly patients are benefiting by the use of artificial limbs. A rule of thumb used in some clinics to decide whether or not to fit the elderly patient is that if he can master crutch-walking he should be fitted. This measure should be used with discretion because in some instances patients who could not meet the crutch-walking requirement have become successful wearers of prostheses.</p> <p>The patient should be fitted as soon as possible, to avoid such complications as the development of contractures. The availability of adjustable pylon-type legs and the use of plaster or plastic sockets now makes early fitting practical, and this approach is being adopted by more and more centers. Many geriatric patients have benefited from the immediate postsurgical fitting procedures.</p> <p>Most clinic teams feel that if the patient can use the prosthesis to make him somewhat independent around the house, the effort is fully warranted.</p> <p>Artificial legs for the older patients, as a rule, should be as light as possible. Except for the most active patients, only a small amount of friction is needed at the knee for control of the shank during the swing phase of walking because the gait is apt to be slow. Suction sockets are rarely indicated because of the effort required in donning them. A quadrilateral-shaped socket is used with one stump sock and a pelvic belt. Silesian bandages have been used successfully, allowing more freedom of motion and increased comfort.</p> <p>For the elderly below-knee cases, the patellar-tendon-bearing prosthesis is being used quite successfully.</p> <h3>Cineplasty <a></a></h3> <p>In 1896 the Italian surgeon, Vanghetti, conceived the idea of connecting the control mechanism of a prosthesis directly to a muscle. Several ideas involving the formation of a club-like end or a loop of tendon in the end of a stump muscle were tried out in Italy. Just prior to World War I the German surgeon, Sauerbruch, devised a method of producing a skin-lined tunnel through the belly of the muscle. A pin through the tunnel was attached to a control cable, and thus energy for operation of the prosthesis was transferred directly from a muscle group to the control mechanism. With refinements the Sauerbruch method is available for use today, but it must be used cautiously.</p> <p>Although tunnels have been tried in many muscle groups, the below-elbow amputee is the only type that can be said to benefit truly from the cineplasty procedure. A tunnel properly constructed through the biceps can supply power for operation of a hand or hook, and there need be no harnessing above the level of the tunnel. Thus, the patient is not restricted by a harness and the terminal device can be operated with the stump in any position. Training the tunneled muscle and care of the tunnel require a great deal of work by the patient; thus if the cineplasty procedure is to be successful the patient must be highly motivated.</p> <p>Some female below-elbow amputees have been highly pleased with results from a biceps tunnel, but as a rule cineplasty does not appeal to women.</p> <p>Cineplasty is not indicated for children. Sufficient energy is not available for proper operation of the prosthesis and the effects of growth on the tunnel are not known.</p> <p>Tunnels have been tried in the forearm muscles but the size of these muscles is such that the energy requirements for prosthesis operation are rarely met. While tunnels in the pectoral muscle are capable of developing great power, in the light of present knowledge the disadvantages tend to outweigh the advantages. It is extremely difficult to harness effectively the energy generated, and very little, if any, of the harness can be eliminated. It is true that an additional source of control can be created, but with the devices presently available little use can be made of this feature.</p> <p>No application for cineplasty has been found in lower-extremity amputation cases.</p> <p>Still another type of cineplasty procedure is the Krukenberg operation, whereby the two bones in the forearm stump are separated and lined with skin to produce a lobster-like claw. The result, though rather gruesome in appearance, permits the patient to grasp and handle objects without the necessity of a prosthesis.</p> <p>Because sensation is present, the Krukenberg procedure has been found to be most useful for blind bilateral amputees. Although prostheses can be used with Krukenberg stumps when appearance is a factor, the operation has found little favor in the United States.</p> <h4>Agencies That Assist Amputees</h4> <p>For several centuries at least, governments have traditionally cared for military personnel who received amputations in the course of their duties. But only in recent years, except in isolated cases, has the amputee in civilian life had much assistance in making a comeback. Today there are available services to meet the needs of every category of amputee. Aside from the humanitarian aspects of such programs, it has been found to be good business to return the amputee to productive employment and, in the case of some of the more debilitated, to provide them with devices and training to take care of themselves.</p> <p>The Armed Services provide limbs for military personnel who receive amputations while on active duty, and many of these cases are returned to active duty. After the patient has been discharged from military service, the Veterans Administration assumes responsibility for his medical care and prosthesis replacement for the remainder of his life. The U.S. Public Health Service, through its Marine Hospitals, cares for the prosthetics needs of members of the U.S. Maritime Service.</p> <p>Each state provides some sort of service for child amputees. If sufficient facilities are not available within a state, provisions can be made for treatment in one of the regional centers set up in a number of states with the help and encouragement of the Children's Bureau of the Department of Health, Education, and Welfare. With assistance from the Vocational Rehabilitation Administration of the Department of Health, Education, and Welfare, every state operates a vocational rehabilitation program designed to help the amputee return to gainful employment. Some of these programs render assistance to housewives and the elderly as well.</p> <p>Private rehabilitation centers, almost universally nonprofit and sponsored largely by voluntary organizations, greatly augment the state and federal programs.</p> <p>Information concerning rehabilitation centers serving a particular area may be obtained from the Association of Rehabilitation Centers, 828 Davis Street, Evanston, Ill. 60201.</p> <p><b>References:</b></p> <ol> <li>Artificial Limbs, Autumn 1957.</li> <li>Artificial Limbs, April 1961.</li> <li>Artificial Limbs, June 1962.</li> <li>Bechtol, Charles O., and George T. Aitken, <i>Cineplasty</i>, Chap. 12 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Blakeslee, Berton, <i>The limb-deficient child</i>, University of California Press, 1963.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower-extremity amputees</i>, Prosthetic and Sensory Aids Service, Veterans Administration, 1967.</li> <li>Committee on Artificial Limbs, National Research Council, Washington, D.C., <i>Terminal research reports on artificial limbs</i>, covering the period from 1 April 1945 through 30 June 1947.</li> <li>Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs</i>, Chap. 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Foort, J., <i>Adjustable-brim fitting of the total-contact above-knee socket</i>, Biomechanics Laboratory, University of California (Berkeley and San Francisco), No. 50, March 1963.</li> <li>Foort, James, <i>The patellar-tendon-bearing prosthesis for below-knee amputees</i>, a review of technique and criteria, Artificial Limbs, Spring 1965.</li> <li>Hampton, Fred, <i>Suspension casting for below-knee, above-knee, and Syme's amputations</i>, Artificial Limbs, Autumn 1966.</li> <li>Klopsteg, P. E., <i>The functions and activities of the Committee on Artificial Limbs of the National Research Council</i>, J. Bone and Joint Surg., 29: 538-540, 1947.</li> <li>National Academy of Sciences-National Research Council, <i>The control of external power in upper-extremity rehabilitation</i>, Publication 1352, 1966.</li> <li>Sarmiento, Augusto, R. E. Gilmer, and A. Finnieston, <i>A new surgical-prosthetic approach to Syme's amputation, a preliminary report</i>, Artificial Limbs, Spring 1966.</li> <li>Staros, Anthony, <i>Dynamic alignment of artificial limbs with the adjustable coupling</i>, Artificial Limbs, Spring 1963.</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasty</i>, Chap. 12 in <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Thomas, Atha, and Chester C. <i>Haddan, Amputa- tion prosthesis</i>, Lippincott, Philadelphia, Pa., 1945.</li> <li>Vultee, Frederick E., <i>Physical treatment and training of amputees</i>, Chap. 7 in <i>Orthopaedic appliances atlas</i>, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</li> <li>Weiss, Marian, <i>The prosthesis on the operating table from the neurophysiological point of view</i>, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Bechtol, Charles O., and George T. Aitken, Cineplasty, Chap. 12 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Blakeslee, Berton, The limb-deficient child, University of California Press, 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Immediate postsurgical prosthetics in the management of lower-extremity amputees, Prosthetic and Sensory Aids Service, Veterans Administration, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Vultee, Frederick E., Physical treatment and training of amputees, Chap. 7 in Orthopaedic appliances atlas, Vol. 2, J. W. Edwards, Ann Arbor, Mich., 1960.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">National Academy of Sciences-National Research Council, The control of external power in upper-extremity rehabilitation, Publication 1352, 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chap. 12 in Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, Biomechanics Laboratory, University of California (Berkeley and San Francisco), No. 50, March 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Artificial Limbs, June 1962.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Foort, James, The patellar-tendon-bearing prosthesis for below-knee amputees, a review of technique and criteria, Artificial Limbs, Spring 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Artificial Limbs, April 1961.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Staros, Anthony, Dynamic alignment of artificial limbs with the adjustable coupling, Artificial Limbs, Spring 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hampton, Fred, Suspension casting for below-knee, above-knee, and Syme's amputations, Artificial Limbs, Autumn 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chap. 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Immediate postsurgical prosthetics in the management of lower-extremity amputees, Prosthetic and Sensory Aids Service, Veterans Administration, 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Weiss, Marian, The prosthesis on the operating table from the neurophysiological point of view, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Artificial Limbs, Autumn 1957.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Artificial Limbs, April 1961.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Sarmiento, Augusto, R. E. Gilmer, and A. Finnieston, A new surgical-prosthetic approach to Syme's amputation, a preliminary report, Artificial Limbs, Spring 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Suite 130, 919-18th St., N.W., Washington, D.C. 20006.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Suite 130, 919-18th St., N.W., Washington, D.C. 20006.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;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">Klopsteg, P. E., The functions and activities of the Committee on Artificial Limbs of the National Research Council, J. Bone and Joint Surg., 29: 538-540, 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>7.</b> </td><td class="clsTextSmall">Committee on Artificial Limbs, National Research Council, Washington, D.C., Terminal research reports on artificial limbs, covering the period from 1 April 1945 through 30 June 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Thomas, Atha, and Chester C. Haddan, Amputa- tion prosthesis, Lippincott, Philadelphia, Pa., 1945.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr., B.S.M.E. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Avenue, N.W., Washington, D.C. 20418.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-12.jpg Figure 3 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-23.jpg Figure 4 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-34.jpg Figure 5 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-45.jpg Figure 6 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-52.jpg Figure 7 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-53.jpg Figure 8 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-54.jpg Figure 9 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-55.jpg Figure 10 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-02.jpg Figure 11 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-03.jpg Figure 12 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-04.jpg Figure 13 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-05.jpg Figure 14 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-06.jpg Figure 15 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-07.jpg Figure 16 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-08.jpg Figure 17 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-09.jpg Figure 18 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-10.jpg Figure 19 http://www.oandplibrary.org/al/images/1967_01_001/1967_01_001-11.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Limb Prosthetics-1967 Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr., B.S.M.E. *